Enemas & Suppositories

Real Poop Story: Enemas for a 3 Year Old Boy

Parents rarely talk to each other about their experiences giving their children enemas.  It's understandable, but it's also unfortunate as there is a lot to be learned, especially when considering giving one for the first time.  I asked a parent I have been working with if she'd be willing to write a little about her experiences giving her 3 year old son enemas and she agreed.  Below is her story:

I recently spoke with Dr. Tom and he asked me to write about our experience with enemas. I was initially reluctant to do them. I've never had one myself and giving them to a 3 year old seemed daunting. Prior to using enemas, we went for months using Miralax, trying to come up with a strategy to get him to move toward the potty when he was about to poop.

If his bottom was naked, he would actually run and poop in the potty. But if I put him in underwear, a pull up, or just pants on him, he would poop wherever he was when he felt the urge and none of my strategies got him to budge. So I finally decided to try an enema. I figured that with an enema I could control when and where he would get the urge and so that when it came I could immediately start moving him toward the bathroom.

We talked about it a lot before doing the first one. We practiced in front of the television with a towel to lie on and a pillow. We explained how we would put the "water medicine" in his bottom and then put his pull up back on. We told him that he could keep watching TV until he felt poop trying to come out. But that as soon as he felt poop coming, we wanted him to run into the dining room before he pooped. Up until this point in the conversation, he'd been agreeable or only mildly reluctant about everything, but he flat out said, “No” to the request to go into the dining room before he pooped. I then told him that if he pooped in the dining room he would get a toy car. He brightened up. "Okay!" I consider that moment the turning point in our efforts.

Initially, getting him into position and then accepting the enema took some time. I used the television as immediate positive feedback for getting closer to the right position (he'd get maybe 20-30 seconds of his show for each tiny step in the right direction) and for allowing me to get the enema into him. He pooped in the dining room that morning, in the kitchen the next day and in the bathroom the next morning.

Transitioning to pooping in the potty took a few more days. I eventually figured out that I had to do two things: I had to be in the bathroom when he pooped and I had to make it easy to get the reward he was interested in. So, as soon as we did the enema and put his pull up back on, I went into the bathroom. He was told that he could get one toy for pooping in the bathroom or two toys if he pooped in the potty. He chose the potty!

We used enemas daily for several weeks. Getting him off the enemas was actually harder for us than getting him started. We had to increase his Miralax dosage a lot. He would beg me for "water medicine" and had several accidents during the transition. But as soon we found the right dosage he started pooping in the potty spontaneously.

Unfortunately, after a few months, he started withholding again so we had to restart the Miralax and the enemas. The return to withholding made everyone unhappy, including him. He remembered what it was like to be able to go when he felt the urge and was clearly frustrated. Right now, he gets one toy for pooping with an enema or two for pooping without one. We've recently gotten a couple of spontaneous poops in the potty but most days require an enema. We'd all love to be done with them, but I expect it will happen on his timeframe and no sooner.

Thanks so much to this parent for such a well-written and detailed description. My book also features a chapter on enemas, including other ideas on how to allow your child some control in what can otherwise be an uncomfortable situation.

Are daily enemas necessary to treat constipation/encopresis?

Daily enemas (for as long as a month or more as some recommend) are not necessary to successfully treat encopresis.  If, during the initial cleanout, a child still has dry, hard stool in her rectum after having been given a lubricant (e.g. Mineral Oil) and/or a water retention laxative (e.g. Miralax) to soften her stool, as many as one (1) to three (3) successive daily enemas may be necessary to completely remove her impacted stool. However, following the removal of the impacted stool, a water retention laxative at a dose sufficient to make her stool the consistency of pudding or applesauce will usually prevent an impaction from reoccurring and therewith the need for any additional enemas.

Some healthcare providers prefer to use rectally administered laxatives rather than orally administered laxatives for cleanouts. Enemas and suppositories remove excess stool from the rectum more quickly and predictably than oral laxatives, however, most children resist them, often strenuously, and parents are uneasy about giving them. Therefore, since daily enemas are not required for the successful treatment of encopresis and since giving daily enemas almost always causes conflict between children and their parents, the vast majority of healthcare providers including pediatric gastroenterologists recommend oral laxatives rather than rectal laxatives for the ongoing treatment of encopresis. 

Enemas as Incentives to Cooperate

Positive incentives such as stars/stickers on a Good Pooping Chart, time on the computer or small pieces of candy (e.g. M&Ms) are almost always necessary to get children to cooperate with the long-term treatment of functional constipation. However, I have found that some children reach a point in treatment where positive incentives alone are not enough. With these children I will sometimes recommend a negative incentive, telling a child that they will be given an enema if they do not poop by the end of the day. The following is a case in point:

“Thanks for recommending that if Peter doesn’t poop we give him an enema. That advice worked great as that night his dad put the enema on the bathroom counter and said, “It’s ready to go if you don’t poop” and, viola, Peter pooped right away. I have had to do the same thing a few times when I can tell he’s not really trying and it always works. Ever since the day we started doing this Peter has been pooping consistently every night. We still need to tell him to go but he does poop on the potty.”

Enemas and Suppositories for Encopresis

Even though many of the parents I talk to have never had a rectal laxative themselves, they resist giving them to their children because they erroneously believe that they “hurt”. This is unfortunate because there are many children with encopresis who can and do benefit from them.

With PEG oral laxatives, such as Miralax, the time between administration and defecation is slow and unpredictable. Because there is no standard dose, the unpredictable response makes it difficult to determine the most efficacious dose whether it is for conducting a cleanout or for helping a child have a large, soft bowel movement every day without accidents. If we give too little laxative, the child’s stool remains dry and difficult to pass. If we give too much laxative, the child’s stool becomes almost liquid and may “leak” out.

However, the time between the administration of a rectal laxative and defecation is typically very brief, usually within 1-5 minutes, if not immediate. When given correctly (see Chapter 14 of my book), rectal laxatives will empty approximately ¼ of your child’s large intestine thereby reducing the likelihood of accidents.

Another benefit of an enema or suppository is an increase in the efficacy of rewards used to reinforce pooping on the toilet. In other words, the almost immediate bowel movement on the toilet following a rectal laxative allows for an equally immediate reinforcement for pooping on the toilet. As I explain in my book, the immediate and frequent reinforcement of a new behavior leads to faster learning of that behavior than when reinforcement is delayed or infrequent.