Constipation

Infants

Normal Stooling Patterns in Newborns and Infants

In the first days of life, newborns pass meconium (black and tar-like) stools. By day of life 3-4, passage of yellow, green, or brown seedy stools is reassuring. All newborns should stool at least once in the first 48 hours of life. After the first 48 hours, some babies will not stool for up to more than 24 hours at a time. If your baby is comfortable, nursing or bottle feeding well, has a soft belly, isn't forcefully vomiting, and is having frequent wet diapers, then it is likely a matter of time before she poops! However, since decreased stool output can be a sign of poor feeding, please call our office during business hours if your infant is less than two weeks and hasn’t stooled in greater than 24 hours. If your baby is not feeding well, seems increasingly sleepy, and isn't urinating adequately, please call our office as he may be dehydrated. Adequate urination for a newborn involves having at least 1 wet diaper per day of life. This means that a 3 day old should have at least 3 wet diapers a day, a 4 day old should have at least 4 wet diapers a day, and any baby 5 days of age or older should have at least 5-6 wet diapers a day.

Stooling patterns vary greatly among infants. Newborns, especially breastfed newborns, often stool with every feed. Formula fed infants tend to stool less often (2-4 times per day) in the first months of life. Some infants don't stool everyday. This is especially true of exclusively breastfed infants over 2 months of age. Your baby might go from stooling multiple times per day to stooling every 3-5 days seemingly overnight. Keep in mind that exclusively breastfed infants are rarely constipated.

Formula changes and introduction of solid foods can also alter bowel habits. As long as your baby is comfortable, eating well, and eventually passing soft stool, don't worry. If your baby is becoming uncomfortable, straining without passing stool, or passing hard, pellet-like stools, then he is likely constipated.

Infant Dyschezia

Some infants scream, cry, and turn bright red in the face for 5-30 minutes before the passage of a normal soft stool. This is called ‘infant dyschezia’ and differs from constipation in that the stools are not hard when passed. This is thought to occur as an infant is attempting to poop, but not effectively relaxing his pelvic floor. So, he is trying to poop and ‘hold it in’ at the same time. His crying helps to increase his abdominal pressure, which eventually results in a soft stool and resolution of crying. There is no treatment for this. Suppositories and rectal stimulation might actually make things worse. Giving juices won’t help either. Although it is very difficult to observe this behavior in your infant, this is a normal occurrence in some infants and in time he will outgrow this tendency.

What to do for infant constipation

Giving your infant juice is generally all that is necessary. Prune juice is by far the most effective juice in treating constipation. Apple and pear juice have some efficacy in treating constipation. It is fine to give juice daily if necessary. Start with ½ ounce of juice per day, increasing up to 2 ounces of juice per day if needed. Do not give an infant less than 4 months old more than 2 ounces of fluid that isn’t breast milk or formula per day without discussing with our office. Too much additional water or juice can upset the salt balance in your baby's body, which can even cause seizures.

If juice fails, try an over the counter glycerin suppository. Babylax liquid glycerin suppositories are easy to use. Alternatively, you can cut an adult glycerin suppository to make it smaller for your infant. Insert the suppository into your infant's rectum and then hold his bottom together for 2-3 minutes to allow it to work (the longer the better). If, after an hour, she has still not had a bowel movement, you can repeat with another suppository. Solid glycerin suppositories do not have to melt to be effective. If your infant is over 4 months of age, consider introducing pureed baby food prunes. Other baby foods that help with constipation (to a lesser degree) are pears, cherries, peaches and apples.

Mineral oil, molasses, or karo syrup is not recommend for the treatment of infant constipation.

Call the office immediately if your infant begins vomiting with constipation, especially if the vomit is green (like bile) or bloody, or if your infant’s abdomen becomes hard, tender, distended, or discolored.

Toddlers and Children

Constipation often becomes a problem during potty training. Toddlers may withhold stools because they are too busy to stop playing, or they are afraid to poop in the potty. Sometimes it becomes a battle of wills - one that he will surely win! If your child has had painful stools in the past, she may become fearful of toileting and begin to withhold stools. This will lead to larger, more painful stools, and more withholding. If your toddler is constipated, don't attempt potty training until the constipation is under control. Often, it is necessary to use a stool softener until improved bowel habits are achieved.

Constipation is common in school-aged children, as well. Some kids, like toddlers, don't want to stop to go to the bathroom. Some are embarrassed to use the bathroom at school. If constipation remains unchecked, the rectum gets stretched out. The nerve endings stop working properly, and the child no longer perceives the need to pass a bowel movement. This can lead to fecal incontinence, which is the passage of often large amounts of stool with very little or no warning. Alternately, they may seem to have diarrhea, as they pass small amounts of liquid stool around the harder impacted stool. These children are often not aware when they have a bowel movement, and often don't even smell that they have stooled. Obviously, this can become a traumatic social problem and children should NEVER be punished for this.

What to do for toddler and childhood constipation

Diet is a good place to start. Try to increase the amount of fluid your child drinks. Offer lots of fruit, vegetables, and whole grains. You don't want to overdo juice, but 6-8 ounces of apple, prune, pear, or white grape juice may help. Try to avoid bananas and white rice, as these foods tend to be binding.

It is also important to establish a stooling routine. The body's natural tendency is to move it's bowels after a meal. Have your child sit on the toilet for 10 minutes after a meal 1-3 times per day whether he thinks he needs to or not. Try to help him relax - reading to him may help.

Stool Softeners

Often, we will recommend stool softeners for patients with constipation. Stool softeners are not stimulant laxatives, and are therefore not addictive. You will want to use the stool softener until your child is having soft stools independently and regularly. Often children need stool softeners for months to a year or longer. Once the bowel is retrained, many children can then stop using stool softeners while continuing to have more normal, regular, soft stools.

Our practice usually recommends Miralax (also known as Glycolax) for stool softening. This can be found over the counter and is a tasteless, odorless powder that is mixed with 6-8 ounces of fluid daily. Different children will need different amounts, ranging from 1/4 tsp to 3 TBS or more per day. The medicine needs to be titrated to the desired effect, which is 1-2 soft stools every 1-2 days.

Generally, start with 1/2 tsp for an infant, and 2 tsp for toddlers and children, daily. Mix this with 6-8 ounces of any fluid (milk, water, juice, etc). It's okay if it isn't finished in one sitting. Increase the amount of Miralax by 1/2 tsp every three days (maximum 3 tablespoons per day) until soft stools are achieved. It takes about 3 days to be effective, so don't increase the amount more than every three days. If your child starts to experience diarrhea, then skip a day and start again at half the dose you have been giving. You can't overdose on Miralax, and it is fine to stop abruptly, so don't be afraid to make adjustments.

As discussed above, have your child sit for 10 minutes on the toilet at least once a day after meals. Discuss with your physician when to stop therapy. If the constipation has been moderate to severe, expect that it may take months to even years for the stretched rectal vault to return to a normal size, and for the damaged nerve endings to work properly again. Stopping too soon may put you right back where you started, and delay the desired outcome of independent, functional stooling. Expect that with a commitment to this regimen, your child will eventually achieve this goal.

If your child is very uncomfortable and unable to pass stool, a stool softener will take too long to work. As with infants, try using an over the counter glycerin suppository. Repeat once in an hour if the first is unsuccessful. Glycerin suppositories can be cut for smaller children, apply lubricating jelly first for ease of administration. If still unsuccessful, try an over the counter pediatric Fleets enema, or half an adult enema. Continue Miralax if recommended when using suppositories and enemas.

When to worry

If your infant or child begins vomiting with constipation, especially if the vomit is green (like bile) or bloody. Call our office if her abdomen becomes hard and distended or discolored, or if she is experiencing severe abdominal pain.