By Steve Hodges, M.D.
I’ve spent half my career advocating a bedwetting treatment many doctors find appalling: one enema per day for at least a month, before tapering to every other day for a month and then twice a week for a third month.
That’s the heart of the Modified O’Regan Protocol (M.O.P.), named for pediatric kidney specialist Sean O’Regan, M.D. Dr. O’Regan pioneered this treatment in Montreal in the 1980s, tracked his patients’ results in an excellent series of published studies, and treated hundreds and hundreds of Canadian children with the regimen before he switched to treating adults.
I’ve treated well over 2,000 patients with the protocol myself, and medically speaking, I’ve had the same experience that Dr. O’Regan reported in his research: significant success and no complications.
But in another regard my experience has been the polar opposite of Dr. O’Regan’s. In his day, physicians didn’t doubt the safety or wisdom of enemas. Today, doctors freak out.
I can’t count the number of parents who’ve told me their physicians consider daily enemas harmful to a child’s physical and/or emotional health. Among the alleged risks: electrolyte imbalance, dependence on enemas to poop, damage to the sphincter, and the all-encompassing “emotional trauma.”
As one mom in our Facebook support group put it: “Our doctor said it was abusive to give enemas to a child.” Even WebMD, a trusted resource for many parents, perpetuates the notion that daily enemas can be harmful.
Is there merit to these warnings?
In a word: no.
As I detail in The M.O.P. Book: Anthology Edition, enemas are safe for children as long as 1.) you limit them to once daily and 2.) your child does not have kidney disease or certain other chronic diseases or congenital abnormalities.
I’ve been so fascinated by modern-day alarm about enemas that I called up Dr. O’Regan, now retired in Arizona, and asked him if any of his patients ever suffered complications on his regimen.
He told me: “Our only complication was a 7-year-old girl who clogged the toilet at our hospital after an enema. She was legendary.”
That’s right: The damage was to the plumbing, not the patient!
Dr. O’Regan told me he got no pushback from physicians in Montreal, where he conducted his research for many years. Once he discovered his regimen was effective (a story I tell in The M.O.P. Book: Anthology Edition), he asked the local pediatricians to send him their bedwetting patients. “They all bought into it,” he said.
None of these doctors suggested oral laxatives would be “safer” or more effective. (Though Miralax wasn’t available back then, senna, magnesium, and castor oil were among common oral remedies.) “We knew the root cause of bedwetting was incomplete rectal emptying,” Dr. O’Regan said, “and enemas were the only way to solve the problem.”
His patients’ parents didn’t question the regimen, either. Of course, Dr. O’Regan noted, “This was before the Internet, when people had more of a blind faith in doctors.”
I’m personally grateful for the Internet and for parents willing to disagree with their physicians. After all, the Internet is how I’ve gotten the word out about M.O.P! Thanks to information I’ve posted online, hundreds, if not thousands, of children have overcome enuresis (wetting) and encopresis (poop accidents) using Dr. O’Regan’s regimen, which is by far the most effective treatment for these conditions.
Still, countless other children continue to suffer embarrassment, discomfort, stress, and rectal damage because their physicians deem enemas “risky” or “abusive.” These kids are prescribed endless doses of Miralax and useless bladder medication. Or, they’re told accidents are “normal” and advised to be patient until they “outgrow” the problem.
I totally understand the idea of inserting a tube into a child’s bottom is scary to parents, and giving a child an enema every day for a month just seems . . . wrong. I also know the packaging on pediatric enemas states: “Do not use for more than 3 days without asking a doctor.” So if your doctor thinks enemas are dangerous or abusive, well, that puts you in a tough position.
In this post I will address the questions I’ve heard doctors and parents raise about enema safety, and I will discuss how long you reasonably can, or should, continue M.O.P. I’ll also cover symptoms, such as discomfort or burning, that suggest a child should switch to a different type of enema.
I urge you to share this post with medical professionals who doubt the safety of enemas for children.
Now, on to the questions!
Q: Can enemas cause electrolyte imbalance?
A: Not unless you give a child more than one enema per day (DO NOT DO THIS!) or exceed the recommended dose (DO NOT DO THIS!) or if the child has kidney disease, heart disease, or certain other chronic diseases. (Ask your doctor.)
The concern about electrolytes pertains to over-the-counter pediatric enemas that contain phosphate, an electrolyte that draws water into the colon. Electrolytes are substances in the blood — including sodium, potassium, calcium, and magnesium — that perform critical jobs such as regulating our nerve and muscle function, our hydration level, and our blood pressure.
Certainly an electrolyte imbalance is a big deal, potentially causing damage to the kidneys and heart, even death. But this does not happen in healthy children who are limited to one enema per day. (Read the FDA’s warning against using more than one enema per day or exceeding the recommended dose.)
How, in theory, could enemas cause an electrolyte imbalance? Well, when a child is given an enema containing phosphate, the colon absorbs this electrolyte; if the colon absorbs too much, the child could end up with a dangerously high phosphate level.
But the human body does an excellent job of controlling our electrolyte levels! A child with normal kidney function will simply pee out the extra phosphate. Any increase will be negligible.
Complications from enemas are so uncommon that a review of 39 studies conducted over 50 years found a total of only 15 cases of electrolyte imbalance in children ages 3 through 18. Over 50 years. The vast majority of these cases involved children who had a chronic disease or were given more than one enema in a day.
I have never had a patient develop an electrolyte imbalance from enemas.
Nonetheless, if you or your doctor remain concerned about electrolyte imbalance, you can do M.O.P. with a different type of enema, such as a liquid glycerin suppository. These work well for many children and have no chance of interfering with electrolyte levels. Or, you can purchase an enema bag and tubing and use saline solution, a much less expensive option that also poses zero chance of causing an electrolyte imbalance. I discuss various options in The M.O.P. Book.
Be sure you read the book carefully. I did hear from one mom who accidentally gave her child twice the recommended dose of Pedia-Lax phosphate enema solution for a few days because she confused phosphate enemas with pure saline enemas. In some children, the regular M.O.P. regimen — using store-bought pediatric phosphate enemas — isn’t effective, in which case I advise moving on to M.O.P.+, a more aggressive regimen involving large-volume saline enemas. It’s safe to give pure saline enemas in higher volume, but it’s not safe to give phosphate solution in high volume. I understand why the mom got confused, because Fleet’s pediatric enemas are actually called Pedia-Lax Saline Laxative Enemas, even though phosphate, not saline, is the active ingredient.
The child who got the extra phosphate did not suffer any consequences, but the advice remains: Do not give a child more than the recommended dose of a phosphate enema.
Q: Will children on M.O.P. become dependent on enemas to poop?
A: No, despite warnings from WebMD to the contrary. Here’s what WebMD states about pediatric enemas:
“This medication may cause a condition known as laxative dependence, especially if you use it regularly for a long time. In such cases, your bowel may stop working normally and you may have ongoing constipation. For most people with occasional constipation, a bulk-forming laxative (such as psyllium) or a stool softener (such as doscusate) is a better and safer product.”
I have no idea if WebMD is sponsored by the makers of oral laxatives or if the unnamed person who wrote this paragraph has ties to products in competition with enemas. But to suggest — let alone state as fact — that enemas cause dependence and stool softeners are “safer” is irresponsible.
Let’s talk about “dependence.” If you have chronic constipation, this means your bowel is already not “working normally.” It means your rectum has become stretched by the pile-up of stool and has lost tone and sensation. In other words, the rectum can’t fully contract and expel poop, and the child cannot sufficiently sense the urge to poop. In children this becomes a vicious cycle: Because they can’t feel it’s time to poop, even more poop piles up, which stretches the rectum even more and further compromises the rectum’s tone and sensation.
Daily enemas clear out the rectum, giving it a chance to regain the sensation and strength to empty fully and regularly. Once that happens, the child will no longer need enemas.
One of the goals for a child on M.O.P. is to poop spontaneously once a day, in addition to pooping after each enema. If the child is only pooping after enemas, this is NOT a sign of dependence on enemas; it just means the child hasn’t fully regained rectal tone and/or sensation. Once the rectum bounces back, your child will be able to poop without enemas.
WebMD offers no evidence for its claim about enema dependence, and I don’t even know of a theoretical basis for this claim.
As for the notion that oral laxatives are “safer,” again, they cite no evidence. For occasional constipation, oral laxatives are fine, and for children on M.O.P., I do recommend osmotic laxatives as an adjunct to daily enemas. Osmotic laxatives — such as Miralax, lactulose, and magnesium citrate (Natural Calm) — draw water into the stool to keep it mushy. (Is Miralax poisoning children? I discuss here.)
However, as my research clearly indicates, osmotic laxatives are a dramatically inferior treatment for any child constipated enough to have accidents.
Q: Can daily enemas damage the sphincter?
A: No! A mom recently emailed this question after a doctor told her frequent enemas can damage the child’s sphincter, the ring of muscle surrounding the anus.
Think about it: An enema tip is around the diameter of a pencil. The stool of a constipated child is as wide as a jumbo sausage! Yes, stool is softer than plastic, but the sphincter of a constipated child is plenty accustomed to stretching wider than it does when you insert an enema.
In fact, pointing this out to children is a great way to ease any fear they might have of having an enema. “It’s a trick I use with hesitant kids,” says Erin Wetjen, PT, a Mayo Clinic physical therapist who specializes in pediatric incontinence. “I have them show me the average diameter of their stools, and then I pull out the enema and show them the small tip in comparison to the large circle they make with their hands.”
I do advise parents to help their children relax during enemas, because when the sphincter is tense, the nozzle won’t slide in easily, and the child may feel discomfort. Our blog post “11 Ways to Ease Your Child’s Fear of Enemas” includes ideas to help your child relax.
At any rate, your child’s sphincter is safe.
Q: Can daily enemas damage the intestinal mucosa?
A: The mucosa is the inner lining of the colon, and in a small minority of children, phosphate enemas can irritate this lining, a condition called colitis. A sign of colitis is blood in the child’s stool. In this case, you’d stop phosphate enemas and switch to saline or liquid glycerin.
If your child feels internal burning with phosphate enemas (this is different from discomfort upon inserting the nozzle), I recommend switching to a different type of enema.
I have never treated a child who developed colitis from enemas, but I have spoken to other doctors who have, and I do watch for signs.
Q: How long is it OK to maintain daily enemas?
A: This is usually not an issue, as bedwetting and accidents typically resolve after the 90-day M.O.P. protocol, beginning with 30 consecutive days of enemas. However, in up to 30% of severely constipated children, 30 consecutive days is not sufficient to clean out the child’s chronically clogged rectum. I’ve got loads of X-rays to prove it!
These children need to keep going with daily enemas. I do not advise tapering to every other day until a child has five to seven completely dry days and nights. If the child is showing improvement during the 30 days but just isn’t consistently dry, I recommend continuing with daily pediatric enemas. But when a child shows little to no improvement — it happens, unfortunately — I advise moving on to M.O.P.+, a more aggressive regimen involving large-volume enemas. (In The M.O.P. Book, I explain what constitutes "progress" and when to move on.)
Either way, parents should not be concerned that continuing with daily enemas well past 30 days is unsafe. My concern is that it can be ineffective. I’ve had parents say, “We’ve been doing enemas for 90 days and my child is still wet every night.” Don’t spin your wheels! There is always a next step to try.
Q: Will daily enemas traumatize children?
A: Not according to the families I’ve worked with. No studies have considered whether a regimen such as M.O.P. will “emotionally scar” a child, as one doctor told a mom in our Facebook support group, but I cannot find any basis for this concern. As far as I can tell, doctors who issue this warning to parents have no actual experience with enemas.
Certainly many parents and children are apprehensive, if not downright afraid, when they start doing enemas. Mostly they fear enemas will hurt, and sometimes they do hurt. This is usually because the child isn’t relaxed or lying in the right position or because there’s not enough lubrication on the tip. Read “11 Ways to Ease Your Child’s Fear of Enemas” or download our free infographic “9 Ways to Make Enemas Less Scary” for specific ideas, all recommended by parents who’ve been through M.O.P.
For most families, enemas quickly become routine, even something to look forward to. As one mom in our support group posted: “My 4.5 year old loves his enemas! He was constipated and had stomach aches for over 2 years with nothing else helping. Now he's going on his own, dry and clean all day and no tummy aches.”
Another mom posted: “My daughter likes how she feels after. Does she want them to end one day? Yes! But she is perfectly content because she has seen how getting them helps. And it helped her to be comfortable pooping at school because she can feel the urge now.”
Yet another mom posted that it was oral drugs, like Miralax, that caused her daughter distress. “[Oral] cleanouts gave her messy accidents, humiliation, and painful rashes. My daughter loves her enemas! We announce, ‘It's enema time’ with the Muppets' Mnah Mnah song: ‘An enema, doot doo doo doo doot.’”
I hear stories like this all the time. Yet many doctors simply refuse to believe children are fine with enemas. One mom posted: “When my child told the doctor she liked enemas because she felt better, her statement was immediately dismissed with a ‘No, you don't. No one likes them.’ "
Another mom wrote: “Our daughter’s urologist still makes a stinky face and says it's really aggressive treatment choice.”
Indeed, M.O.P. is aggressive — in the best possible way. Chronic constipation in children is a notoriously stubborn problem, and in my experience, aggressive treatment is the only kind of treatment worth doing.