By Steve Hodges, M.D.
The other day I had a routine colonoscopy — fun stuff! The “bowel prep” gave me an opportunity to empathize with my patients and reflect on why similar colon washouts often don’t suffice for children with chronic constipation.
Of course, by “bowel prep,” I mean drinking massive amounts of laxative and sitting on the toilet endlessly while you essentially pee out your bottom. Or, as the great Dave Barry once described it:
You spend several hours pretty much confined to the bathroom, spurting violently. You eliminate everything. And then, when you figure you must be totally empty, you have to drink [more], at which point, as far as I can tell, your bowels travel into the future and start eliminating food that you have not even eaten yet.
By the time I checked in for my procedure, my bowels were, no doubt, 100% empty.
I thought: It’s so easy to get empty! Miralax clean-outs should work great for constipated kids.
However, that was after I’d consumed nothing for 24 hours besides clear liquids, so I was a bit lightheaded. Later, when I could think more clearly, I remembered why colonoscopy-type clean-outs often don’t help my enuresis and encopresis patients: These kids are stopped up with large amounts of crusty, old stool, whereas I was not constipated to start with.
As an adult, I’ve been a rock-star pooper, but it was not always thus. Throughout my childhood, I didn't poop at school or anywhere in public, actually. At my middle school if you tried to poop, students would bang on the stall doors or throw wet paper towels at you. No way was I subjecting myself to that.
As a result, pooping was painful for me, and I’d have poop smears in my underwear. Luckily, I did not have a sensitive bladder and managed to avoid bedwetting or daytime wetting.
Eventually, for reasons I don’t recall, I became uninhibited about pooping in public restrooms and have not experienced constipation as an adult.
So, the mega dose of laxative I took before my colonoscopy didn’t have to accomplish much. It was essentially like taking a shower when you’re already pretty clean.
But for my patients — well, a high-dose oral clean-out is like showering when you’re caked with massive amounts of hardened, sticky dirt. Even an industrial-strength power wash isn’t going to leave you squeaky clean.
Often, the liquid cleanse washes past the impacted mass of stool, so the child ends up with diarrhea and constipation. Or, the “clean-out” just propels the poop in the colon downstream, so the rectum becomes even more clogged.
Also, kids with enuresis and encopresis have learned to override the urge to poop or, in many cases, they don’t even feel the urge because their stretched rectum has lost sensation.
So, to continue my analogy, they’ll going to get caked with more mud shortly after their power wash.
A mom in our private Facebook support group offered a different analogy on oral clean-outs: “I’ve come to believe a clean-out is like a strict diet to lose 5 pounds: The effects are only temporary. I found that it cleaned my daughter out, but as soon as the cleanse was over, she started to fill back up.”
Another mom posted: "[With the clean-out], we had major output, like an ice cream machine for DAYS. Then, we were on the Miralax merry-go-round for years. Has not helped."
Oral laxative clean-outs are immensely popular with doctors in the United States and elsewhere. Many enuresis and encopresis patients referred to me were instructed by their physicians to do an oral clean-out every month for months on end.
But in most cases, these washouts did nothing besides ruin the kid’s weekend — or worse, leave the child in a lot of discomfort.
“Oral clean-outs gave my daughter messy accidents and painful rashes,” one mom told me.
Early in my career, I routinely prescribed Miralax clean-outs, followed by a daily maintenance dose. That was before I discovered that enemas are far more effective and not “dangerous” or “traumatic,” as most doctors assume.
These days, many parents tell me they follow through with oral clean-outs simply to placate their anti-enema GI doctors. One mom told me her child had done three fruitless oral clean-outs in a single month to demonstrate compliance, since her doctor disapproved of the Modified O’Regan Protocol (M.O.P.), the enema-based regimen I recommend.
“I was being nice with the GI,” she posted. “I’m not totally surprised [the clean-outs didn’t work] but had wishful thinking.”
Her daughter resumed enemas following the unhelpful “clean-outs.”
Another mom posted: "GI doc prescribed full clean-outs every 6 to 8 weeks, accompanied by heavy daily doses of Miralax. Told us enemas are 'too traumatic.' Needless to say, M.O.P. is the only thing that has ever really helped us make sustained progress."
Another mom chimed in: "We did clean-outs every 3 months or so for years. It didn't help. M.O.P. gave us our lives back! We also used Miralax and Exlax, eventually weaning off."
This isn’t to say oral clean-outs are unhelpful for all kids. Some families report that occasional clean-outs, in conjunction with M.O.P., have resulted in breakthroughs after their child stalled out on enemas.
“Only when we added in periodic clean-outs to M.O.P. did we see progress,” one mom posted in our support group. “I think they’re helpful, but not as a way to avoid enemas.”
In children with enuresis and/or encopresis, even emptying the rectum with a daily enema regimen can prove difficult. Most folks underestimate the challenge in cleaning out a rectum that has been clogged and stretched for years.
One mom posted that two months of M.O.P. had barely made a dent in her daughter’s stool mass, as indicated by an abdominal x-ray. She wrote: “If enemas aren’t even doing the trick, it makes me realize how inadequate our oral clean-outs were.”
In children with a stubbornly clogged rectum, I often recommend starting with overnight oil enemas followed by a morning stimulant enema (the Double M.O.P. regimen described in the Anthology). Other kids do well with a daily enemas plus daily Ex-Lax (the M.O.P.x regimen).
My general philosophy is, Hey, whatever works. So, for those who wish to try oral clean-outs, the Anthology include instructions for variations using Miralax and magnesium citrate.
Just keep in mind that chronic constipation in children is, well, chronic and therefore requires ongoing, aggressive treatment.
The oral laxative super-wash that cleaned me out so well before my colonoscopy likely would have accomplished little for the patients I treat.