This is a 12 minute listen.

Resources signposted in this episode

A parents guide to disimpaction

How to prepare macrogol laxatives

Template letter for school about disimpaction

ERIC's guide to children's bowel problems

The Poo Nurses - video

Here is a transcript of Alina and Natalie's conversation.

So today we're going to be talking about the disimpaction process. If your child has been constipated, for more than a few days, your doctor or the nurse may recommend a disimpaction regime.

This means clearing out the bowel of all the old poo using laxative medication. So Natalie, can you explain a bit more about why families might need to do this disimpaction process.

Starting to take Macrogol laxatives

Sometimes it's advised by your doctor or your nurse just as you start taking a macrogol laxative, like Movicol or Cosmocol or Laxido. And sometimes you may have been on that medication for some time, before you realise that you may need to do a disimpaction.

You're aiming for one to three, really soft, easy to pass poos a day. And it's much easier to get that right when you're starting from a bowel that's completely empty.

The thing is, if you just start straight on a maintenance dose, what you might find is actually things get a bit worse. So you might end up with a lot of soiling. 

Why do you sometimes get soiling when you start taking a macrogol? 

Well, with a maintenance dose, you're just adding a small amount of water into the bowel just to keep things ticking over. If your bowel is already full of poo, what that little bit of water is going to do is it's going to make things soft, which could mean that you soil more. But it’s not a big enough a dose to completely empty the bowels.

So quite often we hear on the helpline that the medication appears to have made things a little bit worse. But actually what's happened is the medication has been prescribed without the best instructions on how to use it. 

Disimpacting clears a blocked bowel 

So it sounds like you've got the blockage there and you're trying to shift it but it's just not enough. You need to do this disimpaction first? 

Yes. So with disimpaction you're just increasing the amount of fluid into that bowel every day until you empty it, basically, right? You want to see that to get runnier and runnier and thinner and thinner until it becomes brown rusty water. That's when you know that the bowel is empty. 

What’s the next step after you have finished the disimpaction?

So you'll know when your child is completely cleared out. When that poo turns into brown rusty water - if we were going to get graphic we're talking thinner than custard thinner than gravy. For all intents and purposes, that poo is water. 

So if you imagine it was in a nappy, that last poo was in a nappy, the bulk of that poo would be completely absorbed into that nappy - obviously it's rusty coloured. And what would just be sat on that on that nappy would be some tiny brown bits, maybe some fibrous looking bits depending on what your child's been eating. That's when you know, that the bowel is completely empty.

Obviously, it's a bit harder to spot when that who's going into the toilet, but it is brown rusty water or tea without the milk. 

Right. So that's, that's really helpful. Thank you for giving us such a good illustration.

Reassuring parents and carers going through the disimpaction process with their child

So how can we reassure families that actually this is something that they can confidently do to help their child?

Yes, I mean, it is safe, and it is scary. You know, often parents are doing this at home without the support of a medical professional. So it can feel quite daunting. Especially with the amount of sachets you could end up having to give you know, depending on the age of your child, but it is safe.

You know that medication is literally going in through the mouth and out the other end so it there's no absorption into the body. It won't give you a lazy bowel or anything like that. 

Drink other fluids in addition to the macrogol mix 

What is really important is that you keep up other fluids so that that water that you're mixing up with each sachet, 63 mils of water that cannot be included in your child's daily fluid intake.

And so you need to keep up other fluids aside from the macrogol, water, and that's how you can help to keep your child safe and stop and reduce the chances of your child getting dehydrated.

Okay, so that's really important point for parents to know, isn't it, that you can't include the macrogol drinks in their usual water intake. 

How will a child feel going through a disimpaction? 

I mean, it all sounds a bit grim, necessary, but grim, I would say. What will the days be like? I'm guessing they probably shouldn't be going to school? How will the child feel do you think?

You don't really know what it's going to be like until you start because, the length of time it's going to take really depends on how much poo in their bowel to begin with. 

So there is the likelihood that it can be quite uncontrollable. So you want to be close to a toilet, if your child's toilet trained.  Or you want to be close to stash of, of nappies and wipes or even some barrier cream as well to make sure their bottom doesn't get too sore. 

Often when you're given the sort of larger doses of the medication, and things start to shift in the bowel, you can get a tummy ache, but it shouldn't be excruciating. You're talking about a bit of tummy ache, it can cause an unsettled feeling it can, it can bring out a lot of sort of trapped wind, so it can be uncomfortable. 

If your child's allowed anything like Calpol or paracetamol, it's absolutely fine for children to be given that alongside the macrogol. 

In terms of school, if your child's not in any particular pain or discomfort, it's absolutely fine to wait until the next school holiday to start your disimpaction. Lots of families do that. It's also quite a valid reason to not go to school as well. So if that soiling or constipation is really impacting on their daily school life, although none of us want our children to miss any more school, it is a valid reason to stay home.

Maybe school can provide them with some work so they don't fall behind. There's also a letter on the ERIC website that you can get signed by your GP to give to the school to let them know the reason why your child won't be there. 

How long will disimpaction take? 

You're not going to know until you start, but the length of time it takes to get to that brown rusty water, depends on just how backed up they were to begin with.

So the quicker it is, the less poo there was, but if it takes days and days, it's just even more reason why it really is important that the job gets done, because you want to get to that stage of empty, cleared out bowels. 

Chronic constipation is a medical condition 

Chronic constipation, after all is a medical condition. So school should really be understanding.

It’s a condition that requires medication and extra support. Disimpaction makes it a little bit easier to get that daily maintenance dose right and what it also does, is it starts your bowel on the road to recovery. 

Following any kind of bout of constipation your bowel needs time to recover. It needs to shrink back to recover to size and actually it can't start to do that until it is completely empty.

So following the disimpaction, that’s where you need to find that daily maintenance dose that helps your child completely empty their bowel one to three times in a day. 

So what you're saying is for some children, it is a really essential part of their process of recovering from chronic constipation, and getting to the point where they're going to be doing normal poos again. 

Yes – normal poos so that they start to recognise their poo signals again. A sign that the bowel is a little bit stretched is your child not recognising when they need to go. And that's telling us that bowel is a little bit stretched. And needs to be able to shrink back to recover so those poo signals return. 

Where can families go to get more help with disimpaction? 

Well, you've got the guide to disimpaction on the ERIC website, which is really useful. And that includes the instructions for mixing up the medication and the template letter that you can give to your school to let them know what you're planning on doing. 

There's also a brilliant video on there by the Poo Nurses, which would be really useful. You might want to ask your GP for a referral to your local bladder and bowel service or continence service if you haven't already had that referral.

And of course, you're always welcome to ring the ERIC helpline, and me or one of my colleagues will be happy to support you through disimpaction 

We also have ERIC’s HealthUnlocked community – an online community, where parents can go and get some peer to peer support. 

So being able to chat to another family that have been through this, while no two experiences are going to be exactly the same, it’s just that bit of added reassurance. Even if it's a case of just, “keep going with it”. If you're not quite a brown water yet, you will get there eventually.