Table 2.

The guidelines for bowel care and function for people with spina bifida and the citations of supporting evidence

Age group	Guidelines		Evidence
0–11 months	1.	Monitor stool frequency, consistency, and amounts.	[7, 8, 11]
	2.	Monitor stool frequency, consistency, and amounts.	[8, 11–14, 16, 18]
	3.	Use dietary management, in particular breastfeeding if possible, as breastmilk is easier to digest and offers better restoration of the microbiome after surgery.	[8, 11–14, 16, 18]
	4.	Consider dietary management (fiber and fluids) before pharmacologic adjuncts (sennoside), and/or rectal stimulants (glycerin suppositories) to manage constipation.	[8, 11–14, 16, 18, 23], clinical consensus
	5.	Use barrier creams to protect perineal area from breakdown as needed.	[11, 17, 24], Integument (Skin) Guidelines
1–2 years	1.	Discuss toilet training and habit training with parents.	[8, 10–11, 17–18]
11 months	2.	Establish goal of working toward bowel continence.	[8, 10–11, 17–18]
	3.	Focus on fiber, fluids, exercise, and timed bowel movements after meals.	[8, 11, 14–15, 18–19]
	4.	Consider two-pronged approach of oral and rectal interventions to meet the goal of bowel continence without constipation.	[8, 11, 14–15, 18–19]
	5.	Use dietary management (fiber and fluids), pharmacologic adjuncts (sennoside, polyethylene glycol), and/or rectal stimulants (glycerin, docusate sodium, or bisacodyl suppositories) to manage constipation and fecal incontinence.	[8, 11, 14–15, 18–19]
	6.	Use barrier creams to protect perineal area from breakdown as needed.	[11, 17, 24] Integument (Skin) Guidelines
	7.	Refer to a Spina Bifida clinic or specialist with expertise in bowel management in Spina Bifida.	[8, 10], clinical consensus
3–5 years 11 months	1.	Discuss consequences of constipation and bowel incontinence (including shunt malfunction, urinary tract infections (UTIs), skin breakdown, social isolation.	[3–5, 7, 10, 18]
	2.	Establish the goal of bowel continence and institute the bowel continence program using guidelines below.	[3–5, 7, 10, 18]
	3.	Focus on fiber, fluids, exercise, and timed bowel movements after meals.	[8, 11, 14–15, 18–19]
	4.	Consider two-pronged approach of oral and rectal interventions to meet the goal of bowel continence without constipation.	[8, 11, 14–15, 18–19]
	5.	Use dietary management (fiber and fluids), pharmacologic adjuncts (sennoside, polyethylene glycol), and/or rectal stimulants (glycerin, docusate sodium, or bisacodyl suppositories) to manage constipation and fecal incontinence.	[8, 11, 14–15, 18–19]
	6.	Use barrier creams to protect perineal area from breakdown as needed.	[11, 17, 24] Integument (Skin) Guidelines
	7.	Refer to a Spina Bifida clinic or specialist with expertise in bowel management in Spina Bifida.	[8, 10], clinical consensus