By Steve Hodges, M.D.
Do you have questions about bedwetting, accidents, or constipation? Post them on the Bedwetting And Accidents Facebook page, or send them to firstname.lastname@example.org.
Q: How many kids who complete M.O.P. are able to stay dry for good? I worry about subjecting our daughter to enemas only to have her relapse and get down on herself, like when her bedwetting medication stopped working.
A: Many children take longer than 30 days to achieve dryness on the Modified O'Regan Protocol — they're so severely constipated that even daily enemas don't clear them out immediately — but once they get through the entire regimen, virtually all of my patients stay dry. They fare much better in the long run than kids on bedwetting medication, which does not attack the root of the problem and has a dreadful long-term success rate.
Still, from parents in our Facebook support group, I do know relapses happen. Many folks are, understandably, so excited when their child's bedwetting stops that they move on with life and get complacent about enemas and laxatives. Constipation creeps back, and the accidents resume. It's critical to complete the entire M.O.P. regimen and to jump back on daily enemas immediately after a relapse. Yes, I know, that is a demoralizing prospect, but the sooner you nip a relapse in the bud, the better.
One suggestion to decrease the odds of relapse is to maintain daily enemas even after your child has 5 to 7 days of dryness — perhaps an extra week or two. Then, stick with enemas every other day for more than the recommended 30 days before you taper to twice a week. Once your daughter fully tapers from enemas, she’ll need to stay on osmotic laxatives for at least six months, ideally longer, to keep her stool soft and keep pooping painless.
Also, I wouldn't worry too much about "subjecting" your daughter to enemas. Yes, they are not fun, but for most families they quickly become routine. Many children find such relief from the daily emptying that they even ask for their nightly enemas! Read "11 Ways to Ease Your Child's Fear of Enemas."
Q: I know kids who have basically never eaten a fruit or vegetable and yet are not constipated and never have accidents. My son loves vegetables yet is chronically constipated and wets the bed. How can this be?
A: Though a highly processed, low-fiber diet is probably the number-one cause of constipation in children, you are exactly right: Many kids who eat poorly have no pooping problems, and others with excellent eating habits nonetheless get backed up.
Genetics and personality certainly play a role, and in some children, intolerance to milk can trigger constipation. Some babies become constipated when they transition to solid foods; the change in poop consistency catches them by surprise, and they start withholding. In addition, early toilet training — before the child is mature enough to heed her body’s signals — also greatly increases the odds a child will become constipated, no matter how well she eats.
But none of this should be taken as license for children to live on goldfish crackers, chicken nuggets, and other highly processed foods. A “real food” diet can go a long way toward minimizing constipation even in children who are prone for other than dietary reasons.
Q: Our pediatrician says it’s normal for some kids to poop just two or three times a week — that each child has a different “normal.” Is this true? She doesn’t think my 9-year-old son is constipated and has advised us to be patient while my son outgrows the wetting.
A: Nope, it’s not normal for a child to poop two or three times a week. Kids must poop every day. However, even children who poop daily or multiple times a day can still be severely constipated, because they never fully empty. It's important to focus not just on pooping frequency but also on stool consistency. Your son should be pooping a substantial pile of mush.
And I mean mush! As our “How’s Your Poop?” chart shows, healthy poop looks like soft-serve ice cream, mushy blobs, or thin snakes. Hard, formed poops are a telltale signs of constipation, as are XXL poops. Our children’s book Jane and the Giant Poop is a fun way to teach kids what healthy poop looks like and to reinforce the importance of pooping every day.
To know for sure whether your son is constipated, ask your pediatrician to order an X-ray called a KUB (kidneys ureters and bladder). I recommend taking aggressive action rather than waiting for your son to “outgrow” the bedwetting. Research shows that children who wet the bed at age 9 are likely to still be wetting as teens, as I explain in “Teenage Bedwetting: Everything You’ve Been Told is Wrong.”
Q: Our pediatrician thinks enemas are “too aggressive,” and my husband doesn’t want any part of M.O.P. They are both pushing for a Miralax clean-out with our bedwetting 8-year-old. Is this a waste of our time?
A: Not necessarily. In It’s No Accident, which I wrote back in 2011, I advocated high-dose Miralax clean-outs as a reasonable alternative to enemas, which I realize are not popular. But in recent years I’ve moved away from recommending oral clean-outs, because they are a lot less effective, both for daytime and nighttime wetting, than the Modified O’Regan Protocol. Also, I don’t think folks’ fear of enemas is a good reason to avoid recommending them.
You could always try the oral clean-out and, if you don’t get results, move on to enemas — that's not unreasonable. Just know that oral clean-outs are rarely a one-and-done deal (they're also a lot messier than enemas). Often, softened poop will just ooze around the hardened mass of stool, so nothing changes. The important point is to keep the rectum empty on a daily basis so it has a chance to shrink back to size, regain tone and sensation, and stop bothering the bladder. If the oral cleanout does stop the wetting, be sure your son stays on a maintenance dose of Miralax or other osmotic laxative for at least 6 months
Q: Despite doing M.O.P. for 30 days, my sons has only had two dry nights. I want to know whether my son is he’s still constipated. Our pediatrician disapproves of M.O.P. How do we get an X-ray?
A: Many — though not all — pediatricians will order an X-ray if you ask for it with conviction, especially if your son complains of belly pain. The “just humor me” approach often works.
Make sure the radiologist who reads the X-ray is instructed to look for stool and to measure the diameter of the rectum, as explained in our free guide “When to X-ray a Child for Constipation.” In case you need a second opinion, photograph the X-ray with your phone while you are at the doctor’s office and get a CD copy as well. Many doctors are not familiar with how to read an X-ray for constipation.
If your doctor absolutely refuses to order an X-ray — some are convinced, based on no evidence, that a plain X-ray will put your child at risk for cancer — insist upon an ultrasound. But again, many ultrasound radiologists aren’t experienced in reading ultrasounds for stool. As one mom in our private Facebook group posted: “The radiologist who read my son's ultrasound did not detect a full colon — even though when his new GI saw the ultrasound, she said he had enough poop in there for 18 grown men.’"
Many parents are astonished that a child on daily enemas can still be backed up, but it happens fairly often. Even two dry nights is progress, though, so I recommend staying the course. However, if you go another 30 days with no further progress, switch to M.O.P.+, the more aggressive, high-volume enema program described in The M.O.P. Book: Anthology Edition.
Q: My son can’t hold an enema for more than 2 or 3 minutes. Any tips for increasing the holding time? I think he would be getting much more output if he could hold longer.
A: Holding for 10 minutes is ideal, but don't make it a stressful thing. Once your son feels a strong urge to go, he should empty completely. Over time, he’ll probably be able to hold longer. For some kids, watching a video can help extend the time.