First: If you have constipation problems please, please try Bifidobacterium lactis HN019 (found in a single strain as "Daily Bowel Regularity" also from yourhealthbasket.co.uk). This has been an utter game changer for us!
For a super quick taste of this see: Constipation" Isn't Just About Not Expelling Enough Stool Across a Week
How to check - there are two ways:
X-ray (see below).
A transit time test (easy!).
Food should go through the gut in about 24 hours.
Check by using something like sweetcorn, a lot of wild blueberries (very dark poo), or perhaps black chia / black quinoa.
Anything that's not normally consumed but that will show up in the stool.
If it's longer than about 24 hours, you're dealing with constipation. Read on!
I know it sounds nuts that you can go every day and still be constipated because I thought it was nuts myself!
I read this over and over and over on the massive Recovering Kids Facebook group: "My kid was going every day but until we got an X-ray done we didn't realise they were actually really backed-up and their colon was full of poop!".
Right! And everything is caused by Candida (if this is the 1990s perhaps...), an MTHFR mutation is effectively a death-sentence and the Nemecheck Protocol will cure any kid (or ruin them!). So much crazy!! 😆 Surely this is just another one of those things?
No, this is for real, I promise you.
How do I know this:
We ended up having an X-ray which showed a colon full of sludgy poop (not hard! No blockage of any kind).
Once we made absolutely certain, by whatever means necessary, that he cleared out everything that he needed to, every single day without fail, he was so, so much happier.
But - and I really want to emphasise this - keeping their bowels moving is a work around. It is not a fix. But you need to be working around the problem while you find the fix (this is great concept to keep in mind generally, when helping a child biomedically).
To be clear; If our son does poop out what he needs to in a day (you'll eventually get some idea of how much that happens to be) he:
Sleeps far better.
Is so much less aggressive.
Doesn't often have horribly painful burping that has him howling for up to two hours.
Focusses more (likely due to better sleep).
Doesn't get upset anywhere near so easily (who doesn't want fewer meltdowns?).
Of course, relieving constipation is "necessary but not sufficient" to really help him. More on that right at the end.
Note: Yes, I know the actual medical criteria for a diagnosis of constipation (the Rome IV criteria) but frankly that is extremely misleading as it misses the kind of constipation we see in our son (a colon full of sludgy poop) and also the problems arising from constipation are so severe by the time those criteria are met then someone is in terrible trouble. The problem should have been addressed long, long before that.
The extremely short answer: 1/2 to 2 capsules of Life Extension Magnesium Oxide daily in a single dose.
One thing I would not do is use a PEG based laxative. They are associated with neurological side effects (it is reported that even NT (neurotypical) kids can develop tics) and they are not even cleared for use in children in the US. The FDA is currently funding a study looking into the reports (and has been for some years - go figure...). Fore more see the Facebook group "Parents Against Miralax Restoralax Movicol (PEG 3350)". If you are using that currently please do not panic, the problems aren't life-threatening and they are reversible. Please, please do not simply stop it but instead transit to other ways of keeping them going. If you stop it cold you could trigger severe constipation which could end with a hospital stay. I've read more than one parent's account of exactly this.
There are obviously many ways to manage constipation (note: I'm talking about managing it here, not fixing it. But as mentioned you need a work-around while you fix). All have some kind of side effect. Some things obviously work better for a particular child than other things. There is no single answer.
Broadly speaking laxatives work by different mechanisms:
Stimulant (effectively irritating the bowel).
The problems here can be that the irritation can cause pain. Also there seems to be a tendency to become dependent on them (after a while you need them to have a bowel movement at all)
Osmotic (drawing water into the bowel).
Obviously this disrupts digestion and will probably therefore decrease absorption of nutrient and certainly shift the microbiome.
Bulking (making the stool less sludgy).
This can obviously backfire simply because they can directly cause constipation in themselves. But this depends a lot on why someone is actually constipated.
Oils (lubricating?)
This is not a category of laxative I've seen listed in the literature but we know from experience that Coconut oil (and MCT oil, and C8 oil) can be excellent laxatives. Our son loves coconut oil and once managed to eat enough of it to painlessly reduce his transit time to seven hours! (We saw totally undigested food appear seven hours after he ate it. Not good! But the lack of pain and the effectiveness were interesting!)
Smooth Move Tea
This is a stimulant laxative that uses Senna. However it is far more gentle (tends not to cause pain) than taking Senna as a capsule. I would only use this for as short a time as possible (a few days, ideally) as it can cause dependence (you need it to have a bowel movement). However we have used it for a matter of a few weeks because the alternative is so unpleasant.
Magnesium (the form is critical!)
Magnesium is mainly an osmotic laxative (Magnesium citrate can be very irritating for some people). It has been used for decades, For example there is a page here from the UK NHS (National Health Service).
There are many different forms of Magnesium. Magnesium is likely to be needed anyway as a supplement simply because it is so depleted in the soil (US and UK figures dating back decades show a decline to about 10% of the level of Magnesium in food). However we are talking about using higher doses than our needed for nutrition.
I have repeatedly seen people claim that high-dose, long-term magnesium use is absolutely safe (surely just that phrasing should give people a clue that it may not be!), and it is safe but, not absolutely. Remember too much water consumed too quickly can kill you.
However, hyper-magnesia (excess Magnesium in the tissues) can cause serious problems. In Japan where Magnesium is the most commonly prescribed laxative there are many case reports in the literature of hyper-magnesia including two or three (I can't recall how many exactly) deaths.
But please do not panic about this! Remember: This is the most commonly prescribed laxative in a country with some of the very best healthcare outcomes in the world, with millions of people, across decades. So, it is not true to say that it is absolutely one hundred percent safe but the risk is very small and it is only ever likely to manifest when using really high doses for extended periods (years and years). As I mentioned; all these things have side-effects.
However this study out of Japan, using Oxide, shows good safety outcomes: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042657/
Also, this Cochrane Review (a charity that produces the highest quality of study review with no ties to commercial or government interests) compares PEG 3350 (Miralax/Macrogol etc) based laxitives with others, including Magnesium hydroxide. It specifically mentions this:
"Meta‐analysis of 3 studies with 211 participants comparing PEG with milk of magnesia showed that the stools/wk was significantly greater with PEG (MD 0.69 stools per week, 95% CI 0.48 to 0.89). However, the magnitude of this difference is quite small and may not be clinically significant."
In other words, Magnesium Hydroxide was just as effective as PEG as a laxative.
The form (type) used is important:
Oxy Powder / Mag O7
Frankly I'm not even sure what the exact chemical composition of these are but they are by far the most effective and gentle ones we've found for us.
I'd start with one of them. But, a few people get wind and cramps (I think it's very few?) - everyone responds differently.
Magnesium Citrate
This seems to be the most commonly advised form. I am not a fan of this for three reasons:
Magnesium Citrate is fairly well absorbed and used as a Magnesium supplement. So therefore there seems more of a risk of hyper-magnesia.
Magnesium Citrate can be very irritating. So yes, it clears someone out but it tends to cause explosive diarrhoea and also pain.
Also it's pretty unpleasant tasting so it's hard to hide.
Magnesium Oxide
This is not what is in Oxy Powder/Mag 07 (which I believe are the same form).
We find this to be the most effective and gentle. Magnesium oxide is a pretty poor form to use as a supplement (therefore it's not so likely to raise tissue Magnesium levels). It seems to cause no cramping. It is also very easy to hide in food. We find 1/2 to 2 caps to work very well (depending on current need of course).
Life Extension Magnesium Caps are very cheap and are what we use. They are almost entirely Magnesium Oxide. I asked LifeExtension and they said:
"Our Magnesium caps provides 487.5 mg of Mg derived from magnesium oxide; 5 mg of Mg from magnesium citrate; 5 mg of Mg from magnesium succinate; and 2.5mg Mg from TRAACS® magnesium lysyl glycinate chelate."
Magnesium Hydroxide (Milk of Magnesia)
This is available over the counter (OTC) in most countries but not here. I imagine it's effective and from what I remember it doesn't taste too bad. It's probably a good option but we've not used it.
Oils
Coconut oil works well, as I mentioned above. Around 2-3 teaspoons is generally needed.
MCT oil (four oils found within coconut and also palm oils) works well also. Again, round 2-3 teaspoons is generally needed.
C8 (caprylic acid) works well but you need to be a little careful as it's also quite strongly anti-fungal and so fungal die-off itself can trigger constipation. Go slowly! Like 1/4 teaspoon building to 1 teaspoon. Note that C8 is turned into ketones by the liver (it can't be metabolised any other way) and so can sometimes suppress appetite but can also be valuable as an energy source for the brain. As an aside, C8 is apparently found in breast milk.
"Poop chocolate" can work very well: Very, very gently melt 70% cocoa chocolate with an equal weight of coconut oil. Pour into moulds. Chill. (Beware, the Theobromine (a metabolite of Caffeine) in chocolate is very alerting and has twice the half-life of Caffeine. A morning treat only!)
When we were first dealing with this we would end up in the regional paediatric emergency unit having them do an enema which our son got so used to he would take off his trousers, grab a nappy and lie down ready to be changed, hoping to skip the actual enema part! I never thought we could do this ourselves but we learned to. It's a last resort for us (some people find this easy - we absolutely do not) but it is extremely effective. Our paediatrician advised us to do 3 days of enemas (large ones which also stimulated the bowel: Klyx. I believe it's only available in Sweden but I'm not sure).
If this works for you, great. I have a hunch that careful use of oral laxatives can avoid them though.
Iberogast has been around for decades. It's made in Germany and actually has a huge amount of evidence to show that it improves constipation. It's not too bad tasting but hard to hide in food. It could be well worth trying.
There are a few probiotics that can help with constipation but mostly it will depend on your specific gut setup.
For example L. reuteri DSM 17938 (Biogaia Protectis drops) can help hugely if there is an overgrowth of methane producing bacteria (it can help in other cases too). Just be careful since it can cause extreme burping in some cases.
Bifidobacterium lactis HN019 (found in a single strain as "Daily Bowel Regularity") has been shown to decrease transit time in two studies.
If you have access, this may be interesting: https://www.probioticadvisor.com/advisor/Bifidobacterium+lactis+HN019/strains/ as well as: https://www.probioticadvisor.com/advisor/Intestinal+Transit+Time+-+Slow/conditions/
But one example study (triple blinded, randomised controlled trial)
Carnitine supplementation can resolve constipation in many cases: Supplementation with carnitine reduces the severity of constipation: a retrospective study of patients with severe motor and intellectual disabilities
Personally I like the Jarrow version.
NOTE: If you see a general improvement in your child with Carnitine OR if your child regressed, please, please read: Reggressive Autism? This Should Be Tried Immediately
Black Seed Oil can be very helpful in some cases, apparently.
The short answer is: Get the microbiome healthy!
Not easy at all but the best way I know of doing that is here: Advanced, Cheap And Effective Gut Testing