By Steve Hodges, M.D.
Our Covid-19 lockdown doesn’t have many upsides, but one of them is that I now have time for weekly Facebook Live sessions with members of our three private support groups.
Parents have asked some excellent questions during these sessions!
I'm including seven of them here (edited for clarity). Among the topics: bedwetting treatment for kids on the autism spectrum, Ex-Lax timing and dosing, store-bought vs. homemade enemas, and when to taper from daily enemas on M.O.P. (the Modified O’Regan Protocol).
A mom who participated in Facebook Live offered her own “silver lining” to being quarantined: “being able to be more flexible and attentive to my kid’s poop issues!”
I hope you can use the information here to make some adjustments, and hopefully some progress, on your family’s journey toward resolving enuresis and/or encopresis.
Q: Is there anything you tend to do differently for kids with neurological conditions like autism spectrum disorder? My boy is 6 y.o. high functioning ASD.
A: In our clinic, the highest rates of dysfunctional elimination are in kids with ADHD, and it’s super common in kids with ASD, too. For these kids, the treatment is basically the same as the standard M.O.P. regimen, except we recommend Ex-Lax more often or in higher doses (in addition to daily enemas) to help deal more directly with their holding behavior.
There is nothing inherent in these conditions that causes kids’ bladders to function poorly. They just tend to have a higher incidence of withholding behavior. X-rays show these kids’ rectums are really, really full. If a child is a habitual withholder, Miralax probably isn’t going to help that much because it just softens poop — it doesn’t stimulate a bowel movement. Even with Miralax, kids can just keep holding. The combination of daily enemas and the strong stimulation from Ex-Lax works well for many ASD and ADHD kids.
Q: How much Ex-Lax is too much? This week I've upped my 13 y.o. son to three Ex-Lax pills (25 mg each) at night and two in the morning. While on M.O.P. he hasn't been making spontaneous poops.
A: Your daily total of five Ex-Lax is fine. Some kids take six, which is about the maximum that most kids need (although going higher is fine if necessary). However, I think a more effective approach is to take the entire dose at once.
Splitting a daily dose is fine with osmotic laxatives, such as Miralax, lactulose, or milk of magnesia, since all those do is make poop mushy. But the purpose of Ex-Lax is to stimulate a bowel movement, and you’ll get more stimulation with a full dose than with two half doses.
Also, taking a full dose once a day makes timing the poop easier; you’ll get a clearer picture of how many hours it takes for the stimulation to kick in.
Q: My son (in high school) usually takes Ex-Lax around 9 p.m. because he was afraid if he took it in the morning he’d have to poop at school. Now that school is closed, should we switch the timing?
A: Yes, I prefer that kids take Ex-Lax during the day because I like them to feel the cramping sensation — the cue that it’s time to poop. Ex-Lax usually takes 5 to 8 hours to work, so if you take it at night, you may get the urge while you’re sleeping.
In normal times, I recommend taking Ex-Lax right after school, so we take the difficulties pooping at school mostly out of the picture. But with school closed, Ex-Lax first thing in the morning is ideal. Your son can respond to the urge in a timely fashion, and you can easily track how how many hours it takes to kick in and adjust the dose as needed.
Keep in mind that Ex-Lax doesn’t just help empty the rectum; it also helps build the association in the child’s mind between feeling the urge the poop and using the toilet. If you can induce a strong urge to go, you can build the psychological component of pooping in a timely manner.
Often parents will stop short of giving a child enough Ex-Lax because they don’t want them to feel discomfort, but that discomfort may be necessary to stimulate a bowel movement and is an important signal for the child to receive. The cramping tends to resolve once the child gets cleaned out.
Q: My daughter has been on M.O.P. for two months, and her poop accidents have stopped. However, she has just recently been passing pellets, despite a good diet and water intake. Should I make sure that BMs are soft before tapering from daily enemas?
A: Yes! You don’t want to stop enemas if your child is pooping rabbit pellets. That’s a set-up for disaster. Kids with encopresis are at high risk for recurrence, and pellets are a sign that she’s still constipated, even if she’s not filled up to the point where she’s having accidents.
Q: I’ve heard you say that sometimes high-volume enemas can make accidents worse by stretching out the rectum too much. My 13 year-old has been on M.O.P./M.O.P.+ for 1 1/2 years. Daytime wetting and skids have gone away. Now just night time wetting. We currently do 500 cc saline enemas with glycerin and Castile soap, and he takes magnesium and 3 senna daily. Do you think it's too much saline?
A: Yes, I would reduce the saline volume. One pattern we’re finding is that for some kids M.O.P.+ (a regimen of daily large-volume enemas) works really well for resolving encopresis and daytime wetting, but these kids can’t get over the hump with nighttime wetting because sometimes the enema volume stretches the rectum enough to further aggravate the bladder.
In these cases, we try the opposite strategy: reduce the enema volume and take a high dose of Ex-Lax. Either use small-volume store-bought enemas, such as liquid glycerin suppositories or Docusol Mini-Enema. Or, if you want to continue with homemade enemas, try lowering the saline volume to 250 cc and raising the stimulant volume to max levels as stated in the M.O.P. Anthology. And for oral laxatives, try Ex-Lax alone, without any osmotic laxatives. For kids in this situation, this seems to be best way to get them empty with minimal rectal stretching.
Q: Are homemade saline enemas as effective as store-bought enemas?
A: In store-bought saline enemas, the active ingredient is actually phosphate, even though the box says “saline laxative enema.” The phosphate is delivered in a saline solution (.9% sodium chloride in water).
These enemas are usually more effective than homemade enemas that use only than saline solution, despite the larger volume typically used with homemade enema kits, because pure salt water does not stimulate the colon; this type of enema is basically just an irrigant.
However, if you add stimulants such as glycerin or Castile soap to homemade enemas, as we describe for M.O.P.+, the enema is more likely than a store-bought enema to induce a big output. Plus, you can save a lot of money, because a homemade enema kit is reusable.
Q: My 5-year-old started M.O.P. three weeks ago. Her night-time wetting and encopresis have resolved, and daily spontaneous BM is observed, but daytime wetting is still an issue. As soon as we skip a day of enemas, she has no BM and daytime wetting persists. How long does it take for the bowel to wake up again and for her to start having a BM without the enema?
A: Wow, that’s really amazing she’s already dry at night! Nighttime wetting almost never resolves before daytime wetting and rarely resolves within three weeks. You are making great progress, so definitely do not skip a day of enemas.
As we explain in the M.O.P. Anthology, don’t even think about tapering until you’ve completed at least 30 consecutive days of enemas plus at least 7 consecutive days of complete dryness, daytime and nighttime. And since your daughter started with all three conditions, you might want to extend daily enemas for an extra few weeks before you taper to every other dayf5.
As for how long it takes for the rectum to shrink back to size and crank out daily BMs without an enema, well, that differs greatly from child to child. A general rule of thumb is that once day and night dryness is achieved, it takes the rectum about three months to recover. However, kids who start with all three conditions often need to have daily enemas for six months or longer before they achieve dryness and can start tapering. Your daughter is making progress faster than usual, so maybe it will take her less time.