Chronic Constipation in Toddler - Movicol not working

[cookiedoughyum]

DD1 (2.5) has been suffering with constipation for 2 or 3 months now. She has a very healthy diet, plenty of fruit, vege, fibre, fluids, not fussy at all. Nothing to do with potty training - we've not tried it yet. Went to the Doctors after 1 week, prescribed Movicol. So have now been on Movicol for over 2 months, firstly 1/2 sachet a day now 1 sachet. She soils approx. 10 nappies a day but only a 'proper' bowel movement once a week or so. I've tried all the usual diet things ('super foods' etc), more fluid, exercise etc.

BUT I am convinced it is not diet related. She has never had problems before until very recently, & the onset of constipation followed a few really explosive nappies filled with funny looking seeds etc & some blood. I am convinced that she has eaten something she shouldn't (from the garden or something) & it is now either physically blocking her bowel or has done some damage. But GP/health visitor insist on trialling different doses of Movicol & doing a diet diary etc. Has anyone ever managed to get a scan (if that's the right terminology) or anything to see if there is actually a physical blockage or damage to bowel? I know lots of people on here have dc's who've been on Movicol for much longer than us & are really struggling - but I just feel that we need to investigate the cause of the problem further; there must be a reason this suddenly happened. Can anyone suggest how best to pursue this i.e. without getting fobbed off! Or anyone been through similar. Thanks.

when my DD started movicol she gradually increased the dose to about 4 or 5 sachets a day over the first week or two. That really started the clear out but was on 2 per day then for a while. probably about a month. then down to 1 per day. after a couple of years she went down to half a sachet maintenance dose. she took it for 4 or 5 years.

I could have written your post a year ago! Docs won't send for more investigations as against nice guidelines even when I'm crying hysterically down phone at them. I think my DD got a bug and this affected her. Movicol was useless- 10mini poos a day then weekly big explosion. It was because she was on too much movicol- she needed max half a sachet, but really it didn't agree with her as a laxative, her stools were already soft so didn't need the softening aspect she needed the urge and push to decrease transit time. We got referred to continence clinic that really helped. She got prescribed Senna and we also experimented with super strength probiotics (optibac sachets), she is now on 5ml senna and a probiotic sachet every morning and she still soils a couple of times a week but mostly her gut is in balance and her poos transformed (she is 3.5 and this has been going on since she was 10months- it's a very long slog!). The docs won't reccomend probiotics but I genuinely believed they helped transform her gut, we ran out of probiotics recently and her poos went awry, and if we miss the senna she also soils more so for now that is the regime we stick too. Good luck with it. (If she is ready for potty time- sitting her on the potty 20mins or so after every meal for at least 10mins can help catch poo as that is most regular time to go, the idea is to encourage a regular bowel habit. My dd usually sits on after breakfast and after tea for 30mins (we have TV or iPad) and we usually catch her big poo that evening.

I have a poo diary I can send you if it would help, keeping records of the poo was a pain but really helped us see progress, even soiling just 5 times a day felt like a massive achievement! Good luck!

Crikey... I know we havent had a problem for long in the scheme of things! But as you will know it makes each day miserable with constant soiling. I'm really concerned about long term use of meds without knowing the cause of the problem.

The soiling is probably overflow - she needs more Movicol. Get the impaction/blockage cleared then you can monitor bowel movements and consistency.

Here's some good info from ERIC if you haven't seen it already

DS used to be xrayed pretty often in A and E but that was when he hadn't been for 10 days + and was under a year, but an x ray should show of there is a blockage or not

To be honest though it doesn't sound like there is, more than the bowels and the muscle movements aren't co-ordinating properly. If the bowel is blocked then they would be able to tell by listening - whenever DS went quiet was the time we were referred to hospital.

Does she get the urge to push when she goes? Is she in pain/distressed at all?

oh I feel your pain,my ds had an xray but I was fobbed of for months and took him privately in the end.
Your right in that if she is compacted she needs to have it cleared first and then a movical type plan to get her going regularly.My D's was glycerin and senacot-under the peads .
Constipation can be diet or lack of fluids but it can also be for no reason at all,the peads in hospital told me this.
I would go back and insist something else is done,there are other options such as enema etc but they need to be done under your drs instruction.
I found my own gp did not take it seriously at all,but leaving long term only stops the child from wanting to go and then they think it hurts and it becomes a cycce.

I doubt any GP is going to refer further until the Movicol is being given at an appropriate dose. 1 sachet a day is insufficient and it's usual to start at 2 sachets daily, then work up to 8 sachets daily to achieve disimpaction, then reduce again to a maintenance dose.

Certainly the OP should see her GP again for further clarification, but I can't imagine they will do much until the child has achieved disimpaction through a proper dosing schedule.

Thanks for all replies. I think part of my worry is that the soiling is caused by too much movicol rather than too little...it's making her feel that she needs to poo when she doesn't?? She's in so much pain it's almost like she's pushing something that's not there, like ladycurd said. But GP says soiling is just overflow. Thats why i'm reluctant to increase movicol without actually seeing what the problem is iyswim.

I would seriously up if it if it's what the GP recs, it could be there's an impaction that needs cleared. It could also be that she has a small tear, that can make things tighter as it heals and thus make you feel like theres a lot there when there's not - I know sometimes I struggle to pass anything as I've a tear.

It's when there's nothing coming out at all you really need to worry.

Try upping the Movicol for a few days and seeing what happens, if there's a blockage it should clear it but then you need to step it down, I think they recommend staying on Movicol for as long as the constipation lasted

She's on a tiny amount of Movicol, and if she's impacted she will have overflow. Have a look at my link further up, it explains how soiling is a classic sign of overflow and why. The pushing with nothing there can be an indicator that she has a significant impaction which will be in the bowel and not the rectum.

I understand your fears but I think you need to be a lot more proactive and get her cleared out, then if the constipation persists you can get the gp to investigate further regarding causes.

Ok, thank you. I will have a good look at that link, thanks.

Look up the Bristol stool chart an record the softness of the poos in a poo diary, it's helpful to have that info to show docs. If they tend to be tiny type 5 then it maybe dose movicol isn't right. A doctor will reasonably easily be able to tell if there is an impaction just by feeling her tummy. With the ten soiling a day my dd had I was often convinced was impaction but it wasn't it was just a whole sachet of movicol was just far too much for her tiny body and making her stools too soft so she had frequent passing of them without working the muscles properly. It's often that the bowel muscle tone needs sorting back out and I'm still not sure my dd can "push out a poo" but she at least now does single solid poos every day or so with occasional soiling instead of constant.

I have same worries about laxative use but once you have right laxative and right dose you can get her bowel muscle tone and regularity right and eventually she won't need them any more but going without them at this stage could do more harm than good.

You may find you will need to start potty training which is so much harder with a bowel issue so she feels the sensation (we started feb half term when she was 3 and it took about 3months to get to where we are now which is 1-2 soilings a week but had we stuck with nappies I think she'd be longer at it. Before that we also did regular potty time (after every meal) but kept her in pull ups. We did try pants with panty liners for a little while to catch the soiling but she kept taking them out and sticking them places!

We also read her loads of potty training books about poo! I literally have every poo book there is! We liked poo goes to pooland and Lulu's loo. When she did soil we had to also not give any real attention (positive or negative) as there was a behavioural element with my dd and adjusted our language to focus on "dry and clean" rather than wet and dirty.

It really is an awful slog and you have my sympathy, we still aren't out of it now but at least it's hundred times better than before! Best of luck. Push for a referral to children's continence service as they were excellent and gp's and health visitors were bit useless.

If Movicol isn't working then you need to increase the dose. Trust me, I'm a Movicol expert of over three years

It does very much sound like you're experiencing overflow at the moment. One sachet is a tiny dose and that can't possibly be too much for a 2.5 year old. My DD was on three sachets a day at that age, and still is at 3.10.

You're aiming for a decent sized bowel movement every day. Mushy pea consistency. It really is a case of trial and error to discover the right maintenance dose for your child. Don't be afraid to tweak it or give "too much". The worst that can happen is she'll have a good clear out, and it sounds like she needs it.

I had this with dd for about a year before a locum gp referred us to the bowel clinic. I had kept cutting the movicol back as I was sure it was making her soil.Turns out she wss impacted so the soiling was basically overflow. I will be eternally grateful to that locum as another year on and dd starts school in August and we've finally cracked it. At one point she was on 10 sachets a day until she was completely cleared out then gradually reduced back down to 2 sachets for about a month. Now she's on 1 sachet a day and is aware when she needs to go and is passingwell. We've to gradually wean her off movicol but I think she'll be on it at least another year. She's 4.8 now and has had problems since 2.3.

I would go back to your doctor and ask for a referral or better support. We spent so long messing about with 1 sachet as per gp instructions. Dd was in pain daily and it could have been sorted so much quicker with the right support

I'd ask for a gastro referral too. DD sees a consultant twice a year, and he told me that GPs can be very ill-informed when it comes to medications like Movicol and getting the dosage right. Some even think that prolonged use can make the bowel "lazy" and so are very conservative with their advice - which is kind of proven by all these children being prescribed one sachet a day, which is useless.

That's a very very low dose of movicol. Really sounds like overflow diarrhoea (as well as you can tell over the internet), because softer poo from higher up is squeezing past hard painful rocks of poo that aren't moving. May need a disimpaction regime (increasing the does steadily until you hit about 8 sachets/day, and aim to have several days of copious quantities of gravy-like poo), and then on the lowish (1 - 4 sachets/day) dose to keep the poo pain free and scrambled egg consistency whilst they recover...but not something you can do off your own bat.

Agree with the person about the doctor needing to feel the tummy - low down on the kid's left - to see if impacted, but sounds very likely. Very rarely xray them nowadays, as it hardly ever adds to what you can find from a decent history and examination, and the national guidance is therefore that you shouldn't irradiate them.

The Eric website is really worth a look - they've got some good stuff on there.

Prepare for the possibility of a long slog OP.

From the information you've given it does sound most likely that your DD is impacted. Lots of good advice on this thread already about that. I agree you should try an impaction regime sooner rather than later. It's a messy job and your aiming for poo that is basically brown water to make sure everything has been emptied out.

I'd also suggest you get a hold of a book by Dr Anthony Cohn about constipation and withholding it's a really good source of information and was invaluable to us.

Yeah, it is asking slog. My DD is four in Sept and has been on Movicol since she was 7 months old. And there's no sign of her being able to reduce her dose, let alone come off it.

But as I keep telling myself, I'm happy for her to stay on meds as long as they make her bowels work. Nothing is worse than the misery and pain of chronic constipation. I am worried about her starting school in a year and how she'll manage, but that's a long way off.

*a long slog.

DYAC

Also for perspective ds at 7 months old was on up to 8 sachets movicol, sodium picosulphate, glycerin suppositories and still needed enemas to make him poo. And was breastfed and only eating fruit. So o e sachet for your DD is woefully inadequate if she is impacted.

Dd2 had impaction.

You need to clear the blockage first. She's younger than dd2 (she was 4yo) but dd2 had a weekend where it went:
Day 1: 8 sachets
Day 2: 10 sachets
Day 3+: 12 sachets until it was clear. They said literally pouring out like water.
Then she was on 2 a day for about the next 2 years and then a slow withdrawal (down to 2 one day 1 the next first) over about 2-3 years.

She's now been off them about 2 years and has very rarely any issue, but if she feels she might be getting a bit stuck up she tells me and we deal with it quickly.

Just wanted to come back with a positive update. I read the NICE guidelines & had a goid look at the ERIC website- big thanks for the link sidge & thanks all for your input. Realky peeed off that we were prescribed sych a low dose- feel that we have wasted 2 months! I should have done my own research (and posted on mn!) sooner! Have been in touch with our GP & HV & we have now stepped up the dose as per the disimpaction regime- i can see now that it definitely was overflow soiling. We are only on day 3 but already I can see a huge difference - have gone from soiling of type 6ish on the scale 8+ times a day to something much bigger & more substantial. I know that it is a long slog though like you've all said so we'll see what day 4 brings tomorrow! Also thanks to the poster who suggested potty training may help rather than hinder because i think it is helping having her sit on the potty after big meals so that she has time to try to poo/focus on it IYSWIM. Not expecting that to solve things alone but I think it's another step in the right direction. Thanks all - & sorry to hear that so many of you have struggled with this/are still going through it.

Glad you're seeing results. Good luck!

Great news

Hope it's still going well. Hang in there. It will get better.