Q&A with Dr Tom

Best time of day to give a laxative such as Miralax?


"What is the best time of day to give Miralax to my 3-year-old? Should we give it to him at the same time each day? Approximately how long does it take to produce stool? I don't want it to interfere with his nap at 2pm. He eats breakfast at 9am and lunch at 12:30pm. Also, we're concerned about the 2 days a week he goes to preschool. Do we wait to give him the Miralax until he gets home or will that throw off his schedule?"



Miralax is a water retention laxative which, at the correct dose, works continuously in the large intestine to keep stool soft and moist. Unlike with a stimulant laxative (e.g., Ex-Lax) there is no predictable time when Miralax produces a bowel movement. Typically, when a functionally constipated child is withholding stool especially a child your son’s age, we are more concerned about him just having a bowel movement every day than we are about the exact time of day it occurs. Scheduling comes later. I always recommend giving Miralax at approximately the same time every day either in the morning or in the afternoon/early evening.









3 y/o Will Only Poop While Standing in a Pull-Up

Many children with encopresis will only poop in a diaper or a pull-up. The longer this continues the more their parents worry that it will become a habit.

Here is what one mom recently said to me:

"My daughter is 3 years old and has been standing to poop with a pull-up on for 3 months now. She is fully potty trained for urine. Would you recommend that I keep trying to get her to poop while sitting on the toilet for a few minutes every day (even if she doesn't push) and only then let her stand to poop in her pull-up? Or, should I wait if she doesn't seem ready? I am concerned that the longer the habit goes on the harder it may be to break?"
Here is my response:

"No need to worry about her developing a habit of standing to poop. She will sit to poop when she is ready. She must first unlearn the habit of withholding. This requires many, many experiences of having a medium to large bowel movement every day, that is softer than normal (e.g. applesauce or pudding consistency) and that does not hurt or cause her discomfort. Unlearning the habit of withholding is a very slow process. The length of time is different for each child, especially for 2 or 3 year olds. You cannot and should not rush her.

While she is unlearning the habit of withholding (in order to avoid an uncomfortable or painful stool even if she has not had such a stool in a very long time!), I suggest that you help her begin to relax on the toilet by making a game of having her sit bare-bottom on the toilet for a minute or two once or twice a day just "for practice" with no expectation of pooping.  This would be in addition to when she sits to urinate.
It helps if she is being reinforced for her bare-bottom practice and urination sits with stars or stickers, etc. Don't force her to practice if she resists now and then. Make it a fun game and encourage her with prizes, e.g. stars and stickers and perhaps an occasional treat for good measure.  Be patient! This is going to take quite a while."

Is it safe to give my child Miralax?

Parents frequently ask me if it is safe to give their child a PEG laxative such as Miralax. Some of these parents have read on the internet or have been told by a friend that these laxatives cause "problems" in children. My answer is the same as that given by most pediatricians or pediatric gastroenterologists. Based on experience, these laxatives are safe.

The vast majority of children taking PEG 3350 experience no behavioral or psychiatric problems. However, for years the FDA has received occasional reports of tremors, tics and obsessive-compulsive behaviors in children taking PEG laxatives but it is not known whether the laxatives are the cause.

As reported early this year in the New York Times, the FDA has asked a group of doctors at the Children’s Hospital of Philadelphia to study the absorption of PEG 3350 in children, especially the very young and chronically constipated. The study is intended to find out whether PEG 3350 is absorbed in the intestines by young children and whether the use of PEG laxatives is linked to the development of behavioral or psychiatric problems. (www.http://nyti.ms/1xy89gQ)

If your child is chronically constipated and your child's healthcare provider has recommended a PEG laxative, you can be reassured that there is currently no scientifically validated evidence that PEG laxatives are unsafe for children.

Reward Charts Need to Be Visible: Q&A with Dr. Tom

In previous posts I have emphasized the need for sticker charts and sometimes (inexpensive) rewards to help motivate children to actively participate in their treatment.  The following Q&A speaks to the need for charts and rewards to be public and to reward the the behaviors required to achieve a treatment goal as well as the goal itself.
Mother: "Thank you so much for your sound advice.  I am using the reward chart as you suggested and marking it on my own & keeping it in a drawer with his poop record & he earned a big reward yesterday.  He is feeling good about himself but we had a big struggle to get him to SIT on the potty after breakfast.  He wanted to stand only which is one of our biggest struggles."
Dr Tom: I recommend that you bring the incentive chart out of the drawer so he can see it. Recall that he gets stars, stickers, etc for doing those things which will increase the likelihood of having quality BMs as well as for having them. Therefore, his chart should start with going to the bathroom cooperatively (allow a little resistance at first) followed by sitting and pushing (at least twice per instructions in my book). Having a BM is the last thing on the list. He gets small prizes (eg an M&M) for each of the first 4 steps and a larger prize for the BM (eg 4 M&Ms or whatever you are giving him now).

Painful constipation, soiling and daytime wetting: Q&A with Dr Tom

A parent recently asked me if soiling at home but not at school and frequent daytime wetting might be related to "painful constipation":

Question: My daughter had some painful constipation several months back which seemed to be the beginning of her soiling issues. After that time she started soiling frequently, as many as 4 or 5 times a day. She is soiling less now but there are two questions I have about the soiling. The first is that she rarely soils at daycare, she typically only soils at home. The second is that she is now wetting her pants frequently, something she didn't do when she started soiling. I think that all of her soiling issues point back to those constipation issues but I don't know if these two behaviors are in line with that idea.

Answer: Painful bowel movements will often lead to withholding followed by soiling (encopresis). Since your daughter continues to soil, albeit less than at first, she is still constipated.That she tends not to soil at school is also typical in the early stages of functional constipation. Ongoing withholding and soiling are often associated with day and night wetting. This is because a distended or stretched rectum will press on the bladder causing occasional leaking during the day and/or bedwetting at night. This is all covered in my book.