Kayla is a bright, round-faced, adorable 3 year-old girl who is having trouble going to the bathroom. She’s often skipping bowel movements for a week at a time, or even more. Like so many kids (and adults!), she gets cranky, uncomfortable, and loses her appetite when she’s constipated. When she finally does poop, it’s painful, to the point that she often avoids going even when she needs to.

Kayla’s pediatrician, like most would, prescribed Miralax for regular daily use, which was working really well. But the parents got concerned after reading a recent New York Times article questioning the safety of Miralax in kids. So they came to me for a consultation.

Miralax: We Give it Like Water

Miralax is the most common medical treatment for children's constipation. It (or similar generic medications) is recommended by about 75% of pediatricians in the US, according to one study. According to a 2012 New York Times article on Miralax use in kids, one doctor, a pediatrician in Beverly Hills, CA, said, “I’ve had kids on it daily for years” and “We literally give it like water.” The recent article, in January 2015, reiterates the problems.

The New York Times has actually run two articles questioning the safety of pediatric Miralax use in the last two years. The 2012 article also stated, “The way many families use Miralax and its many generic equivalents has strayed far from its original intent. The Food and Drug Administration [FDA] approved the drug for use only by adults, and for only 7 days at a time.”

To date, no long-term studies meeting FDA criteria have ever been conducted on Miralax (or a similar generic product) use in children. Moreover, it has never been approved by the FDA for pediatric use. When it was first approved for adult use by the FDA in 1999, it came with a warning: “Miralax should not be used by children.”

When I was in my medical training, we were in fact, taught that it was basically as safe as water.

Most likely, however, it’s not.

There’s Antifreeze in Your Kids’ Medicine!

In 2012 the Empire State Consumer Project, an environmental consumer action group in New York, petitioned the FDA to more aggressively investigate the use of Miralax in children. Should we be concerned about this medication?

I think so! The FDA admits to years of reports of tremors, tics and obsessive-compulsive behavior in children given laxatives containing PEG 3350, the active ingredient in Miralax. A 2014 FDA investigation into the safety of Miralax discovered that tiny amounts of ethylene glycol (EG) and diethylene glycol (DEG), the main ingredients in antifreeze, were found in all batches of the drug they tested.

Furthermore, an FDA spokesperson admitted that “many of the reported adverse events were classic symptoms of ethylene glycol ingestion.” Some children regularly using Miralax had blood acidity when tested, according to the FDA. This is another known effect of ethylene glycol poisoning.

In spite of this, small amounts of these toxic contaminants are actually considered acceptable in the final product, and are, according to FDA standards, and considered “safe.” However, this is when used in adults, and only for up to 7 days at a time.

There’s still no data on what happens in kids, whose nervous systems are developing well into their teens, when they chronically ingest these toxins.

While a new research group, funded by the FDA, is convening at Children’s Hospital in Philadelphia to investigate the safely of these substances in children, it is disturbing that anyone would ever think it’s okay to consciously include antifreeze in a children’s medication – particularly one that is used daily over a long period of time.

So What’s a Mom To Do?

While I know it works, and a lot of you rely on it, I’d definitely stop using Miralax and similar generic products on a daily basis unless there's a medical reason to continue using them (i.e., your child gets dangerously impacted without them), reserving them for urgent use only (meaning it’s been a week, no BM, and your child is really uncomfortable). I’d avoid it altogether in very young children, perhaps those under 2 years old, because their nervous systems are still under heavy development. And I’d try natural approaches first.

Natural Approaches to Children's Constipation

Constipation can be treated naturally. There is reliable scientific data on both the safety and effectiveness of the tips I’m about to share with you. I’ve used these in practice for 30 years.

But first, what is constipation? Most researchers agree that fewer than 3 bowel movements per week, in a child of any age, is considered constipation. Also, discomfort in passing stool, even with regular BMs, is considered constipation.

If your child is often constipated, and then has a big or loose bowel movement, sometimes in inappropriate places (in clothing, bed – i.e., not in the toilet) then this is called encopresis, and it’s a result of chronic constipation. The loose stools are due to “overflow incontinence” and are not intentional or even controllable.

Some children have very hard stools, and others have very large stools – making them difficult to pass. This is also constipation, even if they have a regular BM.

If your child is chronically constipated, has overflow incontinence, blood in the stool, or regular belly pain and difficulty passing stool, please have an evaluation with your pediatrician before using home remedies. It’s important to make sure everything is in working order, and for older children, to make sure they don't have inflammatory bowel disease (i.e., Crohn’s disease or ulcerative colitis).

Many pediatricians will be supportive of trying the following safe and effective remedies once they know everything else is AOK.

Dr. Aviva’s Top 7 Steps for Treating Children’s Constipation, Naturally

Below is a step-wise approach to safely and naturally treating children's constipation. You can try each step for a few days, then add in the next, or you can tackle all the steps from the outset.

Step #1 Go Gluten and Dairy Free

Gluten-containing foods and dairy products can both cause constipation in sensitive kids, and this may be the only sign of a food sensitivity. Gas and bloating or belly aches after these foods increase the likelihood that they are a trigger. I always recommend starting any treatment plan for chronic constipation out with a basic elimination diet for 3 weeks to see if there are dietary triggers. See here for how to do a basic elimination diet.

Step # 2 Add the Right Foods and Fiber

In addition to taking out the triggers, it’s important to add in good quality fiber in the form of plenty of fresh vegetables in whatever form your child is old enough to tolerate (from purees for little ones to whole forms of veggies for older kids). It’s tough when kids are picky eaters, so head to some mommy blogs or even Martha Stewart for creative recipes.

In addition to fiber from whole food sources, fiber supplements have been shown to be safe and effective for children. Pick just one or two of the options below to use at the same time. Too much fiber can be irritating to the gut, and bulk fiber like flax and chia seeds can glum up in the gut and cause constipation if your child isn't drinking enough water. Each fiber “dose” should be accompanied by about 4-8 oz of fluid

Glucomannan from the Japanese konjac root, which is available in natural food stores (the dose is 100 mg/kg of child’s body weight, to a max of 5 gm per day, with 50 mL of water), has been shown to be safe and effective in children.

Flax seeds, up to 1 tsp. ground twice daily for children aged 2-7, and up to 1 TBS ground twice daily in children over 7, is an effective bulk laxative that can be mixed into a smoothie, mixed into nut butter and spread on an apple of crackers, or mixed into a 4 oz. of water or juice.

Here’s a great recipe for incorporating flax seeds into your child’s daily diet. The dried fruit is also rich in iron and calcium.

RECIPE: Fruit Balls Rich in nutrients, fruit balls are a healthy treat for kids of all ages and a great laxative. They are really sticky, so get kids to brush their teeth after eating them to prevent cavities. ½ cup raisins

½ cup prunes

½ cup almonds

½ cup shredded coconut or almond meal

¼ cup flaxseed To prepare: Slowly grind all ingredients except the coconut or almond meal in a blender or food processor. Add a little water as needed to form a slightly sticky dough. Form into 2-inch balls and roll in the coconut or almond meal. Have fun creating your own variations. Kids love making these, too. Serving size 1-2 fruit balls, depending on your child's age. These are sweet so consider them a “treat” or dessert.

Chia seed is also mildly laxative. There are some wonderful chia seed puddings online. Chia seed should be used in a ratio of 8 parts liquid to 1 part chia seeds, otherwise it can absorb water from the intestines and add to, not fix, the problem!

Psyllium or plantain seeds can be mixed into smoothies or a small amount of juice, similarly to ground flax seeds.

Step # 3 Reduce Stress

There’s a strong connection between stress and our gut health. In some people stress causes constipation. Do your best to identify stressors at school, at home, or in other settings and help your child to resolve these. A variety of mind-body techniques, including biofeedback, have been found to be helpful for children experiencing stress-related constipation.

Abdominal massage can be very relaxing to children, and according to medical literature review, may be helpful in the treatment of childhood constipation. The technique is simply to massage the abdomen in a circular clockwise direction, firmly but comfortably, in a diameter a few inches from the navel, using the palm of the hand, for about 5 minutes. A small amount of massage oil can make the massage strokes easier to perform.

Sometimes the constipation itself leads to a vicious cycle of stress because it hurts to have a bowel movement, so using prebiotics and probiotics as discussed below, and the herbs, is important to also include in your plan.

A fantastic herbal formula for kids with stress is Herb Pharm's Children's Herbal.

Step # 4 It's “Potty Time”

A lot of people just get too busy to bother sitting on the can. This happens to adults, and it also happens to kids, especially if the morning routine at home is a big hectic rush, and there’s no time to just sit and S#it! So carve out some potty sitting time for your child, regardless of the age. About 30 minutes after meals is ideal, as it is the natural time for the body to evacuate. Let them sit for a max of 10 minutes. If constipation is a chronic issue, make it a casual time – bring a book, allow for 10 minutes of video watching on an Ipod – whatever it takes. With little kids, let them have their sitting time on the potty while you have yours. You can have a chat and scat.

Step #5 Fix Potty Posture

Squatting is the most natural position for having a BM; sitting upright, as we do on the toilet, is one of the least natural positions! For little kids, switch to a squatting potty like a Baby Bjorn if you don’t already use one; for older kids, purchase a squatty potty type of toilet stool. It allows them to sit on the toilet but have their legs elevated to more of a squatting position. This is great for pregnant moms and constipated adults, too!

Step #6 Have the “Potty Talk”

Our society isn’t the most open about bathroom functions, yet kids in school are still required to raise their hands to get permission to leave class to use the loo. Imagine being at a committee meeting and having to raise your hand to ask permission to go poop! You’d probably hold it. And that’s what tons of kids do in school.

A lot of people also don’t like pooping in public bathrooms – they’re embarrassed by making bodily sounds. So yup, that causes them to hold it, too. Enough holding it and guess what, your body just stops giving you the regular signal and soon you don’t even have the same urge to go. Having regular potty time before and after school can prevent the need to go at school, but helping your kids, from a young age, realize that Everybody Poops and that constipation is common and that holding it can cause it, can go a long way to reducing their embarrassment and their constipation.

If your child has a medical issue with constipation, you can also get special permission for your child to leave the classroom to go without having to raise a hand and make it a public spectacle. Most kind doctors would happily write a bathroom pass note for your child’s teachers – you’re not obligated to provide medical details in the note.

Step #7 Try Safe Herbal and Natural Supplements

In this section are my go-to herbal and natural supplements for constipation in kids. I've given you a variety of options to accommodate different ages and food preferences — from teas to smoothies, and of course, the Fruit Balls above. The herbs in this article can be obtained online from Mountain Rose Herbs, and the various remedies can be tried singly, or in combination. Generally, give things each a few consecutive days of use to see if they are working.

TRY: A daily probiotic is a must for kids with constipation, and can make an enormous difference. Get a product that ideally contains a blend of Lactobaccilus and Bifidobacterium, species, and give daily. Prebiotics, in the form of fructose oligosaccharide, may be just as important as the probiotic, as they provide the food that the probiotic needs to thrive, and have been shown to lead to healthier, softer stools.

TRY: Magnesium citrate is an osmotic laxative — meaning it works the same way as Miralax, by pulling water into the intestines. It is safe in moderation for even young children. A typical dose range is as follows:

1–3 years 65 mg/day

4–8 years 110 mg/day

9–18 years 350 mg/day

I recommend taking it before bed, which will often lead to a soft BM in the morning. It can be purchased in powder form and mixed into a small amount of almond milk or water and taken in a cup with a straw, which is easy for young kids.

TRY: HERBAL RECIPE 1: Slippery Elm Sprinkle (for children 1-3 years old): Mix 1 tsp. of slippery elm bark powder and 1/8 tsp. of cinnamon powder. Sprinkle onto a small amount of apple sauce, into oatmeal, or into water or a small amount of smoothie. Give twice daily for 2 weeks. Discontinue if this does not result in regular BMs; use up to 3 times per week if effective for your child.

TRY: HERBAL RECIPE 2: “Smooth-Move” Infusion (for children 1 year old and over) Slippery elm provides the bulk and moisture that aid elimination while the remaining herbs ease gas to prevent possible cramping. Fennel and licorice are also mildly laxative. 2 tsp. slippery elm powder

1 tsp. fennel seeds

1/2 tsp. licorice root

½ tsp. powdered gingerroot

1 pint boiling water To prepare: Combine all the herbs in a glass jar. Add the boiling water, cover, steep for 20 minutes, then strain. To use: Dosage is 2 teaspoons for children under two years, 1 to 4 tablespoons for children ages two to seven, and 1/4 to 1/2 cup for older children. This can be repeated twice daily. You should notice results in a few days. Omit the licorice root in children with adrenal or blood pressure problems.

Or try this:

HERBAL RECIPE 3: Cocoa-Licious Smoothie 1 Tbs. organic cocoa powder

2 tsp. ground flaxseed

½ frozen banana

3 frozen organic strawberries

2 TSP coconut oil

1 cup of plain or vanilla almond milk To prepare: Combine all the ingredients in a blender and mix well. Give 1-2 cups daily. You should notice results in 1-2 hours after drinking the smoothie. This can be taken daily if effective for your child. Coconut milk can be used instead of almond milk if your child doesn't tolerate nuts. You can vary the fruit as well.

TRY Senna: Senna is approved by the FDA for children 2 years old and older. It is a strong stimulating laxative so I don’t recommend it for daily use, but it does come in handy in a pinch. To cut down on the belly cramping that sometimes comes along with using senna, use a tea bag combination that contains ginger and fennel seeds, or peppermint leaf. Smooth Move by Traditional Medicinals is a good example of a tea blend you can use. Gaia Herbs Natural Laxative Tea is another.

To prepare: Steep the senna blend tea bag in 1 cup of boiling water as usual, and give 1/8-1/2 cup 1-2 times daily, depending on your child's age and the extent of the constipation. Expect to see results 5-7 hours after taking the tea.

In Summary

There are many natural approaches to treating uncomplicated children's constipation, from simple steps like changing the diet and adding in a pre- and probiotic, to massage, biofeedback, and herbal medicines. All have a track record of safety with kids.

In a world already rife with toxic environmental exposures, I’d start there and save Miralax for urgent use only.