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4 year old, chronic constipation and not recognising when he needs a poo(9 Posts)
I know its not a nice topic but I really don't know how to help my 4 year old DS and hope someone has some advice. He was toilet trained at about 2.5 and took longer to get it with poo than he did with wee but he got there and was fine for a few months.
Then he started having accidents again and then blood when he went. We took him to the doctor who diagnosed chronic constipation and put him on movicol. He said the constipation could have damaged his muscles meaning he doesn't get the signal properly when he needs the toilet. He said this would repair over time. This was about 8 months ago.
He still has accidents regularly now. It seems to be if I don't get his movicol dose exactly right. This is difficult because he very slowly over time needs less and less. Right now we are just dropping him from 1/6 of a packet a day to 1/6 of a packet every second day. Recently when I took him off it altogether he had an accident every day. When I put him back on it he was fine for 10 days then had many accidents again.
I am obviously taking him back to the doctors again tomorrow but this has been going on for so long without a real solution I was just hoping for any ideas. It's a topic no one wants to talk about but he knows this doesn't happen to other kids and is finding it really hard. I feel for him so much and wish I could fix it. I have also spoken to doctors a couple of times about it in the last 8 months but not got many helpful answers.
My DD was on movicol from age 4 till about 9. You are in for the long haul ime. She still takes it every now and again for a few days and she is nearly 15.
Have you read the ERIC website? There is a lot of good information on there.
Your DS will need to be on the movicol for at least as long as the constipation has been a problem. Probably twice as long. Stopping it too early will only make things much worse.
Has your GP referred you for specialist help? There is usually a big psychological component to this and often family therapy is necessary to help to fix things.
Thank you both for your advice. Am i right then to reduce his dose of movicol when the stools become too loose and he has accidents because of this? I've just had a read of the ERIC website thanks for the suggestion 3liitlefrogs.
YY to ERIC website.
DS has a reward chart. He gets a sticker for each day he sits on the toilet for a few minutes after breakfast and before bed, and for eating his 5-a-day foods. A full week of stickers earns pocket money.
We have weaned off Movicol after several years and he's not had an accident for a good while now, other than one night when he had a tummy bug.
You need to do a month or so of quite a high dose initially to clear out all the blockage. This period leads to accidents. After that you need to work out a maintenance dose. This does change with time as the child grows and gets better at managing their toileting.
I think near the end DD was down to having it measured in teaspoons... as opposed to sachets.
However, if he is still constipated the accidents could be overflow. It all depends on why he is having accidents? Is he still got loads of poo inside or not really?
I agree with cece. it could be overflow. When you say 'accidents' do you mean he is soiling his pants? Is it a full poo or just anything from heavy skid marks to something the size of his palm or hand but flattened? Mya be fresh or may be dried and gritty? If it's the latter (heavy skid marks to something the size of his hand, fresh or gritty) it could be overflow.
If it's a full size poo, very soft and no 'form' to it then the dose of the movicol may be a little high BUT...
If he has an accident and it's a small amount, can he get the rest out on the toilet or does it not come? Again, if it's an accident you would expect the remaining poo to come out easily. If it's not coming he could still be constipated. Think of if you have a tummy upset and don't get to the loo. As soon as you get on it the poo comes doesn't it? If it's not doing that with him it could be overflow. When the poo dries out in the body it becomes a hard plug. Soft poo with seep round it as your body is trying to get rid of its waste. The soft poo is seepage, not proper poo.
Is he poo-ing regularly. Regular is 5 plus poos a week - one a day if possible. If he's not then he is constipated OR withholding (and the differences are very subtle unfortunately).
My DS has a distended bowel due to constipation (he's now 8). He's been on Movicol since he was 4. He was soiling (the latter type I described) 4-5 times a week. We did clear outs with Movicol, raised it, lowered it. Did rewards, lectured him, ignored it - basically didn't know what to do! I got 2 excellent books. One called Constipation, Withholding and your child by Anthony Cohn and the other called Stool Withholding - what to do when your child won't poo by Sophia Ferguson.
The first one gave me a lot of information about what DS was doing. We realised he was holding on to his poo (amazing how kids with distended bowels or constipation can hold days worths in). If there was a TV programme he was in the middle of and he got a signal to go to the loo, he'd try to hold on. Of course, he couldn't do it indefinitely and he'd soil.
The second book is written by a mum who used Movicol. She explains how to use Movicol until you get the magic 5 poos a week and gives the maximum you should go on for maintenance and for how long. She recommends at least 3 months at the dose that produces the 5 poos a week then gradually drop month by month. The idea, if you suspect it's withholding rather than 'true' constipation, is that the poo is soft enough that the child has to pass it but not so soft that it flows. Sophia Ferguson also recommends the book by Anthony Cohn. I liked his book but hers was much more straight forward from my point of view. And has worked!
DS has produced 5 poos plus each week since we got him on that regime at the end of November and has got the signal to poo 4 or 5 times (which isn't much but is a miracle compared to the previous years and years of not getting anything). He has soiled twice. Once he didn't get to the loo in time and once he tried to hold it in as he was on the PC.
The general rule is that if a child just can't pass a poo it is probably constipation. If there is soiling but no poo comes out it MAY be withholding. If they seem to soil when they are engrossed in something it MAY be withholding. If they wiggle about a lot when seated, stand on tiptoe then back on flat feet, walk about a lot when you'd expect them to sit down, look like they are straining when they are sitting - they could be trying to hold the poo in.
Don't rush the movicol. I just checked my Sophia Ferguson book. For a 4 year old she suggests starting on one movicol sachet per day and increase every other day (we did every third day as we know DS's reaction can be 'explosive'!), the maximum a day is 4 for a child of your DS's age. When you get to the dose that makes them poo a soft, normal poo, stay with that dose. You should start getting to the 5 poos a week fairly quickly - if not, raise the dose just a fraction. Then stay on that dose for three months. Every day. Remind them to go to the toilet (don't rely on them getting a signal - they don't always know what the signal is!) and give them a book or a game to keep them occupied. Within a week of DS doing a normal poo on two movicol, he was doing 5 a week - no soiling.
Reduce down by a sachet after three months BUT, if the 5 plus poos a week show any sign of stalling, straight back onto the original dose. it only takes a couple of days for constipation to set in and you'll be back to square one. Following month reduce again if everything has been OK. Again, if the reduction causes a backslide (no poos or less than 5 a week), go back to the last dose you were giving (so if you've dropped from 2 sachets to 1 successfully but the next drop brings things to a halt, go back to 1 sachet immediately) and don't be worried about raising again if that doesn't work. Stay on that for a month or so and try again.
It is a slow process. The thing that parents do wrong is assume everything is OK once they have a few weeks of 'proper' poos. Your DS's body, like my DS's one, needs to get out of habits it's been used to since potty training. It needs time to adjust. Think of the movicol as a teaching aid - it's teaching your child's bowel how it should operate.
Sorry for the novel. I'm just so amazed at how things changed once we realised what we were trying to achieve with the movicol. You can lose sight of the rule - 5 poos a week at least or raise the dose and don't lower for at least three months - when you're washing soiled clothes and worrying about school, events and your sanity!
Thank you so much for all the responses. Especially knockme. Your essay made things make much more sense about what we are aiming for with the movicol and how to use it. That has been my biggest issue. I feel like I have been left to find the correct dose myself without guidance on how to do that and you have just provided that so again, thank you.
I'm pretty sure he is not constipated any longer because his poos are soft but fully formed. The key now is to slowly lower the dose as you did cece but I can see that it is a slower process than I expected.
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