By Steve Hodges, M.D.
The other day I received an urgent email from the father of a 7-year-old boy with encopresis. This family was 8 days into the Modified O’Regan Protocol when their pediatrician insisted they stop. The dad wrote:
We spoke to our doctor today and he recommended that we don't go down the enema path. He said it could possibly be traumatic for our son and it addresses the rectum, but not the colon. It is very important that we speak to you as soon as possible. We need reassurance that we're on the right path.
And then today, just as I was about to post this article, I received this email:
We are two weeks into M.O.P. and my daughter has gone 9 days without poop accidents (after 18 months of accidents and worsening symptoms on Miralax). Our doctor called this morning and wants us to stop. She is concerned about electrolye imbalances and long-term dependence on enemas. She hasn't been able to demonstrate any significant knowledge in this area, but I feel ill-equipped to defend my desire to follow M.O.P.
I look forward to the day when physicians, on the whole, accept that enemas are a) safe for children and b) by far the best way to resolve bedwetting and accidents.
But that day does not appear to be on the horizon!
My colleagues tend to oppose enema treatment — on reflex, rather than science or experience, I believe — and many won’t order X-rays to diagnose constipation, preferring methods far less reliable.
In The Physician’s Guide to M.O.P., a free download, I address my colleagues directly, in hopes they will keep an open mind. However, on a daily basis, I don’t spend much time trying to persuade fellow physicians. Instead, I focus on assuring parents they’re doing the right thing.
Parents are the ones in the trenches — the ones wiped out from 2 a.m. bedsheet changes, frustrated that their kids aren’t “outgrowing” the accidents (as promised by their physicians!), distressed when their children opt out of sleepovers or, worse, wet their pants at school.
Of course, it’s kids who suffer the most, but they’re generally not the ones making medical decisions (though I do get emails from bedwetting teenagers who’ve taken matters into their own hands).
At any rate, parents are the ones most likely to research enuresis and encopresis treatments and most are willing to push the envelope. So I put my time and energy into persuading these folks that M.O.P. is indeed the right path.
In this post I will counter the most common objections cited by physicians about M.O.P. and abdominal X-rays — not so you can change your doctor’s mind but so you can have peace of mind when implementing M.O.P. on your own.
Here’s a rundown of the most common objections parents in my private Facebook support group report hearing from their pediatricians, GI doctors, and urologists, along with my response to these concerns.
•Physician objection: It’s pointless to X-ray a child for constipation. A “marker” study is more useful.
One mom in our support group posted: Our doctor said the X-ray isn’t of value because how much poop it shows is related to when the child last had a bowel movement.
In reality, it doesn’t matter when the child last pooped, because these kids never fully empty. A child who’s chronically constipated will always have excess stool in the rectum, the only location that matters. (It matters because the rectum resides near the bladder and will squash it when stuffed with stool; excess stool in the large intestine won’t trigger bedwetting.)
X-rays are not necessary for diagnosing constipation, but they can be very helpful, as I explain in our free guide “When to X-ray a Child for Constipation.” If you do get an X-ray, make sure your doctor measures rectal diameter, an objective measure your doctor can’t (or shouldn’t) argue with.
So these doctors who find X-rays worthless — what do they recommend instead? Often, they push the sitz marker study or the DIY corn test. Both tests measure “transit time,” aka how long it takes the child to pass stool after eating.
As one mom posted: In our GI’s view, an X-ray doesn’t say anything because the colon ‘should’ be full of poop. His read on our daughter’s marker test is that she passed with flying colors and is actually on the slightly quicker side of normal.
There’s just one problem with the doctor’s assessment: Transit time tells you nothing!
Bowel transit time is not a reliable indicator of constipation. A child who is “regular” can nonetheless have a rectum chock full of stool. In fact, many severely constipated children poop two or three times a day. That’s because softer stool can still ooze around the large, hard lump that has formed in the rectum. When a child poops multiple times a day, this usually signifies the child isn’t fully emptying.
Don’t waste time or money on marker studies
•Physician objection: Enemas cause dependence.
One mom posted: Our GI scolded me that I would make my daughter addicted to enemas by doing them every day.
Another wrote: A doctor told us if we give suppositories for more than a few days, there is a risk that the bowel becomes reliant on that and the child will not be able to poop on his own again afterwards.
There is zero evidence to support this idea, yet it may be the single most popular objection to M.O.P.
In a severely constipated child, the rectum is already not working normally. It has become so stretched that it no longer has the oomph to fully expel poop. M.O.P. allows the rectum to remain clear long enough to regain the sensation and strength necessary for full and complete emptying. Once the rectum has recovered, your child will no longer need enemas.
One goal for a child on M.O.P. is to poop spontaneously once a day, in addition to pooping after each enema. If your child is only pooping after enemas, this is NOT a sign of dependence; it just means the child hasn’t fully regained rectal tone and/or sensation.
Physician objection: M.O.P. will traumatize your child.
I get it: a daily enema regimen just sounds traumatic. And indeed, when a child is tense or fearful, the insertion of an enema can hurt. However, with a shift in positioning, some extra lubrication, and time to adapt to the process, M.O.P. becomes routine. Our post “11 Ways to Ease Your Child’s Fear of Enemas” has great suggestions from families who’ve been there.
As for “traumatic,” well, here’s how parents in support group reacted when their doctors used that term.
•My own response is that 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. A quick, painless enema is much easier.
•I responded: "We're at the pick-your-trauma point. My kid is crying multiple times a day because we are having to clean him up with a shower sprayer and his skin is raw, and he has to leave his pre-K classroom every single day, sometimes twice, to have the unfamiliar school nurse clean him up and change his pull-up and pants. And, yes, he's in a pull-up 24/7 and he's five and starts kindergarten next year."
•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.
Physician objection: It makes no sense to do enemas when Miralax will solve the problem.
One mom posted: We were advised by different doctors that Miralax is the only solution and if our son is still clogged, we haven't given enough Miralax.
I hear this all the time! I believe oral laxatives — whether Miralax or an alternative such as magnesium citrate, magnesium hydroxide, or lactulose — have a place in resolving chronic constipation. But for children who have accidents, laxatives are best used as an adjunct to enemas, not as the sole therapy.
My research clearly shows enemas are far more effective than Miralax at resolving enuresis. I challenge any physician to demonstrate otherwise.
Believe me, virtually every one of my patients who was deemed constipated by a pediatrician tried Miralax first. And then more Miralax. And then more! If that stuff worked as doctors promise, these kids would not be showing up at my clinic.
I used to recommend, as an alternative to enemas, a high-dose Miralax clean-out, followed by a daily maintenance dose of Miralax. I no longer endorse this approach, since it is so clearly inferior to M.O.P. It works for some kids with enuresis, but the relapse rate is high, and in most cases, the Miralax-softened poop just oozes around the hard rectal clog. Nothing is solved.
Many parents, desperate to avoid enemas, asked me if their child can just do “one of pre-colonoscopy clean-outs” and call it a day. I refer them to my blog post “Bedwetting Treatment: Why Even the ‘Nuclear’ Option Can’t Replace Enemas.”
Physician objection: Enemas should be used only in case of acute constipation.
One mom in our group was told by her doctor that “enemas are only good as a kind of ‘rescue’ measure” and are not appropriate as a daily treatment.
The reason enemas must be done daily is that resolving bedwetting isn’t about the clean-out; it’s about giving the stretched rectum a chance to shrink back to size, so it has the tone to fully evacuate and the sensation to detect the urge to poop. This can take several months, or longer, even when the rectum is cleaned out daily. If you only clean out the rectum once, it’s just going to fill right back up, and you will have solved nothing.
Withholding poop is a deeply ingrained habit in kids. It doesn’t vanish with a single enema!
Physician objection: Bedwetting under age 7 is normal, so treatments like M.O.P. are pointless.
Heck, many parents in our group have been told bedwetting is normal at age 9, 10, and 12! Every year these families are assured the child will soon “outgrow” the accidents.
I cover this subject in depth in “Teenage Bedwetting: Everything You've Been Told is Wrong” and “Don’t Assume Your Child Will Outgrow Bedwetting.”
I recommend taking action when a child is 4.
Physician objection: Enemas cause electrolyte imbalance.
Countless parents have been warned of this alleged risk by their physicians. But if your child is healthy and you limit enemas to one per day, as spelled out in M.O.P. safety guidelines, this risk does not exist.
At any rate, the concern about electrolytes only pertains — even in theory — to over-the-counter pediatric enemas that contain phosphate. You can easily implement M.O.P.
with alternative enemas, such as liquid glycerin suppositories or large-volume sodium
Even with phosphate enemas, complications are so uncommon that a review of 39 studies conducted over 50 years found a total of only 15 cases of electrolyte imbalance in children ages 3 through 18.6. Over 50 years! The vast majority of these cases involved children who had a chronic disease or were given more than one enema in a day.
In a decade of prescribing daily enemas, I have never had a patient develop an electrolyte
imbalance. Neither did Dr. Sean O’Regan, the pediatric kidney specialist who pioneered the M.O.P. regimen. If electrolyte imbalance were a legitimate concern, we would have found out by now.
Other Objections to Daily Enemas
These may be the most common objections to M.O.P., but they’re not the only ones. Many parents have been told M.O.P. is pointless because kids have accidents intentionally. One mom posted: We were told our son will stop peeing and pooping himself when he starts to care about the issue or when the other kids shame him.
Countless parents have been advised to use rewards charts and other incentives — for a condition children have no control over.
Others have felt pressured to pay for all sorts of tests to rule out conditions, such as Crohn’s disease, for which these kids have no symptoms — even though the kids have all the signs of constipation.
One mom asked me to compile a “cheat sheet” with pithy retorts to the various objections physicians have to M.O.P.
She posted: Obviously a GI has a great deal more knowledge than I do about this subject. And yet the one I saw gave me unhelpful advice, and was, well, wrong. I found trying to work with the doctor intimidating. While I did my best to summarize my understanding of your research, it didn’t come out exactly as I might have hoped.
A cheat sheet is a good idea, in theory, but I don’t think it would help. If your doctor won’t read The Physician’s Guide to M.O.P. (and many won't), I would simply respond to any concerns with this question: Are you basing your concern on research or experience?