1. Dietary Considerations & Peristeen ® Anal Irrigation System Presented by: Tiffany Gordon, MSN, RN, CRRN, CPN Karri Larson, RD Gillette Children’s Specialty Healthcare Sponsored by Coloplast June 27, 2016

2. Objectives What you eat and drink impacts your outcomes Review of the impact to both bowel and bladder management programs Peristeen demonstration and in depth conversation discussing bowel diaries, taking personal responsibility, etc.

4. Fiber is Important Fiber is found in plant based foods Fiber is the portion of the plant that our bodies cannot digest Fiber provides bulk to the stool Fiber is found in fruits, vegetables and whole grains Soluble Fiber – oats, seeds, barley, beans and fruits Insoluble – wheat bran, nuts, beans and vegetables To receive the most benefit from a high fiber diet, eat a variety of high-fiber foods To add more fiber to your diet: Choose whole grain breads, pasta, brown rice The more refined a food is, the less fiber it contains Try to incorporate fiber in every meal/snack (popcorn & dark chocolate!) Substitute whole wheat flour for white flour in recipes Add Chia seeds or ground flax to yogurt, cereal, baked goods Eat the skin or peel of foods (apples, sweet potatoes, squash) Substitute (or add) beans in your favorite family recipes, use hummus as a dip Gradually increase fiber in your diet to prevent diarrhea Aim for fiber sources from REAL FOOD first Then foods that have fiber added to them (Fiber One products) Use a fiber supplement if necessary

5. Water is important too All the fiber in the world isn’t going to help if your child is not getting adequate hydration Water helps the fiber provide bulk to the stool Thirst is not always an accurate indicator of hydration Most kids need to be reminded to drink often Tips for increasing water intake: Purchase a special water bottle at the store Non Caffeinated/Non Caloric water beverages are okay Develop a child specific incentive program to meet fluid goals Eat high volume foods whenever possible Grapes have a higher water content than raisins Use a fun timer to help remind kids to take a break for fluids Make it fun: ice cubes with frozen raspberries or silly straws

6. Bowels & Fiber DescriptionAction to Be Taken Did I have a Bowel Movement Today? Stool Consistency: Soft & Formed?Same dose of fiber Hard & Ball shaped? ↑ dose of fiber, ↑ water intake Soft & Pasty? ↑ dose of fiber, ↑ water intake Loose & Oatmeal? Slightly ↓ dose of fiber Adjust your fiber intake based off of what your stool looks like.

7. Impact of Bowel on Bladder Effective management of your bowels, assures the best outcomes for bladder management. If you are constipated, the pressure of stool on the bladder constantly or intermittently causes the bladder to act differently, regardless of medication and/or cathing programs. If you want to have the best ability to be continent, you need to manage both your bowel and bladder.

8. Anatomy

10. Peristeen system includes: Screw top Bag Pump & control unit Catheters with balloon

11. Benefits of Peristeen ® Initially Peristeen ® clean out is done every day, but most patients get such good clean out that they can eventually go to every other day Peristeen ® significantly reduces the amount of time spent for bowel program (most patients take 30 minutes or less including set-up) Most patients can reduce or eliminate bowel medications that they are taking once Peristeen ® is established

12. Testimonial

13. Questions

14. References: Anderson JW, et al. Health benefits of dietary fiber. Nutrition Reviews. 2009;67:188. Ausili E et al. Transanal irrigation in myelomeningocele children: an alternative safe and valid approach for neurogenic constipation. Spinal Cord 2010; 48: 560-565. Braun, P. et al. Bowel Management and Spina Bifida. Spina Bifidia Association 2009. Choi E et al. The effects of transanal irrigation as a stepwise bowel management program on the quality of life of children with spina bifida and their caregivers. Spinal cord 2013;51: 384-388. Christensen P, et al. A Randomized, controlled trial of transanal irrigation verses conservative bowel management in spinal cord-injured patients. Gastroenterology 2006; 131:738-747. Christensen P, et al. Scintigraphic Assessment of retrograde Colonic Washout in Fecal Incontinence and Constipation. Diseases of the Colon & Rectum 2003: 46: 68-76. Corbett P et al. Peristeen integrated transanal irrigation system successfully treats fecal incontinence in children. J pediatric Urology 2013, E pub http://dx.doi.org/10.1016/j.jpurol.2013.08.006.http://dx.doi.org/10.1016/j.jpurol.2013.08.006 Lopez Pereira P, et al. Transanal irrigation for the treatment of neuropathic bowel dysfunction. J Pediatric Urology 2009; 6:134-138. Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurologic Conditions. Multidisciplinary Association of Spinal Cord Injured Professionals. Developed 2012 Position of the American Dietetic Association: Health implications of dietary fiber. Journal of the American Dietetic Association. 2008;108:1716. U.S. Department of Agriculture: "Dietary Guidelines for Americans, 2010."