By Steve Hodges, M.D.
Among parents of children with enuresis or encopresis, a common fear is that their child will become “dependent” on laxatives or enemas to poop.
I often hear, “How soon can we start weaning? I don’t want my child to become reliant on Ex-Lax.” Or “My doctor says enemas can cause lazy bowel.’’
But other parents have the opposite concern: They worry about tapering too soon, fearing a recurrence of their child’s constipation, along with pee and/or poop accidents.
“We’ve worked SO hard to get where we are today,” the mom of a 9-year-old posted in our private Facebook support group. “I’d hate to give all that up by letting go too soon.”
Both concerns surface frequently in my practice and in our support group. Below are a handful of related questions that folks have posted recently, along with my commentary.
For further discussion about enema and laxative “dependence” — an unwarranted concern for chronically constipated children — see pages 58 to 60 of the M.O.P. Anthology 4th Edition. The book also discusses how and when to taper off enemas and laxatives.
Q: When it is safe to stop being so focused on pooping? My daughter, age 9, overcame daytime accidents almost 2 years ago and has been dry overnight for almost 1 year, thanks to a combination of liquid glycerin suppositories [LGS], Ex-Lax, and a bedwetting alarm. We’ve weaned off the LGS, but if we skip Ex-Lax, she won’t poop — or just barely. I’m not comfortable with Ex-Lax longer than needed, but I don't want her rectum to stretch and fill again. For now, I’m still making sure she takes Ex-Lax every day and poops. In the past, we’ve tried osmotic laxatives, which soften things up but don’t give her the urge to poop, like Ex-Lax does. At what point should I let go?
A: I understand your reluctance to ease up, as children with a history of constipation are prone to backing up again. However, a child who has been accident free for as long as your daughter has will likely do just fine without Ex-Lax.
I suggest she taper off Ex-Lax, reducing the daily dose by one square a week, and add a daily osmotic laxative, such as PEG 3350 (Miralax), lactulose, magnesium hydroxide (milk of magnesia), or magnesium citrate. Even if osmotics weren’t as helpful in the past, a daily dose should suffice at this point. Continue to stay vigilant, and if your daughter hasn’t pooped for two days or shows signs of holding her poop, increase the laxative dose or use an LGS. Once kids overcome accidents and the holding habit, they just don’t need stimulant laxatives anymore.
Q: My 7-year-old has had encopresis since age 3, and after years on the Miralax train, we tried M.O.P. and the accidents stopped. After the 30-day mark, he had accident free for 7 days, but I did not start tapering to every other day because he hadn’t had any SPs. After 14 days accident free, he’d had only one SP, but we started tapering anyway, on your suggestion. Well, we only made it 4 days in Phase 2 before he had a relapse (big skid mark). During those 4 days, he had no SPs. Should we start over again with Phase 1? He’s on an osmotic (magnesium citrate). Should I also add in a stimulant laxative?”
A: Well, it was worth a try! We know kids who overcome accidents but still don’t poop daily on their own have higher odds of a recurrence, but often the child stays accident free. You don’t necessarily need to repeat Phase 1 entirely, if he just had a skid mark (a sign of withholding) rather than a full-on accident (a sign of a major back-up).
However, if you suspect he’s gotten pretty clogged up again, a return to daily enemas, even for a week or two, might be in order. Sometimes, kids become accident-free without overcoming their holding habit, and the osmotic laxative isn’t enough to prompt them to poop. Skid marks usually signal poop trying to exit — poop the child is trying to hold in — rather than true encopresis.
Regardless, I would add a stimulant laxative such as Ex-Lax in a high enough dose that makes the urge to poop is difficult for him to resist. Your son may be a kid who needs extra stimulus. Alternately, you could try increasing his osmotic laxative dose to the point where he can’t hold it.
I’d talk through the situation with him, explaining that holding his poop will cause his accidents to come back. See what barriers might be preventing him from pooping on his own. Is he reluctant to use the school bathroom? Does his teacher restrict restroom access? Does he not feel the urge to poop? (In that case, Ex-Lax will help, and a Phase 1 do-over might be in order.)
Q: My daughter is almost 5, and I’m afraid of giving her too much Ex-Lax. After 7 months on M.O.P., her daytime enuresis stopped. Now we’re just treating nighttime wetting. A recent x-ray showed her rectum was empty but still dilated. You recommended we add Ex-Lax, but is it normal that we keep having to increase the dose? She’s now up to 4 squares daily. Is that too much? Or is it worse to not give enough? She’s starting kindergarten this fall, and I’m so nervous for a setback.
A: Yes, when the rectum is empty but dilated, it’s normal for the child to need higher doses of Ex-Lax; more “squeeze” is required to stimulate a bowel movement. As long as circumstances warrant Ex-Lax — certainly as long as she is still having nighttime enuresis — it’s fine for her to take whatever dose is necessary to stimulate pooping, up to 6 Ex-Lax squares. Research conducted by Nationwide Children's Hospital in Columbus, Ohio, confirms senna-based laxatives are safe when used long-term for chronically constipated children.
Once she’s dry overnight, she can wean off the Ex-Lax. When a child has overcome daytime enuresis but bedwetting persists, the most effective protocol is M.O.P.x: nightly LGS plus daily Ex-Lax in a sufficiently high dose (explained in the Anthology). That usually means the child will feel some cramping.
Q: Can you please review this recent x-ray of my 8-year-old son? He's had encopresis for 2+ years and has been on 3-4 caps of Miralax for a year. For a week following the x-ray, he did enemas daily plus senna, and he had no accidents. Two days ago, our GI doc did a digital rectal exam and said our son was not impacted. He advised us to stop the enemas, reduce Miralax to 2 caps a day, and give him 1 senna square at night. After two days on this new protocol, his poops went from soft to hard logs, and he had a poop accident. Questions: 1.) Does he look impacted on this x-ray? 2.) Are digital rectal exams reliable? 3.) What do you recommend?
A: In answer: 1.) The x-ray shows his rectum is full of stool and dilated. 2.) Digital rectal exams are unreliable. The doctor can only feel for poop up to the length of a finger, so stool can be missed. An x-ray is far more reliable. 3.) As you’ve discovered, oral laxatives alone are unlikely to resolve the accidents. Enemas are warranted. With encopresis, I recommend dropping an osmotic laxative for at least the first two weeks of M.O.P., and perhaps altogether, as osmotics can often make poop accidents worse. I’d go back to what was working.
Keep in mind that when a child has encopresis (or enuresis), the goal is not to stop daily enemas as quickly as possible; it's to ensure the rectum has healed, so accidents will resolve for good. That process requires complete evacuation of the rectum daily, and enemas do the job far more effectively than Miralax.