Infant Constipation

Prevalence Constipation affects around 15% of infants in their first year of life.¹What is infant constipation? In the absence of an organic cause (or aetiology), infant constipation is painful and characterised by hard stools that are difficult for the infant to pass. ²In the first 12 weeks infants pass anywhere from 5 to 40 motions per week, progressively decreasing to 4–20 motions per week at 1 years of age and 3–14 per week at 3 years of age.²Constipation in infants according to Rome IV criteria must include at least two of the following consistently observed for at least one month:^2,3

• Two or fewer defecations per week.
• History of retentive posturing or excessive volitional stool retention.
• History of painful or hard bowel movements.
• Presence of a large faecal mass in the rectum.
• History of large diameter stools.

What are the signs and symptoms? Diagnosing constipation can be difficult, as it requires a parent to assess what is considered normal for infants in terms of stool motions and behavioural issues. Infant constipation can be very stressful to witness and manage as a parent. Symptoms can include:³

• Stomach cramps (pain that comes and goes)
• Infrequent stools
• Holding on behaviour to avoid painful poo
• Hard lumps of poo may be felt in the abdomen
• Hard lumpy poos
• Behavioural issues

Supporting parents to classify the ideal stool formation is important in supporting diagnosis – the following diagram is adapted from Singh H and Connor F, 2018²

Infant constipation treatment There are two key challenges in infant constipation –learning to toilet train and the transition from a liquid to a solid diet. It is important to treat it early as the longer it persists, the harder it is to treat. In infants, the earlier the onset – the more likely it is to have an underlying pathophysiological cause.Red flags to watch out for:³

• Infants presenting <6 weeks of age
• Delayed passage of meconium
• Weight loss/poor growth
• Persistent vomiting
• Abdominal mass

Management of infant constipation can include parental education and dietary interventions³

1. Parental education – providing parents with information about what is normal and what is not can help relieve some of the misconceptions about stool frequency. Using the Bristol Stool Chart is a good reference point.
2. Dietary Modification - Breastfed infants should continue with breastfeeding. If a baby is formula-fed, advise parents to look out for a nutritionally complete formula that’s specifically designed for the dietary management of constipation.

Pharmacological interventions should only be considered when parental education and dietary interventions are not effective.³FOR HEALTHCARE PROFESSIONALS ONLY 

References

1. Vandenplas Y et al. J Pediatr Gastroenterol Nutr 2015;61(5):531-537.
2. Singh H, Connor F. Paediatric constipation: An approach and evidence-based treatment regimen. Aust J Gen Pract. 2018 May;47(5):273-7. PubMed PMID: 29779292. Epub 2018/05/21.
3. Royal Children’s Hospital Melbourne. Clinical Practice Guidelines for Constipation. Available at Clinical Practice Guidelines : Constipation (rch.org.au)Accessed Sept 06, 2021.