Toddler constipation/enema help

[indeepsht]

My dc has always been a bit difficult with BM since potty training, could go 3-4 days without one. Lately it’s been getting worse had lactulose from GP but ended up she went 10 days without BM and couldn’t pass urine.

Ended up being sent to hospital and she had an enema, immediately passed urine too. There was a fair amount of BM that passed. Doctor in hospital prescribed movicol and says she needs to have a BM every day ideally.

We are already on day 4 without BM since enema, despite the movicol.

Seems fine in herself but this morning refused to wee, and had a bit of a tantrum (her mood seems to get progressively worse the more constipated she gets).

What do I do? The GP can’t do much more? Do I need to take her back to hospital or give the movicol more time?

It sounds as if she is witholding. She probably needs a long term movicol programme, usually called a disempaction regimen.
If your gp doesn't know how to manage this your first port of call should be to the ERIC helpline.
You can also ask your gp to refer you to a specialist service like a continence nursing team.
Google The Poo Nurses and watch the video right to the end.
Treating this takes at least twice as long as the problem has existed.
It requires committment from the whole family.

Forgot to add Movicol Mummies on FB.

Have you spoken to your Health Visitor? Is there a Continence Service in your area?
It can take a while to get the Movicol dose right. Does she have a restricted diet?

A warm bath can help, one of the padded toilet training seats with knees up and blowing bubbles!
( helps with relaxation)
You’ll find tips on the ERIC website.
Hope you find some solutions I know how awful it can be.

How much Movicol is she having. She's obviously impacted so you need HUGE doses... usually 8 sachets a day if I remember rightly (DS2 had the same issues)
And LOTS of fluid. It takes a few days to really work but by day 4 something should be happening. Movicol by itself might not be enough...Id phone GP and ask to prescribe a stimulant to go with it.. senna or even picolax.
And yes ERIC. It's a problem that needs long term help (but it does usually resolve eventually!)

straight back to GP I think.

The GP can do more eg prescribe a massive dose of movicol to help. It's really stressful I know and she must be so uncomfortable but please don't think you are on your own.

But if you have been given a phone number from the hospital to call back on if needed (paeds?) then do that. But if not, GP emergency appt rather than A&E.

Thank you all. I feel like a terrible mum to let it get to this point. She definitely withholds and goes to a lot of effort to do so, many interesting poses and faces coming out!

Shes on 4 sachets a day but said can go up to 8? So I don’t know if to take her back at this point of keep increasing it up… surely she has to pass something at some point?!

She had a little dribble yesterday, tiny amount of dark brown sludge. I thought it might be working but nothing.

I think she’s started withholding wee as well as she just doesn’t want to sit on the toilet at all, as it’s harder to hold her BM in.

I will look at ERIC and the poo nurses, thank you.

They only gave us a 24hr return, so I’d have to go back through a & e again. The GP sent us last time.

We went through withholding when mine was 2. They get constipated, it hurts, so they develop a fear and withhold, which obviously exacerbates the problem. It was hugely stressful and I am so sorry you are going through this. We needed a long-term program of high doses of lactulose to soften plus stimulants to force her to go (I baked up prunes and black beans into little brownie things which did the trick), and I think it took a few months to really crack it. 8 years later, she is still a bit slow in that department and I try to make sure she has lots of chia seeds, flax seeds, raw carrots etc in her diet, but otherwise it is a thankfully distant memory. Best of luck

Coming back to this I think not being able to wee is a medical emergency and worthy of A&E, so keep a close eye on that. But some toddlers can hold their bladder for England. I know this doesn't sound helpful but you can see her, your instinct is the best judge. If you think she needs A&E then that is good enough. Going in blind I would say if you are cleared for 8 doses a day and she is ok in herself you can increase above 4 for a day or two without needing to talk to anyone BUT if you are uncomfortable with this then by all means check in with the Dr.

Impaction clearing doses are vast and movicol is completely inert, as you have probably had explained to you, but yes I get it looks scary with so much going in and nothing coming out. Getting a bulk of liquid in is really important too but I imagine this is super tricky with a 2 year old with tummy ache. We used to buy baby pear juice or cloudy apple juice and water it down.

I’m not sure about the advice here to give multiple sachets of Movical and treat it as an intensive problem. The poor toddler is feeling the pressure and that is having the opposite affect! Get an over the counter bottle of Lactulose from the chemist and let things happen. Food wise kiwi, apple etc. no white bread.

Not being able to wee is caused by the impacted stool obstructing the urethra. It is an indication of serious impaction.
It is not adviseable to give high, raw roughage when chronic impaction has distended the bowel and rectum. You just end up with a large, solid blockage.
OP you need a supervised disempaction regimen.
Safe fibre is things like stewed fruit, cooked vegetables and pulses. Lots of fluid. It takes a long time to retrain the bowel and restore normal function. Usually, as pp said, movicol and a stimulant. Some gps know how to manage this, others don't.

So my daughter had lactulose originally but wasn’t helping, still withholding for long periods. What’s the difference between that and the movicol?

Would the enema in the hospital not cleared her out or could she still be impacted?

Lactulose is helpful once the impaction is clear and the bowel is retrained.
Have you spoken to the ERIC help line?

She will keep getting impacted until the bowel is completely retrained and the distension improves. The enema has dealt with the immediate problem in the rectum only. It takes a long time to deal with the whole problem. Witholding is a physical, psychological and whole family problem.

To update, she has passed a pencil thin, squiggly type stool. Seemed to hold together so wasn’t too liquid but very thin!

Do I take this as a good sign the movicol is starting to do its work?

I haven’t phoned Eric today but had a quick look at their website and very useful, I will be phoning them. Completely understand this won’t be a quick fix.

Join movicol mummies on Facebook and you’ll get some sound advice. We are 8 years into this journey. She needs more movicol in the immediate future. There are other options going forward.

The poo nurses video includes a Bristol stool chart that is very helpful. It is worth printing a copy to keep for reference.

Dark brown sludge is the liquid poo leaking past the blockage higher up in the bowel. That suggests that the impaction is still there. Do speak to ERIC tomorrow and get clear advice.

Lactulose is fairly useless. I remember before movicol was invented, we had toddlers on 30ml 3 times a day (way bigger doses than people prescribe today) and they didn’t poo. Absolutely agree that you need a full disimpaction regime. You’re aiming to reach the point of 3 days of shedloads of loose watery poo before reducing, and then on the level of sachets that gives soft squidgy daily poo for at least weeks, often months.

Have you dealt with impaction and had it resolve following your advice?

Lactulose is generally less effective than movicol or osmolax. You don't want a high fibre diet until you are sure the impaction has passed.

It is an intensive problem and can get worse if it is not effectively treated. Things are very unlikely to happen. I don't understand what you think the 'pressure' is doing? The child is in pain and withholding and that's not going to resolve without intensive support.

I am definitely not putting pressure on her. I’m not even mentioning the P word. I waited 10 days for things to happen “naturally” with the lactulose and trying dietary things/more fluids etc.
She has had an issue with going since potty training but it is getting worse and the periods between BM are getting longer.

She was also so blocked up that she wasn’t able to pass urine. I doubt the hospital would have given her an enema which was a thoroughly unpleasant experience for all, if it wasn’t necessary.

Echo what others have said. You need a long term movicol program. Treating it will take a long time but it will get better. Needs commitment from everyone in the family.

look on ERIC website. Go back yo GP ask for referral to specialist.

it’s horrible.

I have been through this exact problem with my child and it started at the same age. Movicol was not the solution for us, after multiple GP visits we were referred to a consultant who prescribed sodium picosulfate (dulcolax). As far as I understand movicol draws water in to the stool but the sodium picosulfate is a stimulant to move the poo along so it becomes difficult to withhold. The GP was not able to prescribe this medication but a consultant can. We are now 2 years into this problem and whilst not perfect it is MUCH better than it was!