Perhaps one of the most common concerns parents have about their little one is constipation. While in diapers, all stools are seen, in all their glorious colors and shapes and sizes and smells! When they change, you can bet that moms and dads notice. But what is normal? What is not normal? And how do we treat it?

Normal Bowel Patterns

The first bowel movements passed after a baby is born (within 24 hours in 90% of cases) are the sticky, dark, tar-like stools called meconium. These stools are formed while the baby is in utero, and are passed automatically after birth as the gut first starts moving. These should pass by 5-7 days of life as the baby begins taking in more breast milk or formula. In breastfed infants, the new stools are typically soft, yellow and seedy, while formula fed infants may have stools that are yellow, green, tan, or brown. By one week of age, breastfed babies have an average of 8-10 soft stools per day, and formula fed infants may have a few less. Because breast milk changes over time, as does the infant gut, around 4 weeks of age, breastfed babies suddenly drop to 4 or less, and may skip a day or two between stools. This is when the pediatrician will typically get a phone call!  By 8 weeks old, many breastfed babies are going only once a day or less, and after this time, they can become even less frequent. I have patients who only go once a week! Breast milk is the perfect food…there is not much waste to be excreted! As long as the baby is eating well and happy, and the stool that comes out once a week is soft, I do not worry. Call your pediatrician if your baby has not stooled, and is vomiting, in pain, or has a rigid, hard abdomen.

The next time we see a change in stool patterns is at the beginning of solid foods, when they may become firmer, decrease in frequency, and increase in smelliness. In addition, toilet training may lead to some significant stool frequency and consistency changes. In the older child, stools should come daily and be soft and easy to push out.

What is Constipation?

Constipation occurs when the intestines become backed up with stool. As the stool sits in the intestines, water is reabsorbed back into the body, and the stool hardens and becomes difficult to pass.

What are the Symptoms of Constipation?

Symptoms of constipation include hard, painful to pass stools. Toddlers and older children may complain of abdominal pain. Please note that toddlers and older children who go once a day may still be quite contipated. As kids get older parents aren’t checking the amount and consistency of the stools – the daily stool may be small and hard and there is backed up stool throughout that child’s colon causing her daily stomach ache!

Many parents become concerned that their baby is constipated when they have not gone in a few days, and they appear to be straining, but the stool is still soft. This is not constipation. Babies may strain, grunt, turn red, and look uncomfortable in general. This is called infant dyschezia, and is a normal phenomenon caused by their immature nervous systems and weak abdominal muscles. If you want to do something for this, try picking them up to get gravity to help them in their efforts, or try holding the knees against the chest to help them “squat” — the natural position for bowel movements. If the stools are small, hard, and pellet-like, call your pediatrician, as this is constipation, and needs to be addressed.

What Happens if Constipation Goes Untreated?

Constipation should be treated and diagnosed by your doctor. For any child with constipation, a physical exam needs to be performed at least once by your doctor to be sure that there isn’t an organic cause for the problem.

If an infant has constipation from early on in his life, he is at increased risk for continued problems, so the earlier the problem is addressed, the better. Toilet training becomes very difficult for children who are constipated, as it can create a vicious cycle of pain with stooling, which leads to withholding of the stool, which again leads to worsening constipation and then increase pain, which just increases the urge to withhold. In more serious cases, the stool is held to the point of severe abdominal pain and even a leaking of loose stool around the hard one, seen as diarrhea accidents by teachers and parents. This is called encopresis.

How is Constipation Diagnosed?

Constipation is diagnosed based on the history and physical exam. It can be seen on x-rays, but these are necessary only in some cases. Children who have constipation that does not respond to treatment may need further evaluation to look for other possible causes of constipation, including Hirschsprung’s Disease, hypothyroidism, celiac disease, botulism, or food allergies.

Often, if the patient has continued or moderate to severe constipation that is difficult to treat, I will do a set of lab tests to rule out celiac disease and hypothyroidism. These two entities can have no other symtptoms aside from constipation and should be ruled out.

How is Constipation Treated?

The treatment for constipation is wide and varied, and depends on severity and age of the child.

Under 4 months: Always call your pediatrician for help with stools in a baby under 4 months of age. Typically for babies over 2 months of age I recommend to first try 1 ounce of water once a day to help babies soften their bowel movements. If this doesn’t work, I will often add to that water ½ ounce of prune juice. I also recommend giving probiotics to the baby. If a baby is on soy formula, I recommend switching formulas as it is well-known that soy formula causes constipation. Occasionally in a small infant, I will have the parents take a rectal temperature, which may gently stimulate the rectum to contract and push out the stool. This should not be done routinely, however, and I recommend it only after consulting your child’s doctor. Babies under 8 weeks of age with hard stools should be sent to the gastroenterologist.

4-12 months:In older babies, as I explained above, constipation often comes with the introduction of solid foods. In particular, rice cereal, bananas, soy products, and products with white flour produce harder stools. If a baby has a history of constipation, I will always skip rice cereal and bananas when introducing solid foods. Barley cereal or oatmeal are good alternatives. If a child starts a cereal and becomes constipated, stop the cereal, and introduce what I call the “pooping foods” as they all start with “P”…pears, prunes, peaches, plums, and peas. Make sure your baby gets some of these foods every day, and mix them with cereal or bananas to help balance the diet and produce softer stools. Increased water intake and prune juice as needed will also help at this age, as may probiotics. Flax meal or flax oil may also help and is a great additive to food.

Occasionally, a hard stool will get stuck in the rectum and cause severe discomfort in an infant. In this case, give your baby a warm bath and put some vaseline around the anus to help decrease the risk of a fissure, or small tear, around the anus when the stool finally comes out. If the bath doesn’t work, give her a glycerin suppository (found at your local pharmacy over the counter) to loosen it up and help her pass the stool. Then call your doctor to come up with a good plan to help create more normal stool patterns.

12-36 months: Toddlers can get constipation for a variety of reasons. They typically will start cow’s milk at this time, which can trigger an episode. If it does, call your doctor to determine a treatment and to discuss alternatives to cow’s milk, such as Ripple milk, which is pea protein based. Toilet training happens in these years, which can be a trigger as I mentioned above, and the start of preschool may cause some changes in frequency and consistency as well. The toddler diet can be extremely picky, which is another leading cause of constipation at this age. Treatment consists of diet changes, increase in liquid intake, and avoidance of over 20 ounces of cow’s milk per day. Increase fiber-rich foods like peas, fruits, bran, beans, and lentils. Again, in an acute, painful situation, the use of glycerin suppositories may be necessary. At this age group, a very helpful treatment is Miralax, which is a colorless, odorless polyethylene glycol powder that is mixed with water or juice or milk. Talk to your doctor about proper dosing. Miralax enters the gut and draws water in, causing softer stools that are easier to pass. This helps prevent the dreaded withholding and pain caused by constipation!

3 years and older: All the treatments mentioned above are appropriate for this age group as well. In addition, mineral oil can be very beneficial. Add the oil to cereal or liquids. Titrate up in dose until the stools are loose. Do not give mineral oil to a child under 3 years of age, as they can inhale it and damage lung tissue.

Please note: if your child is not responding to treatment of constipation, please call your pediatrician for an evaluation. 

Constipation is a major issue in children and adults. Discuss stool patterns with your pediatrician at every well visit so as to assure that any issues will be addressed quickly. Constipation is painful and can lead to fears of the toilet and significant abdominal pain. Do whatever you need to do to assure soft, painless stools for your child. Here’s to soft poops and happy kids!