Constipation in Infants

Parents of newborn and small infants are usually quite concerned about the character and frequency of their child’s stools. Elimination is an important body function, but is seldom a cause for great concern. The frequency and character of bowel movements in infancy are quite variable. Some infants may have a stool with almost every feeding, while others only have a stool every three to five days. Both of these patterns are probably normal. Most breast fed babies tend to have frequent, watery stools several times per day.  This is more so than for formula fed babies who tend to have less frequent, firmer stools. Breast fed babies tend to have loose, frequent stools for the first three to six weeks of life.  After three to six weeks of age, the stools tend to firm up and become less frequent.

Parents are often concerned about constipation in their infant because of straining during a bowel movement. Part of a newborn infant’s normal behavior is grunting and straining to pass stools. The infant will often turn red in the face and seem to be having difficulty in passing his stools. This behavior is normal. As long as your baby is having a stool every three to four days and is not having an extreme amount of difficulty in passing them, her bowel habits are normal. If however, it has been seven days since a bowel movement or if she has extremely thick, pasty stools or has to strain excessively to push out firm balls, she is probably constipated.

Constipation Treatment in Infants: Since constipation is caused by having hard stools which are difficult to pass, treatment is aimed at softening the stools. If your baby’s stools are soft, she needs no treatment for constipation. The following measures are usually helpful for constipation.

  1. If your infant is crying in pain from a hard stool which is difficult for her to pass, one-half of a glycerin suppository can be inserted. These can be obtained without a prescription.  You should not make a habit of using glycerine suppositories, however. They should be used very infrequently because a child can become dependent upon them to have a stool.
  2. To loosen the stool, give prune juice up to three times per day.  Other juices like apple or pear juice can also be effective.
  3. You may also try offering 4 oz. of water with a tablespoon (15 mL) of dark Karo syrup.
  4. If juice and or karo syrup is not effective, you may try Milk of Magnesia. The dose is one-half teaspoon two to three times per day until a stool is produced.
  5. Honey is no longer recommended in the treatment of constipation during the first year of life because of the potential for infant botulism poisoning.
  6. Mineral oil may also be used to soften the stool. It should be chilled and added to a small amount of juice for your child to drink. Begin with one-half teaspoon three times per day and increase the dose if needed.
  7. Constipation which persists despite treatment needs to be evaluated by the doctor.

Constipation in Older Children

Constipation in older children is usually due to a combination of inappropriate diet and bad bowel habits. The diet should be tailored to increase the amount of fresh green vegetables, other vegetables, fresh fruit, fruit juices, water and other fiber foods (such as bran) in the diet. A good way to determine if there is enough fiber in a child’s diet is to observe their stool in the toilet. If the stool floats in the toilet, the child has adequate fiber in the diet; if it sinks to the bottom, the child does not have adequate fiber and fiber should be increased. The vast majority of the cases of constipation in older children are due to inadequate fiber. The treatment of constipation in older children is primarily directed at the increasing dietary fiber.  If your child has a diet of chicken nuggets and macaroni and cheese with few vegetables, constipation is almost guaranteed.  Diet changes are needed.

In addition to diet changes, bowel habits must be addressed in a child with constipation.  Toilet sitting times are needed.  The best time to have your child sit on the toilet, is right after a meal. This timing takes advantage of the Gastro-colic reflex.  Eating stimulates a reflex in the colon to have a bowel movement.  So, after a meal, once or twice per day, have your child sit on the toilet for 10 minutes or until they have a bowel movement.  This strategy is quite helpful in treating constipation. Encourage your child to refrain from retentive behavior in which they strain to keep a bowel movement from passing.

Treatment of Constipation in the Older Child:

  1. The amount of fiber in the diet should be increased. Simply have your child eat a healthy diet with fresh green vegetables, other vegetables, green salads and fresh fruit. If you have a Chicken Nugget, Mac and cheese addict, then forced diet changes are needed.  Please see the section on how to handle a picky eater in this handbook.  We can sum that section up here:  offer only nutritious vegetables, salads, fruits and meat to your child at mealtime.  When you child is hungry enough, he or she will eat them.  Chicken nuggets, mac and cheese, grilled cheese and peanut butter and jelly on white bread are all foods with no fiber. Don’t give in to bad diet habits such as these food choices. What your child eats now, will be a permanent life-style pattern for life.
  2. Fiber can also be increased with the use of bran. Unprocessed bran can be added to casseroles, hamburger, meat loaf or any kind of baked goods. Bran crackers or wafers can be given. These are commercially available for constipation.  Actually, bran is a good idea for the whole family because it reduces cholesterol in the blood and probably helps reduce certain types of gastrointestinal cancers. If attempts at a high-fiber diet are unsuccessful and this is evident by stools which still do not float in the toilet, then it is possible to add bulk laxatives to the child’s diet. This includes methyl-cellulose (Atrucel), psyllium hydrophilic mecelloid (Metamucil), Equalactin, Benefiber, or Fibercon tablets.  These are medicinal forms of fiber instead of dietary fiber.  Use the doses on the label.
  3. The amounts of juices and water should be increased in the diet.
  4. The amount of dairy products in the diet should be decreased somewhat. The total milk intake should be approximately 16 to 24 ounces per day. Larger amounts of milk products can be associated with the constipation. Besides milk, dairy products include, cheese, ice cream, cottage cheese, yogurt, etc.
  5. Medications such as Ex-Lax and other laxatives should not be used chronically, because they are potentially habit-forming.
  6. If your child is acutely constipated and having abdominal pain, a suggested regimen to relieve the constipation includes a pediatric Fleets enema, followed by two or three days of Milk of Magnesia. This will generally relieve the acute problem of constipation. Then of course, you should attack the main problem and increase the child’s dietary fiber.
  7. Mineral Oil. As discussed above, you should chill the mineral oil and add a small amount to juice. Start with a dose of one teaspoon three times per day and increase as needed to one tablespoon three times per day as needed.
  8. Miralax: Once a prescription laxative, this medication is now available over the counter.  For children over 40 pounds, use the adult dose, 1 capful mixed with 8 ounces of juice or water once or twice daily. For children less than 40 pounds, contact us for the proper dose. This medication is meant to be usually taken for several weeks or more due to chronic constipation.  This is our most commonly used medication for constipation and is our usual recommendation.
  9. A 10 minute toilet sitting time is needed once or twice a day shortly after a meal.
  10. If the above measures fail, your child should have a regular office visit. Rarely, medical conditions such as Hirshsprung’s disease or hypothyroidism may be the cause of constipation. These conditions require more in depth work up and treatment. We will investigate these possibilities during an appointment to discuss the problem.

Extremely rarely, constipation in any age child, can be due to a life threatening intestinal problem. Examples are bowel obstructions and a condition called toxic megacolon, a possible complication of Hirshsprung’s disease, a cause of constipation due to a lack of intestinal nerves. For most children who have severe constipation that makes them severely ill, it will be obvious that they need immediate medical attention to decompress the obstruction. Abdominal distention and discomfort are the rule in these cases. Any such child should be brought to our immediate attention. This is rare.

Reviewed 3/16/17 by Dr. Byrum