A parent’s guide to disimpaction

If your child has been constipated for more than a few days your doctor or nurse may say that they need to follow a disimpaction regime.

This means giving laxatives in sufficiently large quantities to ‘clear out’ all the accumulated poo.

It is important to follow their advice; if you give a standard dose of laxative it is likely to soften the poo but not stimulate the bowel to empty fully. This means that symptoms such as soiling may get worse rather than better!

NICE GuidelinesConstipation in Children and Young People (CG99) recommend disimpacting with paediatric macrogol sachets as follows:

Age Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Child under 1½-1½-1½-1½-1½-1½-1½-1
Child 1-5 years2446688
Child 5-12 years46810121212

Children over 12 years should be treated with the adult preparation – the macrogol is exactly the same but there is twice as much in the sachet:

Age Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Child over 124688888

The macrogol sachets might be called Movicol, CosmoCol or Laxido. Ensure macrogols are prepared correctly – see advice sheet How to use macrogol laxatives. You don’t have to give all the sachets at once – you can spread them out across the day. Some people mix the whole day’s sachets in advance and keep the macrogol water in a jug in the fridge, adding a bit to every drink and every suitable food. Just make sure it is all drunk within 12 hours.

The dose needs to be increased as above until all the backlog of poo is cleared. Although the dosing regime is written out over 7 days, that does NOT mean that disimpaction will only take one week. It will take as long as it takes to clear all the accumulated poo – and that depends how much there is, which depends on how long your child has been constipated! Listen to our helpline podcast Episode 6 - Disimpaction explained by a Paediatric Specialist Continence Nurse to hear what to do when it continues for a long time.

The only way to be sure disimpaction is achieved is to continue until your child is passing watery poo - i.e. brown water with bits in. You may feel worried about giving such large doses, but as long as you follow the regime you will not hurt your child. Macrogol laxatives are not absorbed into the bloodstream but simply ‘bind with’ the water and deliver it to the large bowel, where it will soften and lubricate the poo and stimulate a bowel action.

NICE Guidelines recommend adding a stimulant if disimpaction is not achieved after two weeks on macrogols; some doctors prefer to add the stimulant earlier. Stimulant laxatives increase the muscular squeezing of the bowel, speeding up evacuation. Because of the way they work, stimulant laxatives can cause abdominal cramps. The medicine prescribed might be called Senna, or Sodium Picosulphate, or Bisacodyl – or there are others. Your doctor or nurse will tell you how much to use.

What to expect:

Whatever laxative(s) is/are used, it is important to prepare yourself and your child.

  1. Lots of poo! The purpose of disimpaction is to clear out the backlog of poo; the child may poo a large quantity all at once, or several small poos. Because the dose is small to start with, it might take a few days to get going. If your child is still wearing nappies buy LOTS of nappies and wipes. If they use the toilet, warn other members of the family that the bathroom is going to be busy and stock up on toilet paper and moist toilet tissue.
  2. Soft/loose stools. You might see some lumps of poo, but don’t be surprised if it is all soft/loose – as macrogols deliver water to the large bowel any hard lumps will be broken down.
  3. More soiling. If your child is experiencing soiling (leaking poo into their pants) explain that this may well get worse to start with as first of all the poo will be softened, then evacuated.
  4. Possibly some abdominal discomfort. If your child has a tummy full of poo, then whatever laxative is used they should expect some discomfort as the poo starts to move along the bowel. Plenty of reassurance will help, and maybe a dose of paracetamol.
  5. Difficulty getting your child to drink all the macrogol. Some children do struggle, so before you start on the big doses do some experiments with your child to work out their preferred flavourings – and check the tips on How to Use Macrogol Laxatives. Make drinking it more fun with a new cup and/or a straw. Plan some rewards before you start!

What about school/nursery?

Because of all the pooing and the possible discomfort, your child won’t really be able to go to nursery or school during disimpaction. It may be that you can wait for the next school holiday. If not, you may like to ask your doctor or nurse for a letter to explain your child’s absence.

What to do once watery poo has been achieved

When your child’s poo has the appearance of brown bitty water on at least two occasions, the disimpaction regime can be stopped. If you are not sure if the poo is watery enough just keep going until you’re certain – you could try putting toilet paper down the toilet before they poo, so you can catch it and see it better. Another day of big doses won’t hurt your child at all. Stopping too soon means you might have to start all over again…

Laxative treatment does need to continue to prevent recurrence of constipation, and to allow the stretched bowel to regain its tone. Your child should therefore be given a maintenance dose of their laxative. NICE recommends macrogol laxatives:

Age Maintenance dose
Child aged less than a year½-1 sachet/day
Child aged 1-5 years1-4 sachets/day
Child aged 5-12 years2-4 sachets/day
Child aged over 12 years1-2 adult sachets/day OR 2-4 paediatric sachets/day

To work out the right dose for your child, look at how much it took to achieve disimpaction. If they needed the maximum disimpaction dose, then start with the maximum maintenance dose.

If they achieved brown bitty water when they were halfway along the disimpaction schedule, then choose a dose halfway along the maintenance schedule.

It will take a few days for the poo consistency to settle down – the bowel will have been very ‘busy’ during disimpaction. So stick to the same dose for the first week. After that, look at the poo your child is passing. They need to pass at least one soft poo every day – so adjust the laxative dose to achieve this.

Your doctor or nurse may choose a different laxative – follow their advice regarding dosage.

Whichever laxative is chosen, the dose should be adjusted to ensure your child poos at least one soft poo every day. You will therefore need to monitor their poos and increase/decrease laxative doses accordingly. It will help to keep a Poo Diary, especially if your child is looked after by a number of different people.

Please note: Your child may need to stay on laxatives for many months or even years. Long term use of laxatives will not hurt your child. Poorly treated constipation will.

You will know if they need less laxatives – just check their poo and decrease the dose if it is too soft/sloppy. If one sachet a day is too much, don’t reduce to alternate days – give them half a sachet a day. Encourage a daily bowel habit with daily laxatives.

If your child is toilet trained you will need to encourage them to follow a regular toileting programme – follow the guidance in Advice for Children with Constipation. They may not reliably know when they need a poo for months, as the stretched bowel does not send reliable warnings, so plan regular toilet visits.

They may not poo every time; you may need to introduce a reward system to motivate them to persevere. A Toileting Reward Chart may help. Soiling may persist for a while – don’t worry, if you keep up the good work with laxatives and toileting your child will get there in the end!

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