Management of Constipation in Newborns with Spina Bifida
The best approach to manage constipation in a newborn with spina bifida is to implement a stepwise bowel management program starting with dietary modifications and polyethylene glycol (PEG), followed by stimulant laxatives if needed, and progressing to rectal interventions for refractory cases. 1
Understanding the Problem
Newborns with spina bifida commonly experience bowel dysfunction due to neurological impairment affecting bowel motility and sensation. This can lead to:
- Decreased colonic motility
- Impaired rectal sensation
- Difficulty with voluntary sphincter control
- Chronic constipation that may worsen over time
Initial Management Approach
Step 1: Dietary Management
- For breastfed infants: Continue breastfeeding as it provides natural laxative effects
- For formula-fed infants: Consider formulas with added fiber
- Ensure adequate fluid intake to prevent hard stools
- As solids are introduced, prioritize fruits (especially prunes, pears, and apples) for their sorbitol content 1
Step 2: First-Line Medications
Polyethylene glycol (PEG): Primary first-line treatment at age-appropriate dosing
- Works by increasing water content in the colon
- Safe for use in infants and children
- Dosage should be adjusted based on response 1
Docusate sodium: Can be used as a stool softener
- Generally produces bowel movements within 12-72 hours 2
- Helps prevent dry, hard stools
Management for Persistent Constipation
Step 3: Add Stimulant Laxatives
- Senna: Can be added if osmotic laxatives alone are insufficient
- Generally causes bowel movement in 6-12 hours 3
- Dosage should be carefully adjusted for infants
Step 4: Rectal Interventions
For refractory constipation not responding to oral medications:
- Glycerin suppositories for occasional use
- Small-volume rectal enemas may be necessary for impaction
Long-Term Management Considerations
Early Intervention Protocol
The CDC Urologic and Renal Protocol for newborns with spina bifida recommends:
- Initial bladder drainage via indwelling Foley catheter or intermittent catheterization
- Teaching parents/caregivers intermittent catheterization techniques regardless of initial bladder status 4
- Coordinated bowel and bladder management for optimal outcomes
Monitoring and Follow-up
- Regular follow-up visits to assess bowel function
- Adjust management plan as the child grows
- Monitor for complications such as impaction or overflow incontinence
Advanced Interventions for Older Children
As the child grows, more advanced interventions may be considered for refractory cases:
- Retrograde colonic enemas have shown effectiveness in 66% of children with spina bifida achieving complete fecal continence 5
- Antegrade continence enemas (ACE) significantly improve fecal continence compared to conventional management in older children 6
- A decision tree approach to bowel management has shown good outcomes in spina bifida patients 7
Common Pitfalls to Avoid
- Delayed intervention: Early establishment of a bowel regimen is crucial
- Inconsistent regimen: Consistency among providers and caregivers is critical for success 7
- Overlooking the impact on quality of life: Bowel dysfunction significantly affects quality of life and emotional wellbeing of both children and caregivers 8
- Failing to adjust management with growth: Treatment needs change as the child develops
Key Takeaway
Establishing an effective bowel management program early in life is essential for newborns with spina bifida. The goals should be predictable bowel movements, prevention of constipation, and laying the groundwork for eventual independence. Starting with dietary management and PEG, and progressing through the treatment algorithm as needed, provides the best approach to managing constipation in these infants.