By Steve Hodges, M.D.
Does your baby or toddler have trouble pooping?
Maybe she grimaces, writhes around, or howls when trying to squeeze out a poop.
Maybe she goes days without pooping — and then cranks out a stool that seem impossibly large for a child so small. Or, for all that struggle, she barely ekes out a few rabbit pellets. Maybe you see a trace of blood from all the straining.
Or maybe she's 2 or 3, and you’ve tried potty training, but no matter what, she just won’t poop on the toilet.
Maybe you’ve sought medical help and were advised to try prune juice, more fiber and perhaps a dose of oral laxative. Maybe you were assured constipation in young children is normal and temporary. Maybe you were told, “Don’t worry. She’ll outgrow it.”
That's not something I tell my patients.
In fact, my experience as a pediatric urologist, along with my research, prompts me to tell folks the opposite: constipation in young children, while quite common, is not normal and is not likely to resolve itself.
Constipation in early childhood is a giant red flag — one that often goes unnoticed or is disregarded by the medical community. As a profession, we do not take childhood constipation seriously enough or treat the symptoms aggressively enough. Not by a long shot.
So, eventually, constipated babies and toddlers become school-age kids who struggle with bedwetting, daytime pee accidents, and/or poop accidents.
Eventually, they become my patients.
My clinic is filled with first-graders who are teased for wetting their pants at recess, 9-year-olds who leave behind poop pellets on play dates, bedwetting 15-year-olds who avoid school overnights and are panicked about having to bring pull-ups to college.
As the parent of a baby or toddler, you probably can’t fathom any of this. It must all sound like sounds like someone else’s nightmare, not scenarios that pertain to you and your baby.
But my patients and your child have something in common: chronic constipation that surfaced by age 3.
Your baby’s pooping trouble is the precursor to the accidents that plague my school-age patients.
Here’s why: When constipation is not resolved, the stool-stuffed rectum gradually stretches and begins to encroach upon and aggravate the bladder. At some point, the bladder will start to hiccup and empty without warning, day or night. In the case of poop accidents, the stretched rectum loses tone and sensation, and stool just drops out of these kids’ bottoms, often without them noticing. In young girls, the same withholding behavior and rectal stool build-up also can lead to recurrent urinary tract infections.
This is a gradual process, and few parents connect their 6th-grader’s bedwetting to the child’s pooping difficulties as a 1-year-old. But you can draw a straight line from A to B.
My patients’ constipation — confirmed by abdominal x-rays and measurements of rectal diameter — can invariably be traced back to one of three eras in their young lives:
• infancy
• at the introduction of solid foods (between 4 and 12 months) or cow’s milk (around 1 year)
• during toilet training (between 18 months and 3 years)
Even when accidents seem to happen “out of the blue” — years after the child was toilet trained — a deep dive into the child’s history reveals that the warning signs were there early on, and they were missed.
The parents who visit my clinic or who join our private Facebook support groups wish they had recognized the signs years earlier. They wish they’d treated their children’s constipation more aggressively and followed up with more vigilance. They wish their doctors had done the same.
As one mom in our support group for enuresis and encopresis posted:
I wish I hadn’t continued to believe “He’ll grow out of it” when my gut told me something was off. But when you have an otherwise healthy baby, you NEVER think that the infant whose constipation your pediatrician deems “normal” could eventually turn into a 4 1/2-year-old who never poops on his own and gets an enema every night. In retrospect, I wish I had been all over the constipation when he was a baby. It’s so frustrating to think, What if I had been more aggressive back then?
The mission of my new book, The Pre-M.O.P. Plan, is to save your family from this frustration.
In The Pre-M.O.P. Plan: How to Resolve Constipation in Babies and Toddlers and Overcome Potty-Training Struggles, I explain how children can become so constipated so early, why the typical treatments are so inadequate, and what actually works to clean out the rectum and reverse the cycle of withholding.
The book is aimed at helping children who show signs of chronic constipation before they have toilet trained, as well as youngsters who are currently potty training and are struggling to poop on the toilet.
I’ve also started a private Facebook support group for parents of this population, modeled after our well-established M.O.P. (Modified O'Regan Protocol) support group. (Both groups are hidden and visible only to members. You can’t search for them, but you can find the details on our Support Groups page.)
The Pre-M.O.P. Plan is based on the premise that early intervention is everything — and that aggressive treatment is the only treatment worth doing.
What is Pre-M.O.P.?
In a nutshell, Pre-M.O.P. combines osmotic laxatives with suppositories or enemas. An osmotic laxative — whether it’s lactulose, magnesium hydroxide (milk of magnesia), magnesium citrate, or PEG 3350 (Miralax), — is given daily. The suppositories or enemas are given at night if the child did not self-initiate a poop during the day or appears not to have fully evacuated.
In the book, I discuss dosing, timing, safety, and the various laxative and suppository options.
And yes, you absolutely can do Pre-M.O.P. without Miralax! (I discuss this controversial laxative in Part 4 of the book.)
If you're not familiar with the Modified O’Regan Protocol, it's an enema-based regimen shown to treat enuresis, encopresis, and recurrent urinary tract infections far better than other methods. The history and details of M.O.P. are spelled out in The M.O.P. Book: Anthology Edition.
Pre-M.O.P. is a limited, easier version of M.O.P. The idea is simple: Implement Pre-M.O.P. before toilet training, and you can save your family from having to go down the M.O.P. road.
Compared to the usual remedies, Pre-M.O.P. may sound excessive. Do you really need to give constipated babies laxatives and mini-enemas?
I believe you do! That is, if you’d like to prevent your child from ever setting foot in an incontinence clinic like mine.
Among the topics I cover in The Pre-M.O.P. Plan:
• 18 signs of constipation, some subtle and not well known
• Medical conditions to rule out
• Why Pre-M.O.P. is more effective than the alternatives
• How to implement Pre-M.O.P. without Miralax
• When eliminating cow’s milk is warranted
• Toilet training a child with a history of constipation
Perhaps even more useful, you’ll get the perspective of parents who’ve been through M.O.P. and are now implementing Pre-M.O.P. with their younger children in hopes of avoiding a repeat.
As one mom in this situation posted in our M.O.P. support group:
I learned my lesson with my older daughter, who’s now 4 1/2. She was constipated at 1 year, but the doctor just told me to give her prune juice and more vegetables. She ended up with encopresis and enuresis and was having 10 accidents a day. It took 8 months on M.O.P. for her to get down to 1 accident.
My baby showed signs of constipation at 6 months, and I started doing for her what I should have done with her sister: a laxative every day and suppositories on days she doesn’t have a good poop. An incredible amount of poop comes out with the suppositories, and I can see she feels so much better. I will do anything not to have to deal with encopresis and enuresis with more than one child.
Resolving chronic constipation in a baby or toddler is exponentially easier than doing so in a 5-year-old or a 15-year-old!
By taking action early — before your child’s withholding becomes more deeply ingrained and before the rectum becomes persistently stretched — you may well save your child from years of discomfort, distress, and damaged self-esteem.
You may also save yourself from 2 a.m. bedding changes and the expense of extra-large pull-ups, plus the financial and emotional costs of treating enuresis and encopresis.
The time to act is now!