Constipation is a very common medical condition in first world countries and is increasingly seen in childhood. With up to 30% of the general population suffering from this bowel related discomfort, a quarter of all cases start in infancy.
It is not a disease but rather a collection of signs and symptoms causing both misery and discomfort to not only the child but the family too. With constipation, bowel movements are abnormally delayed or infrequent and stools are dry and hardened (in most cases). When stools accumulate in the rectum (and sometimes in the colon), the bowel is impacted causing soft or liquid stools to leak; this is referred to as soiling, mostly affecting toddlers and older children.
Normal bowel movements can vary; infants pass stools up to 4 times per day in the first couple of months and even as little as twice per week from the first year of life. At the age of 4, toddlers normally have similar bowel movement patterns to adults, going once a day (but ranging from 3 times per day to three times per week). Overall breastfed babies tend to have softer and more frequent bowel movements compared to formula-fed infants.
The exact cause of constipation is not fully understood, but is mostly due to a combination of factors;
- Pain is experienced with passing large or hard stools pain. Passing large or hard stools can also cause an Anal fissure (a tear in the lining of the anal canal); this is very common in infants and toddlers (especially between 6 – 24 months), and can lead to a negative cycle, withholding stools to avoid further pain.
- Fever, dehydration and immobility as a result of an infection or illness can all cause dry (hardened) stools.
- Formula milk is harder to digest leading to fewer bowel movements that can be thicker in consistency and have a greenish colour. Another reason would be that babies cannot drink more that the amount offered to them, leading to slight dehydration.
- Weaning difficulties are one of the most common causes of constipation. Inadequate dietary fibre, increased milk intake, low fluid intake, over feeding and fussy eating can all trigger constipation.
- Delayed or inappropriate toilet training, bad position whilst on the toilet and changes in daily routines will also contribute to constipation.
- Lastly a family history of bowel related problems and the perception about “normal” bowel patterns are also risk factors.
Symptoms and signs of constipation include;
- Irregular bowel movements
- Foul smelling wind and stools
- Abdominal pain and discomfort
- Alternating stool textures (some hard and others soft)
- Withholding or straining
- Decreased appetite
- Lack of energy
- Grumpy or irritable
- Blood on toilet paper (indicating anal fissure)
Prevention and treatment
The management of constipation often requires a combination of nutritional, medical and behavioural interventions. If constipation is recognised early, simple interventions may be adequate and effective. Laxatives should only be used when other interventions have failed to work (or with faecal impaction) and prescribed by a medical professional. Once on laxatives regular review by a medical professional is required as the dose and type of laxative should be adjusted as needed.
Babies suffering from constipation that have not yet started taking any solid foods should be offered extra fluid (water) between their regular milk feeds. The same treatment should be followed for formula fed babies or alternatively parents should prepare an additional ounce or 2 for each bottle. Formula milk should always be made to the manufacturer’s directions and not diluted.
For the bowels to work properly a balanced and varied diet is needed. Regular meals and well planned snacks are required to provide a steady flow of nutrients to your growing child.
Stools are composed of various components, with dietary plant materials being the largest part thereof; this includes fruits, vegetables and cereals, also known as dietary fibre.
Fibre also promotes the growth of healthy bacteria in the colon, which in turn can assist in preventing constipation. Ensure that sufficient amounts of fibre are consumed by including;
- A variety of fruits and vegetables (pureed or chopped depending on your baby’s ability to chew)
- Best fruits for preventing and treating constipation in babies are; apples, peaches, apricots, pears, prunes, plums, raspberries, strawberries and grapes.
- Beans, pulses and lentils
- Cereals and grains (white and wholegrain varieties as appropriate for age and weaning stage)
A total fibre intake per day of approximately 5 – 7g is recommended for toddlers.
Bear in mind that whole grains, lentils, beans and pulses may fill your child up before they have eaten enough other foods, so do not serve large portions.
It is vital that a well balanced varied diet will be implemented and encouraged from the weaning age, to ensure the formation of good habits. Some babies and toddlers are fussy eaters and parents should take extra care in these cases to ensure adequate fibre intake is achieved. Never force your child to eat, if they do not want to. Forcing them to eat can turn mealtimes into a battle and become a source of frustration, seek help form a dietitian if needed.
Hydration is another key point in preventing (and treating constipation). A large part of stools comprise of water and a lack of water in the diet will cause hard stools. Breastfed babies are less likely to be dehydrated as they regulate how much they want to drink and when. Formula-fed babies are only able to drink the amount offered to them, even though they would like to drink (or need to drink) more, thus it is advised to always make 1 – 2 ounces of extra formula milk.
For older infants and toddlers aim to offer 6 – 8 drinks per day (100 – 120ml each) these can be offered with each meal and one in between meals or with a snack. All fluids count towards their daily intake, water diluted juice or age appropriate milk; this will ensure that stools are soft and easy to pass.
More fluid will be required in active times or hot weather on when taking laxatives. Take care that an excessive milk intake will lead to a decreased consumption of other foods (including fibre) which can increase the risk of constipation. Aim for a maximum of 3 milk based drinks per day.
If constipation persists after the necessary changes in your child’s diet, a laxative may be prescribed. Babies will usually take osmotic laxative as bulk-forming laxatives are not suitable for them.
Encourage physical activity in toddlers and allow infants some tummy time of a play mat, to encourage movement. Alternatively gently massaging your baby’s tummy or moving their legs in a bicycling motion may help to stimulate bowel movements.
Toilet training is an important milestone in a child’s development. Ensuring the right environment, providing motivation and encouragement as well as teaching the correct position for passing a stool are all helpful to establish a positive toilet routine. The ideal position would be to have the knees higher than the hips, keep the spine straight and the stomach pushed out with the elbows on the knees. Children toilet seats or foot stools can provide further support to ensure the child is comfortable, as a minimum of 10 minutes on the toilet is required to ensure good bowel movements.
If you think you baby or child is constipated, do not be afraid to seek help – sooner is better than later.
Bianca Parau, Senior Paediatric Dietitian, Bupa Cromwell Hospital, Cromwell Road, London, SW5 0TU
T: 020 7460 5566 | F: 020 7835 2518 | E: