Do some constipated children need laxatives for life?
- Steve Hodges, M.D.
- 9h
- 7 min read
By Steve Hodges, M.D.
Will chronic constipation plague a child for life?
Lately I’ve received a flurry of questions like this from parents in despair, typically over a discouraging prognosis from the child’s doctor.
One mom wrote: “Our doctor told us that kids with constipation typically require medicine life-long. I was a bit alarmed when she said this. She said autopsies of people with constipation revealed permanent scarring and dysfunction.”
Another mom wrote that according to her doctor, “the colon never shrinks back to normal size” and “my son will have to be on Ex-Lax for life, as will most kids.”
Yet another mom, reacting to difficult cases posted in our private support group, asked about the long-term outlook for “trifecta” kids — those with bedwetting, daytime wetting, and encopresis.
“Do most recover?” she asked. “Or do they need treatment like Ex-Lax or enemas for life? I’m panicking.”
I have three words for all these folks: Do. Not. Panic.
Children with encopresis, nighttime wetting, and/or daytime enuresis absolutely can overcome these conditions and the chronic constipation that is the root cause.
I see kids recover all the time. Heck, I’ve treated thousands of patients who moved on with their lives, even after struggling with severe encopresis or enuresis. I’ve viewed countless x-rays showing complete healing in a child’s rectum that had been stretched to double or triple normal size. My private Facebook support group has a collection of farewell posts from parents whose kids graduated from treatment and never looked back.
The children who need lifetime treatment are those with congenital conditions such as spina bifida or Hirschsprung’s disease. A small minority of children with redundant colon require surgery to remove a portion of the colon. (I discuss these rare scenarios in the M.O.P. Anthology 5th Edition.)
Virtually all other kids, if appropriately treated, will recover.
The key words: if appropriately treated.
Problem is, kids with encopresis or enuresis typically are treated with half-measures, like a week of Ex-Lax or periodic Miralax “clean-outs” followed by a daily “maintenance” dose of Miralax.
As I learned from experience, that’s about as useful as treating obesity with a week of healthy eating and exercise. Many parents are familiar with the Miralax merry-go-round.
Back when my go-to treatment was Miralax, my patients would return three months later still wetting the bed or experiencing daytime pee and/or poop accidents. It wasn’t until I began treating constipation with a daily enema regimen that I grasped how inadequate my earlier approach had been.
I suspect doctors who perceive constipation as a life-long problem are not using regimens such as the Modified O’Regan Protocol (M.O.P.).
When you under-treat constipation, sure, it’s going to linger indefinitely, sometimes into adulthood. I’ve seen patients who took Miralax for an entire decade before landing in my clinic. That does not mean they had an “intractable” case of chronic constipation. It means Miralax was a lousy treatment!
As I’ve explained, under-treatment of constipation stems from a definition problem. The medical community tends to view constipation as “infrequent pooping.” A more useful definition is “incomplete rectal emptying.”
When some stool remains in the rectum — day after day, month after month, year after year — the rectum stretches, gradually losing tone and sensation. This triggers a vicious cycle: The child can’t feel the urge to poop, so even more poop piles up, so the rectum stretches further, so more stool accumulates, and so on.
In some children, the enlarged rectum encroaches upon the bladder nerves, causing the bladder to spasm forcefully and empty without warning. These are the kids with sensitive bladders. In other kids, the bladder remains unaffected, but the enlarged rectum becomes so floppy that poop just drops out of the child’s bottom, without the child noticing. The most unlucky kids experience both scenarios: enuresis and encopresis.
What may have started with a single bout of painful pooping turns into a years-long struggle with enuresis and/or encopresis. Children become demoralized by the lack of control, and parents become frustrated because it appears the child is “refusing” to poop.
READ: “Potty Regression,” “Potty Refusal,” “Not Fully Potty Trained": Why These Terms Should be Canceled
Treatments like Miralax only make matters worse, perpetuating the lack of complete emptying.
In reality, successfully treating chronic constipation a three-part process:
•First, empty the rectum. This process alone can take months. Some kids are so clogged and that even daily enemas don’t make a dent in the pile-up of hard, dry stool. In some kids, even two liquid glycerin enemas a day doesn’t do the trick, and they require overnight olive oil enemas to soften the stool before a stimulant enema will help. If there’s any doubt, an x-ray will reveal whether a child’s rectum has cleared out.
READ: Olive Oil Enemas for Childhood Constipation: An Old-School Treatment Gets Scientific Validation
•Second, keep the rectum empty for several months. This is no easy task, either and is much more effectively achieved with enemas (liquid suppositories) than with oral laxatives. In my experience, it takes a good three months for the rectum, once fully emptied, to regain tone and sensation. In some kids, it takes longer.
But healing won’t happen if the rectum only partially empties. In children with encopresis, partial emptying may be enough to keep accidents at bay, at least for a while. But without an ongoing enema regimen, these kids tend to fill right back up. In enuresis patients with a highly sensitive bladder, accidents may not diminish until the rectum is fully healed. Even a slight rectal bulge will aggravate the bladder nerves.
•Third, once rectal sensation has returned, the child must relearn to act on the urge. In other words, they must overcome the tendency to delay pooping — aka “withholding.” I don’t love that term because it reinforces the idea that kids are intentionally “refusing” to poop. Most kids don’t even know they’re overriding the urge. It’s just become deeply ingrained — second nature.
Ex-Lax (senna) is hugely helpful in this stage of recovery, as I explain in the Anthology, though some children will resume pooping on their own simply with an osmotic laxative. Tapering off enemas at a very gradual pace (see the Slow Taper section on page 68 of the Anthology) is helpful, too.
The process I’ve described can take many months, experimentation (with different types of enemas and different enema/laxative combinations), and perseverance. Many parents are floored by how much time and effort is required.
As one mom in our support group cautioned others, “Be emotionally prepared for M.O.P. to take longer than you expect. I thought if we can put a man on the moon, we can get impacted stool out of my child and move on. My biggest surprise has been that for my son, this is a long process.”
Here’s the thing: Chronic constipation is both more serious and less serious than many doctors realize.
I say “more serious” because emptying a clogged, enlarged rectum requires far more aggressive treatment, for far longer, than most doctors realize. Miralax won’t cut it. But since that’s all most doctors offer, they end up concluding that, well, some kids will just need laxatives for life.
Nonsense!
Constipation should not be a life-long condition. When you really attack the problem in a child, you can conquer it for good. So, in the end chronic constipation is not a dire, life-long condition but rather a temporary, highly treatable scenario.
What about those autopsies showing “permanent scarring and dysfunction” in the colons of patients with life-long constipation? I don’t know what studies that mom’s doctor was referring to, but I do address the issue of scarred, damaged colons in long-term laxative users in my blog post Ex-Lax Safety in Children: Are “Toxicity” and “Tolerance” Legit Concerns? I also discuss the research in my 45-minute Zoom course Ex-Lax, Miralax, and Enemas: What the Research Actually Shows About Safety and Dependence.
If you're feeling despair that your child's chronic constipation will never end, perhaps you can derive some hope from moms who posted in our support group.
The mom of a boy who’s now 17 reflected on her son’s struggle with both encopresis and bedwetting posted:
At age 6 my son received a diagnosis of significant constipation, confirmed by an x-ray. He’d had poop accidents for years. The pediatrician instructed us to have him do a weekend oral “clean out” to—we thought--“fix” the problem. . . At age 8, we decided to try M.O.P. We made our way through various phases and variations. My son stopped soiling but still had night-time wetting. We just kept going. . . Eventually, he started waking up with a dry pull-up. My son is now 17. He hasn't used an enema for 7 years.
The mom of a 13-year-old with long history of encopresis posted:
My son struggled with daily accidents since age 4.5 and hid dirty underwear, smeared poop on walls and resisted help. . . We did enemas daily for months and then weaned VERY slowly after each phase. Adding in daily Ex-Lax was the key to success for us. That’s what helped get us past the smears. . . I hope our success gives someone else a bit of hope. He is now almost 13 and is NOT reliant on daily Ex-Lax . . . He is NOT reliant on enemas. He only uses one occasionally, and he can now feel the urge to have a bowel movement. This DOES get better. There will be setbacks along the way but please stick with it.