Constipation and gut problems in babies

Bowel habits in infancy vary enormously, which makes it genuinely difficult for parents to know what is a problem.

What is normal

Breastfed babies in the early weeks typically pass frequent soft yellow stools.

After around six weeks, some breastfed babies go several days or even longer between stools, which is normal provided the stool is soft when it comes and the baby is comfortable and feeding well.

Formula-fed babies typically have firmer, less frequent stools.

Straining, grunting, going red and appearing to work hard while passing a soft stool is normal — infants are learning to coordinate pushing while relaxing the pelvic floor, and this is sometimes called infant dyschezia.

It resolves without treatment.

What constipation actually is

Defined by the stool rather than the frequency.

Hard, pellet-like or large hard stools.

Pain on passing.

Straining without producing anything, or producing only small hard pellets.

Blood on the surface of the stool or on the nappy, usually from a small anal fissure.

Reduced appetite, a distended abdomen, and irritability that improves after passing stool.

And withholding behaviour in older infants — clenching, crossing legs, hiding — which is a response to painful stools and which perpetuates the problem.

Common causes

By age.

In exclusively breastfed babies, true constipation is uncommon and warrants a feeding assessment and consideration of other causes.

In formula-fed babies, incorrectly made feeds — too much powder for the water — are a frequent and important cause, and checking the preparation method is the first step.

Around the introduction of solids, when the change in diet commonly causes a temporary change.

Inadequate fluid, particularly during hot weather or illness.

Cow's milk protein allergy, which can present with constipation as well as diarrhoea.

And a painful fissure creating a cycle of withholding.

What helps

Depending on age.

For young babies: checking formula preparation, offering extra feeds, and gentle measures such as tummy massage in a clockwise direction and cycling the legs.

Evidence for these is limited and they are harmless.

Extra water is not appropriate for babies under six months without medical advice.

For babies on solids: more fluid, more fruit and vegetables, and specifically fruits containing sorbitol such as prunes, pears and apricots.

Whole grains as tolerated.

And regular unhurried opportunities to open the bowels once older, with a footstool once on a toilet.

Where dietary measures are insufficient, laxatives are used in infants and children under medical guidance — osmotic laxatives such as macrogols are first-line in most guidance and are safe for prolonged use, which parents are frequently anxious about unnecessarily.

What not to do

Several traditional measures are advised against.

Do not add sugar, corn syrup or juice to bottles for young babies.

Do not dilute formula, which causes dangerous electrolyte imbalance.

Do not use suppositories, enemas or rectal stimulation with thermometers or cotton buds without medical advice, since repeated stimulation can cause dependence and injury.

And do not stop treatment too early — chronic constipation frequently requires weeks to months of treatment, and stopping as soon as things improve is the most common reason it recurs.

When to seek help urgently

Presentations that are not simple constipation.

No stool at all in the first forty-eight hours of life, which requires assessment.

A distended, tender abdomen with vomiting.

Green or bile-stained vomit.

Constipation from the first weeks of life, particularly with poor growth, which may indicate Hirschsprung's disease.

Red jelly-like stool with intermittent severe pain and drawing up the legs, suggesting intussusception, which is an emergency.

A swelling in the groin, which may be a hernia.

Significant blood in the stool.

Poor weight gain alongside.

And any baby who is generally unwell.

Other common gut symptoms

Briefly.

Wind and apparent discomfort, which is extremely common and where the evidence for most remedies is poor.

Frequent loose stools in a thriving baby, which is generally not a problem.

Mucus in stools, which occurs with infection and with allergy.

Green stools, which have many causes including foremilk-hindmilk imbalance, infection and iron in formula, and which alone in a well baby are usually not significant.

And undigested food in stools once eating solids, which is normal and does not indicate a digestive problem.

General information only, not medical advice. Consult a health visitor or clinician about persistent constipation, and seek urgent care for a distended abdomen, green vomit or blood in stools.