OVERVIEW
Constipation in infants is said to occur if they pass hard stools or have difficulty passing stools. There may be associated pain or the baby may be unable to pass stools even after straining or pushing.

Constipation in babies below one year is not uncommon, but can be a source of anxiety for parents. Usually, an infant’s stool is soft and passed without difficulty. Even in babies who are not constipated, bowel movements may not be regular. Normal bowel movements vary greatly between infants. Breastfed babies may have a bowel movement after every feed, or only once per week. Bottle-fed babies and older children will usually pass stools every two to three days

During the first month, infants typically have bowel movements about once a day. They can then go a few days, sometimes even a week without bowel movements. Since their abdominal muscles are weak, it is difficult for them to pass stools. They tend to cry, strain and become red in the face while passing stools. This does not necessarily mean they are having constipation. If stools are soft, then it is unlikely there is any problem

SIGNS OF CONSTIPATION IN BABIES AND CHILDREN
• Difficulty and discomfort while passing stools
• Passage of hard, dry stools
• Pain during a bowel movement
• Belly pain and bloating
• Fussy eaters and spitting out food
• Stools that are wide and large
• Traces of blood on stool or on toilet paper
• Traces of liquid stool in the baby’s underwear (a sign of fecal impaction)
• Less than three bowel movements a week (children)
• Assuming various positions of the body or clenching the buttocks

Ensure your baby is really constipated before treating. Some babies do not pass stools every day, yet may pass soft stools. Others may have firm stools but able to pass them easily

CAUSES OF CONSTIPATION IN BABIES AND CHILDREN
Constipation results when stools remain in the colon for a longer time and more water is therefore absorbed by the colon making the stools hard and dry. Some common and easily treatable causes include
• Changing to solid foods or from breast milk to formula (infants)
• Diet lacking in fibre content
• Not taking in enough fluids
• Child ignores the urge to pass motion
• Change in routine such as travel, starting school, or stress

Medical causes of constipation may include
• Diseases of the bowel, affecting muscles and nerves
• Other medical conditions that affect the bowel
• Thyroid hormone deficiency
• Spinal cord diseases that can affect the bowel
• Certain metabolic conditions
• Use of certain medicines

Medical causes of constipation in babies are fortunately rare but consult the doctor for further evaluation

MANAGEMENT OF CONSTIPATION AT HOME
Dietary Changes – Infants
• Feed your baby additional water or juice in between feeds during the day. Juice will help make the stool soft
• In babies over 2 months old try giving 2 to 4 oz. of fruit juice (apple, pear, cherry, grape or prune) twice daily.
• In babies over 4 months, if solid foods have been started, try adding baby foods with high-fiber content such as apricots, beans, prunes, peas, peaches, pears, plums, and spinach twice a day.
• Babies on formula with constipation might need their formula switched.

Older babies and children – Dietary and Lifestyle Changes
• Give your child plenty of fluids every day. Your doctor can tell you how much.
• Include more fruits (at least 2 servings per day) and vegetables (at least 3 servings per day) and high fibre containing foods, such as whole grains and cereals. Give fruits with the peel such as raisins, plums, prunes, peaches and apricots that have a lot of fibre.
• Prune juice is a mild, natural laxative that helps some children. It may taste better if mixed with another juice, such as apricot, apple or cranberry juice. Alternatively you can freeze the prune juice and make icy popsicles
• Avoid or limit certain foods such as cheese, prepared and processed foods, fast food meat, and ice cream.
• Temporarily halt toilet training if your child becomes constipated. It can be resumed once the child is no longer constipated.
• Encourage and train older children to use the toilet right after eating a meal even if they do not feel the urge
• Many young children are anxious that they might fall into the toilet. A foot stool can help. Giving them a favourite book during this time might help
• It may be useful to check if the child is uncomfortable about using the toilets at school, child care, or kindergarten and see if this can be addressed
• If your child is above 18 months, limit cow’s milk intake to a maximum of 500 ml per day and avoid snacking or drinking juice before meals. This will improve the child’s appetite at meal times

WHEN TO SEE A DOCTOR
• If your baby is less than 12 months old and you feel it may be constipated, consult your GP or a child specialist
• In older children, if simple dietary changes are not having the desired effect, or your child is in significant pain or passing blood from the back passage with or without stool
Your doctor may advise a laxative treatment, especially in children who have been constipated for many months in addition to teaching the child healthy bowel habits

LAXATIVE OPTIONS – NOT TO BE TAKEN WITHOUT A DOCTOR’S ADVICE
• Liquid paraffin mixtures (e.g. Agarol, Parachoc)
• Macrogol3350 (e.g. Movicol, Osmolax
• Lactulose (e.g. Duphalac)
• Docusate/poloxalkol (e.g. Coloxyl)

• Senna
• Bisacodyl (e.g. Durolax, Dulcolax)
• Psyllium husk fibre (e.g. Metamucil)
• Suppositories and mini-enemas (e.g. Glycerine, Duralax and Microlax) come as small tablets or liquid and placed into your child’s rectum, which stimulate bowel emptying. These are occasionally advised for severe constipation, but laxatives given orally are more effective and less stressful for most children. Avoid giving an enema to your child unless specifically advised by your doctor
• Bowel wash out – Rarely, some children get severely constipated and need admission to hospital for a bowel washout. This is given as a ‘bowel prep’ drink or via a tube into the stomach (nasogastric tube)

KEY POINTS TO NOTE
• Frequency and consistency of stools is highly variable in children
• You should be concerned only if is causing problems
• Your child may feed poorly or be irritable if constipated
• Consult a doctor if simple home measures are not helping
• Constipation can usually managed with lifestyle changes and medicines as advised by a doctor