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Miralax, Magnesium Citrate, Enemas, and Suppositories: Your Questions Answered

By Steve Hodges, M.D.

I receive questions every day about all the different children's laxative products on the market. The array of products is confusing! Folks want to know: What's the difference between liquid glycerin suppositories and solid glycerin suppositories? What's the best substitute for Miralax? Here's a roundup of questions I've received lately, some of them via email and some via our private Facebook support group.

Q: Our pediatrician said Miralax is not effective when mixed in milk — that it must be mixed with clear liquid such as water or juice. Is this true?

A: Miralax works fine in milk. Just do some extra mixing, because the powder doesn’t dissolve as easily in milk as it does in clear liquids. I have patients who will only drink Miralax in milk, and that’s not a problem.

Q: How does magnesium citrate compare to Miralax as a stool softener?

Magnesium citrate has more of a laxative effect than Miralax and none of the concerns about psychiatric symptoms. (Read “Is Miralax Poisoning Children?”) However, many children don’t like the taste. Miralax is far more popular because it has no flavor and better tolerated.

That said, I do have a number of patients who don’t mind taking magnesium citrate. The most popular option seems to be Natural Vitality’s Natural Calm powder, either in raspberry lemon or orange flavor. Some families swear by the liquid or tablet forms.

An alternative to both Miralax and magnesium citrate is lactulose, a sweet-tasting, low-cost prescription liquid that kids tend to tolerate well. Another option is magnesium hydroxide, also known as milk of magnesia. It’s the active ingredient in Pedia-Lax Chewable Saline Laxative tablets.

Bottom line: Experiment and see what works best for your child. Keep in mind that for children who have accidents, I recommend oral laxatives in addition to — not instead of — daily enemas, as I explain in The M.O.P. Book. (M.O.P. is short for Modified O'Regan Protocol.)

Q: What's the difference between a pediatric enema, a liquid glycerin suppository, and a solid glycerin suppository? Which is the most effective?

A: Both pediatric enemas and liquid glycerin suppositories are enemas — in other words, both involve injecting liquid into the rectum to stimulate evacuation of stool. Both trigger pooping within 5 to 10 minutes. The difference is the solution. Liquid glycerin suppositories contain glycerin a thick, clear, sugar-based liquid that draws water into the colon. Pediatric enemas contain a mix of phosphate and saline. Phosphate, an electrolyte, is the active ingredient; like glycerin, it draws water into the colon.

(Note that despite its name, the Fleet Pedia-Lax Saline Enema contains phosphate as its active ingredient. Don’t confuse this product with “saline enema,” a homemade enema I recommend as part of the M.O.P.+ regimen for the most stubborn cases.)

Pediatric enemas have a larger volume than liquid glycerin suppositories and therefore tend to be more effective. That’s why I recommend them for the M.O.P. regimen. However, the two can be used interchangeably, depending on how well they work for your child. For reasons unknown, some children get more output with liquid glycerin suppositories.

A very small minority of children experience a burning sensation from phosphate. For those kids, I recommend liquid glycerin suppositories.

Both pediatric enemas and liquid glycerin suppositories tend to be more effective than solid glycerin suppositories, bullet-shaped gels that can take several hours to work.

However, solid suppositories can be useful for children who won’t tolerate liquid enemas and who have the time to wait for the solid gels to work. I recommend that these children take the suppository right after school, in hopes they’ll poop before bed.

Solid suppositories also can be helpful as a supplement to pediatric enemas for children on M.O.P. who don’t poop daily on their own (other than after their enema) or who don’t get much stool output with enemas. Because these gels dissolve slowly, they sometimes can break up an impacted poop mass more effectively than enemas.

Q: My 5-1/2-year-old daughter has daytime and nighttime wetting and says her tummy hurts. She poops normally — at least every couple of days. Her doctor felt her tummy, said she’s not constipated, and implied she’s complaining for attention. The doctor won’t order an X-ray “due to the risk of radiation on her ovaries” and has prescribed a daily laxative to appease us. Will that be enough?

A: Highly unlikely. Let’s clear up a few misconceptions here. First, pooping every couple of days is not “normal”; children must poop every day. (And the poop should be a big pile of mush, not formed like a log or pellets.) Second, a child with wetting issues is severely constipated; a daily dose of Miralax or other osmotic laxative is not powerful enough to break up the large, hardened mass of stool that is stretching her rectum, aggravating her bladder, and making her stomach ache.

Third, an X-ray will not put your daughter’s ovaries at risk. However, I don’t think an X-ray is necessary in your case. X-rays can be useful, but you can already assume, based on her symptoms, that your daughter is quite constipated and treat her symptoms accordingly, ideally with the Modified O’Regan Protocol.

Q: I know my daughter doesn’t drink nearly enough water, especially at school. If I can get her to drink more, could that clear up the constipation that is causing her accidents?

A: Drinking plenty of water is important for any constipated child, not just because fluid helps propel stool through the colon but also because it keeps the bladder on a healthy filling/emptying cycle. Infrequent peeing aggravates the bladder and shrinks its capacity, exacerbating the problems caused by constipation. However, once a child is constipated to the point of having accidents, you need to take more much more aggressive measures than just increasing her fluid intake.

Meantime, let your daughter choose a fun water bottle to keep at school and one to keep at home and take to the store or on play dates. Urge her drink a few ounces every few hours. You don’t want her bladder to either fill too rapidly — that can cause overactivity — or to stay empty too long.

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