Constipation

Constipation is a common problem when babies are formula-fed and when they start eating solid food. Straining is typical newborn behavior that is often mistaken as a sign of constipation. Find out how to tell if your baby is constipated, why it might happen, and what you can do about it.

What normal infant stools look like

When your baby is breastfed

CONSISTENCY: Soft or runny.
COLOR: Yellow, mustard to orange with little white flecks that look like seeds.
FREQUENCY: Can vary from every feed to once every week or so.

When your baby is bottle fed

CONSISTENCY: Soft paste.
COLOR: Grayish green, yellow, tan or brown, depending on the type of formula.
FREQUENCY: Once (sometimes twice) every 1 or 2 days.

When your baby is eating solid food

CONSISTENCY: Paste to formed stools. Often contains undigested food.
COLOR: Can very depending on what has been eaten.
FREQUENCY: Can be less frequent - particularly for a breastfed baby.

What is infant constipation?

A baby is considered to be constipated if his poop is firm, dry and pebbly!

Crying while having a bowel motion, bleeding from the anus, abdominal pain and reduced appetite can also be signs a baby is constipated.

If your baby's poop is fluid, soft or paste consistency, then he's not constipated.

What causes infant constipation?

Insufficient fluid
New foods
Low fiber
Different types of formula
Medications

1. Insufficient fluid

Is your baby gaining enough weight for his age?
Does he provide you with 6 or more wet diapers each day?
Are you making his formula correctly?
If he has started on solid foods, are you offering him additional water?

If the answer is 'no', he may not be getting enough fluid in the form of breast milk, formula or water and this can lead to constipation.

It is rare for a thriving, fully breastfed baby to become constipated. Your breastfed baby does no need to be offered water before he starts eating solid foods. Water or other fluids should not replace breast milk.

Depending on the climate, your formula fed baby may need extra fluids before he starts on solid foods. If you live in a warm climate, offering your baby water (in addition to formula) is often recommended at an earlier age.

Check how you prepare your baby's formula. Incorrect preparation of formula can result in an insufficient water ratio which can cause constipation. (See Preparing and warming formula for more information).

2. New foods

It's common for a breastfed baby to experience constipation for the first time when solid foods are introduced into his diet or if he is switched from breast milk to infant formula. His little body is just not used to digesting anything other than breast milk. Introduce new foods slowly to allow time for him to adjust.

Some foods are more constipating than others for both breastfed and formula fed infants. These include cheese, ice-cream, yogurt, white bread, spaghetti, macaroni, white rice, banana, green apples, cooked carrots, corn, turnips and potatoes. Small amounts of these foods will generally not cause a problem, but larger amounts may result in constipation.

3. Low fiber

Fiber is only found in plant foods such as cereals, fruits and vegetables. Babies over 6 months with high intakes of formula or cow's milk (only recommended after 12 months) often experience constipation. It's not the milk itself that causes this, it's simply that the child fills up on milk which means he will have limited appetite for other foods that provide fiber.

4. Different types of formula

Formula fed babies are more at risk of becoming constipated than are breastfed babies.

Some types of infant formula can be more constipating than others. Casein dominant formula, lactose-free formula, AR (anti regurgitation) and thickened formulas can be more constipating for some babies. Variations can also occur between different brands of the same type of formula.

Switching formula (or switching to cow's milk) can lead to changes in stool consistency, resulting in either constipation or loose runny stools. Most often this change is only temporary, until your baby's little tummy gets used to the new formula. (We recommend you rule out other reasons for constipation before switching formula).

5. Medications

Common medications given to babies can sometimes cause constipation.

Pain-killers containing paracetamol, acetaminophen and ibuprophen.
Antibiotics.
Antacids containing alumimum.
Iron supplements

When to treat infant constipation

Most babies are not truly constipated unless they experience all of the following...

Firm, dry pebbly stools.
No bowel motions for 2-3 days for formula fed babies or 7-10 days for breastfed babies*; and
Strains and cries while having a bowel motion.

Unless your little one has a problem with all three, he's probably not constipated and you needn't do anything. If your baby is constipated, treatment may be necessary. We suggest you start with 'natural remedies' first.

*It is rare for a fully breastfed baby to become constipated prior to starting solids. 7-10 days without a bowel movement can be very normal where a baby is only offered breast milk. Breast milk is the perfect food for babies and very little is left to waste. Breast milk also has a natural laxative effect that helps protect your baby against constipation.

Natural remedies

Water
Sugar e.g. brown sugar
Fruit juice
Fruit
Probiotics

1. Water

Increasing the amount of water your offer your baby is often more effective than adding sugars to his diet. For babies less than 6 months old offer 1 oz of cooled boiled water, once or twice a day. For babies over 6 months offer 2 oz, once or twice a day.

2. Sugar

A remedy for constipation that has been around for centuries and still recommended today, is to add some form of sugar to a baby's diet. The sugar works by drawing additional fluid into the baby's bowel to soften the stools. Sugar can come from fruit, in the form of fructose or sorbitol or sucrose from sugar cane.

It's frequently recommended to add some form of sugar (particularly brown sugar) to baby's formula. Rather than do this, we suggest you offer it in a small amount of cooled, boiled water for two reasons...

The additional water is helpful; and
Your baby may fuss with feeding once the sugar is stopped.

In the past honey was recommended as a treatment for constipation. However, it is no no longer recommended for children under the age of 12 months because of the associated risk of botulism (a gastro-intestinal illness).

Brown sugar

Add 1/2 teaspoon of brown sugar (the one used for cooking) to 1 oz of cooled boiled water. Offer this to your baby 3 times a day, directly before formula feeds, until his poop is soft and then stop.

While brown sugar is recommended because it contains molasses, white sugar would do.

CAUTION: Only add sugar or corn syrup to your little one's diet, if you are treating constipation, not both.

3. Fruit Juice

Apple, pear or prune or pear can be very effective at relieving constipation. To begin with dilute the juice to 1/4 strength by adding cooled, boiled water. Slowly increase the concentration to 1/2 strength if necessary.

If your baby is aged 3 - 6 months, offer 1 oz of diluted juice (2 oz if he's over 6 months). Offer this twice a day until his poop is soft. Give less rather than more to start with as too much juice can result in abdominal gas, bloating and diarrhea. (See Carbohydrate malabsorption for more information.)

CAUTION:

Do not treat infant constipation with diluted juice and addition sugars (including Karo) at the same time. Choose only one treatment.
Diluted fruit juice as a treatment for constipation is not recommended for babies less than 3 months old.
It is not recommended to offer fruit juice on a regular basis to babies less than 3 months.

4. Fruit & vegetables

If your baby has started eating solids, include more fruit and vegetables to his diet, as this may help to reduce the chance of constipation developing in the first place.

Bananas and apple sauce can result in firmer stools. Carrots and squash are constipating for some babies. Prunes, peaches, pears, plums, apricots and peas make stools softer. Colored vegetables tend to help, where as white vegetables can be constipating for some babies.

If your baby is under 9 months avoid citrus fruits such a orange, grapefruit and pineapple, as the acid content in these fruits can be harsh on little tummies, as well as the skin around his mouth and bottom (when it comes out).

5. Probiotics

In recent decades, there has been much research into the benefits of maintaining a healthy intestinal microflora. Healthy intestinal flora include friendly microorganisms. The main source of friendly microorganisms in a baby's intestinal flora is bifidobacteria. Formula fed babies have only approx 25% of bifidobacteria in their intestines compared to 95% in the intestines of breastfed babies.

Probiotics involve providing live non-pathogenic microorganisms that improve the balance of intestinal microflora. Drinking infant formula with probiotics changes a formula fed baby's intestinal flora to be closer to that of a breastfed baby. Studies have shown probiotic infant formula may soften a baby's stools, decrease nappy rash and provide some protection against gastroenteritis.

Some countries produce infant formulas that include probiotics. (You will find the formula label is clearly marked if it contains probiotics). You can also purchase bifidobacteria from health food stores, which can be added to regular infant formula. Discuss this with your healthcare provider before starting your baby on probiotics.

Medications

Laxatives

Laxatives are only necessary if 'natural remedies' have failed or where constipation is severe. Although many different types of laxatives can be purchases over-the-counter, most laxatives are not suitable for babies and small children. If you feel your baby needs a laxative to relieve his constipation, we recommend you consult with your baby's doctor about a suitable treatment.

Different laxatives work in different ways;

Some simply soften the stool.
Others act as a peristaltic stimulant (in other words they stimulate the natural contractions of the bowel in order to push the stools out).
Some offer a combination of softener with peristaltic stimulant
Others offer additional fiber.

Laxative can be given to babies orally, in the form of drops or anally by a suppository or enema.

Parents often worry unnecessarily

Parents often become concerned about infant constipation when they observe normal changes in their baby's bowel habits and behavior, which commonly occur around 2 - 6 weeks of age. It's around this age that the frequency of babies' bowel motions often decreases, (this being more obvious in breastfed babies). It is also around this age that many babies are first observed to strain when having a bowel motion or passing gas.

Unfortunately, these changes frequently occur at a time when many babies are becoming increasingly irritable and so parents naturally assume there is a connection. However, in most situations changes in bowel habits have nothing to do with an infant's irritable behavior.

It's not the frequency of bowel motions or straining that determines if your baby is constipated; it's the consistency of his stools.

Why the frequency of stools change

A decrease in the number of times your baby poops doesn't necessarily mean he is constipated.

A decrease in the frequency of bowel motions is often noticeable around 4 weeks of age, particularly when a baby is breastfed. As your baby's digestive system matures his body is better able to digest and absorb the many nutrients in milk (breast or formula) and as a result there in less waste (poop).

It is around this time that a mother's breast milk supply settles to meet her baby's needs, so this also results is less poop. (Nursing mother's often have an abundance of breast milk during the early weeks of breastfeeding.)

A reduction in the number of of bowel motions of a formula fed baby may also be seen around this age. However, it generally less obvious than changes seen in fully breastfed infants.

Other time where a change in the amount and how often a baby poops, may occur as a result of changes in diet. A sudden change in the frequency of bowel motions is commonly seen when...

A baby is switched from breast milk to formula.
The type of formula is changed.
A baby first starts to eat solid foods.
The amount of solid foods is increased.
When a baby is first introduced to regular cow's milk.

Why babies strain!

Straining alone is not a sign of constipation!

Adults strain when they are constipated, so it's natural to assume your baby's straining is due to constipation. However, straining is normal behavior for infants, particularly during the early weeks of life, and is not a sign of constipation unless bowel motions are firm, dry and pebbly.

Young babies often strain due to the effects of the gastro-colic reflex and the defecation reflex. (See infant reflexes for more information). The 'straining' action helps to move stools through your baby's intestines.

Grunting, groaning and going red in the face while having a bowel motion (fluid or paste consistency) or passing gas is commonly seen in infants around 4 - 6 weeks of age. It is at this age your baby is becoming more aware of his body sensations and he is learning to gain some control over his body movements (that will eventually be necessary to voluntarily control his bowel motions in the future).

As your baby strains he's also learning which muscles do what and how much effort is needed to poop. He may use a little more effort than necessary to begin with, but after a few weeks of practice he will become a 'poop expert' and straining will settle.

Straining may also occurs at times when your baby is learning to pass a larger or slightly thicker consistency stool than he's used to. This often occurs if his diet is changed such as, changing from breast milk to formula or when he starts on solid foods. This is also normal and generally settles in a week or so.

Straining is normal - Crying while having a bowel motion is not!

What to do when your baby strains

It's not necessary for you do anything when your baby strains while trying to poop. However, if you feel he is straining because of constipation (i.e. firm, dry pebbly poop) you may find lifting his knees to his chest, which is a natural squatting position, by holding his ankles can help him to exert enough pressure to push it out.

Alternate this with gently moving his legs backwards and forwards in a 'bicycle' movement. Also try...

A warm bath.
A tummy massage.

Tummy massage

Your baby's large bowel sits in his abdomen in one large loop. Stools travel in a clockwise direction (clockwise as you face him). To assist him to expel gas that can occur with constipation, it's best to follow the natural path of his large bowel.

Put some oil on your hands and gently but firmly massage his abdomen in a clockwise direction using long stroking actions. Alternate this with lifting his knees and the 'bicycle' movement.

When to see a doctor

If your baby cries while straining.
If constipation remains a persistent problem.
If your baby is not gaining weight.
If the number of wet diapers each day is less than 6.
If your baby's poop looks unusual or has blood in it.
If you notice any bleeding from his anus.
For advice on suitable laxatives.

* Constipation in infants is rarely due to excess iron. Low iron formula should only be given if recommended by your doctor.

Written by Rowena Bennett.