Infants, Formula and Fruit Juice

“Parents often worry that their baby is constipated because infants from a couple of weeks to 6 months old will often strain and grunt and turn red when passing a stool,” Dr. Brouard says. “As long as the stool is soft, this is fine. The babies just need to learn to push and, at first, they strain with their efforts.”

In infants, constipation is defined as hard-to-pass, very firm stool and not how often the baby has a stool. Breastfed newborns will initially go many times each day, a 2 week old will have seven to 12 stools a day, and 6-week to 4-month old babies may have only one stool every seven days or so, she says.

A formula-fed infant (or any baby who has some formula introduced) will have greater volume of stool due to more waste, but also firmer and less frequent stool. As long as the firmness is not more than that of peanut butter, the baby is not constipated, Dr. Brouard notes.

Constipation is rarely seen in breastfed infants and more common in formula-fed babies, she says.

“Many babies do not tolerate formula well due to the fact that it is made from non-human milk ingredients, especially cow’s milk protein and soy proteins, which form hard curds and can create constipation,” Dr. Brouard explains. “If a baby develops constipation, it is worth considering using a partially hydrolyzed or fully hydrolyzed formula, in which the proteins are broken down and more easily digestible for a baby.”

Dr. Brouard says infants should not be given laxatives or enemas, but if they are trying to pass a very hard stool and crying, a glycerin suppository and warm bath may help.

The American Academy of Pediatrics recommends talking to your pediatrician about giving your infant small amounts of juice (apple, pear or prune) to help loosen stool.

“Many people recommend juice for children with constipation,” Dr. Brouard says. “In terms of an immediate effect, yes, juice – especially prune juice – does help. However, juice is concentrated fruit sugar and not a healthy part of any child’s diet. It is much better to increase fiber by adding more fresh fruits and vegetables, rather than just causing the baby to have temporary diarrhea by giving excess fruit sugar. Prevention of constipation is the goal.”

Older Babies and Solid Foods

“Most older babies have a stool once or several times each day,” Dr. Brouard notes. “It should not be hard to pass or formed into nuggets, but it will be firmer than a newborn’s stool due to solid foods being introduced.”

What foods you introduce to your baby’s diet can contribute to constipation. Dr. Brouard recommends starting solid foods with vegetables around 4 months old, when an infant shows signs of interest when others are eating. Peas, green beans, winter squash, avocado and sweet potato are easily digested, but carrots should be limited.

Cooked carrots in particular can be constipating, as well as applesauce, she says. To help avoid constipation, always offer water with your baby’s meal.

“After about 6 months of age, all foods except for honey and uncultured dairy products – like milk and ice cream – can be introduced,” Dr. Brouard says. “At that point, some babies will get constipated if they are suddenly getting too much starchy or protein-based foods, and not enough of a balance of vegetables.”

It’s important to remember that all of us, including babies, need half their plate to be vegetables, she says. The amount of daily protein that a baby needs is only two of their own palm-sized servings, so about 2 tablespoons for a 6 month old.

“Many babies get constipated due to being overstuffed with proteins, or from snacking on starches, such as crackers, pretzels and corn puffs, which are low in fiber and nutrition.”

Toddlers and Older Children

Beyond infancy, children usually have one to three stools per day, but may go every other day. Usually if it is more or less often than this, there is a problem in nutrition, absorption or behavior. Constipation is when a child's stool is uncomfortably hard – no matter how often they go – or if they are going less than every two to three days.

Children ages 1 and up often become secretive about going to the bathroom, and may hide in a corner to have a bowel movement, Dr. Brouard says. Sometimes they just want some privacy and sometimes it’s because we put pressure on them to toilet train.

“One common cause of constipation in this age group is withholding,” she says, “which is when a child is afraid to go, either because of having a bad experience with a hard stool, or because we are trying to whisk them off to the potty while they are trying to pass a bowel movement. Either way, they start learning to hold back the stool.”

Dr. Brouard explains when children withhold, the stool stays longer in the lower colon and rectum, and more and more of the fluid is removed the longer it sits, creating harder and larger stool. Eventually this can lead to chronic constipation and a problem called encopresis.

“In encopresis, the stool mass becomes so large that the child actually gets a distended intestine,” she says. “The intestine's nerves become insensitive, and the child no longer feels the urge to have a bowel movement. Eventually, liquid stool from more recent meals starts to leak around the hard, large mass of impacted stool in the rectum, causing ‘skid marks’ or smears in the underwear, or outright diarrhea.”

If you suspect your child has encopresis, you should contact your pediatrician. Long-term use of laxatives and lubricants may be required to retrain the child.

“It’s best to prevent constipation through good diet and through gentle, positive potty training methods,” she says. “In a healthy child's diet, half the volume of each meal is supposed to be high-fiber foods, such as vegetables, legumes and fruits. Many constipated children suffer from a lack of fiber in their diet.”

Dr. Brouard explains the lack of fiber is sometimes due to overconsumption of meat and starches, or they may be filling up on juices, sodas, sports drinks and sweets, and do not have an appetite to eat high-fiber foods as a result.

“Occasionally a child is sensitive to something in the diet,” she notes. “One such sensitivity that may cause constipation is celiac disease. In celiac disease, a child is intolerant to the protein present in wheat and barley, so foods made of flour (white flour and whole wheat flour) will cause trouble with digestion.”

Some children are constipated when they have this disease, others get diarrhea, and it negatively impacts the body due to malabsorption of vitamins and nutrients, Dr. Brouard says.

“If a child is chronically constipated in spite of following what appears to be a healthy diet with high fiber content, it is worth speaking with the child's doctor about celiac disease testing, which is done initially through a blood test.”

To help prevent constipation in older children, AAP recommends:

• Adding more high-fiber foods (prunes, apricots, plums, raisins, peas, beans, broccoli, whole grain cereals and breads).
• Cutting back on foods that are not high in fiber (rice, bananas, some cereals and breads).
• Encouraging your child to drink enough water.
• Establishing regular toilet habits.
• Increasing daily activity and exercise.

When to Call the Doctor

You should contact your child’s pediatrician if you have questions or concerns about constipation, and during the following situations:

• If the anal area has any tears (fissures) that are deep or won’t heal, or that have bled more than twice.
• More than six days have passed without a bowel movement.
• Three days of dietary changes does not produce a bowel movement.
• Constipation is a recurring problem for your child.
• If your child is in extreme pain, or if the pain is constant and has persisted for more than two hours.