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Constipation

The expert consensus is that the worldwide prevalence of functional constipation in infants age younger than 12 months is estimated to be approximately 15%, depending on the type of feeding.1

The exact cause is not understood. Hypotheses include: 

  • Dietary and fluid intake (especially dehydration), dietary changes, psychological, pain, fever & medicines2-4

ROME IV criteria for the diagnosis of constipation

Must include 1 month of at least 2 of the following in infants up to 4 years of age5:

  1. Two or fewer defecations per week
  2. History of excessive stool retention
  3. History of painful or hard bowel movements
  4. History of large-diameter stools
  5. Presence of a large fecal mass in the rectum

In toilet-trained children, the following additional criteria may be used:

  • At least one episode/week of incontinence after the acquisition of toileting skills
  • History of large-diameter stools that may obstruct the toilet.

Parents should be able to supply you with a reasonable account of the frequency and consistency of their infant’s stools. To determine constipation in an infant, the following should be queried with parents6.

  1. The consistency or hardness of the stool: Constipated stools are firm, dry pellets which do not soak into an infant’s nappy
  2. Straining at stool: Some straining is normal for infants, but straining with crying can be a sign of constipation

The Brussels Infant and Toddler Stool Scale (BITSS)7

NICE guidance on constipation8

The NICE Clinical Guidelines recognise the role nutrition plays in the management of FGIDs in infants and recommend conservative and nutritional approaches ahead of medical interventions3.

The guidance states that laxatives and diet modifications may help:

  1. Try polyethylene glycol 3350 plus electrolytes (for example Movicol Paediatric Plain). Use a stimulant laxative if this does not work
  2. Dietary modifications may then be considered to ensure adequate fluid intake; however, this is assumed to come from breastmilk

Very little guidance is given specifically for formula-fed infants under 6 months of age with functional constipation

Managing constipation in infants

It is recommended to conduct a careful history to diagnose either functional or organic constipation. Only a small number of children will have an organic cause for constipation, and beyond the neonatal period, constipation in children and infants is commonly functional constipation9. If an infant more than 2 weeks old presents with constipation, the following steps should be followed6:

  1. Complete a medical history and physical exam and investigate occult blood (if indicated)
  2. Arrange an appointment with a consultant if any of the following symptoms are present:
  • Delayed passage of meconium
  • Anal stenosis
  • Fever
  • Tight empty rectum
  • Vomiting
  • Impaction
  • Bloody diarrhoea
  • Distension
  • Failure to thrive

Practical management for constipation

Parents may find the following techniques useful to stimulate bowel movement6:

  • Massage the infant’s tummy in a clockwise direction, making firm but gentle circular motions from the belly button outwards.
  • Put the infant lying on their back. Gently move their legs backwards and forwards – in a ‘bicycle’ motion.
  • Give the infant a warm bath to relax the bowel.

Dietary treatment for constipation

If an organic cause of constipation has been ruled out, parents should be advised on the following areas as appropriate:

  • If powdered infant formula is the infant’s usual milk, ensure it is prepared correctly. Over-concentration of infant formula can cause constipation.6
  • Make sure the infant is getting enough fluid; if they are meeting their fluid requirements, additional fluids may be necessary provided by cooled, boiled water6. However, it is vital that any water given does not displace milk in the infant’s diet.
  • For formula fed infants consider trialling a specialised milk for the dietary management of colic and constipation click here for more info.

If education and diet are unsuccessful, the GP should then consider treatment with medication, e.g. lactulose, malt extract or glycerine suppository.6

IMPORTANT NOTICE: Breastfeeding is best for infants. Infant formula is suitable from birth when infants are not breastfed. Follow-on milk is only for infants over 6 months, as part of a mixed diet and should not be used as a breastmilk substitute before 6 months. We advise that all formula milks including the decision to start weaning should be made on the advice of a doctor, midwife, health visitor, public health nurse, dietitian, pharmacist or other professional responsible for maternal and child care. Foods for special medical purposes should only be used under medical supervision. May be suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6–12 months. Refer to label for details.

  1. Vandenplas Y et al., Prevalence and health outcomes of functional gastrointestinal symptoms in infants from birth to 12 months of age. J Pediatr Gastroenterol Nutr 2015; Nov 61(5):531-7
  2. NICE. Constipation in children and young people. 2010. Available at: https://www.nice.org.uk/guidance/cg99 (Accessed Nov 2016)
  3. Tabbers MM. et al., Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPCHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014;58:265-281
  4. Kamer B et al., Food allergy as a cause of constipation in children in the first three years of life – own observations. Med Wieku Rozwoj 2011;15:157-161
  5. Benninga MA. et al., Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016; 150:1443-1455.
  6. Food Safety Authority of Ireland 2012. Best Practice for Infant Feeding in Ireland. From pre-conception through the first year of an infant’s life: A guide for healthcare professionals. The Scientific Recommendations for a National Infant Feeding Policy, 2nd Edition (2011). Available at: www.fsai.ie
  7. Huysentruyt K, Koppen I, Benninga M, Cattaert T, Cheng J, de Geyter C, Faure C, Gottrand F, Hegar B, Hojsak I, Miqdady M, Osatakul S, Ribes-Koninckx C, Salvatore S, Saps M, Shamir R, Staiano A, Szajewska H, Vieira M, Vandenplas Y and the BITSS working group. The Brussels Infant and Toddler Stool Scale: A Study On Inter-Observer Reliability. J Pediatr Gastroenterol Nutr. 2019 Feb;68(2):207-213. doi: 10.1097/MPG.0000000000002153.
  8. NICE. Constipation in children and young people. 2010. Available at: https://www.nice.org.uk/guidance/cg99
  9. NASPGHAN. Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Paediatric Gastroenterology, Hepatology and Nutrition. Journal of Paediatric Gastroenterology and Nutrition 2006; 43:e1-13.

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