A ‘Hard’ problem – Constipation in Babies

Eran was always very conservative with nappies. After 6 weeks of age he would only have a dirty nappy once a week. His record was no poo for 14 days!! This totally freaked me out, but he looked quite happy and comfortable. He was exclusively breastfed, so he had really good absorption of the nutrients, and when he did pass stool it was always soft and yellow.

There is such a large variety of normal when it comes to baby-poo. So how do you know when to start worrying and when is it constipation?

(Warning: this is quite a “crappy” topic, excuse all the puns! 😉)

Stool-patterns vary by age and diet. The number of stools passed decrease as your baby gets older (with an average of 4-5stools per day for the first week of life, then 3-4 for the first three months and 1-2 by 2years of age). In exclusively breastfed infants it can be normal to pass stools 7 times in one day, or only once in 7 days!¹ There is also a difference in stool-patterns with different formulas: soy-based formulas produce harder and less frequent stools, while hypo-allergenic formulas can produce looser and more frequent stools.

“When the going gets tough, the tough get going.” – Joseph Kennedy

There are a few developmental milestones in your baby’s life when constipation is more likely to be a problem:

• Introduction of formula
• Introduction of solid food
• Introduction of cow’s milk
• Potty training
• Going to school

Constipation in an infant (below 1year) is diagnosed when there is a change in the stool pattern for your baby, it looks like your baby has pain / excessive straining while passing the stools AND the stools are large, hard, dry or pellet like. This last part is especially important, because many babies have dyschezia.² This big word just describes what we see with most young babies: they strain, become red in the face and cry before passing a stool. The stool is then always soft and the baby is otherwise healthy. This is not constipation, but happens because the baby is still too young to coordinate his muscle movements when trying to pass a stool. You can help your baby to relax the pelvic floor by gently bending his hips and bringing his knees up to his stomach. Dyschezia usually resolves as your baby grows and no further treatment is necessary.

So when should you worry? And when is it something more than functional constipation (meaning it is a common childhood/lifestyle problem with no serious pathology causing the problem)? Constipation in babies and toddlers are mostly (>95%) functional, so take a step back and relax, this too (like all poo…) shall pass! 😉

RED FLAGS :

(These are signs or symptoms that will worry me if you tell me your baby does not poo and he has one of the following. Please consult your doctor asap.) ³

• No stools passed in the first 48hrs of life
• Constipation before one month of age
• Associated with other symptoms such as a distended abdomen, vomiting, fever, not passing any gas
• Any blood in / on the stools
• Any abnormalities of the spine, buttocks, genitals or legs
• Not growing well
• Recurrent lung infections

When we introduced solid foods (in the form of vegetable purees) for Eran at 5months of age, he became very constipated. His normal “once a week poo” changed from easy to pass and soft, to a hard dry mass that caused him severe discomfort and effort and even a small tear to his anus. Luckily he had none of the red flags, so I knew I could safely treat him at home.

Treatment in infants for functional constipation:

To treat any constipation successfully you need to remove the dry, hard stools that are currently causing pain, and then you have to address the cause and keep the next stools soft so that it is easier to pass (for more detail see the next post on Toddler constipation). The longer stool stay in your gut, the more fluid is absorbed and it is thus important to maintain a frequency of at least 1 stool per day.

We used the following treatments when Eran was having a HARD time:

To help your baby remove the initial hard, dry stools :

• Glycerine suppository for babies (you can cut it in ½ or ¼ and insert it with some lubricating jelly). You can also squirt 1ml of liquid glycerine into the anus with a small syringe. This softens the stool and the insertion also stimulates the bowels to pass the stool.
• Bend baby’s legs at the hips and push his legs toward his stomach to relax the pelvic floor.

To keep the stools soft:

Diet:

• Constipation often occurs after starting a solid diet as there are insufficient fibre and fluid in the transitional diet (often only consisting of cereals). It is thus important to increase the fibre by adding fruit and vegetable purees. Prune, apple, pear and pea purees worked for us. Be aware of banana and sweet potato as these often have the opposite effect. Try to change from rice-cereals to whole-wheat / mixed grain / barley cereals. Try to rather stay away from fruit juices as these contain a lot of sugar and very little fibre.

* If your baby develops constipation when you change from breast-milk to formula milk, it is worth-while to consult your doctor to discuss the best type of formula to use for your baby. You can also add a teaspoon of olive oil or sorbitol-containing fruit juice to their formula.

* If your baby develops constipation when adding cow’s-milk to their diet, it is important to ensure that they are not allergic to the cow’s milk.

Medication: ⁴

• Lactulose is a safe and effective medication in the treatment of constipation. It is an indigestible and osmotically active sugar, which means they do not absorb any of it and it only works by pulling water into the bowels to soften the stools. It is not “addictive” , it will not make the bowels lazy and you cannot really overdose your baby. It is safe to start with 2.5mls twice a day, and then increase to three times a day / increase the dose by 2.5ml increments until your baby passes 1-2 soft stools per day. Decrease the dose or frequency if the stools become too loose.

• Polyethylene Glycol (PEG) can also safely be given as an osmotic laxative after 6months of age.
• Glycerine suppositories: Rather keep these for a backup as baby can get used to the anal stimulation to initiate a bowel movement, he needs to stay sensitive to the internal stimulation that the stretching of the bowels provide.
• Do not give stimulant laxatives or enemas to infants.

As Eran’s fibre intake increased and he became used to all the new food his bowels had to process, we gradually weaned and stopped the Lactulose at about 6months. Since then we have used it intermittently as needed, and Eran is managing his poo-schedule very well! Did your baby struggle with constipation at some point? What worked for you?

Next week I will discuss constipation in toddlers and some practical solutions to this pain in the b-hind!

1. Den Hertog J, van Leengoed E, Kolk F et al; ‘The defecation pattern of healthy term infants up to the age of 3 months.’; Arch Dis Child Fetal Neonatal Ed. 2012 Nov;97(6):F465-70.
2. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko; ‘Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.’; Gastroenterology. 2016 Feb;
3. Nurko S, Zimmerman LA; Evaluation and Treatment of Constipation in Children and Adolescents; Am Fam Physician. 2014 Jul 15;90(2):82-90
4. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA ; Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN; J Pediatr Gastroenterol Nutr. 2014;58(2):258.