By Steve Hodges, M.D.
Worldwide, the medical profession overwhelmingly has one answer to chronic constipation: PEG 3350, sold as Miralax in the United States, Movicol in the United Kingdom, and under other brands elsewhere.
Even when a child’s constipation is chronic and severe enough to cause enuresis (bedwetting or daytime pee accidents) and/or encopresis (poop accidents), doctors almost always prescribe Miralax. When accidents persist or even worsen, the answer is always more Miralax. And then more.
I have enuresis and encopresis patients who, prior to visiting my clinic, were prescribed daily Miralax for 5 years despite no improvement. I have patients who were instructed to undergo high-dose Miralax clean-outs — a messy, uncomfortable, time-consuming, weekend-ruining process — every month for a year. Or every weekend for months.
One mom in our private support group reported that at age 4, her daughter was having up to 20 accidents a day, causing "ulceration of the skin around her anus." And yet, she wrote, "for three years, our pediatrician and pediatric GI specialists did nothing other than recommend more Miralax and clean-outs, which would help for a couple of days, then she would regress again. I was at the end of my rope, it was so stressful and emotionally draining."
These families dutifully followed through, because they were not offered alternatives and because their doctors were insistent. “Oral clean-outs have never really helped us, but we have done them, anyway, to appease our GI,” one mom told me.
Needless to say, appeasing your doctor should not be the goal of treatment!
I’m not opposed to Miralax or other osmotic laxatives, such as lactulose and milk of magnesia. These laxatives soften stool, make pooping easier, and can play a helpful role in keeping constipation at bay. I gave Miralax to my own children. But my kids didn’t have enuresis or encopresis. In children who have accidents, PEG 3350 will rarely suffice and often exacerbates poopy leakage. Enemas simply work better, as I have written about extensively.
When my own clinic compared Miralax with enemas in a three-month study of children with daytime enuresis, accidents ceased in 85% of the children on the enema regimen, compared to 30% of the Miralax group. When Dutch researchers compared the two treatments for children with fecal impaction and encopresis, they found PEG 3350 “is likely to cause more episodes of fecal incontinence.”
And yet the medical establishment remains opposed to enemas except in very limited circumstances. For example, the United Kingdom’s national guidelines for treating constipation in children state, “Do not use rectal medications for disimpaction unless all oral medications have failed.” The American Academy of Pediatrics, on its web page about encopresis, states: “For the first week or two the child may need enemas, strong laxatives or suppositories to empty the intestinal tract so it can shrink to a more normal size.”
But here’s the thing: Oral medication for disimpaction is a short-term help, at best — and often totally useless. Often, the liquid cleanse washes right past the impacted mass of stool, so the child ends up with both diarrhea and constipation. Contrary to what the AAP suggests, a chronically stretched rectum will not shrink back to normal in one or two weeks. X-rays show it takes about three months.
Notably, in the Dutch study, six days of enemas did not have lasting results. After the disimpaction, both groups were instructed to take daily doses of Miralax for two weeks. During that time, the Miralax kids averaged 5.9 accidents per week, compared to 5.4 accidents for the enema kids, confirming everything I’ve ever learned about treating encopresis: What matters most is the follow-up, not the method of dis-impaction.
Most of my patients can’t get anywhere near accident-free in the long-term without persistent enema treatment. “Our doctor told us my daughter would be completely cleared out and in control by a 1-time clean out of Miralax and then 1 cap a day afterward,” one mom posted in our support group. “It would be hilarious if it wasn’t so maddening.”
I have to admit that, early in my career, I was one of those doctors. I was just following what I’d been taught in med school and did not grasp what it actually takes to resolve chronic constipation in children with enuresis or encopresis. Fifteen years later, I know better! That’s why the regimen I advocate, the Modified O’Regan Protocol (M.O.P.), calls for daily enemas for at least 30 days and until the child is reliably accident-free (no accidents, day or night, for at least a week).
Every week, in my clinic and online, I receive countless questions from parents about Miralax. I will leave you with this question from a dad — a common scenario that perhaps you will relate to.
Q: Our 4.5 y.o. old son has never shown interest in pooping on the potty. We transitioned him out of diapers 6 months ago, but he just started pooping in his underwear. He has had numerous bouts of constipation since age 2. Doctors put him on Miralax, but we kept going in a circle – weaning and then more constipation. After months on the Miralax merry-go-round, we started daily dosing him. Now he sits in corner and lifts his legs slightly to try and poop. Everyone is preaching that potty training needs to be his decision. We have been potty training for 12 months and nothing is changing. How strict should we be about where he poops?
A: Being “strict” should not play a role in potty training. This boy has a textbook case of chronic constipation, and treating the constipation, not potty training, should be the focus. It is an exercise in futility and frustration, for parent and child, to attempt potty training with a constipated child.
Hiding to poop, pooping in his pants, reluctance to poop on the toilet — all of these are classic signs of significant, chronic constipation, and Miralax won’t resolve this situation. An enema-based regimen such as M.O.P. is needed.
The poop pile-up in the boy’s rectum has stretched his rectum, so he has lost the sensation and tone needed to fully evacuate. No amount of cajoling or waiting around for him to “decide” to potty train will resolve this. Enemas will more effectively clean out his rectum daily, allowing the rectum to heal so he can regain the urge and ability to fully poop. At that point, he won’t need to potty “train.” He will heed his body’s signals to poop on the toilet.