Solid Starts - How To Relieve Infant Constipation

How to Relieve
Infant Constipation
How to Relieve Infant Constipation
Constipation is a common childhood ailment that impacts up to 30% of children worldwide, of which
about 50% continue to experience symptoms into adolescence and adulthood.1,2,3 While constipation
is most prevalent during toddlerhood, 17-40% of constipated children begin to experience
constipation in their first year of life.4 If left untreated, constipation can cause negative associations
between eating and pooping pain and worsen underlying constipation.
During infancy, constipation most commonly presents after introducing solid foods. Constipation
negatively impacts the quality of life of not only the affected child but also their family.
Left untreated, chronic constipation becomes more difficult to successfully treat.
This guide is intended for children younger than 12 months. In infants, constipation can be tricky
to diagnose as stool frequency varies considerably, especially among infants who receive breast/
human milk. Talk to your child’s health care provider if you are concerned about your infant’s stooling
patterns and/or consistency as it is important to rule out any rare underlying conditions. Also talk
with your child’s health care provider if your infant experiences pain with stooling, passes blood in or
around stools, experiences no improvement in stooling after trying non-pharmacologic interventions
below, or if you have any concerns.
What is constipation?
Among infants, constipation is the passage of hard, sometimes painful, difficult-
to-pass stools that may be very large or small, like hard little pellets.5 In general,
prior to solids, infants who receive formula should poop at least once every 2-3
days and among those receiving breast/human milk, pooping should occur at
least weekly for most.
However, frequency alone does not rule out constipation. Dry or hard stools are not normal during
infancy and are consistent with constipation. Stools usually transition to a more formed consistency
after starting solid foods, which is often where constipation is most often noted in infancy.
Constipation can be associated with decreased appetite, fussiness, and anal fissures and/or
hemorrhoids which can cause blood around the stool. Although constipation has several possible
causes, the vast majority of children do not have any underlying medical disease responsible for
constipation.
1
van den Berg, M. M., Benninga, M. A., & di Lorenzo, C. (2006). Epidemiology of Childhood Constipation: A Systematic Review. The American Journal of
Gastroenterology, 101(10), 2401–2409. https://doi.org/10.1111/j.1572-0241.2006.00771.x
2
Ferreira-Maia, A. P., Matijasevich, A., & Wang, Y. P. (2016). Epidemiology of functional gastrointestinal disorders in infants and toddlers: A systematic review.
World Journal of Gastroenterology, 22(28), 6547. https://doi.org/10.3748/wjg.v22.i28.6547
3
Pijpers, M., Bongers, M., Benninga, M., & Berger, M. (2010). Functional Constipation in Children: A Systematic Review on Prognosis and Predictive Factors.
Journal of Pediatric Gastroenterology & Nutrition, 50(3), 256–268. https://doi.org/10.1097/mpg.0b013e3181afcdc3
4
Tabbers, M., DiLorenzo, C., Berger, M., Faure, C., Langendam, M., Nurko, S., Staiano, A., Vandenplas, Y., & Benninga, M. (2014). Evaluation and Treatment of Function-
al Constipation in Infants and Children. Journal of Pediatric Gastroenterology & Nutrition, 58(2), 258–274. https://doi.org/10.1097/mpg.0000000000000266
5
Zeevenhooven, J., Koppen, I. J., & Benninga, M. A. (2017). The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers.
Pediatric Gastroenterology, Hepatology & Nutrition, 20(1), 1. https://doi.org/10.5223/pghn.2017.20.1.1
@SolidStarts | SolidStarts.com
2
© Solid Starts Inc. 2022. All Rights Reserved.
What are some signs/symptoms caregivers should be aware of that suggest
an underlying cause?6
• First stool (meconium) was passed after 48 hours of life
• Signs of constipation in the first month of life
• History of thin ribbon-like poop
• Big bloated belly with or without bright green (bilious) vomiting
• Intermittent episodes of presumed pain, drawing knees to chest, inconsolable
• Weight loss or not gaining weight

Important history
• Blood in or around poop
• Family history of: Hirschsprung disease, autoimmune diseases
(i.e., celiac disease, type I diabetes, cystic fibrosis)
• Chromosomal abnormalities (i.e., Trisomy 21) or a history of gastroschisis
What are some causes of constipation?

• Sometimes solid foods—rice cereal, bread, pasta, noodles, dairy
• Recovery from an illness (i.e., stomach bug)
• Recent antibiotics
• Medications (i.e., iron supplementation)
• Change in routine—traveling, new daycare
• Stress in the household
The constipation masquerader: Infant dyschezia

Infant dyschezia is a relatively common ailment that affects up to 3% of infants worldwide under
the age of 9 months. It is often mistaken for constipation, especially in infants who have not started
solids. Infant dyschezia is when an infant less than 9 months of age experiences difficulty passing
stool that is ultimately very soft when successfully passed. Pooping requires increasing intra-
abdominal pressure (infants will often grunt) while also relaxing pelvic floor muscles, a task that can
be difficult to learn. Symptoms of infant dyschezia include a combination of straining, screaming,
crying, and turning red or purple in the face that lasts for about 10-20 minutes. While this behavior
ultimately resolves on its own without any medical intervention, it can be very distressing for
caregivers to witness, prompting visits to the child’s primary health care provider. Treatment includes
avoiding rectal stimulation (as an infant may become dependent on it) and laxatives. There is no
evidence to support that children who experience infant dyschezia are at greater risk of developing
constipation later in life.7,8
6
Tabbers, M., DiLorenzo, C., Berger, M., Faure, C., Langendam, M., Nurko, S., Staiano, A., Vandenplas, Y., & Benninga, M. (2014). Evaluation and Treatment of
Functional Constipation in Infants and Children. Journal of Pediatric Gastroenterology & Nutrition, 58(2), 258–274. https://doi.org/10.1097/mpg.0000000000000266
7
Kramer, E. A. H., den Hertog-Kuijl, J. H., van den Broek, L. M. C. L., van Leengoed, E., Bulk, A. M. W., Kneepkens, C. M. F., & Benninga, M. A. (2014). Defecation
patterns in infants: a prospective cohort study. Archives of Disease in Childhood, 100(6), 533–536. https://doi.org/10.1136/archdischild-2014-307448
8
Zeevenhooven, J., Koppen, I. J., & Benninga, M. A. (2017). The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers.
Pediatric Gastroenterology, Hepatology & Nutrition, 20(1), 1. https://doi.org/10.5223/pghn.2017.20.1.1
3
Hirschsprung disease
Hirschsprung disease (also known as congenital aganglionic megacolon) is a motor
disorder of the large intestine characterized by the absence of ganglion cells (motor
neurons) in the rectum and final portion of the large intestine. Without ganglion cells,
the rectum or large intestine cannot move, causing poop to get stuck. Most children
with Hirschsprung disease are diagnosed shortly after birth or within the first few
months of life. There is a genetic component to Hirschsprung disease and it is also
associated with some syndromes, like Down syndrome.
Red flags signs of Hirschsprung disease:

• Meconium (dark, tar like stool) passed after 48 hours of life
• Big bloated belly
• Vomiting, especially bilious (green)
• Difficulty with pooping early in life regardless of manner of feeding.
Often needs stimulation to poop and with stimulation, the poop will squirt out.
• Infant with constipation and Trisomy 21 or family history of Hirschsprung disease
It is extremely important that any infant with a suspicion for Hirschsprung disease be promptly
evaluated. Nothing can replace a thorough physical exam and diagnostic procedure.
4
How to Relieve Infant Constipation
1 2
If 6 months or older, consider offering

small amounts of water. Incorporate poop-friendly foods.
3 4
Substitute refined carbs with Include poop-friendly additions

poop-friendly alternatives. to meals and recipes.
5 6
Offer lots of warm baths. Massage abdomen
7 8
Double check how you are mixing

formula when using powdered or
Physical activity liquid-concentrate formula.
5
How can we treat constipation in infants?
1. If 6 months or older, consider offering small amounts of water.
Water is essential to maintain hydration and help poop move through the intestines. Breast/human
milk and standard infant formula are approximately 85% water.9 While plain water is not appropriate
for infants under 6 months of age, the American Academy of Pediatrics states that infants 6 months
and older can have up to 8 ounces of water per day. We recommend starting slow, with 1-2 ounces
at a time to minimize the risk of replacing key nutrients. Too much water is dangerous in babies.
Never serve water in a bottle as baby can drink too much and can displace the valuable nutrition of
breast milk or formula. Only offer water in an open cup or straw cup.
Daily Water Intake for Infants

Optional
6-9 months
Less than 4oz
(118 mL) a day* 2oz 2oz
Optional
9-12 months
Less than 8oz
(227 mL) a day* 2oz 2oz 2oz 2oz
*Unless otherwise directed by your child's health professional.
9
Martin, C., Ling, P. R., & Blackburn, G. (2016). Review of Infant Feeding: Key Features of Breast Milk and Infant Formula. Nutrients, 8(5), 279. https://doi.
org/10.3390/nu8050279
6
2. Incorporate poop-friendly foods.
Every food impacts poop, and one of the most effective strategies for relieving constipation is to
focus on foods that will loosen or soften poop. In general, high-fiber foods loosen/soften poop;
simple carbs tend to harden and bind poop; and some foods have a neutral impact on bowel
movements. Here are some of the most effective whole foods to help relieve constipation:
Almond Apricot Artichoke Asparagus Avocado Beans Berries Broccoli
Cherries Chia Chickpeas Collard Dragon Durian Figs Flaxseed

Seeds Greens Fruit
Grapefruit Guava Hazelnut Jackfruit Jicama Kale Kefir Kiwi
Lemon Lentils Lime Mandarin Mango Oatmeal Orange Papaya
Peach Pear Peas Pecans Pineapple Pistachio Plum Sapodilla
Soursop Spinach Squash Sugar Sweet Tangerine Watermelon Yogurt

Apple Potatoes
7
3. Substitute refined carbs with poop-friendly alternatives.
There are a few easy swaps to help make common or daily foods promote softer stools.
Continue offering fruit and vegetables regularly, even if the child ignores them.
Pasta. Swap regular pasta for whole grain, lentil, or legume-based pasta. Legumes are a great
source of fiber, iron, and protein.
Flour. Swap white flour for ground oat flour, whole wheat flour, coconut flour, sorghum flour, or
buckwheat flour.
Bread. Swap white bread for whole wheat, whole grain, or sourdough bread.
Rice. Swap white rice for barley, buckwheat, bulgur, millet, quinoa, fonio, freekeh, or farro.
4. Include poop-friendly additions to meals and recipes.

When preparing meals, warm cereals, or baked goods, add poop-friendly additions to the recipe
without changing the texture or recipe measurements.
Add flaxseeds and chia seeds to warm cereals, pancakes, waffles, and
muffins. When preparing these foods, add a tablespoon or two of ground
flaxseed to the mix. If making baked goods from scratch, try whole wheat
flour or add fiber with ground oatmeal flour or blended dried oatmeal.
Add oil to warm cereals. Add a teaspoon of oil to the child’s warm cereal or
yogurt. Avocado oil and flaxseed oil are relatively neutral in taste.
5. Offer lots of warm baths.

Warm baths help relax the body, which can encourage
pooping. The warm water is soothing to any unconformable
areas around the anus (like an anal fissure or small tear)
while also encouraging the external anal sphincter
(a collection of skeletal muscle fibers that surrounds
the anus) to relax, a necessary step for stool to
exit the body. Some babies actually poop during
bath time and this is normal.
8
6. Abdominal massage
Research increasingly shows that massage promotes pooping in adults and children.10 Massaging
facilitates movement and relaxation in the intestine. The large intestine is shaped like an upside-down
“U,” starting in the lower right quadrant and ending in the lower left quadrant of the abdomen.
For abdominal massage in infants, try the “I love you” massage begin by tracing an upside-down
capital “I” from the left upper section to left lower section, then trace an upside capital “L” by starting
in the right upper section, move across to left side, and then trace down, and then finally trace an
upside down capital “U” by starting in the lower right section, going straight up, then across, and
then down. Make sure your infant’s tummy is well lubricated with lotion or Vaseline/Aquaphor.
Continue massaging for about 10 minutes.11
7. Physical activity
Exercise is one of the best ways to get poop moving. Exercise increases blood flow to muscles, including
the intestines, and encourages food to move through the intestines faster.12 What does physical activity
look like in infants? Depending on the developmental stage, this includes all types of movements:
• Tummy time
• Sitting up
• Rolling over
• Crawling
• Cruising
• Standing
• Walking
• Water play (splashing in the tub or kicking feet on a water mat
• Performing bicycle kicks or intermittently bringing your infant’s knees to chest can also help
get things moving.
To help prevent spit up, try to wait about 30 minutes after feeds before placing any pressure on your
little one’s tummy, including tummy time, bicycle kicks, knees to chest.
10
Santucci, N. R., Chogle, A., Leiby, A., Mascarenhas, M., Borlack, R. E., Lee, A., Perez, M., Russell, A., & Yeh, A. M. (2021). Non-pharmacologic approach to pediatric
constipation. Complementary Therapies in Medicine, 59, 102711. https://doi.org/10.1016/j.ctim.2021.102711
11
12
Kwiatkowska, M., & Krogulska, A. (2021). The significance of the gut microbiome in children with functional constipation. Advances in Clinical and Experimental
Medicine, 30(4), 471–480. https://doi.org/10.17219/acem/131215
9
8. Double check how you are mixing formula when
using powdered or liquid-concentrate formula.
A more highly concentrated formula can contribute to constipation and even
dehydration. Too much water can also be dangerous. Unless recommended by
your health care provider, follow the instructions on the formula container.
For example, when using powdered formula, make sure that you measure water
first (ex. 2 ounces) and then add unpacked, leveled scoop(s) of formula to
the bottle. Rounded scoops can increase the calorie concentration of
the formula, and thereby decrease the percentage of water.
What about 100% fruit juice?

According to the American Academy of Pediatrics, 100% fruit juice is generally
not recommended for children less than 1 year of age unless it is recommended
by a health care provider to treat constipation.13,14 While juice is rich in sorbitol
which can get poop moving in the large intestine, we prefer using whole foods
(see list above) first. Juice, even 100% fruit juice, is high in sugar and low in
fiber, so while extremely palatable, it is associated with increased risk of dental
caries/cavities and rapid weight gain.
What about rectal stimulation or infant glycerin suppositories?

Occasional rectal stimulation (usually via a rectal thermometer) or insertion of an infant glycerin
suppository can be used under the direct guidance of a health care provider to unplug a rectal stool
ball. However, regular or frequent rectal stimulation and/or application of infant suppositories is
not recommended because infants can become dependent on these interventions in order to poop.
Enemas should never be administered to an infant. If you feel like your infant needs any of these
measures to stool, please contact their primary health care provider as further work-up, evaluation,
and referral to a pediatric gastroenterologist may be warranted. Remember, stooling is a coordinated
effort. If you find your infant grunting and trying to poop, you can help them by bringing their knees
to their chest intermittently to facilitate expulsion of poop.
Can prebiotics or probiotics help my child poop?

Possibly. The relationship between a child’s microbiome and functional constipation is an emerging
research field. It is hypothesized that children who suffer from constipation have a different microbiome
than those who do not and if a constipation-prone microbiome is altered with the help of probiotics,
prebiotics, or a combination of both, poop can more easily move through the large intestine.15
13
Heyman, M. B., Abrams, S. A., Heitlinger, L. A., Cabana, M. D., Gilger, M. A., Gugig, R., Hill, I. D., Lightdale, J. R., Daniels, S. R., Corkins, M. R., de Ferranti, S. D., Gold-
en, N. H., Magge, S. N., & Schwarzenberg, S. J. (2017). Fruit Juice in Infants, Children, and Adolescents: Current Recommendations. Pediatrics, 139(6).
https://doi.org/10.1542/peds.2017-0967
14
Baker, S. S., Bodnar, L. M., & Benjamin-Neelon, S. E. (2021). Guidance for Beverages in the Diets of Children Younger than Two Years. Journal of Pediatric
Gastroenterology & Nutrition. https://doi.org/10.1097/mpg.0000000000003161
15
10
Probiotics are a combination of beneficial live bacteria and or yeast that naturally live in our GI
system. To date, the research does not support the use of probiotics in the treatment of pediatric
constipation. This does not mean that they are not helpful. Probiotics are inherently difficult to study
because there is no standardization of strains or doses.16
Prebiotics are food ingredients that are only digested in the large intestine by favorable bacteria.
The most common prebiotics are inulin (a type of fiber), fructo-oligosaccharides, and galacto-
oligosaccharides. Synbiotics are a combination of probiotics and prebiotics. While emerging research
supports the usage of prebiotics and synbiotics in treating constipation, more is needed to determine
optimal dosing especially among young children.17,18,19
It is important to remember that your child can increase the number of beneficial
microbes in their gut by simply eating everyday foods, without over-the-counter
supplements. See poop friendly foods above but also keep in mind that a varied diet
comprised of whole foods naturally helps foster a diverse microbiome.
When to seek professional support

Never hesitate to seek guidance from the child’s primary health care provider if you have any
concern. Nothing can replace a thorough physical exam, medical history, and individualized tests or
studies if warranted.
If the infant is experiencing any of the following, seek support from the child’s health care provider:
• Blood in or around poop
• Large, painful stools
• Weight loss
• Abdominal pain
• Lack of improvement in poop despite trialing the above suggestions
16
17
18
19
Shahramian, I., Kalvandi, G., Javaherizadeh, H., Khalili, M., Noori, N. M., Delaramnasab, M., & Bazi, A. (2018). The effects of prebiotic supplementation on weight
gain, diarrhoea, constipation, fever and respiratory tract infections in the first year of life. Journal of Paediatrics and Child Health, 54(8), 875–880. https://doi.
org/10.1111/jpc.13906
11
By:
V. Kalami, MNSP, RD, CSP
K. Grenawitzke, OTD, OTR/L, SCFES, IBCLC, CNT
K. Rappaport, OTR/L, MS, SCFES, IBCLC
Dr. R. Ruiz, MD, FAAP. Board-Certified General Pediatrician & Pediatric Gastroenterologist
Last updated: December 2, 2022
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How to Relieve

What are some causes of constipation?

The constipation masquerader: Infant dyschezia

Red flags signs of Hirschsprung disease:

If 6 months or older, consider offering

Substitute refined carbs with Include poop-friendly additions

Offer lots of warm baths. Massage abdomen

Double check how you are mixing

Daily Water Intake for Infants

*Unless otherwise directed by your child's health professional.

Almond Apricot Artichoke Asparagus Avocado Beans Berries Broccoli

Cherries Chia Chickpeas Collard Dragon Durian Figs Flaxseed

Grapefruit Guava Hazelnut Jackfruit Jicama Kale Kefir Kiwi

Lemon Lentils Lime Mandarin Mango Oatmeal Orange Papaya

Peach Pear Peas Pecans Pineapple Pistachio Plum Sapodilla

Soursop Spinach Squash Sugar Sweet Tangerine Watermelon Yogurt

4. Include poop-friendly additions to meals and recipes.

5. Offer lots of warm baths.

What about 100% fruit juice?

What about rectal stimulation or infant glycerin suppositories?

Can prebiotics or probiotics help my child poop?

When to seek professional support

Last updated: December 2, 2022

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