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Constipation Q&A: Enema Dependence, Miralax, and Bedwetting Meds


Here's our latest round of questions about the Modified O'Regan Protocol (M.O.P.), weaning off Miralax, the "spontaneous poop," and bedwetting medications.

Q: Our 5-year-old is 60 days into M.O.P., and her urgency to pee and daytime pee accidents improved immediately. But she still wets at night and doesn’t poop other than after an enema. Our pediatrician wonders: Could daily enemas cause her to become “lazy,” relying on them to poop?

A: Nope, enema dependence is a myth, as I explain in our free download, The Physician’s Guide to M.O.P. Print it out and hand it to your doctor!

In a child who has accidents, the rectum has become so stretched that it has lost the ability to fully contract and expel poop. Daily enemas allow the rectum to regain its tone and sensation.

One goal for kids on M.O.P. is to poop on their own, besides after the enema, once a day. (Read “Has Your Child Achieved the Spontaneous Poop?”) However, in chronically constipated children — especially kids who have both daytime and nighttime accidents — this can take many months to achieve. Spontaneous poops are generally a sign the rectum is regaining tone, so it comes later in the recovery process.

Pooping only after enemas isn’t a sign of dependence; it just means your daughter hasn’t fully regained rectal tone and sensation.

As you’ve discovered, it is normal for urinary urgency and daytime wetting to resolve before bedwetting. Hang in there — you’re clearly on the right track!

Q: Our son has achieved dryness on M.O.P. and we will soon be done with twice-a-week enemas. We plan to keep him on Miralax for six months after that. But at that point, how should we wean from Miralax?

A: Gradually! Six months after you complete the final phase of M.O.P. (enemas twice a week), cut his laxative dose in half for two weeks. Then give him half a dose every other day for two weeks, and then every third day for two weeks. Then stop.

This weaning regimen applies to any osmotic laxative used with M.O.P., including lactulose, magnesium citrate, and PediaLax chewable tablets. I cover all the options in

The M.O.P. Book.

If, at any point, your son appears to be constipated again, resume daily laxative use. If your son relapses into daytime or nighttime accidents, you will need to restart the full M.O.P. program.

Q: Our doctor warned us not to use liquid glycerin suppositories for more than a few days. She also said my son might be the type of kid who only needs to poop every three or four days, so he wouldn’t need to continue with suppositories after the initial blockage is clear, anyway. Could this be right?

A: Everyone who eats every day should poop every day — period. Not only that, but the poop should be soft, like frozen yogurt, mushy blobs, or thin snakes; hard logs or pellets indicate constipation, as you can see on our How’s Your Poop? chart.

It is fine to give your child liquid glycerin suppositories (which are like small enemas) for more than a few days. Many children on M.O.P. use them daily for weeks. In The Physician’s Guide to M.O.P., I address physician concerns about long-term use of suppositories and enemas.

Q: My son has achieved dryness on M.O.P. and is ready to start tapering to enemas every other night. However, for the last few nights, every time I send him in the bathroom for his enema, he has a spontaneous poop and doesn’t do the enema. Should I insist he do the enema, anyway?

A: Yes! His spontaneous poops are a great sign his rectum is recovering, but it’s still important for him to complete the full M.O.P. regimen. The enemas are aimed at clearing out hardened, old stool and keeping the rectum completely clear on a daily basis, so it can fully bounce back.

Many families get so excited when the child finally achieves dryness that they assume the ordeal is over and stop enemas early. This is the #3 mistake in “Want to Fix Your Child’s Bedwetting? Avoid These 5 Mistakes.”

But stopping enemas early dramatically increases the child’s odds of relapse. Remember, complete recovery doesn’t just require keeping the rectum clear; it also requires reversing the holding habit, which becomes deeply ingrained. Urge your son to stick with the program!

When this issue came up in our private Facebook support group, one mom posted: “In my opinion, after a spontaneous poop is actually the best time to do an enema, as it has more chance of getting up to the old stuff, if the soft stuff is out of the way. I make a point of sitting my daughter down to poop before her enema, if she hasn’t done so already.”

Most kids have more stool hiding in the colon than families can imagine. Another mom posted: “My daughter does a spontaneous poop pretty much every day, but after the enema, even more poop comes out. Sometimes I wonder where it all comes from!”

Q: Our pediatric urologist says that because my son is pooping every day, there is no reason to believe he is constipated, and our only option for his bedwetting is to put him on imipramine. We don't like the idea of putting our child on medication. Should we even consider imaprine?

A: I do not recommend imaprine (sold as Tofranil), an antidepressant that also relaxes the bladder. This drug tends to stop bedwetting only on the nights when it is used, so it is not a viable long-term solution. Like the medications I discuss in “Bedwetting Medication Doesn’t Work — Here’s What Does,” imaprine does not get to the root of cause of bedwetting. But imaprine is even less popular than other bedwetting drugs because taking too much could cause cardiac irregularities and convulsions. Other potential side-effects are described here by UCSF Benioff Children’s Hospitals in San Francisco and Oakland, which are on our Find a Provider list.

As for the daily pooping, your urologist is mistaken: A child can poop every day and still be chronically and severely constipated. Many constipated kids poop two or three times a day; they just don’t fully empty. Pooping frequency isn’t a good gauge of constipation. More telling signs are XXL poops, hard poops (logs or pellets, as oppose to mushy blobs), stomach aches, “skid marks,” the frequent or urgent need to pee, and, of course, bedwetting and accidents. Check out “12 Signs Your Child is Constipated.”

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Must-read books for kids by Steve Hodges, M.D.

• Bedwetting and Accidents Aren't Your Fault

• Jane and the Giant Poop

CONTACT​ US

Feel free to contact Dr. Hodges or Suzanne directly:
shodges@wakehealth.edu
suzanne@bedwettingandaccidents.com

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