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Infant Constipation

Watching your child cry while having a bowel movement can be extremely distressing.  Our feature article covers some of the causes and possible remedies to infant constipation. It’s important to note that it’s not necessarily the frequency of bowel movements or straining that determines if a baby is constipated or not, it’s the consistency of the stool (firm, dry or pebbly).

Changes in frequency
It’s true that infant constipation can result in less frequent bowel movements than normal, however, this is not always a sign that he/she is constipated.  A change in diet e.g. switching formula or introducing new foods, can result in changes in the amount and frequency.

A decrease in the number of times a breast fed baby has a bowel movement is often noticeable around 4 weeks of age, as baby’s digestive system matures. Although a formula fed baby’s digestive system matures at the same rate, there may not be any noticeable change in the number of bowel movements a formula fed baby has at this age.

Why babies strain
It can be very alarming to see your young baby draw his little legs up and grunt and groan and go red in the face while trying to pass a stool. However, this is very normal behaviour for an infant particularly in the early weeks of life! Straining helps move the stool through his intestines.

Straining commonly occurs around 2 - 4 weeks of age, as baby becomes more aware of his body sensations. He strains as he’s learning to control his body. He needs to figure out which muscles do what and how much effort is needed. He will often use a little more effort than is necessary while he’s learning! Within a couple of weeks straining should settle.

Straining can also occur when a baby is learning to pass a larger or slightly thicker consistency stool than he’s used to, e.g. when changing from breast feeding to formula or when he first starts on solid food. This also, is normal and generally settles within a week or so.

Staining is normal, but crying during straining can be a sign of constipation.

Causes of infant constipation
1.  Inadequate fluid
Is your baby gaining appropriate amounts of weight for his age?  Does he have at least 6 or more wet diapers each day?  If the answer is no, he may not be getting enough fluid in the form of breast milk or formula and this can lead to constipation.

A breast fed baby does not need extra fluids until he starts eating solid foods. Even then only small amounts are offered, more for the benefit of providing learning opportunities than for hydration. Additional fluids should not replace breast milk.

Depending on the climate, a formula fed baby may not need extra fluids until he commences solids. However, if you live in a warmer climate, offering baby water (in addition to formula) is often recommended at an earlier age.

Check how you are preparing his formula. Make sure you are adding the correct number of scoops of formula powder to water, as recommend by the manufacturer. Take care not to overfill or tightly pack the formula powder in the scoop. This can lead to a more concentrated formula and result in constipation.

2.  The type of infant formula
Switching formula (or switching to cow’s milk) can lead to a change 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.

Some types and brands of formula are more constipating than others. If constipation continues to be a problem for your little one, it may be necessary to change formula.

3.  New foods
It’s common for a breast fed baby to experience constipation for the first time when solid foods are introduced into his diet. 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. If your baby’s stool is firm, dry or pebbly, think back to what he’s eaten in the previous 24 hours. Did you offer him a new food? If there’s something you can identify, wait until his constipation has cleared, then try offering it in smaller amounts next time.

4.  Low fibre
Fibre 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) can become constipated. It’s not the milk itself that causes this, it’s simply that the child fills up on milk which means he will have no appetite for other foods which provide fibre.

5.  Medications
Common medications given to babies can sometimes cause constipation.

• Pain-killers containing paracetamol, acetaminophen and ibuprophen
• Antibiotics
• Antacids containing aluminium
• 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 movement for 2-3 days for formula fed babies or 7-10 days for breastfed babies, and
  • Strains and cries while having a bowel movement.

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 the simple things first.

* It’s rare that a fully breast fed baby will become constipated prior to the commencement of solids. 7 or 10 days without a bowel movement can be very normal where 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 baby against constipation.

Natural remedies
1.  Water
Increasing the amount of water offered is often more effective than adding sugars to a baby’s 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 baby’s bowel to soften the stools. Sugar can come from fruit, in the form of fructose or sorbitol or sucrose from sugar cane.

We suggest you add ½ teaspoon of brown sugar (Old Fashioned Brown Sugar would be best) to 1 oz of cooled, boiled water, and offer this to the baby 3 times a day, directly before formula feeds, until his stool is soft (then stop.)

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

3.  Fruit juice
Offer diluted apple, prune or pear juice. To begin with dilute the juice to ¼ strength by adding cooled boiled water to the juice. Slowly increase the concentration to ½ strength if necessary.

Diluted fruit juice is not recommended for babies less than 2 months old. For babies aged 2 – 6 months, offer 1 oz of diluted juice (2 oz for babies over 6 months), twice a day until his stool is soft. Give less rather than more to start with. Too much juice can result in abdominal gas, bloating and diarrhoea.

Unlike added sugars, fruit juice can be offered on a regular or daily basis to maintain soft stools.

Caution: Do not treat infant constipation with diluted juice and additional sugars at the same time. Choose only one treatment.

4.  Fruit
Rice cereal, 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.

For a baby under 9 months, avoid citrus fruits such as 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.  Chiropractic treatment
Although Chiropractic therapy does not claim to cure constipation, there have been cases where simple chiropractic adjustments have restored normal motion to the spine and therefore normal nerve system control of the intestinal system.

It is important to understand that the doctor of chiropractic does not treat conditions or diseases. The expertise of the chiropractor is in checking the child's spine for misalignments that impair nervous system function therefore affecting overall body function. The bones of the spine, the vertebrae, house and protect the spinal cord. The spinal cord is an extension of the brain and carries information from the brain to the body parts and back to the brain again.

Many chiropractors believe that all babies should have their spines assessed shortly after birth, as they do in the USA.  Julian Keel, a doctor of chiropractic specializing in pregnancy and paediatrics, says, “Recent research in Denmark has provided compelling evidence that infantile colic can originate from spinal nerve stress and chiropractic management is significantly more effective than medical treatment with colic drops.

One study of 1250 babies examined 5 days after birth, found that 211 suffered from vomiting, hyperactivity and sleeplessness. Ninety-five per cent were found to have spinal abnormalities, and all showed improvement after chiropractic treatment.

Medications
Laxatives are only necessary if natural remedies have failed or where constipation is severe. Although many different types of laxatives can be purchased over the counter, most laxatives are not suitable for babies and small children. If you feel your little one’s needs a laxative to relieve his constipation, we recommend you consult with your baby’s doctor about the best 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 stool out).
  • Some offer a combination of a softener with a peristaltic stimulant.
  • Others offer additional fibre.

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

Treatment recommendations
Babies under 2 months old

1. Offer additional water.
2. Try brown sugar in water.
3. Change formula if constipation returns.

Babies between 2 – 6 months
1. Offer baby additional water.
2. Try brown sugar in water OR diluted fruit juice.
3. Reduce the amount of solid foods offered (if you have already started baby on solids)
4. Change formula to a whey dominant formula if constipation returns.

Babies over 6 months
1. Offer baby a mixed grain cereal.
2. Offer diluted fruit juice.
3. Increase the amount of fruit offered daily.
4. Change back to a ‘starter’ formula if you have recently switched to a ‘follow-on’ formula.

Babies over 12 months
1. Offer plenty of water.
2. Increase activity.
3. Offer diluted fruit juice.
4. Increase the amount of fruit and vegetables offered daily.
5. Check milk intake, decreasing the amount to 24 oz per day if necessary.

If your child develops constipation while learning to use the toilet, stop toilet training temporarily. It is reasonable to wait two to three months before restarting toilet training.  For those who are trained or in the process or toilet training, encourage regular toilet times or sit your child on the potty after meals.

What to do when baby strains
When your baby strains, lift his knees to his chest (which is a natural squatting position) or gently move his legs backwards and forwards in a ‘bicycle’ motion. Also try…

  • A warm bath.
  • A tummy massage.

Tummy massage
Baby’s large bowel sits in his abdomen in one large loop. 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 massage his abdomen in a clockwise direction using long stroking actions. Alternate this with lifting his knees and the ‘bicycle’ motion.

When to see your doctor

  • If 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 has also decreased.
  • 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.

*If you are concerned your baby’s constipation is due to iron, please consult your doctor before making any changes to his diet.