Constipation in Babies and Little Kids: What You Need to Know

What to Do When Baby Can’t Poo

When my son was a newborn, it seemed like he had a dirty diaper after every feeding. I went through 12 diapers a day and a box of wipes every few days. Then, when he was four months old, it just . . . stopped. One day went by, then two, then three. By day four without any action, I was panicked. What could be the problem? After all, he wasn’t eating anything but breastmilk! Could he be constipated?

I’m not alone in my new parent worry. According to Dr. Susan Baker, MD, PhD, a pediatric gastroenterologist (a doctor who specializes in disorders of the digestive system) at Women and Children’s Hospital of Buffalo, up to 40 percent of referrals to her office by primary care physicians concern constipation in infants and young children. Reassuringly to us parents out there, Dr. Baker says that “most of the time, there’s not a darn thing wrong!”

What is constipation? A normal stooling pattern for infants and toddlers changes according to age. On average, newborn babies have four bowel movements per day during the first week of life, which falls to an average of 1.7 per day at age two years. By the time a child is four years old, the average number of bowel movements per day is 1.2, and this stays the same throughout childhood. Because not all children fall within the average, doctors define constipation as a difficulty or delay in having a bowel movement that is present for two or more weeks.

Constipation in Infants

Recognizing true difficulty in having a bowel movement is a tricky situation for parents of babies. It frightens parents when they see their baby grunt, cry, turn beet red, and kick her legs before passing what turns out to be a soft stool. “This is normal,” says Dr. Baker. “Babies don’t have the benefit of gravity, and they are learning which muscles to use to make a bowel movement. It’s very hard sometimes to help parents understand that this behavior is very, very normal.”

In general, if your baby passes soft stool and seems healthy in every other way, these grunting and kicking behaviors are just a part of the learning process. On the other hand, if your baby has any red flags, such as hard stool, fever, blood in the stool, failure to gain weight, or failure to pass the first meconium bowel movement by 24 hours after birth, a doctor’s visit is in order.

So what about my four-month-old son? It did not appear that he was having any difficulty, but he certainly was having less than one dirty diaper per day. This brings up one key exception to the above average number of stools per day: a baby who receives only breastmilk. “It’s very common for an exclusively breastfed baby to go several days without a bowel movement,” explains Dr. Baker. “When they do have a bowel movement, it will usually be large and very soft.” No one knows exactly why breastfed babies may go up to a week without having a bowel movement, but it probably has to do with the fact that human milk is very easily absorbed, and there may not be much left to come out as stool.

Constipation in Toddlers and Preschoolers

Constipation is also a big concern for parents of toddlers and preschoolers. As Lisa Carmen, mom of two in Massachusetts, says, “I felt like every time I turned around my daughter was constipated when she was a toddler! We had to give her prunes every single day!” Common causes of constipation at this age include:

  • Not enough fruits, vegetables, and whole grains in the diet
  • Low fluid intake
  • Withholding stool during potty training
  • Ignoring the urge to have a bowel movement because the child is too busy playing

When a young child passes a hard stool, it is painful and can be frightening. Most of the time, all the child needs is a lot of positive reassurance and an improved diet and liquid intake to prevent future problems. If you suspect that your child often holds his stool because he is too busy playing, have your child sit on the toilet for at least 10 minutes at about the same time each day, preferably after a meal. You can reward your child for sitting on the toilet with a favorite activity or stickers on a chart. Try to avoid using food as a reward.

It is worth mentioning that a small number of children respond to an episode of hard stool by trying not to have more bowel movements. “They might go on tiptoe, clench their buttocks, dance around, and even hide,” says Dr. Baker. “Sometimes parents understandably mistake this for their child trying to have a bowel movement, when really they are trying not to have one.”

If this behavior goes on long enough, more and more stool collects and becomes impacted in the rectum. Eventually, the child may have some leakage in the underwear. “It’s very important for parents to understand that the child has no control over soiling once impacted, and [the child] absolutely should not be punished for it. It is not willful and defiant behavior,” says Dr. Baker. The only way to resolve this situation is with medication to clear out the impaction, so if you suspect this problem, have your child see the doctor.

Preventing Constipation

Experts agree that the best remedy for constipation is prevention. According to Jan Hangen, RD, LDN, a clinical nutrition specialist at Children’s Hospital Boston, there are three key ways to prevent constipation in young children:

  • A healthy, high-fiber diet with fruit, veggies, and whole grains
  • Adequate intake of water
  • Adequate physical activity, which helps the intestines to move stool along

The problem that many parents face, of course, is how to get their child to eat a healthy diet. “I am a big fan of stealth nutrition,” says Hangen. In other words, it is OK to be sneaky to get the fiber to go down. The goal is your child’s age plus five in grams of fiber per day. So, if you have a three-year-old, aim to get her to eat eight grams of fiber daily.

In addition, Hangen reminds parents that kids need two kinds of fiber. The first is insoluble fiber, like that found in leafy greens and wheat bran, which adds bulk to stool. The second is soluble fiber, like that found in oatmeal, beans, and citrus fruit, which makes stool soft. Here are some of Hangen’s tricks to meet these goals:

  • Space the healthy fiber foods throughout the day. Try tomatoes at breakfast, carrot sticks and dip for snack, hummus on whole-wheat pita for lunch. Don’t load up kids’ small tummies with fiber-heavy vegetables only at dinner time—it might give them stomach discomfort and turn them off of eating healthy foods in the future.
  • Eat on the rainbow. By choosing fruits, veggies, and grains of different colors, you will ensure that your child gets both insoluble fiber and soluble fiber.
  • Be sneaky! Try hiding wheat germ in cereal, adding granola to ice cream or yogurt, or slipping bran into pancakes, cookies, rice pilaf, hash browns, casseroles, meatballs, and macaroni and cheese.
  • Think whole wheat. Switch to whole-wheat bread, or at least bread made with some whole-wheat flour. Use whole-wheat English muffins, pitas, tortillas, croutons, crackers, and pasta. Try breading chicken or fish in whole-wheat bread crumbs.
  • Ease off on the juice. While it’s true that fruit juices like prune, pear, and apple can help with hard stool, Hangen notes that it’s easy to over-do, since juice is mostly sugar and contains no fiber. The best drink is water.

Practically speaking, young kids can be picky and difficult to feed. The best course of action is to keep offering fruits, veggies, and whole grains even if they are refused. Don’t force your child to eat something, but also don’t give up and resort only to unhealthy food without first offering healthy choices. Even picky children will often happily eat cut-up fruit, which can be beneficial.

As with anything, if you feel that something isn’t right with your child’s health, call the doctor. Rest assured, though, that most of the time constipation is short-lived and goes away with a few simple measures.

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