Constipation in Kids & Is Miralax (polyethylene glycol 3350) Safe?
Polyethylene glycol or PEG 3350, commonly known as MiraLAX is the most commonly prescribed medication for constipation in children. However, although it's popular use, the FDA has never approved the product for use in children. PEG 3350 is an "osmotic laxative" that has no data to support the long term management of childhood constipation. In theory, how PEG 3350 is suspected to work is that it is a molecule that is too large to be absorbed by the intestine. Therefore, when it is consumed it stays inside the intestine and holds water. This can help flush out the bowels. Then, the product is excreted in the stool and not suspected to stay inside the body. Reports of diarrhea, gas an bloating can be common when using PEG 3350, or other natural alternative laxatives for that matter. However, over the past few years the FDA received a number of reported adverse events of neuropsychiatric symptoms in children taking PEG 3350 such as anxiety, rage, mood swings and depression. As with any adverse reaction, there could be a number of underlying conditions or factors such as pre-existing depression, anxiety or behavioural issues.
However, we know that the human gut microbiome (essentially bacterial in the gut) is a complex ecosystem that can be affected by medications, foods and drugs. Over the years, studies have pointed to the fact that behavioural issues may be influenced by the gut microbiome. One study, in 2018 found that "the induction of mild osmotic diarrhoea by administration of PEG induced long-term changes in the gut microbiome, transient disruption of the mucus barrier and subsequent innate and adaptive immune responses" In addition, A 2014 FDA investigation into the safety of PEF 3350 discovered that small amounts of ethylene glycol (EG) and diethylene glycol (DEG), the main ingredients in antifreeze, were found in all batches of the PEG 3350 that they tested.
A spokesperson for the FDA admitted that “many of the reported adverse events were classic symptoms of ethylene glycol ingestion.” Some children that use Miralax had blood acidity when tested, according to the FDA. This is another known effect of ethylene glycol poisoning. So, does this mean that all children that take PEG 3350 will have an adverse reaction? Of course not! However, this information tells me that using natural therapies for constipation first, before trying medication, may be ideal as many natural therapies may not carry the same potential for side effects.
Over the years of my clinical practice, these are the things I have found to be helpful for constipation in children (and adults alike!). As always, please speak to your healthcare provider first if these therapies are right for you or your child.
Water: Studies have found an associated between low fluid intake and constipation. I never suggest forcing a child to have more water or more food, but offering water and having it easily available may be helpful. My kids have their favorite water bottles that they use inside and out of the house. Adding ice to the water at times can sometimes increase water uptake, or a little lemon, lime or cut up cucumbers. We tend to avoid any juices, aside from fresh squeezed or fresh pressed juice but I do offer warm and cold teas such as chamomile, peppermint and lemon balm.
Fiber. increasing vegetables and fruits is the top of my list for adding fiber to childrens diet, especially apples, pears, berries, avocadoes and prunes. Although legumes like peas and beans are high in fiber, some people find them aggravating and gas producing. Seeds such as ground flax and chia seeds, provide a high amount of fiber and can be a good option to add into smoothies, sauces or baked goods for extra fiber. As flax an chia are known to be bulk laxatives, it is important to ensure the child has an extra cup of water when increasing flax or chia in the diet. Otherwise, these seeds can be mildly constipating.
Stress. for both children and adults alike, stress can cause constipation and other gastrointestinal issues. If you do believe stress is an issue for your child, a variety of relaxation techniques may be helpful. Both my children love massage and I find it a wonderful activity to connect and relax with my children. Foot massages are great, but for constipation an abdominal massage with a very small amount (1tsp-1tbsp) of castor oil (used externally only) can also help get things moving. If you do not have castor oil, I have also used olive oil or coconut oil. Other stress reducing activities can include walking outside and spending more time in nature or teaching your child some basic deep breathing techniques, depending on the age of the child. Screen time is often a common "go-to" activity for "down-time" or relax time in kids, however too much sitting and a sedentary lifestyle can also contribute to constipation
Exercise. Movement and exercise has been shown to be an effective therapy to help constipation. Children require at least 60 minutes of moderate to vigorous activity a day for good health. The colon responds to activity. Good muscle tone in general is important for regular bowel movements. The abdominal wall muscles and the diaphragm all play a crucial role in the process of bowel movements. If the muscles around the digestive tract are weak, they are not going to be able to do as good of a job helping stool along.
Supplements. Both probiotics and magnesium citrate have been found to be helpful in the use of constipation. Probiotics provide beneficial bacteria into the gastrointestinal tract, helping to restore gut balance. Magnesium citrate works in a similar way as miralax as it is an osmotic laxative. Magnesium, unlike PEG3350, is a natural substance typically found in food, not a man-made chemical substance. Magnesium is also used to help relax the nervous system and the muscles and may also help improve sleep quality and quantity.
Homeopathy. Homeopathic remedies are extremely diluted natural substances that have been used in natural medicine for hundreds of years. Certain homeopathic remedies may be beneficial for constipation.
Bryonia is the homeopathic remedy that is indicated for constipation when the stools are very hard and dry. The child may also complain of being very thirsty, yet the stool is dry.
Calcarea carbonica is indicated when the child is constipated but does not have any urge to pass stool. The child may not be uncomfortable without passing stool, but yet still be constipated as they are not having regular daily bowel movements.
Nux vomica is the homeopathic remedy used when the child is experiencing lots of straining to try and push the stool out. Typically the stool comes out in little pellets as is hard and painful to pass.
Do you have favorite natural remedies or tips and tricks to use for children's constipation? Leave them in the comments below!
Weersma RK, Zhernakova A, Fu J. Interaction between drugs and the gut microbiome. Gut. 2020 Aug;69(8):1510-1519. doi: 10.1136/gutjnl-2019-320204. Epub 2020 May 14. PMID: 32409589; PMCID: PMC7398478.
Doestzada M, Vila AV, Zhernakova A, et al.. Pharmacomicrobiomics: a novel route towards personalized medicine?Protein Cell 2018;9:432–45. 10.1007/s13238-018-0547-2
Boilesen SN, Tahan S, Dias FC, Melli LCFL, de Morais MB. Water and fluid intake in the prevention and treatment of functional constipation in children and adolescents: is there evidence? J Pediatr (Rio J). 2017 Jul-Aug;93(4):320-327. doi: 10.1016/j.jped.2017.01.005. Epub 2017 Apr 25. PMID: 28450053
Ashish S. Chogle, MD Science, concerns behind the MiraLAX laxative debate, October 2017
Gao R, Tao Y, Zhou C, Li J, Wang X, Chen L, Li F, Guo L. Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials. Scand J Gastroenterol. 2019 Feb;54(2):169-177. doi: 10.1080/00365521.2019.1568544. Epub 2019 Mar 7. PMID: 30843436