Misperceptions

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.

But he poops! How can he be constipated?

Our doctor says my 5-year old can't be constipated because he poops every day! But he has frequent "poop accidents."  Any ideas?

This is a very common misconception about constipation even among pediatric healthcare professionals. The fact is that a child can have a fairly large, soft stool every day and still be constipated.

In my book, I talk in more detail about the two types of withholding: complete and incomplete. With incomplete withholding a child may go to the bathroom every day but still not fully evacuate his or her rectum. Over time, this results in a gradual backup of stool which slowly, but surely, stretches the rectum to the point where a child begins to have stool accidents.


Is drinking more water a treatment for functional constipation (encopresis)?

When parents tell me that they think their child is constipated because he or she does not drink enough water, I remind them  that diets low in water do not cause functional constipation and that drinking more water is not a treatment for functional constipation. Functional constipation is caused by stool withholding and subsequent rectal distention. I tell them there is no good reason to tell their child to drink more water. Constipated children are no different than other children. They will drink more water when their body tells them to drink more water, that is, when they are thirsty.

In an article in the NY Times titled, "No, You Do Not Have to Drink 8 Glasses of Water a Day" pediatrician Aaron Carroll, an expert in this area, says that, "there is no formal recommendation for a daily amount of water that people need. The amount obviously differs by what people eat, where they live, how big they are and what they are doing."

In my book I point out that the "officially" recommended liquid consumption from all sources for children 1 to 8 years of age is 4 to 5 cups (32 t0 40 fluid ounces). I underlined "from all sources" as a reminder that there are many other sources of water that should be included when trying to determine how much water a child drinks in any given day such as milk, soda, soup, fruit and vegetable juices.  

 

 


13 Year Old with Encopresis Cries While Reading "The Ins and Outs of Poop"

I recently received a request for a telephone consultation from the mother of a 13 year old girl who had been withholding her poop for eleven years. She said that her doctors had recommended Miralax, ultra sounds, x-rays, therapy and even a barium enema when her daughter was only 4 years old, which, she said, "was horrible beyond belief and probably made everything worse".

Because she had not yet read my book, I suggested that she do so before we talked by phone. Shortly thereafter she sent me the following email:

Dear Dr. Tom,

Just to let you know that my 13-year old daughter wept like I haven't seen her weep as we read your book together and we read about kids who were like her, who are great achievers and great kids, but who have greatly struggled with functional constipation. When she read that a girl had actually recovered, she just started sobbing. There it was, a possibility she had never heard of... she has felt so alone. We all have because most people aren't willing to talk about this, so, we haven't known that this was a problem others were facing.

There has been so much shame. Doctors have mostly just sent us away telling us to feed her more prunes or giving us sheets on normal constipation which we knew somehow was very different. There has been much trauma and loss of trust with the medical world over the fact that doctors couldn't hear us, for example, when we told them that she was able to hold in an enema for 13 minutes as a four year old.

It has been a week and we are all supporting my daughter in going to the bathroom every day with Miralax.  We are going to continue for 6 months with her going every day and see how this goes and contact you again if we need guidance along the way.


Counselor Says Child's Encopresis Is Caused By Poor Parenting

A mother recently told me that when she sought advice from a counselor about her 5 year old son’s encopresis, the counselor told her that his accidents and his seeming indifference to having poop in his underwear was due to her poor parenting. Needless to say, this mother was very relieved to hear from me that her son’s soiling behavior was not her fault. 

Unfortunately, there are still many medical and nonmedical healthcare providers who know very little, if anything, about encopresis.  Encopresis is not a topic that is typically covered in detail in medical school (general or pediatric).

When the parent of a child with bowel problems is looking for a healthcare provider for advice or guidance, their first question should always be, “How familiar are you with functional constipation or chronic constipation or encopresis in children?”

If the provider says that they do know about this condition, the second question to ask is, “How many children with this condition have you seen in your practice?” Ideally, what you want is a provider with both knowledge and clinical experience.

(If you cannot find a provider who has either or both of these traits, but you do have a provider you like and trust, I am always available to speak with the provider regarding your child's specific situation. Please visit Consultations and sign up for a free 15-minute telephone consultation.)


Beware of Laxative Scare Mongers!

The mother of a child with chronic constipation recently wrote to me in a panic after reading an internet article (though as I note below, it is actually a well-disguised advertisement for the author's product) titled   “Is MiraLAX the Next Vioxx? No, It's Much Worse!” She said that, on Miralax, her daughter is “now pooping every day” and “has made major progress towards pooping on the toilet”. However, having read the article, she decided to stop giving her daughter Miralax. In its place, she said that she was going to try some “natural alternatives”.

In other words, the article scared this mother into not giving her child a laxative that is safe and effective and replacing it with natural remedies which are helpful for occasional constipation but which are largely ineffective for treating chronic constipation (encopresis).

The author of this article very cleverly uses half-truths to deceive readers into believing that Miralax causes a host of neurologic disorders such as autism, dementia, depression, schizophrenia, multiple sclerosis, Alzheimer’s disease and even encopresis!

The active ingredient in Miralax is polyethylene glycol 3350 (PEG 3350), NOT ethylene glycol. However, the author leads people to believe that PEG 3350 is exactly the same as ethylene glycol which, when used in products such as “automotive antifreeze and brake fluid“, can cause neurologic problems.  There is no scientific evidence that laxatives containing PEG 3350 cause neurologic or neuropsychiatric disorders.

When read carefully, this article is no more than a well-disguised advertisement for a scientifically untested and non-FDA approved combination of supplements and probiotics developed by the author for a veritable shopping list of conditions:  “chronic constipation, bloating, diarrhea, irritable bowel disease, diverticulosis, depressed immunity, chronic fatigue, anemia, infertility, amenorrhea, acne, hair loss, graying hair, premature aging, pre-diabetes, diabetes, respiratory and urogenital infections" and on and on.

And, as if this wasn’t enough to scare parents into discontinuing a safe and effective treatment for childhood constipation, the author recommends stopping giving your child FIBER because he says it makes stools so big that they hurt. As any medical professional will tell you, fiber, just like PEG laxatives, may make stools bigger but it also makes them softer so they do not hurt

Do not believe everything people tell you about laxatives, especially on the internet. My advice? When in doubt, ask your pediatric healthcare provider.


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.


Can laxatives cause poop accidents?

The mother of a child with encopresis recently told me that when she asked her pediatrician if Miralax might be the cause of her son’s frequent poop accidents, her pediatrician said, “Absolutely not!  In all my years of practice I have never seen Miralax cause accidents!” 

My first thought was that this doctor must not have treated many children with encopresis.

Any PEG or water retention laxative such as Miralax can cause stool to leak, sometimes uncontrollably, if given in unnecessarily high doses. This is, unfortunately, very common. In my experience, the main reason why children are unintentionally given more (or sometimes less) laxative than they need is because parents and even some healthcare professionals think that “one cap” of the PEG powder is the “standard dose” even for children, so that is how it is typically prescribed. But, often that is far more than the child needs.

The last thing a child (or their parent) wants is to soil or leak MORE than usual! In my experience, the most common reason parents feel that laxatives don't work for their child is that their child has been on an incorrect dose.

The fact is that there is no one dose that is correct for all children. A dose that works for one child may be too much or too little for another child. That’s why I always advise that PEG laxatives be prescribed by the teaspoon and not by the cap, keeping in mind that one cap equals five level teaspoons.  My book describes in detail how to determine the correct dosage for your child.