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.





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).


Encopresis Laxatives: Mineral Oil?

Mineral oil is the most commonly used lubricant laxative in the treatment of encopresis. It is usually given in large quantities (multiple teaspoons) during initial cleanouts to remove very dry, hard stool that is stuck in the colon and cannot be pushed out. This condition is known as an impacted bowel or fecal impaction. Mineral oil facilitates bowel movements by coating the large intestine and the stool with a waterproof film which keeps the stool soft and able to move more easily. Seepage of mineral oil sometimes occurs when mineral oil is used for cleanouts because of the higher than usual doses often required for cleanouts.

During cleanouts mineral oil is often combined with a water retention laxative such as Miralax or Restoralax. However, once the cleanout is finished the mineral is usually discontinued or the dose is significantly reduced so as to avoid seepage or "accidents" during the maintenance phase of treatment when we are relying on the water retention laxative to keep your child's stool softer than normal, e.g. pudding or applesauce consistency.

Contrary to common thought, mineral oil does not cause a vitamin deficiency.



Milk of Magnesia: Q&A with Dr Tom

Question: My daughter is turning 4 in a month. She is not potty trained, still in diapers and won't even sit on the potty at all. She has tried a few times, mainly in a public restroom but absolutely refuses now. We have been using Milk of Magnesia for a year now, and upped the dose since I have read your book in hopes to clean her out and start potty training more seriously. Her moods are so much better when she is cleaned out! My question is, do you think Milk of Magnesia is okay as our laxative choice?  Thanks

Answer: Milk of Magnesia works well as a laxative for many children with functional constipation. However, I prefer to use a PEG 3350 laxative such as Miralax. Whether you stay with Milk of Magnesia or not depends on whether it helps your daughter to have a comfortable, very soft, medium-to-large bowel movement at least six days a week. If not, I would try a PEG laxative.
Dr Tom

Treating Encopresis: PEG Laxative Dose and Stool Consistency

 A water retention laxative such as Miralax is the type of laxative most commonly recommended by pediatric healthcare providers for the treatment of encopresis. When Miralax is prescribed, parents are usually advised to give one or more "caps" or "half caps" of the powder diluted in water. A "cap" is the amount recommended on the container and is therefore assumed to be the "standard" dose. However, the fact is that there is no one dose that is the most efficacious for all children. A cap or half cap may be too much or too little as evidenced by its effect on stool consistency. In my book, The Ins and Outs of Poop, I strongly recommend dosing PEG laxatives like Miralax by the teaspoon (one cap is approximately 5 level teaspoons). Dosing by teaspoons makes it much easier to determine the most efficacious dose for each child.

Why is getting just the right dose so important?

The key to successfully treating encopresis is to find that dose of a laxative that enables a child to have 1 to 2 medium-to-large, very comfortable BMs a day, 5-7 days a week that are softer than the normal "toothpaste" consistency. 

The desired consistency is like that of pudding or applesauce but not watery.

Over the many months required to effectively treat encopresis, the laxative dose may need to be raised or lowered in small increments to maintain the desired consistency until withholding has stopped and the rectum has shrunk back to it's normal size.

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.

How Long Does a "Clean Out" Take?

When we are doing a "clean out" by increasing the laxative dose as you describe in your book, how do we know the stool has been sufficiently cleaned out to reduce the laxative dosage? 

As part of their initial assessment, some healthcare providers will obtain what is called a lower abdominal x-ray to determine if there is excess stool anywhere in the large intestine. If this was done, a second post-cleanout x-ray can help determine whether the cleanout was successful.

When x-rays have not been done, which is typically the case, the answer to this question is based on the quantity and the consistency of the stool that was moved during the 3-4 day cleanout, compared to the amount and consistency of stool moved in the 3-4 day period prior to the cleanout. Ideally, in about two to four days, the higher dose of a  laxative will enable the child to produce considerably more stool than in the days prior to the cleanout, and the consistency of the stool will become very loose or watery.

At this point we assume that the rectum has been cleaned out and we gradually begin to lower the dose of the laxative until the stool consistency becomes more like apple sauce or pudding. Once this has been accomplished, you then continue on into Step #3 of my Six-Step Program which is to "End Withholding."

Why are laxatives almost always necessary?

I read an article that says that laxatives could be bad for kids. Why do you say that "they are always necessary" (on the back of your book)?

Children who have occasional constipation, the kind that we all experience from time to time, rarely need laxatives. Occasional constipation is relieved with natural remedies such as adding more fiber to a child's diet or encouraging exercise. In my book, I devote a whole chapter to the treatment of occasional constipation with natural remedies.

Children with functional or long-term constipation, often referred to as encopresis, almost always do need one or more laxatives as part of their overall treatment. Without laxatives, it is not possible for these children to produce sufficiently soft, large stools every day long enough to end their stool withholding and soiling. With regard to the safety of laxatives, the fact is that research and clinical experience over the past 25 years has clearly shown that, when used properly, laxatives are safe for children.

In my book, I discuss how and when to safely introduce, maintain and then remove laxatives.

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.