Stimulant Laxatives: Your colon squeezer

While osmotics soften stool, they don't make the stool come out more easily. Many children need a medication to help get efficient squeezing from the colon. I like to think about a stimulant laxative as adding some throttle or “horsepower” to bowel movements. Maybe that’s an odd image, but it works for me. 

What do stimulant laxatives do?

• Cause stronger gut contractions

• Get more poop out

• More complete bowel movements

• More frequent bowel movements

Overcome a tough spot

There are a few situations for which stimulants are particularly helpful:

Incomplete evacuation: 

In longstanding constipation, that colon gets really stretched out from all that stool overload. That stretch makes the colon sluggish. This is the feeling that the poop “just won’t come out”. Or if it does, it’s incomplete–like there’s still just more in there. A stimulant laxative helps wake up that sluggish gut to get things moving again. It helps get it ALL OUT at once.

Stool withholding:

A child who is afraid to poop will hold on to stool. They get really backed up and uncomfortable, as you can imagine. We know that poop has to come out somehow. A stimulant laxative helps squeeze the poop out even if the child tries to hold it in. 

As part of a bowel clean-out regimen: 

When trying to completely empty the colon, stimulant laxatives add a lot of efficiency to that process. A clean-out should always be supervised by a doctor.

Special needs

Some children with special needs may have a better quality of life with regular use of stimulant laxatives. Children with low muscle tone, tight pelvic floors, and poor sensory integration are all frequent candidates for these medications. 

2 Types of Stimulant Laxatives

There are two main stimulant laxatives but each of these come in different types of products:

1. Senna: Senna is a natural medicine containing sennosides that are derived from the leaves of the senna plant. Sennosides irritate the lining of the bowel causing it to contract. The active ingredient is usually a liquid or is added to small pieces of chocolate, which makes it an easy medication for a young child to take. The irritation, by the way, is not dangerous or medically concerning. Technically caffeine is an “irritant” as well. You all know what I’m talking about: It’s that “gotta go” feeling after drinking coffee.

2. Bisacodyl: This is also an “irritant” technically. Most people use the pill form. This needs to be swallowed whole. There is also a suppository form, which is less commonly used in children. Bisacodyl tends to be a bit stronger of a squeeze (and therefore a bit more crampy) than senna. So I tend to stick to senna in younger children. Older kids do fine with both senna and bisacodyl.

5 Parent Concerns About Stimulant Laxatives

1. Will the extra contractions cause my child pain? Yes and no. Stimulant laxatives make the bowel contract or squeeze harder. When you think about bowel contractions—that strong urge ‘to go’–it doesn’t actually feel pleasant. Contractions are mildly uncomfortable, some adults would say. Some would say it is normal to feel strong contractions before pooping and so it doesn’t raise any alarm bells. To children, however, these movements can be translated as “pain”, “alarming”, or something to “fight off”. Usually, children tolerate these medications well, when supervised by a doctor. 

2. Is it dangerous to cause a child’s colon to have extra contractions? When dosed correctly, stimulant laxatives cause minor enough contractions that there should be no safety issues using these for constipation and incomplete stool output. Families usually get a lot of value in discussing dosages and administration of stimulant laxatives with their doctor.

3. Will stimulant laxatives cause malabsorption or nutritional issues? No. Since there is a flushing effect through the bowels, food may move a little more rapidly through the bowels. However these medications are gentle enough that your nutrition will still be fully absorbed. It would take a really large, continual overdose of medication (and lots of explosive, persistent diarrhea) before a child was at risk of not absorbing their nutrition. So if the medication is working well, you do not need to be concerned about nutritional issues caused by the medication.

4. Are stimulant laxatives habit forming? Will my child ever be able to come off of these medicines? Stimulant laxatives are not habit forming. There is no biologic mechanism by which someone can develop a dependence on these drugs. When you have overcome the primary problem (stool withholding, sluggish bowel, tight pelvis, etc) you should be able to come off of these medications. Despite this fact, some children with special needs may have a better quality of life with ongoing use of stimulant laxatives without stopping them. Children with low muscle tone, tight pelvic floors, and poor sensory integration are all frequent candidates for regular, ongoing use of these medications.

5. Will stimulant laxatives make my potty trained child have accidents? Counter-intuitively, adding more squeezing to the colon does NOT usually lead to more poop accidents. The reason is that these medications do such a good job emptying out that colon that there isn’t really much stool to leak out of there. So again, while the contractions may be stronger, there’s less poop “hanging around” so leakage and accidents typically go DOWN. Good news! 

How to use stimulants

Use intermittently

Stimulants work best when used intermittently. There are some days when your child will not be able to get all of their stool out. Maybe they are holding their poop. Maybe the gut is feeling slow that day. For whatever reason, if stool is not easily passed, a stimulant laxative can help. By contrast, there may be days when stool comes out much easier, more complete, or without withholding. That could be a "holiday" from giving an extra squeezing medication to your child. A small group of children will do better with DAILY use of a stimulant laxative. But even then, the goal is still to use just the right amount to keep things moving and to hopefully taper the medication with time.

Monitor effects regularly

Since we are talking about using a medication intermittently, how do you expect to know when you child does or does not need medication? Well, if you are changing diapers, your life is easier in that sense. You can just monitor the stool output when you do diaper changes. However if your child uses a bathroom without you, it requires discussing making sure you are tracking what is coming out in the toilet. Make sure your child’s care givers are all communicating with each other!

Get the timing right

I tend to dose stimulant laxatives at bed time. They tend to “kick in” the next morning, which is a very convenient time for children to help deliver efficient bowel movements. They usually do not stimulate bowel movements while your child is asleep. But this occasionally happens. On the rare chance that the medication is causing middle of the night poops, you would want to switch to early afternoon for school-age kids. You can dose it first thing in the morning for children who are not going off to school. Really the worst time to give a stimulant laxative is right before a child leaves for a major activity like school or swimming at the beach. It’s just not very convenient for most kids trying to learn the ways of the toileting world.