The experience of finding an effective bowel management program for children with spina bifida: the parent's perspective

Patient-Reported Experience in Colorectal Disease is Predicted by Cleanliness

BACKGROUND

Children with colorectal diseases such as anorectal malformations (ARM), Hirschsprung disease (HD), and functional constipation (FC) undergo bowel management programs (BMPs) to achieve cleanliness. While patient outcomes, such as cleanliness and quality of life, are well understood, patient experience, such as relationships, ability to participate in sports, and independence and self-confidence is less well understood. We aimed to assess the relationship between BMP and patient experience.

METHODS

A cross-sectional survey was administered to 295 patients ≥3 years old with ARM, HD, and FC completing BMP. The survey contains 22 questions regarding patient-reported experience measures (PREMs) and 11 regarding patient-reported outcomes measures (PROMs). Each was graded on a Likert scale, with higher scores meaning better experience. Scores were compared by demographics and clinical characteristics and logistic regression was performed controlling for clinically significant variables. A p-value of ≤0.05 was significant.

RESULTS

There were 205 eligible respondents (69.5%) with a median age of 8.9 years [IQR: 6.1-12.4]. ARM was most common (51.2%) and most achieved cleanliness on BMP (69.3%). There were no differences in experience scores by age, diagnosis, or bowel regimen. Patients that were clean had significantly higher PREM scores (67.7 [IQR: 64.0-83.0] vs. 64.8 [IQR: 55.0-70.1], p = 0.0002) and PROM scores (36.8 [IQR: 33.0-41.0] vs. 34.0 [31.0-38.5], p = 0.005). On regression analysis, cleanliness remained a strongly significant predictor of positive experience scores (β 7.37, SE 1.86, p < 0.0001).

CONCLUSIONS

Achieving cleanliness was associated with positive patient experience of bowel management programs. This finding suggests that achieving cleanliness, regardless of regimen, may allow patients the best functional and experiential outcomes.

The impact of a health care transition clinic on spina bifida condition management and transition planning

BACKGROUND

To better serve the growing population of individuals with spina bifida (SB) living into adulthood, pediatric SB clinics have developed structured health care transition (HCT) supports for adolescents and young adults. Evaluating the impact of structured HCT on SB-related chronic condition outcomes and transition planning goals is needed to assess such interventions.

OBJECTIVE

This study explored the impact of a SB HCT Clinic on SB-related chronic condition management outcomes (e.g., reported bowel and bladder regimens and presence of pressure injury) and transition planning goals (e.g., decision-making, insurance, and transportation).

METHODS

A retrospective chart review was conducted of young adults with SB who did and did not participate in an SB HCT Clinic before establishing an adult clinic to compare SB-condition outcomes and HCT planning goals between groups. Associations between demographic and clinical variables and outcomes were also assessed.

RESULTS

The HCT group (n = 68) was more likely to use a bowel regimen (P < 0.01) compared to the non-HCT group (n = 94). There were no differences regarding bladder regimens or incidence of pressure injuries. For HCT planning, the groups differed regarding decision-making supports (P = 0.01). Additionally, the HCT group was more likely to use self-transportation (P = 0.01) or Medicaid transportation (P < 0.01).

CONCLUSION

This single-center HCT program improved the use of a bowel regimen at the time of transfer to adult care and impacted HCT planning regarding decision-making and transportation. These initial findings support the need for further development and assessment of HCT programs for this population.

Improving continence in children and young people with neurodisability: a systematic review and survey

BACKGROUND

Children and young people with neurodisability often need help to achieve socially acceptable bladder and bowel control. Approaches vary depending on whether or not the impairment results from spinal cord pathology that impairs motor control and sensation of the bladder and bowel. Currently, there is uncertainty about which interventions are effective.

OBJECTIVE

The objective was to summarise the available evidence on and current practice for improving continence in children and young people with neurodisability.

DESIGN

A systematic review of the effectiveness, cost-effectiveness and factors that modify intervention implementation, alongside a cross-sectional, online survey of current practice with health professionals, parent carers, school and care staff and young people with neurodisability.

RESULTS

Twelve databases were searched in the review, resulting in 5756 references; 71 studies (72 papers) were included in the analyses. Most of the evidence was for children with spinal cord pathology, which involved evaluations of pharmacological approaches and surgical techniques, whereas the evidence pertaining to those with non-spinal-cord-related pathology tended to be for behavioural interventions. The methodological quality of studies was rated as being moderate to poor. There were three robust qualitative studies about the experience of continence among children with spinal cord pathology. We found substantial heterogeneity across the interventions that we evaluated in terms of quality, study design and outcomes measured. No economic studies were found. The results were synthesised narratively and reported in text and tables. We did not find any eligible studies evaluating interventions using toilet and clothing adaptations in the review, although the survey highlighted that these types of interventions are frequently used and considered. In total, 949 people responded to the survey: 202 health professionals, 605 parent carers, 122 school and social care staff, and 20 young people. The survey results illustrated the different roles that professionals have in improving continence, highlighting the importance of a multidisciplinary approach to supporting children and young people and their families. Clinicians employ a range of assessments and interventions to improve continence or independent toileting, depending on the needs of the child.

LIMITATIONS

Quantitative studies in the review were not methodologically robust. The survey had a risk of response bias.

CONCLUSIONS

Our research found a dearth of good-quality evidence for many of the interventions currently in use, and no evidence of experiences of implementing interventions for children with non-spinal-cord-related pathology. There was also no evidence of cost-effectiveness of any of the interventions.

FUTURE WORK

There is a need to involve young people and families in the design of high-quality evaluative research for interventions that aim to improve continence. This is especially the case for children with autism and learning disability, who have been neglected in previous evaluative and qualitative research. We recommend better training for health, education and care professionals about toileting, informed by evidence and the lived experiences of children and their families. We recommend a joined-up multidisciplinary and holistic approach to improving continence to maximise independence, dignity and comfort. It is vital that children and young people with neurodisability have early access to regular, integrated assessment of their bladder and bowel health, and are fully supported with appropriate personalised treatment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018100572.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 73. See the NIHR Journals Library website for further project information.

The Quality of Life of Children with Myelomeningocele: A Cross-Sectional Preliminary Study

Objectives: To investigate the relationship between the defects and symptoms caused by myelomeningocele (MMC) and quality of life. Design: A cross-sectional questionnaire survey. Methods: The subjects were 52 parents of children with MMC. Structured questionnaires were used: the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL^TM 4.0) and a Study-Specific Questionnaire (SSQ). Results: The overall PedsQL^TM 4.0 score was 56.4 (SD ± 14.7). A strong, significant negative correlation was found between the children’s age and emotional functioning. Functioning in this area deteriorated with age by a mean of 1.5 points per year of age. Children with no hydrocephalus functioned significantly better than those with this defect in the physical, social, and school areas (p < 0.05). Foot deformities significantly (p = 0.033) adversely affected the children’s physical functioning. Living in a single-parent family had no statistically significant impact on functioning in any of the areas analyzed (p > 0.05). Conclusion: Understanding the QoL of children with MMC and identifying its determinants may help in planning interventions to minimize the adverse impact of the illness.

Parents' Perception of Self-Management Behaviors for Their Children With Spina Bifida in South Korea: A Qualitative Study

PURPOSE

This study aimed to explore parents' perceptions of self-management behaviors for their children with spina bifida (SB).

DESIGN

Qualitative method.

METHODS

In-depth interviews were conducted with nine Korean parents of children with SB. The data were analyzed using the content analysis method.

FINDINGS

Parental perceptions of the experiences of self-management behaviors in children with SB were classified into risk factors that hinder self-management behaviors and protective factors that accelerate them. Each category of factors was then further classified into child-, parent-, and school-related factors.

CONCLUSIONS

To promote self-management behaviors in children with SB, reducing risk factors and promoting protective factors considering child, family, and school dimensions based on cultural differences are necessary.

CLINICAL RELEVANCE

Rehabilitation nurses should be considered essential healthcare providers who can offer stepwise guidance to achieve self-management behaviors in children with SB according to their stage of development.

Assessment of neurogenic bowel symptoms with the bowel dysfunction score in children with spina bifida: a prospective case-control study

AIM

To compare the quality of life (QoL) in children with spina bifida with a control group of their peers using a validated questionnaire, the Neurogenic Bowel Dysfunction Score (NBDS).

METHODS

The NBDS questionnaire was prospectively distributed to children attending a multi-disciplinary Spina Bifida clinic and healthy controls attending pediatric urology clinics. A score (out of 41) was assigned to each child based on their responses to the validated questionnaire. A lower score indicates better bowel function-related quality of life. SPSS software (v.25) was used for all statistical analysis.

RESULTS

There were 98 respondents to the questionnaire, 48 children with spina bifida and 50 controls. The average age of respondents was 7.88 years (3-16 years). Of those with Spina Bifida, 33 (69%) were on retrograde rectal irrigations, [19 (58%) Peristeen® system, 11 (33%) tube rectal irrigations, and 3 (9%) Willis system], 6 (12%) were on laxatives, and 9 (19%) were on no treatment. The median NBDS for Spina Bifida patients was significantly higher 13.5 (2-32) compared to the control group 2 (0-26, p < 0.001). Amongst Spina Bifida patients, there was no difference in quality of life between the modalities of bowel management (p = 0.203).

CONCLUSIONS

Despite active bowel management, children with spina bifida report a worse quality of life compared to the control group. In those with spina bifida, the lack of a difference between various bowel management strategies, including no treatment, indicates the need for a longitudinal study to evaluate the basis for this unexpected finding.

Needs assessment survey for children and adults with spina bifida in Georgia

PURPOSE

We conducted a needs assessment among parents/guardians of children and independent adults with spina bifida, served by the Spina Bifida Association of Georgia (SBAGA). The objective was to assess if SBAGA is adequately meeting the needs of its constituents and to identify challenges and opportunities to improve services.

METHODS

The survey targeted all members of SBAGA in 2017. Survey questions were drafted separately for parents/guardians of children, and independent adults with spina bifida. Both closed- and open-ended response options were provided. The survey was pilot-tested, and administered in English and Spanish, using email, post, or in person.

RESULTS

A total of 119 individuals completed the survey. For parents/guardians (n= 96), the most important needs were bladder and bowel education, social and communication skills education, medical support, and transition and independence training. Independent adults (n= 23) responded that they mostly needed bladder and bowel education, medical support, and transition and independence training. Location of the SBAGA events and transportation to the events were the most frequent limiting factors for both groups.

CONCLUSIONS

Our survey findings highlighted that SBAGA services are valued overall. The survey findings will be used to guide quality improvement of current programs, and develop programs addressing emerging needs and challenges.

Palestinian children's narratives about living with spina bifida: Stigma, vulnerability, and social exclusion

BACKGROUND

Living with spina bifida in Palestine is a critical issue that might influence various aspects of the individual's life. It is a challenge for children, their families, and health care providers because it requires lifelong treatment and follow-up of care provision. However, little focus has been placed on these children's perceptions about their daily life experiences with spina bifida.

PURPOSE

To illuminate the lived experience of children with spina bifida in the West Bank, Palestine.

METHODS

A qualitative study was conducted using the phenomenological hermeneutical method to interpret the meaning of being a child with spina bifida in Palestine. Ten children with spina bifida, aged 7-18 years, were interviewed. The two local authors independently analyzed the Arabic transcriptions, whereas the two Swedish authors analyzed the transcriptions after translation to English. Finally, the four authors discussed their analysis and reached agreement about the themes.

RESULTS

Studying the children's experience with spina bifida helped us highlight their feelings, needs, and challenges. The findings were formulated into one main theme, Vulnerability and suffering due to social exclusion and stigma, which was grounded in three themes: Experiencing negative self-concept, Experiencing vulnerability, and Obtaining a sense of security. These three themes were in turn derived from subthemes.

CONCLUSION

The Palestinian children in this study faced physical, emotional, and psychosocial challenges, which negatively influenced their health and development. They were vulnerable and stigmatized, and they lived with a negative self-concept. The findings could help health professionals, families, and caregivers to achieve a deeper understanding of what being a child with disabilities entails, and the findings may also serve as a platform for interventions that seek to promote these children's development and to enable them to experience childhood as a meaningful and positive process.

Bowel Management and Quality of Life in Children With Spina Bifida in South Korea

Bowel management is a concern in patients with spina bifida. We evaluated the status of bowel management in children with spina bifida (SB) and the effects on quality of life (QoL) of children and their caregivers. Data were collected from 173 children with SB between January and June 2011, whose bowel management status and QoL were assessed using a self-administered questionnaire. Of the 173 children, 38 (22.0%) reported normal defecation, 73 (42.2%) reported constipation only, and 62 (35.8%) reported fecal incontinence with/without constipation. For defecation, 59 children (34.1%) used digital stimulation or manual extraction, 28 (16.2%) used suppositories or enemas, 35 (20.3%) used laxatives, 4 (2.3%) used an antegrade continence enema, and 3 (1.7%) used transanal irrigation. There were significant differences in QoL, depending on defecation symptoms. Children with fecal incontinence and their caregivers had difficulties in travel and socialization (p < .0001), caregivers' emotions (p < .0001), family relationships (p < .0001), and finances (p < .0001). Constipation and fecal incontinence affect QoL of children with SB and their caregivers. Therefore, more attention should be paid to bowel problems and help should be provided to children and their caregivers to improve QoL.

Predictors of permanent disability among adults with spinal dysraphism

OBJECTIVE Predictors of permanent disability among individuals with spinal dysraphism are not well established. In this study, the authors examined potential risk factors for self-reported permanent disability among adults with spinal dysraphism. METHODS A total of 188 consecutive individuals undergoing follow-up in an adult spinal dysraphism clinic completed a standardized National Spina Bifida Patient Registry survey. Chi-square tests and logistic regression were used to assess bivariate relationships, while multivariate logistic regression was used to identify factors independently associated with self-identification as "permanently disabled." RESULTS A total of 106 (56.4%) adults with spina bifida identified themselves as permanently disabled. On multivariate analysis, relative to completion of primary and/or secondary school, completion of technical school (OR 0.01, 95% CI 0-0.40; p = 0.021), some college (OR 0.22, 95% CI 0.08-0.53; p < 0.001), college degree (OR 0.06, 95% CI 0.003-0.66; p = 0.019), and holding an advanced degree (OR 0.12, 95% CI 0.03-0.45; p = 0.002) were negatively associated with permanent disability. Relative to open myelomeningocele, diagnosis of closed spinal dysraphism was also negatively associated with permanent disability (OR 0.20, 95% CI 0.04-0.90; p = 0.036). Additionally, relative to no stool incontinence, stool incontinence occurring at least daily (OR 6.41, 95% CI 1.56-32.90; p = 0.009) or more than weekly (OR 3.43, 95% CI 1.10-11.89; p = 0.033) were both positively associated with permanent disability. There was a suggestion of a dose-response relationship with respect to the influence of educational achievement and frequency of stool incontinence on the likelihood of permanent disability. CONCLUSIONS The authors' findings suggest that level of education and degree of stool incontinence are the strongest predictors of permanent disability among adults with spinal dysraphism. These findings will be the basis of efforts to improve community engagement and to improve readiness for transition to adult care in a multidisciplinary pediatric spina bifida clinic.

Depressive Symptoms in Parents of Children with Spina Bifida: A Review of the Literature

To review the literature on the prevalence of depressive symptoms in parents of children with spina bifida (SB) and factors related to these symptoms. A search was conducted using the major health databases (CINAHL, MEDLINE, and PsycINFO). Nineteen studies were identified that met inclusion and exclusion criteria. A context, process, and outcome framework was used to organize the findings. This review identified both: (a) a high prevalence of parental depressive symptoms (PDS); and (b) specific factors: demographics, condition, child, family functioning, and parent factors that explained 32-67% of parent depressive symptoms (PDS). Although contextual factors were important, they alone were not sufficient to explain PDS. Process factors accounted for more variance in PDS than context factors. Findings warrant implementation of depression screening in parents of children with spina bifida. This review identified factors related to PDS and highlighted gaps in the literature to guide future research.

Parent perceptions of health promotion for school-age children with spina bifida

PURPOSE

To gain insight into how parents develop their beliefs of health promotion for their children with spina bifida (SB) and how they develop and promote health promotion practices for their children.

DESIGN

Qualitative, exploratory design with semi-structured interviews of parents of children between 6 and 12 years of age diagnosed with SB was used for this study.

RESULTS

Perceptions of health promotion were maintaining healthy bowel function and managing SB care. Good bowel function and SB management is health promotion and adequate bowel function is viewed as a marker of health. Maintaining healthy bowel function was identified by parents as the key marker of health for their children with SB. Further, the term health promotion brought up plans, concerns, and goals more related to their child's physiologic functioning and health care needs rather than promoting health and avoiding preventable disease.

PRACTICE IMPLICATIONS

Nurses and healthcare providers are in unique and powerful positions for strategizing with parents on how to integrate health promotion into the lives of children with SB. Team-based, whole-person, holistic assessment and teaching inclusive of promoting healthy lifestyle behaviors in addition to providing excellent care related to their physiologic systems affected by SB can improve how we promote health for these children.

A qualitative exploration of the experiences of children with spina bifida and their parents around incontinence and social participation

BACKGROUND

Urinary incontinence is frequently experienced by children with spina bifida, putting them at increased risk for low self-esteem and impacting upon participation in home, school and leisure activities. However, little is known about children's experiences of these continence issues.

OBJECTIVE

This study explored the experiences of children and young people with spina bifida around continence issues, social participation and peer relationships, in order to identify potential areas of support healthcare professionals can provide.

METHODS

Children and youth aged 6-18 years with diagnoses of spina bifida and neurogenic bladder and their parents were invited to participate in semi-structured interviews. Descriptive thematic analysis was employed.

RESULTS

Eleven children (with a range of mobility levels, types of spina bifida and degrees of bladder control) and their parents participated in the study. Three broad themes were identified, which encompassed the following: (1) normal versus different; (2) independence, ownership and the road to continence; and (3) peer relationships and acceptance.

DISCUSSION

The experiences discussed by the children and parents in this study ranged from minimal impact of incontinence on their day-to-day living to significant social isolation and rejection. The stigma of incontinence was apparent in all interviews. Children and youth who were able to control their bladder with minimal accidents had greater independence and more opportunities for social participation. Healthcare professionals need to take into account that parents and their children may differ in attitudes and desires about the management of incontinence.

Transitioning adolescents and young adults with a chronic health condition to adult healthcare - an exemplar program

Pediatric specialists have successfully improved the longevity and quality of life of many children with chronic health conditions. As these children reach adolescence and young adulthood, the scope of their concomitant medical problems often include those typically seen in older patients. As a result, these individuals need continuing quality health care in focused adult healthcare facilities. This article describes the effective partnership between pediatric and adult healthcare providers to create and implement an exemplar Spina Bifida Transition Program. The processes, strategies and tools discussed are likely to be useful to other healthcare professionals interested in developing pediatric to adult transition programs for adolescents and young adults with chronic health conditions.

Family management of a chronic health condition: perspectives of adolescents

A growing number of adolescents and their families are dealing with a chronic health condition that impacts their daily life. Research using the Family Management Style Framework (FMSF) has added much to our understanding of how the family integrates chronic condition management into family life. Less clear, however, is the adolescent perspective of the FMSF components. The purpose of this secondary qualitative analysis was to explore 25 interviews of adolescents with spina bifida to uncover the adolescent's perspective of the three major FMSF components: Definition of the Situation, Management Behaviors, and Perceived Consequences. Adolescents were able to articulate their perspectives and their observations of their parents' behaviors that related to the three components and related dimensions of the framework. Data from this analysis led to proposed expansion of the FMSF definitions from an adolescent perspective. Implications for integrating the adolescent perspective into future research and clinical practice are discussed.

Transition in young adults with spina bifida: a qualitative study

BACKGROUND

Adolescents and young adults with spina bifida are an at-risk population because of the complexity of their condition, developmental stage and social challenges. The purpose of this qualitative study was to examine the transition to adulthood in young adults with spina bifida and to explore condition-related needs and life skills required during the transition process.

METHODS

This qualitative study using narrative inquiry was part of a larger multi-site study of adaptation in young adults with spina bifida. Interviews were completed with 10 participants ranging in age from 18 to 25 years. The guided interview questions focused on specific dimensions of the transition experience related to the ecological model: self-management, independence and inner strength.

RESULTS

Three themes capturing different dimensions of the young adults' transition experiences emerged in the analysis. The themes included: (1) Struggling for independence, (2) Limiting social interactions and experiences with stigma, and (3) Building inner strength.

CONCLUSION

The qualitative study contributes to a better understanding of the challenges of transition to achieve self-management and social development for young adults with spina bifida. Findings in the life stories highlighted issues that necessitate increased advocacy and interventions from professionals within the health and social system.