Constipation: tips for keeping things moving

Constipation is a common concern for new parents. Paediatric dietitian Jennifer Douglas, shares her top tips on how to keep things moving this summer.

Constipation is common in childhood and can last only a few days, or can carry on for many months, which can be a worrying time for parents. So what are normal bowel motions, how do we identify and manage constipation, and when should we seek help?

What is normal?

For a breastfed infant, it’s normal to pass a motion after every feed, but it can also be normal to pass a motion every ten days. Breastfed infants pass a very soft/runny mustard coloured stool with minimal odour.

Breastmilk is so highly bioavailable that some babies take out every ounce of that amazing nutrition and pass motions infrequently.

For formula fed babies, it is normal to pass motions 1-2 times per day or every other day. A formula fed infant will pass a soft motion that may be yellow to light brown in colour with a slight odour. Some formula may give a slightly green motion if they are allergy/hydrolysed formulas.

The Bristol Stool Chart (see below) is a way to identify what a normal poo might look like, with the aim for type 4. It may be hard when they have a nappy on to identify what the stool looks like, but if it's soft in the nappy rather than solid or pellet-like, and is not explosive out of the nappy, then it is likely that is normal.

Signs of constipation

It can be quite difficult to identify constipation in infants and children, but some of the common signs are:

+  If your baby has not passed a bowel motion in three days or more when they were previously regular

+  Straining or crying when passing a motion

+  ‘Pellet-like’ hard motions or large diameter motions that are difficult to pass

+  Abdominal pain or bloating

+  Reluctance to feed due to discomfort

What causes constipation?

Constipation is likely to occur at least a few times in your child’s life, but sometimes it is hard to understand how/when it started. Some common causes for constipation are:

+  Drop in fluid intake, e.g. sickness, dropping milk feeds, dehydration

+  Change in diet, or the introduction to solid foods for an infant

+  Change from breastmilk to formula, or a change of formula type

+  Introduction of high fibre foods too quickly for a young infant

+  Withholding behaviour that can occur after passing an uncomfortable bowel motion

+  Underlying medical condition, such as Hirschsprung’s disease, or short gut

How to manage constipation

Focus on fluid:

+  Offer breastmilk and formula more often. Breastmilk has a natural laxative property and can be very helpful in getting the bowel moving

+  If they are formula-fed, ensure that you are making the formula up as it says on the tin and consider moving to a different formula if constipation continues

+  Offer water to a baby that is over six months in-between milk feeds

+  If you have just started on solid food, your baby might need to return to basic foods, such as vegetables and fruit with plenty of milk feeds until constipation resolves and then slowly increase food intake again.

Food to help bowels

You may have heard of the ‘P’ fruits for poop, and this is a good saying to keep in mind for all ages and stages. Puree pear, peach, plum, and prune are all great at getting the bowel moving.

Other stone fruits such as apricot can also help, as stone fruits contain natural sorbitol to aid bowel movement.

Some other food options might be adding blitzed oats into their day, or kiwifruit that has an enzyme that aids gut motility and fibre that helps soften the stool.

Although there are foods that help the bowel there are some that can slow things down. The most common foods that can cause a slowdown of the gut are excess banana intake, and rice cereal. But another cause can be a rapid or sudden increase in fibre content when a baby starts on solids or using high fibre grains such as bran too quickly. Grains should be introduced to your baby slowly from six months onwards. Start with gentle options such as oats and quinoa.

High fibre foods can be useful for long term management of constipation, but they should be introduced slowly and with plenty of fluid.

Gentle activity to help the bowels

+  A warm bath

+  Giving your baby tummy time

+  Gently moving your baby’s legs in a cycle motion while they lie down

+  Gently massaging your baby’s tummy in a clockwise motion

Laxatives

Laxatives may be needed to help manage constipation and these can be prescribed by your GP. It’s important they are used under the guidance of your GP and/or medical specialist to ensure correct usage but also to help you identify the underlying cause for the constipation. Some common laxatives given to babies are:

+  Coloxyl drops, which are a stool softener and can be prescribed by your GP or bought over the counter from your pharmacist

+  Lactulose, which is a stool softener and can be prescribed by your GP

+  Enema/suppository may be used if your baby has significant constipation and can be prescribed from your GP

Probiotics

Probiotics have been studied for their potential role in managing constipation in infants. While the research is still evolving, some specific probiotic strains have shown promise in alleviating constipation. You might like to start with using a probiotic yoghurt containing Bifidobacterium lactis (BB-12) for an infant over six months of age as this has been shown to increase stool frequency. Or you could trial a commercial probiotic containing a multi-strain of probiotics including Bifidobacterium lactis, Lactobacillus Reuteri, and/or Lactobacillus Rhamnous GG strains, as these have some evidence for the use of constipation management in infants by softening the stool and increasing stool frequency.

When to seek help

It’s important that you and your baby get the right support for managing constipation and you might need to seek help from your GP or health professional if the following symptoms are present:

+  Constipation in a baby less than four months of age

+  Excessive mucus in stools

+  Blood in the stools

+  Excessive crying or pain

+  Vomiting or refusing to feed

+  Green stools later in infancy (green stools can be common in the first few weeks)

+  Ongoing constipation that does not resolve with the dietary changes

Constipation can be a challenging time for you and your baby. Understanding what’s normal and what may be causing constipation can help you identify which strategy may alleviate your baby’s discomfort and promote healthy bowel habits. If you are worried about your baby, then chat to your GP, dietitian or health provider who can support you to improve your baby’s health and wellbeing.

Jenny Douglas is a registered dietitian with around 20 years experience working with families and is a leading expert on baby and child nutrition. Co-author to the YUM cookbook with Nadia Lim, Jenny is also director of Jumpstart Nutrition – a company of dietitians working to improve nutrition for families. Jenny holds regular workshops around NZ and sees families in her Dunedin clinics or online. Visit her website jumpstartnutrition.co.nz or follow her on Instagram @jumpstart_kids_nutrition_nz on Instagram.