Constipation: Bowel Cleanout for Impactions

What is an impaction?

Your child is blocked up (impacted). That means he has so much stool inside that he can’t push it out without help. The retained stool is too wide and hard to pass on its own. This can happen in children who have had constipation for a long time.

Your child’s healthcare provider can diagnose an impaction by finding a large lump in the lower abdomen, a full pelvic cavity on rectal exam or a positive abdominal X-ray.

Children who are blocked up cannot control their bowel movements. Because of the large amount of stool inside and the pressure on the anal sphincter, they usually leak small pieces or smears of stool many times per day. Your child may also have stomach aches from being blocked up.

How do I give a bowel cleanout?

There are different ways to relieve an impaction. Some healthcare providers just use high dosage stool softeners by mouth (called an oral cleanout). Some healthcare providers just use enemas (called a rectal cleanout). The following cleanout uses a combination of these 2 approaches.

Stool Softener

First, soften up the stool for 3 or more days with high dosage polyethylene glycol (MiraLAX). Mix the polyethylene glycol powder the following way: 1 cap in 8 oz (240 mL) of clear liquid. The liquid can be any fluid your child likes. (such as juice, water, Gatorade or even soda). You can keep the premixed solution in the refrigerator for up to 1 week.

• Ask your child’s healthcare provider what your child’s dose should be, and how many times per day you should give it.
• Continue high dose MiraLAX for 3 or more days, as directed by your child’s healthcare provider.
• Caution: Keep your child home and near a toilet. Your child will have diarrhea and could have a massive blowout. If your child is not toilet trained, be sure to keep him in a pull-up at all times.
• Diet: no restrictions on regular diet. This is different than a bowel prep for endoscopy.
• Fluids: encourage lots of extra fluids because high dose MiraLAX will make your child dry.

Enemas

Second, after the stool is soft, give an enema to help the stool break loose and come out. Usually you will give the enema at the end of the second day on MiraLAX.

Use the enema solution recommended by your healthcare provider and follow the instructions carefully. Saline (phosphate) enemas can cause complications if too much is given. The dosage of enemas must be accurate, based on your child’s weight.

Enemas are given once daily. Ask your healthcare provider how many days you should give your child an enema.

Caution: Enemas are generally not used under 2 years of age. Don't give any child more than 4.5 ounces of the enema.

Dosage (based on your child's weight): 
  20 pounds   1 ounce 
  40 pounds   2 ounces 
  60 pounds   3 ounces 
  80 pounds   4 ounces 
  90+ pounds  4.5 ounces 

Suppositories: For some children, a glycerin suppository can be used instead of an enema to release the soft stools.

How do I give an enema?

1. Have your child drink 1 or 2 glasses of water before the enema. Sometimes enemas can cause dehydration.
2. Have your child lie on his stomach with his knees pulled up and under him.
3. Enemas come in a disposable squeeze bag with a soft-tipped nozzle. Lubricate the enema nozzle and gently put it 1 1/2 inches to 2 inches into the rectum.
4. Gradually squeeze the contents of the container into the rectum.
5. When the bag is empty, remove the tube.
6. Your child should wait to sit on the toilet until he feels a strong need to have a bowel movement (usually 2 to 10 minutes). Encourage your child to hold back the enema for 5 minutes.
7. For children who are not toilet trained, try to give the enema in the bathroom. Also try to put the child on the toilet after a few minutes. But if he resists, just put him in a diaper or pull-up. The main goal is to get your child to release lots of stool.

How do I keep my child from getting blocked up again?

After your child is unblocked, always start maintenance medicines. For new onset constipation, medicines may only be needed for a few weeks. For chronic constipation, they will be needed for 3 months or longer. It will take at least 3 months for your child’s rectum to work normally. The muscles of the bowel have been stretched and no longer know how to squeeze out the stool. They will return to normal strength only by helping the rectum empty every day. The goal is to give enough medicine so your child passes 1 or 2 large, soft stools each day, without any stool leakage or pain.

When should I call my child's healthcare provider?

• Cleanout causes vomiting or bad abdominal cramps.
• Cleanout doesn’t work.