Transanal Irrigation in Children – information for parents and carers

Introduction

Transanal irrigation (TAI) is a common treatment for constipation and soiling which does not require surgery and can be performed at home. This leaflet provides information on TAI in children including why it may be suggested for your child, what TAI involves, an introduction to different devices that can be used to deliver TAI and alternative treatments.

Anatomy

What is Transanal irrigation (TAI)?

Transanal irrigation (TAI) involves using a specially designed device to deliver fluid (sodium chloride or water depending on the child’s age and volume of fluid needed) via the anus into the child’s rectum. The fluid is then expelled (washed out) along with the stool (poo) whilst the child is sitting on the toilet at home.

Transanal irrigation is increasing being used in the treatment of childhood constipation with different devices used as briefly outlined in the treatment ladder below. You will be provided with a detailed leaflet specific to the device advised for use for your child, as well as training by one of the nurse specialist team.

Treatment Ladder

1. Regular, pre-emptive, active toileting; Optimal fluid intake; Dietary modifications; Laxative medication.
2. Suppositories
3. Low volume TAI using 'mini' system
4. TAI using cone toilet system
5. TAI using balloon irrigation system
6. Surgical intervention

Low Volume TAI ‘Mini’ System

Depending on your child’s age, a ‘MiniGo’ or ‘MiniGoFlex’ low volume TAI set may be used. The cone is lubricated with tap water and the container filled with warm tap water. The cone is gently inserted into the rectum (bottom), the container gently squeezed to instil the water (approximately 160ml) into the rectum, then the device removed. The water stretches your child’s rectum, stimulating it to contract and squeeze the poo out into the toilet.

‘Cone Toilet’ and ‘Balloon Irrigation’ systems

The remainder of the range of TAI devices all enable a larger volume of fluid to be administered; the exact volume being calculated on your child’s weight. In young children (below the age of 10 years), a prescribed salty water called ‘0.9% sodium chloride’ is used rather than tap water to prevent changes in electrolytes (essential slats) in the body. Like the ‘mini system’, the ‘cone toilet’ system has a cone which is passed into the rectum whereas the balloon TAI systems incorporate a rectal catheter which, when passed into the rectum, is held in place with a small inflatable balloon for the duration of the irrigation. All incorporate a container to hold the irrigation fluid and tubing which connects the container to the cone / rectal catheter.

Which of these TAI devices is appropriate for your child will depend upon factors such as effectiveness at achieving adequate clearance of stool in your child, degree of leakage of irrigation fluid, your child’s dexterity and their level of independence.

Why might my child require trans-anal irrigation?

Most commonly, TAI is used to help treat children who have a distal evacuation problem distal meaning the final part of the bowel nearest the anus) that may have also led them to have developed a ‘megarectum.’ This may include the following conditions:

1. Chronic idiopathic constipation (constipation without a known physical cause) where lifestyle modifications and laxatives have failed
2. Children who have had surgery for congenital (present at birth) abnormalities that affect the bowel like Hirschsprung’s disease or anorectal malformations
3. Children with neuropathic bowel – for example with a congenital spinal abnormality (such as Spina bifida) or acquired spinal abnormality.

What is a ‘megarectum’?

Mega means ‘big’ and therefore the term ‘megarectum’ refers to the rectum having, over time, become bigger than it should be. A megarectum is still present after the bowel has been ‘dis-impacted’ (cleared of stool using high dose laxatives) and will re-fill again leading to recurrent constipation and soiling. When a child has a megarectum laxatives tend not to give a particularly effective or predictable bowel movement. Instead, the megarectum requires targeted treatment via your child’s anus called the ‘transanal approach’. The aim of TAI is to enable more regular and effective emptying of the megarectum to allow it, over time, to reduce in size and stop the soiling. TAI needs to be performed alongside regular active toileting after meals and adherence to other behaviours that support good bowel health such as achieving an optimal fluid intake and healthy varied diet.

Is TAI suitable for all children?

TAI is suitable for most children as long as they can engage and sit on the toilet.

There are few children for whom TAI is not recommended:

• Within 7 days of having a biopsy taken from the bowel
• Within 6 months of bowel surgery
• In children with inflammatory bowel disease
• In most children under the age of 3 years

How will it be decided if transanal irrigation might benefit my child?

Your child will be assessed by our specialist Consultant and nursing teams. Depending on your child’s underlying condition assessment may include:

• Review of history of symptoms
• Completion of bowel diary including frequency of passage of stool, type of stool passed (Bristol stool chart) and soiling
• ‘Symptom severity questionnaire’ which helps review the impact of symptoms on your child’s life.
• Physical examination of the abdomen
• Physical examination of the anus
• X ray Colonic Transit study which involves your child swallowing some tiny markers which show up on x ray. The markers can be swallowed in their capsule or sprinkled on food but must not be cut. The transit study helps understand the type and severity of constipation your child has and if TAI may help.

How often will my child require transanal irrigation?

Initially while learning the technique we often recommend performing this daily.

The frequency required will vary for each individual child and will depend on factors such as the reason for needing TAI and the type of TAI system being used.

Most children with a congenital abnormality will require a daily or alternate day regimen.

Children with a distal evacuation problem such as megarectum usually commence on a daily regimen although a few will need TAI twice per day. Once TAI is established your child will be reassessed with an aim of gradually reducing frequency of TAI as the child starts to pass stool with a regular pattern independently.

What are the benefits?

• No surgery is required
• TAI can be performed at home
• Easy to use
• Passing of stool becomes more predictable because treatment is being given directly into the bowel (whereas oral laxatives need time to move through the body and get to the bowel so their effect can be unpredictable).
• Children gain greater control because passage of stool happens at a pre-determined time rather than unpredictably.
• Laxative doses can often be reduced
• Increased independence; whilst it can often take a few months to identify the most appropriate transanal regimen for each child, the ever increasing range of devices has meant that even young children have been able to successfully participate in their own bowel washouts via transanal irrigation.
• In many underlying conditions it can successfully treat constipation and allow a child to establish independent passage of stool without washouts in time

What are the risks or complications?

Risks and complications associated with the TAI recommended within our department are rare. However they may include:

• Minor discomfort as the rectal cone or rectal catheter is inserted
• If your child has an anal fissure (a small tear in the lining of the bottom (Anus), or sore skin around the anus this may be more prone to bleeding, so the use of a barrier cream may help.
• Perforation of the bowel has not been reported with use of the TAI devices we use and recommend but, exists as a theoretical risk and hence your child will be thoroughly assessed for suitability and full teaching will be given.

Who will teach how to perform transanal irrigation?

Teaching on TAI is provided by the hospital based nurse specialist team; usually during a clinic or ward visit. In some geographical areas there are also community based children’s nurses available who can continue teaching and provide support at home.

What are the alternatives?

1. Oral laxative medication

There are a wide range of oral laxative medications available some of which help to soften stool and others which help the bowel to push stool along. Children often benefit from a combination of laxatives. It is important that sufficient time is given to trying different laxative combinations and assessing their effectiveness.

2. Rectal laxative medication

Laxatives can be given rectally (directly into the back passage) in the form of suppositories or enema’s. Sometimes children benefit from a combination of oral and rectal laxative medication.

3. Surgical intervention

Surgical intervention (such as types of stoma) is reserved for those children who are of an age where they wish to be independent but lack the physical dexterity to use the TAI equipment or, in children who lack a competent sphincter.

How else can I help my child?

It is extremely important that lifestyle modifications such as those listed below are made:

Children can improve symptoms of constipation and soiling by:

• Making modifications to diet. Aim for your child to have a varied diet (often referred to as a colourful plate of food rather than a plate of foods of similar colour).
• Ensuring your child drinks enough every day.

The following information provides a guide of how much water based drink children should have per day:

Aged four to eight years

Boys and girls - 1000 to 1400ml

Aged nine to 13 years

Girls - 1200 to 2100ml

Boys - 1400 to 2300ml

Aged 14 to 18 years

Girls - 1400 to 2500ml

Boys - 2100 to 3200ml

• Having a regular toileting pattern. Your child should plan to sit on the toilet for 5 to 10 minutes, approximately 20 minutes after a meal at least twice daily as eating results in the contraction of the bowel. Coloured egg timers can be useful for younger children.
• Sitting on the toilet in a position which helps to aid defecation that is, with knees raised slightly (younger children may need a footstool to achieve this position).
• Using abdominal (tummy) muscles actively whilst sitting on the toilet (called the ‘brace position’ or ‘moo to poo’) by, for example, blowing down a straw, blowing bubbles or toy windmill, to encourage stool to pass.
• Avoiding passively sitting on the toilet with technology gadgets; the attempts as trying to pass stool need to be an active, focused attempts.
• Use of health food supplements such as ground linseed may be advised depending on your child’s age as these can help improve the form of the stool and the transit of stool through the bowel.
• Keep a bowel chart so you can identify patterns and so learn to work with your child’s body for example, if stool tends to be passed in the morning then ensure adequate time is always given to allow for sitting on the toilet at this time each day.

The most important action you can do to help your child is to remain positive and help them engage. Remember that use of TAI is a new skill; it takes time to learn and time for your child’s body to respond so patience is essential. We are here to provide support and advice so please call us using the number at the end of this leaflet.

Follow-up care and ongoing supplies

Follow up will initially be provided via telephone consultations with the clinical nurse specialist team who will review progress with using the TAI system and advise adjustments to the regimen being used. Further face to face clinics reviews will also be arranged.

Once TAI is established, ongoing supplies can be arranged (with your verbal consent) via a home delivery company. The nurse specialist team will register your child’s details with the company who will then liaise with your family doctor (GP) to obtain the required prescriptions following which equipment will be supplied directly to your home address. Once a home delivery system is set up you will need to make contact with the company directly when you need further supplies and we advise this is a monthly arrangement.

Chaperoning

During your child’s hospital visits your child will need to be examined to help diagnose and to plan care. Examination may take place before, during and after treatment, is performed by trained members of staff and will always be explained to you beforehand. A chaperone is a separate member of staff who is present during the examination. The role of the chaperone is to provide practical assistance with the examination and to provide support to the child, family member / carer and to the person examining.

Who shall I contact if I have any queries, concerns or questions?

For further information / queries please contact:

• Clinical nurse specialist team (Monday to Friday 08:00 to 18:00) on 01223 586973