By Steve Hodges, M.D.
As a dad, I’m dismayed by all the learning and dance practices and socializing my girls are missing out on these days, not to mention the insane amount of screen time happening at my house. My youngest watched all nine Star Wars movies in two days!
But as a doctor and researcher, I’m intrigued by a silver lining school closures have brought: insight into the pooping habits of constipated kids.
While media outlets obsess over our society’s new cooking habits (everyone’s baking bread!) and cell phone habits (we’ve rediscovered the phone call!), I’ve been interested in how our new way of life has affected children working to resolve bedwetting and accidents.
For years I’ve written about how school restroom policies harm these kids. But what happens when these restrictions disappear, along with school itself?
What happens when students grossed out by school restrooms can relax on their own thrones?
What happens when kids with encopresis or enuresis can amp up their treatment regimens without fear of having an accident at school?
Turns out, lots of good things happen, along with some unexpected challenges related to stress and the loss of daily routines.
I’ve been able to keep tabs on my patients via telemedicine, and parents in our private support groups have posted valuable insights as well.
Here’s what’s happening on the pooping front.
More Pooping, Fewer Accidents
Among my patients, not much pooping happens at school. In normal times, these kids avoid the restroom at all costs, even to pee. School restrooms can be smelly and intimidating, and bathroom passes can be hard to come by. Many of my patients hold pee and poop for 8 hours straight, suppressing their bodies’ urges and wreaking havoc on the rectum and bladder.
These same kids are pooping freely during the day and, unsurprisingly, are experiencing more dry nights.
“It definitely confirms that my son’s withholding at school,” the mom of an 8-year-old posted in our private forum. “One day he went poop at 1 p.m., and I asked him what he would have done if he was at school. He totally owned it and said: ‘I’d hold it.’ His school is great about allowing him to go when he needs to go, but he’s afraid of missing out on something, and he’s grossed out by the school’s bathroom.”
Many parents are using this -shelter-in-place time to ramp up kids' treatment regimens, in ways that were inconvenient back when kids spent their days in the classroom. (How long ago that seems!)
For example, some families have implemented Double M.O.P., a super-cleaning regimen that involves an overnight oil-retention enema followed by a high-volume enema in the morning. When school is in session, this protocol (explained in The M.O.P. Book: Anthology Edition) is usually limited to weekends, as it’s tough to throw an enema into the morning rush.
Of course, now there’s no rush!
“It would be almost impossible to do Double M.O.P. every day if our son were in school,” posted the mom of an 8-year-old, who began M.O.P. with a severe case of encopresis, along with enuresis. “We are on week six, and for the first time in his life, he’s had no poo accidents for one month. He also went three weeks without any pee accidents during the day.”
That's because, with his rectum emptier, the bladder nerves are less aggravated, and the rectum has a chance to start shrinking back to size and regaining tone and sensation.
The mom of a 5-year-old with encopresis also reports improvements with the addition of Double M.O.P.
“It has been hard not having our daughter at school, but I’m so glad for the opportunity that would otherwise not have presented itself,” she posted. “I am also more aware of how much and when she poops and her behavior around that without school. I can see definite lack of emptying and FOMO!”
Yet another mom also attributes her 7-year-old progress to the addition of Double M.O.P. “He’s had his longest streak without a daytime accident, which was 2 weeks. He's only had a couple of daytime pee accidents in the last month.”
Numerous families have used this time to add Ex-Lax or senna to their M.O.P. regimen or to experiment with the timing and dosing of these stimulant laxatives.
In general, I recommend fairly high doses of Ex-Lax, enough that kids really feel the urge to poop. When school is happening, folks are, understandably, reluctant to give their kids sufficiently high enough doses, for fear the signal will arrive in the middle of science class or on the playground.
Ex-Lax is tricky because you just don’t know how long it will take to kick in — maybe 5 hours or maybe 8. Maybe in less time or more. Many families are afraid to use it at all, though stimulant laxatives can be a game-changer for kids with a deeply ingrained holding habit. Not only does Ex-Lax help evacuate the child’s rectum but the stimulation also helps the child make the psychological connection between feeling the urge and using the toilet.
Our new normal has given many parents the confidence to gradually increase the Ex-Lax and have their child take a full dose earlier in the day.
“Our son couldn’t do that before because at school he can’t go to the bathroom immediately when he needs to,” one mom posted.
Another mom said her son’s response to Ex-Lax is “completely unpredictable in timing,” so she’s glad for the risk-free opportunity to experiment.
“We go out around the neighborhood but usually don't venture much further, so it's really nice to be able to give Ex-Lax without worrying about having a bathroom nearby.”
Learning What Works, What Doesn’t
Not all experimentation will be successful, but learning what doesn’t work for your child is just as helpful as figuring out what does.
One family used this time to try a high-dose Miralax clean-out, a favorite strategy of GI docs.
I generally don’t recommend these clean-outs, at least not as an alternative to enemas, because they’re just not that effective. Often, the flood of Miralax just soften poops to the point where it oozes around the big, hard, intractable lump of stool that’s causing the problem.
Also, even when clean-outs are shown by x-ray to have done the job, the rectum — still floppy and stretched — tends to fill right back up within a day or two.
However, some families have found periodic Miralax clean-outs useful in conjunction with M.O.P., and I’m always in favor of trying something that may work! Since these clean-outs can be messy and consume a weekend, it’s hard to find time for them. But now that life has become giant weekend, more or less, this is a good time to experiment.
Alas, this mom reports that her almost-5-year-old’s first Miralax clean-out was an “epic fail.”
Now the family can cross that treatment off the list!
Despite that failure, this mom reports that she has gained valuable insight into her daughter’s pooping habits, realizing that her daughter is not fully emptying, no matter what the girl reports.
“Now that I am home to fully observe,” she posted, “I have seen her go poop and confirm she is empty, only to go again in 20 minutes. This has happened several times. She also gets so involved with what she is doing that she ‘forgets’ to go pee and has had some dribbles on her way to running when it becomes urgent — this despite being reminded to go regularly. It is good to be present to see all of the subtle issues that are at play.”
With Routines Vanished, More Withholding
While many folks offer positive pooping reports, others report the opposite: an increase in constipation and withholding.
That’s not a surprise, given the cancellation of P.E., dance classes, and organized sports, along with the closing of playgrounds. Physical activity helps keep that internal conveyor belt moving, and when life comes to something of a halt, well, things are going to slow down in the colon, too.
All the uncertainty and isolation we’re dealing with doesn’t help, either. Some kids really internalize the anxiety.
“Holding is a way of controlling one of the only things they have control over right now,” one mom observed.
The loss of our daily routines takes a tool, too.
“I fully expected things to get easier, but they did not,” one mom posted. “There are certain times my kids always use the bathroom out of habit, like before we leave the house and when we get home. But we’re leaving the house a lot less now.”
Another mom lamented the lack of a daily schedule as well.
“The biggest challenge has been getting our daughter to drink the whole cup of Miralax in an hour. Before, she chugged it before school. Now her routine is disrupted, and we spend hours reminding her to drink.”
“We are on week 3 now with no accidents"
School closures have brought hardship for so many, but one mom reports this big, giant pause has bought her family time to fully implement an enema regimen.
“It's been life changing,” this mom wrote.
Before the shutdown, she was considering pulling her 8-year-old daughter out of school, because the administration was giving the girl such a hard time about her accidents.
She wasn’t even allowed to sit on the carpet with her classmates!
“It’s been a nightmare,” this mom posted. “She has had to move schools three times now, and she’s only in grade 2. Trying to convince the school administrators that she isn’t a brat and needs support is so draining. It’s a battle I am so done fighting.”
Prior to starting M.O.P., this mom wrote, she had brought her daughter to a urologist, a gastroenterologist, a pediatrician, a chiropractor, an acupuncturist, and a pelvic floor physiotherapist. “Nothing has worked. The only success we ever see is with the enemas, but school has always gotten in the way, with her being told she can’t go to the washroom.”
With school out of the picture, they’re doing enemas and Ex-Lax daily, and her daughter is using the toilet even without reminders.
“We are on week 3 now with no accidents,” she posted. “It’s amazing. All I can hope is that by the time September comes, she will have had so many months of success that school won't be an issue.”
The coronavirus closures will leave all of us changed, in more ways than we can imagine right now. For kids struggling with constipation, I hope some of these changes will be for the better.