Constipation in infants under the age of 1 – everything you need to know

How often should a baby pass stool?

The answer to this question depends on what the baby feeds on.
Babies who feed on breast milk have a wide range of normal stool frequencies, anywhere between a number of bowel movements per day to once a week is considered normal. However, most breastfed babies have at least one bowel movement per day.
The number of bowel movements that non-breastfed babies have per day is much smaller than those that are breastfed. However, one bowel movement per week in babies that are non-breastfed is considered constipation.
The number of bowel movements babies have per day decreases as they grow older during their first year of life, regardless of whether they are breastfed or non-breastfed. The consistency of the stool also becomes thicker and harder.

So how is constipation defined in babies?

Constipation in babies is not only defined by the number of stools they pass per day. The main emphasis is on the consistency and the ease in which these stools pass.
Keep in mind that during the first years of life, some babies experience lots of crying and strain when trying to pass stool. This does not necessarily mean they are experiencing constipation, and sometimes it is the normal process of gastrointestinal tract maturation. Nonetheless, if a baby is suffering and their stool is hard and round, even at a very young age, this is considered constipation and should be managed accordingly.

What are the common causes of constipation in infants under the age of 1?

In most instances this constipation is not associated with structural abnormalities in the gastrointestinal tract. That means that this is a situation in which there is an interruption to the function but not a disorder in the nerves or muscles in the gastrointestinal tract.
The baby’s body is developing, and some babies find it more difficult to learn how to activate their muscles in order to pass stool properly. Sometimes this defecation is associated with pain and they try to avoid it. One of the reasons for constipation can be sensitivity to cow’s milk protein. In these situations, once the physician has done their assessment, the baby’s formula is changed or the mother’s diet is restricted. It is important to consult with a pediatrician when switching the baby’s formula so as not to reach a point where the baby’s formula is changed too often, unnecessarily. These changes put families and babies under lots of stress. It is important to keep in mind that cow’s milk protein allergy is not very common, and constipation is not a very common symptom either. Nonetheless, the European society for gastroenterology recommends avoiding milk in babies who are struggling with constipation and in whom alternate methods of treatment were unsuccessful.

What are some rare causes of constipation in infants under the age of one?

There are some rare causes of constipation as well. These are significant disorders that require investigations and interventions.
When constipation is congenital, or presents at an early stage of infancy, the physician will focus on ruling out congenital disorders of the gastrointestinal tract and ruling out Hirschsprung, a disease that causes a disorder in the innervation of the gastrointestinal tract. In addition, the physician will rule out a disorder of thyroid function that could cause constipation as well. In certain situations, there could be concern for cystic fibrosis, and workup will be warranted.
Nonetheless, it is important to keep in mind that only in a small fraction of the cases will these disorders be of concern, and most cases of constipation will not require any investigations.

What kind of investigations will the doctor perform to assess constipation in infants under the age of 1?

Investigating constipation in babies will start if with a good history from the parents, including the past history of the pregnancy and delivery, a physical exam to assess the structure of the vertebral column, the abdomen and the anus. In a small fraction of the cases further work up will be done including bloodwork (thyroid function tests and sometimes celiac testing, depending on the age of the baby) and a sweat test (a test done to rule out cystic fibrosis). Sometimes, the investigations will also include anorectal manometry – an examination that assesses the sphincter and reflexes in the baby. This assessment can raise concern for Hirschsprung disorder and if the suspicion is high the baby will be referred to surgical workup.

How is constipation managed in babies?

The management of constipation under the age of one is a little bit more complex and is limited in the number of products that can be administered. In addition, the treatment depends on the cause of the constipation and the child’s age.
The treatment of constipation in these young ages includes:
1. Massage – gentle massaging along with flexing of the legs increases the abdominal pressure (which is supposed to increase during detection) and help the baby pass stool.
2. Nutritional management – in babies that have started solids you can consider supplementing with tomato juice, prune juice of blended fruits.
3. Pharmacological management – this ought to be only used if recommended by a physician:
a. Oral treatment – in the young babies this includes:
# Paraffin oil – softens stool and makes it easier to pass. It’s important to remember not to use these in children with respiratory disorders, because if the paraffin oil goes into their respiratory tract it can be very dangerous.
# Lactulose – this is a sugar that cannot be digested and it causes very water stools. It is a safe drug and there is plenty of experience with its usage that has accumulated over the years.
# Polyethylene glycol – this substance is not absorbed and remains in the gastrointestinal tract. There is lots of medical literature that supports the use of this medication in young ages, but it is important to make sure the child is taking in sufficient fluids when they use it.
b. Rectal treatment – suppositories are very efficient in babies and they allow efficient emptying of the gastrointestinal tract. Management of babies with constipation should not rely solely on suppositories. However, they can be combined with other methods as needed.

What about stimulation of the rectum in order to help a baby who is experiencing constipation?

Some parents perform rectal stimulation, often with the help of a thermometer, to encourage a baby to pass stool. As a general rule, rectal stimulation is not recommended, except for rare situations, because it prevents the child from learning how to pass stool on their own. In addition, rectal stimulation through insertion of a foreign body can cause injury.

What should you know and remember in the long run for babies with constipation?

It’s important to keep in mind that constipation in babies is a common condition and is usually one that resolves with time. Nonetheless, it requires monitoring and care, because when managed correctly, it can prevent the baby from experiencing pain and suffering and prevent the development of chronic constipation and its complications.

In summary, a common condition that typically resolves with time, but requires monitoring and care. Only in a small number of the cases with further work up and investigations be required, and it is then important to see a specialist in the field in order to provide your child with the best care available.