Constipation in Infants and Children

Constipation in Infants & Children

Constipation is a common problem in infants and children.

As a pediatric dietitian, I see this problem frequently and the cause is seldom because of lack of fiber or fluid.

Children in general does not require a lot of fiber. Their intestines are shorter, thus, shorter transit time. And we don’t want food to go through the intestine too quickly. Otherwise, the body would not have enough time to digest and absorb nutrients during the precious growth period.

Fluid intake or hydration is seldom an issue either. Most infant’s main diet is either breastmilk or formula, so hydration is not an issue. Same for toddlers, who usually consume 16-32oz whole milk along with couple ounces of diluted juice.

However, too much milk can be constipating for some children.

Let’s first define constipation

Constipation is usually defined as having infrequent bowel movements that are hard and painful. However, in children, it is less related to the frequency of pooping. But more the consistency of the poop.

Infants that strain or groan when they poop are not constipated if their stool is soft, even if they only have a bowel movement every two or three days. It is also important to remember that many breastfed infants only have a bowel movement once every week or two.

Parents frequently describe the poop of their constipated kids as “rabbit’s turds”, “hard pellets”, “pebbles”, “hard rock”, “golf ball”, etc.

What Causes Constipation?

Remember, constipation is not a condition itself. It is a sign or symptom that something else is wrong, such as an underlying medical condition, such as Hirschsprung's disease, cystic fibrosis, Celiac disease, spinal bifida, hypothyroidism, food allergy, etc.

Constipation is also often found in children with special needs, such as spina bifida, Down syndrome, mental retardation and cerebral palsy, and it can be a side effect of many medications and hypotonia.

Children with developmental delays that involve hypotonia or low muscle tone tend to have constipation. And this is due to weak musculature of the child. Hypotonia does not only affect skeletal muscles, but is affects smooth muscles in the inters tines as well.

Cow’s milk protein allergy is a common cause of constipation in infant and young children. Other signs to rule out that constipation is the result of cow’s milk allergy is projectile vomiting and bright red blood in stool.

There are many reason why an infant poops only once a week. Some breastfed children poop once a week. And there poop is normal yellow seedy poop and growing well. Then, I would say, that’s their normal.

If on the other hand, an exclusive breastfed infant is pooping only once a week with normal yellow seeding stool, but not gaining weight or failure to thrive. Then, I would suspect inadequate intake from breastmilk.

Either the child is not latching properly or mom’s milk supply is being compromised.

Further investigation is needed.

Constipation is frustrating in both the child and the parents.

In pediatrics, we always say that children control their parents with 3 things: eat, sleep and poop. These are the three things that drive parents nut the most.

Treating Constipation in Infants and Children

Constipation, if not treated, can lead to a vicious cycle of constipation, not want to eat, then become more constipated, then not want to eat even more. Eventually vomiting, poor growth, and abdominal distention may result.

Like I said, I see constipated children frequently in my practice. I also see many children with constipation on medication, such as miralax. Almost every constipated child I see is on miralax.

You can read more about miralax for constipation here.

Now that you have better understanding of the cause of constipation, we’re going to talk about the treatment.

The treatment is for the cause of constipation. We’re not talking about giving a medication to “manage” the constipation. We’re going to “cure” constipation or make it disappear for good.

Medication should be save for the very severe case of constipation involving obstruction and causing other problems. Warning signs that may indicate a more serious condition causing your child to be constipated include poor appetite, vomiting, weight loss, poor weight gain, fever, abdominal distention or having a poor appetite.

It is important to note that infants that are exclusively breastfed rarely become constipated. Infrequent bowel movements do not mean constipation if your infant's stools are soft when he finally passes one. And, most importantly, your infant is growing nicely on the growth chart.

I’ve heard parents adding Karo syrup or other light or dark corn syrups to their infant's bottles of formula. I have never have any parents tried this. It just does not sound right. So I would not recommend Kara syrup or whatever other syrup in infants.

Infants’ digestive system is very delicate, you don’t want to put random things in it.

If you have an exclusively breastfed infant with hard pellet stools, projectile vomiting or blood in stool. I would suggest mom to first remove all dairy (cow’s milk, cheese, yogurt, etc) from her diet. If that doesn’t solve the problem, then remove soy products too.

If the infant is formula-fed with hard pellet stool, projectile vomiting or blood in stool. Change to either soy, or better yet, a semi-elemental formula, such as Alimentum or Nutramigen. If these do not work, and symptoms persist, then try elemental formula, such as Neonate Infant or Elecare Infant.

WIC will provide these formula with a physician prescription with a diagnosis of milk protein allergy.

Projectile vomiting in infants can also be the result of gastric reflux, tracheomalcia or pyloric stenosis.

But with blood in stool, cow’s milk allergy sits highly on the list.

In cases where it’s just simple constipation, there is no projectile vomiting or blood in stool, I usually suggest parents to give couple 2-3 ounces of diluted juice (apple, pear, white grape or prune) a day. This usually resolve the constipation.

For older children, it may be the amount of dairy product they consume. The most common dietary culprit I see with constipation is dairy products, such as milk or cheese.

I personally do not think dairy products is necessary. And that human babies consuming cow’s milk is just not natural. But the dairy industry has so much power over the dietary guidelines that dairy occupies one whole food group of its own instead of being part of the protein group.

Read more about dairy in “Got Milk or Not Milk”.

What if your child is constipated because he/she is intentionally hold their poop?

Having infrequent and large poop that are painful to pass is not fun. Did I mention painful too?

When this happens frequent enough, your child may start to associate pooping with pain, and he/she will try to hold his poop to avoid the pain.

This creates a viscous cycle, where bowel movements are painful, so he holds them in, causing his stools to be even larger and harder, which causes even more pain when it finally does pass.

To stop painful, large and hard poop is to not get constipated in the first place. If it is ruled out that milk allergy is to blame, then avoid dairy products at all cost.

If it’s Celiac disease, then eliminate gluten from the diet.

Anything else…dietary changes and behavioral modification will do.

Is there a special diet for constipation for children?

Yes and no…it depends on your child’s current diet.

The general recommendation is that everyone, including children 1 year old and older and all ages, should consume a well-balanced plant-based diet - 50% all fruits and vegetables, 25% whole grains and 25% protein (mostly from nuts, beans and seeds).

If you’re child and your family is already eating plant-based, there is nothing to change.

But if your family’s diet consists of mostly processed and convenient food, there is a diet for you. And it’s the plant-based diet.

We all know the dietary association with constipation. And we know what food is constipating and what food is not.

But getting a toddler or even young children to eat a healthy diet is difficult, despite the colorful rainbow display of color from all fruits and vegetables. Not to mention if your child has been constipated for a while, there is likely no appetite and they’re probably picky too.

So good luck getting broccoli, kale or spinach in them. But at least decrease milk, yogurt and cheese, bananas, and other constipating foods.

Then, try these strategies to get more fruits and veggies in them.

Fruits and veggie smoothies. 1/4 green leafy vegetables, 3/4 fruits, 1-2 tablespoons of flaxseeds or chia seeds for extra fiber, 1 tablespoons of nuts for protein, then non-dairy milk for the liquid portion.
If they don’t want to drink it, freeze the smoothie into popsicles for snack.

2. Hide or blend fruits and veggies in food or dishes. Consult kid-friendly recipe books, such as Deceptively Delicious by Jessica Seinfield and Sneaky Chef by Missy Lapine. These are my favorites.

3. Simple kid-friendly fruits and vegetables recipes that your child can help make. This empowers them to make good choices on their own, with your setting the limits.

4. Power Pudding. The legendary grandma’s recipe for constipation.
Mix 1 cup unsweetened applesauce, 3/4 cup prune juice and 1 cup unprocessed wheat bran into a pudding form. Take 1 tablespoon each morning.

Power Pudding

5. Add flaxseed or chia seeds to stews, casseroles, smoothies, pudding, etc. They’re not only high in fiber, they’re also good sources of protein and omega-3 fatty acid for brain development.

How Much Fiber is Enough?

Don’t get overzealous with the fruits and vegetables.

Speaking of too much fruits. My daughter loves fruits and vegetables, even as a toddler. She loves watermelon and it’s watermelon season. She keep asking for watermelon, and I thought she would stop when she’s full, but I guess I was wrong.

You know how you can tell your child ate too much watermelon?

When watermelon was coming out of her wasu (literally).

Children’s fiber needs is a lot less than adults’. The daily recommendation is 5 grams of fiber plus their age in years each day. So a 4 year old should have 9 grams of fiber each day.
Because children’s have much lower needs of fiber than adults, you don’t have to intentionally give very high fiber food at each meal.
Just eating some fruits and vegetables throughout the day, should be enough.

Excessive fiber intake in children can result in malnutrition too. So moderation. Just enough to have a normal soft poop every day or other day.

Children with constipation as part of a medical condition, on the other hand, tends to need more fiber. Because of hypotonia, many children with development delays are less mobile, which also contribute to constipation.

In these children, stool softener or a fiber supplement, such as Metamucil or Citrucel or Benefiber, may be needed.

Behavioral Training

Once your child's stools have become soft and regular, it is important to encourage regular bowel movements. This can be accomplished with having your child sit on the toilet for about 10 minutes after meals once or twice a day. You can keep a diary or sticker chart of when he tries to have a bowel movement, then offer a reward for regular compliance.

With proper evaluation of the underlying cause and dietary intervention, your child should be able to have normal soft and pain-free poop.

In severe case of acute constipation, your child may need a 'clean out' or disimpaction before all these dietary and maintenance therapy can work.

Constipation CAN become a chronic condition if not treated properly. In addition to pain, constipation can lead to anal fissures or tears in the skin around the rectum, bleeding, hemorrhoids, rectal prolapse, and impaction. Encopresis is another complication of chronic constipation and can lead to involuntary stool leakage secondary to the impaction of large masses of stool.

In situations where constipation cannot be resolved with any common therapy, a referral to a Pediatric Gastroenterologist may be needed, especially if our child has any warning signs of a more serious condition or if he/she isn't improving with your current therapies.