Bowel Management & SMA

Jennifer Trust Information Leaflet N° 003.
Developed in conjunction with Dr Ros Quinliven MRCP, FRCPCH

Constipation is very common in young children and even more so in young disabled children, because of their lack of mobility and underlying muscle weakness. When a child is chronically constipated, the bowel wall is in a permanent state of stretch and loses normal tone. The normal mechanism reminding the child to use the toilet is therefore less effective, and the child may not have the urge to use the toilet for several days or even weeks. The bowel becomes filled with hard impacted faeces with only liquid stool able to get past. The result of this is that some parents are led to believe that their child has diarrhoea. Sometimes the anus becomes so stretched that soft stools leak continuously; this is called overflow incontinence. If this occurs, parents will notice that once in a while the child will pass an enormous stool and then be clean for the next few days. Sometimes an enema is needed to remove the impacted fæces, which almost act as a "blockage".

The colon is the body's reservoir for fæcal (waste) material. The normal mechanism for propelling material along the bowel is by contraction and relaxation of muscles surrounding the bowel wall. The stimulus for these muscles to contract is mediated through a stretch reflex in the nerve endings of the bowel wall. Stretching of the anal sphincter gives us the message that we need to use the toilet.

Sometimes hard fæces may cause a tear in the skin at the anus. This is extremely painful; a small amount of bright red blood may be visible on the toilet paper. This is not dangerous, but the pain may cause the child to further resist a bowel movement thus increasing the constipation. The pain can be relieved by the application of a small amount of local anaesthetic such as lignocaine gel.

Please remember that any strategy to relieve constipation is likely to be long term and there is no overnight solution. Below is a list of some possible medicines or remedies that can be tried, these should only be tried under the supervision of a suitably qualified health care practitioner.

LATULOSE: This laxative is basically a sugary solution which draws liquid into the bowel using osmosis (The movement of a weak solution to a strong solution through a semi - permeable membrane), softening the fæces and adding bulk thus helping the individual to void more regularly. Because it is a sugary sticky solution, it is wise to brush teeth after taking it. It can cause some tummy ache, although this is not frequently a problem.

SENNECOT: This is a stimulant laxative and is derived from a natural product. The bowel stimulation can cause some tummy ache and watery diarrhoea. Often used in conjunction with Lactulose.
DOCUSOL: Stimulates the colon and also has a softening effect. Often used in conjunction with Lactulose.
LAXOBEROL: This is a very strong laxative, used to clear the bowel rather like an enema from the top end! It is also used as bowel prep before bowel surgery. It is usually effective the day after taking it, and may cause tummy ache and diarrhoea.

There are also a range of pædiatric suppositories and enemas available; these may be embarrassing for older children and adolescents.

GLYCERINE SUPPOSITORIES: dissolve slowly and lubricate the faeces. Will not clear the upper colon. May be distressing and uncomfortable.
ENEMAS: Such as Microlax, this is squirted internally and stimulates further up the colon. This is useful when the bowel is impacted. Enemas may be distressing and uncomfortable and can sting.

Unfortunately, there is no certain or quick remedy for constipation. Most often a combination of stool softener and stimulant laxative will be the most effective. Individual adjustment of the doses may be required as people often respond quite differently. Obviously, if the child develops diarrhoea the dose should be reduced. More often, however, failure of treatment is due to inadequate dosage, sometimes very high doses are required initially, and then weaned slowly over months once the bowel has been cleared. Stopping treatment too soon is another common reason for failure.

A PARENTAL PERSPECTIVE ON BOWEL CONTROL

Keep an accurate diary, keep records of frequency, size and consistency. This will help to assess the need for, and effectiveness of, any interventions.
Be patient, but try to make sure your child clears their bowel at least every two to three days, if this does not happen use appropriate intervention.
It is very difficult for a child to clear their bowel lying down. Gravity is a great aid, make sure your child uses an appropriate toilet seat. An Occupational Therapist should be able to advise on and supply an appropriate toilet seat.
Sitting on a nappy also blocks the movement and makes the process more difficult.
Some period in a standing aid is useful; gravity can help to move things along.
Put aside a regular time each day for toiletting, routine can help with the child's awareness of their bowels and help to stimulate action.
Ask your Physiotherapist to show you techniques for bowel massage.
When using any form of intervention always remain calm, distress is easily transferred.
A child will quickly learn when something helps, they may not like it, but they will usually accept it.

This is not an exhaustive list and is meant for guidance only, always consult and discuss these issues with your Doctor regularly.

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