Is it safe to use a stimulant laxative?

A common misconception about stimulant laxatives such as Ex-Lax and Senokot is that chemically-stimulated peristalsis ((intestinal muscle contractions that move stool toward the rectum) will begin to replace natural peristalsis because of damage to the intestinal tissue caused by the long-term use of senna-derived laxatives. However, studies over the past 30 years or more have concluded that the long-term use of stimulant laxatives does not cause intestinal damage. Moreover, published clinical research involving large groups of children treated with stimulant laxatives for a year or longer report that these children did not become dependent on stimulant laxatives to have bowel movements.

Nevertheless, I recommend the following usage guidelines:

  • Use the lowest dose possible.
  • Use intermittently if possible.
  • Discontinue if recipient experiences repeated cramping.
  • Limit continuous use to twelve months.

How do stimulant laxatives (Ex-Lax, Senokot) work?

Stimulant laxatives are used to encourage bowel movements by irritating the inner lining of the intestinal wall. Stimulant laxatives (such as Ex-Lax and Senokot) increase muscle contractions in the large intestine which push stool toward the rectum. These smooth muscle contractions called peristalsis cause the intestine to narrow and then propel the narrow portion forward. Peristalsis looks like an ocean wave travelling slowly through the large intestine.

Unlike water retention laxatives (such as Miralax or Milk of Magnesia) which are used to keep stool consistently moist (soft) and easier to pass, stimulant laxatives are used to increase the feeling of urgency (the need to poop) and to increase the amount of stool produced the following day. It is not uncommon to treat functional constipation/encopresis with a combination of both of these laxatives.

 

 

 

 


Cleanout unnecessary following one poop accident

If a child has just one poop accident during the maintenance phase of encopresis treatment, some parents and pediatricians mistakenly think that the child is constipated again and needs (another) cleanout. Logically, one accident alone, by a child who is on a laxative and has been having regularly large, softer-than-normal bowel movements, is not indicative of a re-occurrence of constipation. Therefore, in this situation, a cleanout is unnecessary.

The correct response in this situation would be to wait and observe what happens in the days that immediately follow the accident. If accidents continue, what is the consistency of the stool? Is it softer or firmer than it has been? If softer, consider decreasing the laxative dose. If firmer, consider increasing the laxative dose. A cleanout should only be considered if the child goes 24-48 hours or more between bowel movements and/or his or her stool turns dark brown in color.


Encopresis, Exercise and COVID-19

Encopresis could be an unfortunate consequence of community efforts to control the spread of COVID-19 due to decreased opportunities for outdoor exercise. Children who are physically active are less likely to become constipated than those who are not. Unfortunately, school closures and stay-at-home orders combined with the closure of parks and playgrounds in some communities severely limit opportunities for physical activity. Forced to stay inside, children will also be spending more time than usual in front of "screens" which we know causes many children to ignore bowel urgency which can lead to constipation.

Parents need to encourage their children to walk, run and ride bikes and scooters etc as much as possible even if it's just up and down the street in front of their home while making sure that they maintain the "6-foot rule". 


Encopresis treatment: 2 frequent mistakes

Parents and even pediatricians frequently make two mistakes when treating children who have encopresis: stopping laxative treatment too soon and treating encopresis as if was normal constipation.

The treatment of encopresis or functional constipation, as evidenced by stool withholding and soiling, typically requires the use of oral and/or rectal laxatives over a long period of time. Stopping laxatives too soon almost always causes withholding and soiling to reoccur.

Normal or occasional constipation the kind that we all experience from time-to-time, is best treated with natural remedies such as eating more high fiber foods, drinking more liquid and getting more physical exercise. Natural remedies are rarely effective for treating encopresis.

On page 5 of "The Ins and Outs of Poop" I list the signs of normal constipation and encopresis with regard to stool frequency (4-5 BMs vs 3 or fewer BMs per week), stool shape and surface ("sausage" with cracks vs sausage/ball/pellet-shaped stools with lumpy surfaces), stool color (dark-to-very dark brown vs dark-to-almost black), hard to push (occasionally vs frequently), uncomfortable or painful to push (occasionally vs frequently), habitual stool withholding (never vs always), soils underwear (never vs often).

 


Withholding bowel movements again following a cleanout

Parents often report surprise and disappointment when their child starts to withhold bowel movements again following a cleanout. This is because they and, sometimes, their pediatrician who recommended the cleanout, do not know the difference between functional constipation (encopresis) and occasional or normal constipation.

Children who have encopresis have developed a "habit" of withholding, which is to automatically contract their anal sphincter to avoid a painful bowel movement whenever they feel bowel urgency. So, because withholding is a learned or habitual response to the feeling of having to poop, it will start again after a cleanout. Step#3 of my Six Step Program is the phase of treatment during which your child's association of pain with urgency is gradually extinguished together with the related habit of withholding.

Children with occasional or normal constipation do not have difficulty passing stool because they are withholding but because their stool has become dry and hard and it is very difficult for them to push out. Normal constipation comes and goes fairly quickly and is usually treated by increasing fiber, liquids and exercise but if continues more than a week or so may require the use of a laxative or even an enema to remove the dry stool in order to prevent the child from starting to withhold.


Fear of Pooping: Treat With "Exposure Therapy"

The fear of pooping is like a phobia. Parents will often ask why their child continues to be afraid to poop and, therefore, refuses to poop even after their child's poop stops hurting. Continuing to fear pain in the absence of pain seems irrational. Although there was a reason to be afraid in the past, that reason no longer exists. Just like a fear of bees can persist long after the first sting, the fear of pooping can persist long after the first painful poop. Such fears require treatment with exposure therapy.

In exposure therapy, phobic fears are neutralized by gradually and repeatedly exposing people to the object or the situation that evokes that fear. In the case of a fear of pooping, the child's fear of pain decreases little by little each time he passes stool and does not experience pain. The number of pain-free bowel movements needed to neutralize or extinguish the fear varies from child to child depending on various factors such as the age at which constipation began and the child's current level of maturity and cooperation.Regardless of these individual differences, however, the number of painless bowel movements required is always going to be large, which is why the treatment of functional constipation takes so long.


Children Who Withhold Poop Are Afraid It Will Hurt

Children who experience pain or discomfort when pooping quickly learn to withhold their poop because they are afraid that the poop will hurt. They learn that the pain or discomfort can be avoided by simply contracting the muscle (sphincter) around their anus whenever they feel the need to poop. Withholding begins as a voluntary response (a conscious decision), but if the painful or uncomfortable bowel movements continue, withholding can become involuntary. This means that the anal muscle "closes" automatically whenever the rectum contracts which is what causes the feeling of urgency, the need to poop. Withholding is no longer a conscious decision. It has become a habit which leads to functional constipation--also called encopresis.

Exactly how long it takes for withholding to become a habit varies with age and temperament. Some infants and children begin to withhold involuntarily after just one painful or uncomfortable bowel movement whereas others are able to tolerate a number of painful bowel movements before becoming habitual withholders. The difference between the two groups is most likely related to the degree of discomfort or pain they experience. The more intense the discomfort the more quickly withholding becomes involuntary.


Explaining Encopresis to Teachers

When enrolling their child in a preschool, kindergarten or first grade class, a question parents frequently ask is "How do I explain encopresis to teachers?

The first thing to do is ask the teacher (and school nurse) what she or he knows about encopresis. If nothing or very little, suggest that the teacher or nurse read my book, especially Chapter 19 titled, "Encopresis Goes to School" so that you and the teacher are both on the same page (literally and figuratively!) about what encopresis is and what it is not. For example, some teachers may think that children who have poop accidents are able to control when they poop and that, therefore, poop accidents are intentional. Providing your child's preschool or kindergarten with accurate information about encopresis at the beginning of the school year will prevent a lot of misunderstanding and stress for you, the teacher and your child.

You should arrange with the teacher to have a change of clothing available at all times in case of an accident. If soiling is frequent, you may want to send a change of clothing every day. If infrequent, one change of clothes left at school may be enough. You should also ask the teacher to allow your child to go to the bathroom whenever she needs to go rather than telling her to “wait” or to “hold it”. Whenever possible, your child should be allowed to use a one-person bathroom like the one at home. Children with encopresis are often unwilling to use a bathroom that is not “private”.


Teacher Punishes Child For Soiling In Preschool

I met this child and her parents in my office two weeks after her preschool teacher had told her parents that she "would quickly stop soiling once she learned that no one was going to help her clean up." The teacher also recommended that the girl be given a backpack to take clean clothes to school and soiled clothes back home. Not surprisingly, this girl was very unhappy  and was having even more trouble with soiling than she did before. 

My first order of business was to speak directly to the teacher to explain encopresis. For children with encopresis, soiling is not a choice.

Parents of children with encopresis (functional constipation) get this kind of advice from all sorts of people: friends, grandparents, daycare and preschool teachers and even healthcare professionals. This “rub her nose in it” advice is based on two erroneous assumptions:

  1. She is able to control when she poops.
  2. Her poop accidents are intentional.

Following this kind of advice inevitably causes shame and embarrassment especially in the classroom. And, as any parent with older children knows, once teasing begins at school it is difficult to stop.

Telling a preschool child with encopresis to clean herself up without help is almost always perceived as punishment, and, as I explain in my book, The Ins and Outs of Poop, punishment is almost always counterproductive. It becomes especially punitive when the accident is large and messy. While I think it’s good to have children HELP with the cleanup as much as they can (e.g. by dumping their poop into the toilet and/or by flushing), they should not be made to do it all by themselves.

Poop accidents can be eliminated through a combination of laxatives and POSITIVE incentives, but most critical is your attitude and willingness to help the child, as well as the attitudes of those other adults she admires and looks up to.