By Steve Hodges, M.D.
How do you know if constipation is actually the cause of your child’s enuresis/encopresis or whether the accidents have another explanation?
Aren’t enemas an “extreme” response to a problem that’s not such a big deal?
What are the odds your child will spontaneously overcome the habit of withholding poop? And do kids start holding poop in the first place?
These are among the most common questions I find in my in-box, so maybe you’ve wondered about some of these topics yourself. Below are excerpts from emails I’ve received in the last month, sent by parents of babies and teenagers alike. I’ve included my answers and links to resources you may find helpful.
Q: My 16-month-old daughter has had constipation problems since she was 10 months old. My pediatrician recommended Miralax and fiber, but my daughter still holds her poop for days, and on several occasions, we’ve had to give her a suppository. Even with prunes, pears, etc., she doesn’t like to poop. Looking for help to change that holding habit.
A: This scenario is super common and warrants a two-part solution: 1.) cleanint out her rectum and 2.) softening her poop so that pooping no longer hurts, allowing her to poop freely.
For chronically constipated children, including babies, suppositories shouldn’t be considered a last resort or a catch-up method after a child has already gone days without pooping. Rather, they’re most effective if used daily until the child is cleaned out and then on any day the child doesn’t fully evacuate.
That’s the gist of the Pre-M.O.P. regimen, which was designed for just this scenario. The combination of suppositories and a daily osmotic laxative, whether Miralax or an alternative, should get her pooping daily . The Pre-M.O.P. Plan explains in detail why prune juice, pear juice, and even daily Miralax aren't getting the job done.
It’s important to get constipated babies fully evacuating daily! Countless cases of enuresis and/or encopresis in kids ages 5, 10, 15 and older can be directly traced back to constipation in infancy that was never adequately treated. Toilet training a child who is chronically constipated is a frustrating endeavor for all involved. So, it’s important to help the child overcome the holding habit well before you potty train.
Helpful resources: The Pre-M.O.P. Plan (book) and A Better Way to Fix Constipation in Kids 3 and Under 3 (bog post).
Q: My 14-year-old daughter still has poop accidents. We took her to doctors when she was younger. They said she wasn’t constipated, so they couldn’t help. My daughter said she cannot feel when she has to go. She only realizes she’s having an accident in her pants after it comes out. I can only imagine the shame and frustration she must be feeling. Do you think pelvic floor therapy or mental health therapy could help?
A: First off, chronic constipation is literally the only cause of encopresis (chronic poop accidents). It’s impossible to have poop accidents without being constipated. Not feeling the accidents is the #1 symptom of encopresis, signaling that the rectum — enlarged by a chronic poop load — has stretched to the point of losing sensation and tone.
This is not a mental health problem and should not be treated as such! Pelvic floor physical therapy can be helpful for some kids, as we explain in the M.O.P. Anthology, but the constipation must be addressed first.
A daily enema regimen such as M.O.P. should stop the accidents in short order. However, even if accidents resolve quickly, it’s important to complete the entire program so that the rectum has time to regain tone and sensation. Stopping the regimen early only invites a recurrence.
It's critical for any child with encopresis — and especially important for teens — to understand that the accidents are not their fault and are totally fixable.
Helpful resources: “Enuresis and Encopresis Are Not ‘Mental Disorders,’” (blog post), and “Children with Encopresis and Enuresis Deserve the Best Treatment, But Most Aren’t Getting It” (blog post). Also: The M.O.P. Book: Anthology Edition (book) and M.O.P. for Teens and Tweens (book),
Q: I was quite surprised at the advice given on your website — i.e. enemas — which feels a bit extreme. You say that a large percentage of bedwetting cases are due to constipation, but how would I know if my child fits into the large percentage or if her case is due to other issues?
A: It’s not just “a large percentage” of enuresis cases that are due to constipation. Virtually all cases of enuresis are caused by a pile-up of stool in the rectum, which in turn aggravates the bladder nerves. The exceptions — mainly neurological disorders such as spina bifida and tethered cord syndrome — are discussed in the M.O.P. Anthology.
It’s easy to confirm constipation via x-ray. Ask your doctor order a KUB x-ray (short for “kidneys, ureters, and bladder”), ideally with a rectal diameter measured. A rectal diameter of less than 3 cm is considered normal. Most children with enuresis have a rectum stretched to 6 cm or more.
As for the “extreme” nature of M.O.P., we believe kids deserve the most effective treatment. If the “less extreme” treatments, such as Miralax alone, actually worked, M.O.P, would not exist. Certainly enemas are nobody’s first choice!
Many of my patients took Miralax for years on end, to no avail, because their parents, on the advice of physicians, wanted to avoid enemas. To me, it makes more sense to minimize the amount of time kids have to suffer through accidents and wear pull-ups. But in the end, families have to go with the approach they’re comfortable with.
Most children, even those reluctant at first, do just fine with enemas. In fact, I find kids are often far more amenable to enemas than their parents expect. In many cases, it’s the parents who are projecting their fears onto a child who is actually quite willing to try a treatment that will give them their life back.
Helpful resources: “Medical Conditions to Rule Out” and “How to Get an Accurate X-Ray Evaluation” in the M.O.P. Anthology), “The M.O.P. Kicktart Guide” (a free download), and “The Enema Rescue Guide” (including in the Anthology).
Q: When is a good time to start potty training outside the house? Not at night -- I will wait years before doing that. My son is 2.5 years old and is able to control his pee really well, no diaper at home. Should we wait until constipation resolves? We've been on liquid glycerin suppositories and Pedialax chewable tablets and for five months, but he still almost never poops spontaneously (without the suppository).
A: Even for kids with no history of constipation, we don't recommend potty training until the child shows the signs of readiness, such as the ability to dress and undress without help, to notice a dirty diaper, and to tell you when she needs to pee or poop. It’s also important for the child to demonstrate the maturity and judgment to pee and poop right when the urge strikes, not 30 minutes or 3 hours later. For most kids without a history of constipation, this is around age 3.
However, for children who struggled with constipation, it's critical to fully resolve the constipation and holding behavior before potty training, even if they are over age 3. Children who are chronically constipated often can’t even sense when they need to poop or pee, so toilet training is a futile and frustrating endeavor for all involved.
For a child who isn’t pooping spontaneously, adding a daily stimulant laxative such as Ex-Lax should help. Senna-based laxatives not only trigger a bowel movement, usually 5 to 8 hours later, but also help the child connect the urge to poop with the act of pooping. Most kids cannot override an urge stimulated by Ex-Lax, if the Ex-Lax dose is strong enough.
Finally, know that there is no such thing as "night training." Overnight dryness will come naturally, assuming constipation is resolved.
Helpful resources: “Nighttime potty training is not a thing” (blog post), “Enema and Ex-Lax ‘Dependence’: Questions About Weaning Your Constipated Child” (blog post), and “The Problem with Preschool Potty Training Deadlines” (blog post).
Q: I have a 4 y.o. daughter doing M.O.P. for encopresis. Her sister is 21 months old and has been holding since age 12 months. We try to keep her poop soft with prune juice and occasional magnesium citrate gummies, because I’m afraid of possible psychiatric effects of Miralax. My questions: Why are my kids holders?? Do most kids grow out of withholding? What is the likelihood my 21-month-old will have the same problems as my 4-year-old?
A: I never assume a child will simply outgrow the tendency to hold poop, I believe it’s important to treat constipation as a chronic condition and to treat the condition aggressively. Occasional or half-hearted treatment usually won’t suffice. I’ve seen many constipated 1-year-olds become 4-year-olds with encopresis. But that progression is entirely preventable.
Chronic constipation is a strongly genetic/personality issue. You usually can’t explain holding behavior, but you can, and should, treat it with a combination of suppositories and osmotic laxatives. There are several alternatives to Miralax, so nobody who is uncomfortable with PEG 3350 needs to give it to their child. Magnesium citrate gummies can help, but I would recommend them daily rather than on an occasional basis. Lactulose is another effective option, as explained in The Pre-M.O.P. Plan.
Helpful resources: “Why Is Your Child Constipated? Because We Live in the 21st Century” (blog post) and The Pre-M.O.P. Plan.