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Updated: Mar 27, 2020

You're talking about what??

I remember it like it was yesterday: my little son, straining, pushing and crying to try to pass a hard bowel movement. It was an intense experience helping him get that stool out, and it was not pleasant for anyone. He was around 15 months at the time and weaning off of breastmilk. We had started whole milk which, for him, turned out to be the cause of his constipation. Thankfully, switching from whole milk to almond milk worked for his stooling issues, but this is an experience I will not soon forget and one that is all too common in infants and children.

Constipation is characterized by:

- passing infrequent bowel movements (once every three days or fewer in patients over 12 months of age),

- having painful bowel movements


- passing large caliber or hard stools that require excessive straining (think a 1 or 2 on the Bristol Stool Chart)

Constipation that is not caused by another disorder (ie neurologic disorder or hypothyroidism) is called functional constipation. Check the Rome IV criteria for more details on definition.

It is important to realize that in infants, passing infrequent bowel movements alone is NOT constipation. A breastfed infant may go several days to a week without a bowel movement. If BMs are still soft, this pattern is still considered normal. Formula fed infants may go every 2-3 days, not usually longer.

Constipation is most common during the following time periods:

1) With the introduction of solids

2) When starting whole milk

3) During toilet training

4) When starting school

The introduction of solids naturally makes infants’ stools more solid: what goes in must come out! However, certain baby foods are more constipating than others, like rice cereal, bread products, white potatoes, cheese and bananas. Fruits and vegetables help prevent constipation: prunes, pears, peaches (“P” fruits), and basically any other vegetable adds the fiber and liquid content needed to keep stools soft. Oatmeal cereal is less constipating than rice cereal.

The introduction of whole milk commonly causes constipation as it tips the fat/fiber balance. Cheese is constipating as well, while yogurt is generally fine in moderation. If your child is experiencing constipation when transitioning to whole milk, discuss with your child’s physician about switching instead to almond milk or Silk protein milk.

During toilet training, a child has to learn the balance between holding the stool for a short period of time until he makes it to the toilet and holding it for too long. Stool withholding can lead to fecal impaction and soiling the underwear with stool. Additionally, if your child has a hard stool, this will disincentivize her from stooling and create a vicious cycle of constipation.

Many children become constipated when starting school. They often forget to drink fluids during the day and are reluctant to stop playing to have a bowel movement at school. As during toilet training, if they have a hard stool they will be reluctant to stool and this will create the same cycle of constipation. These common predispositions are magnified if there is any developmental delay.

The first step in correcting constipation is changing your child’s diet! There has to be a balance between foods that are binding and foods that are not. If your child is taking whole milk, talk with your child’s physician about whether switching to almond milk or other plant-based milk is a good option. Generally, avoiding excess intake of starches and grains as well as apple sauce and bananas is a great step. What should be added to the diet as you remove those starches? More FLUIDS and more FIBER. Fiber increases the bulk of the stool, resulting in a laxative effect. Vegetables are a wonderful way to increase fiber and fluids at the same time. Fresh fruit will always add fluids; some are better for adding fiber than others. Plums, apricots, melons, and figs, for example, are high fiber fruits.

The recommended amount of fiber per day is generally a 5-8 grams + the child’s age in years.

I also recommend an omega-3 supplement daily to promote stool regularity. If your child eats omega-3 containing fish twice weekly it may not be necessary.

Besides prunes, increased fiber and increased fluids, other remedies include:

- Magnesium citrate, an OTC preparation that draws water into the stool.

- Lactulose. Lactulose, a prescription remedy that is a poorly absorbed sugar. It thus lubricates the stool and results in a softer stool.

- Miralax, suppositories, enemas, etc. which I do recommend depending on the situation.

Beating constipation requires all caregivers to send a unified, positive message to the child about toileting. Positive reinforcement, ie sticker charts and rewards (raisins? :)) for stooling can go a long way.

Talk with your child’s physician to see which remedies would be most appropriate for your child.

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