Yes, Enemas are Safe for Children — And They Work Better Than Miralax

By Steve Hodges, M.D.

If there’s one word parents don’t want to hear, it’s “enema.”

When I explain to families that enemas are the express route to resolving enuresis (bedwetting or daytime wetting), encopresis (poop accidents) and chronic urinary tract infections — and are far more effective than oral laxatives and dietary changes — I get three responses:

1.) But aren’t enemas dangerous for children?

2.) But can’t we try Miralax first?

3.) But my kid will never allow enemas!

Here are the short answers:

1.) No, enemas are not dangerous! There is no evidence suggesting that enemas are unsafe for healthy children and lots of evidence demonstrating enema safety.

2.) Sure, you can try Miralax first, but it won’t work as well and may not work at all.

3.) To the surprise of their parents, most children with enuresis and/or encopresis get on board with enemas pretty quickly. They are more embarrassed by accidents than they may reveal and will generally do what it takes. Before long, enemas become routine for kids.

Parents are particularly dismayed when I explain that the most effective regimen — the Modified O'Regan Protocol (M.O.P.) — involves daily enemas.

But you know which of my patients get better fastest? Those who follow this regimen.

Do you know which of my patients end up the happiest, freed the embarrassment, discomfort, and stress of having accidents? Those who follow this regimen.

M.O.P. is the regimen pioneered by Sean O’Regan, M.D., the pediatric kidney specialist whose published studies changed the course of my medical practice.

READ: Children with Encopresis and Enuresis Deserve the Best Treatment, But Most Aren't Getting It

Back in the 1980s, while I was watching “Back to the Future” with my 8th-grade buddies, Dr. O’Regan was making a breakthrough contribution to the scientific literature. He first tested this regimen on his 5-year-old son, who was wetting the bed multiple times a night. The child’s rectum was so stretched out from a chronic pile-up of stool that the boy could not even detect the presence of a tangerine-sized air balloon in his bottom. (Want to find out for sure how stretched-out your child’s colon is? That’s the test to request. It’s called anorectal manometry.)

After one week of nightly enemas, the boy’s wetting diminished. After three months on the step-down regimen, the boy had stopped wetting the bed completely and Dr. O’Regan had stopped getting grief from his wife. Dr. O’Regan then tried the regimen with his own patients and had so much success he conducted formal studies.

In one investigation, Dr. O’Regan tracked 47 girls with recurrent UTIs and severe constipation and toileting problems. By the end of the regimen, 44 of the girls stopped having UTIs. Among the 21 patients with encopresis (poop accidents), 20 stopped having accidents. Of the 32 patients with enuresis (pee accidents), 22 stopped wetting.

Building on Dr. O'Regan's studies, colleagues and I at Wake Forest University conducted our own research on children with daytime accidents, comparing his regimen with the standard Miralax therapy so many doctors recommend. Our study, published in Global Pediatric Health, found that after three months, 85% of children with enuresis stopped wetting, compared to 30% who used Miralax and other traditional therapies. As I explain in the M.O.P. Anthology, I have "modified" Dr. O'Regan's protocol — hence the name "Modified" O'Regan Protocol — in multiple ways. (The Anthology discusses the five different variations of M.O.P.)

Pediatricians and pediatric urologists and GI docs tend to push back hard against enemas, claiming they are "traumatic" or "too aggressive" or that they cause "dependence." These are false assumptions, as I explain in great detail here and in the Anthology.

Just this week a patient’s mom reported to me that three different pediatricians told her “no way” when she asked about giving enemas to her son. The boy is 13 years old and has wet the bed his entire life. (These are the same doctors who told her that her son would “outgrow” the bedwetting. Um, when?)

READ: Don’t Assume Your Child Will Outgrow Bedwetting

The most common safety concern is that enemas will cause an electrolyte imbalance.

First off, this issue applies only to phosphate enemas (such as the Fleet enemas sold as "laxative saline enemas"). So, if you have the slightest concern, simply use another type of enema, such as liquid glycerin or docusate sodium, both discussed in the Anthology.

As for electrolytes, they are chemicals in the blood that regulate our nerve and muscle function, hydration level, and blood pressure. One of these electrolytes is phosphate, an ingredient used in many overthe- counter enemas. Certainly, an electrolyte imbalance would be a big deal, potentially causing serious damage to the kidneys and heart. But the human body does an excellent job of controlling our electrolyte levels. A child with normal kidney function will simply pee out the extra phosphate. I have never had a patient develop an electrolyte imbalance from enemas. Among healthy children who receive one enema per day, electrolyte imbalance is practically unheard of. A review of 39 studies conducted over 50 years found a total of only 15 cases of electrolyte imbalance in children ages 3 through 18. Over 50 years. The vast majority of these cases involved children who had a chronic disease or were given more than one phosphate enema in a day.

Another concern about enemas is that they cause dependence or "lazy bowel." But that's untrue. In a constipated child, the bowel is already not working normally. Once the rectum regains the sensation and tone needed to empty fully, the child will no longer need enemas.

In the early stages of treatment, many kids don't poop on their own, other than after the enema. But this is NOT a sign of dependence on enemas. It is a sign the child’s rectum hasn’t fully recovered. Dependence is something different. A patient with type 1 diabetes, for example, will always be dependent on insulin to live. A child on M.O.p. will not always rely on enemas or suppositories to poop, though it may take many months to wean off them. In the meantime,

if enemas are what it takes for your child to fully evacuate every day, what’s wrong with that? Certainly, pooping with the help of an enema is a lot healthier than not pooping.

Why Miralax Often Fails

One reason Dr. O’Regan’s original protocol involved enemas instead of Miralax is simple: Miralax didn’t exist back then. It was not approved by the FDA until 1999. But even when it did become an option, Dr. O’Regan continued to recommend enemas because they work better.

The fact is, “new” does not always mean “improved.” Remember the New Coke debacle? OK, terrible analogy. For the record, I am not in favor of soda of any kind. But you get the idea.

Sure, it’s much easier to hand a child a glass of water mixed with a powder than it is to insert a tube up his bottom. No argument there!

But Miralax often does not fully clean out the child’s rectum. The new, soft poop just washes past the hardened crusty stuff, so nothing is accomplished. So, the rectum may never shrink back to normal size and stop bothering the bladder nerves or regain the tone and sensation necessary to fully evacuate.

READ: Getting Your Constipated Child Off the Miralax Merry-Go-Round

Don't Assume Enemas Are "Traumatic" for Children

Dr. O’Regan’s son would read Winnie the Pooh while waiting for the enemas to work. Most parents I work with assume their child will absolutely refuse enemas. But often they are, pardon the pun, pulling this assumption out of their own bottoms!

In my experience, when you explain to a child, even to a teenager, that this regimen is the ticket to dryness, they are plenty willing to give it a try. It’s typically when parents convey squeamishness or fear that kids pick up on it and become reluctant themselves.

As for the concerns about enemas being "traumatic," doctors who issue this warning to parents seem to have no actual experience with enemas and are likely just guessing.

One mom in our private Facebook support group posted: “When my child told the doctor she liked enemas because she felt better, her statement was immediately dismissed with ‘No, you don’t. No one likes them.’” Yet another mom wrote: “When I told our doctor we were getting good

results with enemas, she told us to ‘stop that right away.’ The most upsetting thing was her language around the ‘trauma,’ which has not been our experience at all. Enemas are just part of our evening routine, like brushing teeth.”

Countless parents have reported that enemas are a lot less traumatic than the alternatives. “It is way more traumatic to poop in the middle of class and stink up a room full of kids who don’t yet have a verbal filter,” another mom posted. “A quick, painless enema is much easier. My daughter asks for enemas and has increased confidence five-fold because she’s not smelly. She used to be unsure and would ask me in a whisper if she smelled OK. It broke my heart. Now THAT was traumatic, especially when you’re in middle school.”

Certainly, many parents and children are apprehensive, if not downright afraid, when they start doing enemas. Mostly they fear enemas will hurt, and sometimes they do hurt. This is usually because the child isn’t relaxed or lying in the right position or because there’s not enough lubrication on the tip.

Our Enema Rescue Guide, included in the M.O.P. Anthology, offers 12 practical strategies to help children (and parents!) overcome their apprehension. The strategies were suggested by parents who have used them successfully.

Two of our children’s books — Bedwetting and Accidents Aren’t Your Fault and Emma and the E Club — are valuable for starting the enema discussion with children. Kids who read these books are comforted in knowing that plenty of other kids get enemas and that they don’t hurt.

Dr. O’Regan recalled that prior to the regimen, his son was “a cranky kid.” But when he got cleaned out and stopped having bellyaches and wetting the bed, he became noticeably more cheerful. Says Dr. O’Regan: “Years later, he told me, ‘Dad, I thought bellyaches were normal.’”

Parents are often surprised when their children not only tolerate enemas but actually ask for them each night because they feel so much better.

Dr. O’Regan noted that he and his colleagues devoted an immense amount of time to their research and that the one hundred or so children tracked for his studies were just a fraction of the patients he successfully treated with the same regimen. “When you find something new that actually works, that makes a difference, it’s quite spectacular.”

Having used Dr. O'Regan's methods for 15 years now, I wholeheartedly agree.