As long as your child is in diapers, every single bowel movement will be right there for you to see when her diaper is changed. During the diaper years, the stools undergo several changes. The first bowel movements are the thick, sticky, tarry meconium stools formed while the baby is still inside you. During the first week these give way, in breastfed babies, to soft, yellow, breast milk stools. These usually look like yellow mustard with little seeds. By the time a baby is one week old, she has an average of 8 to 10 of these pleasant (as stools go) stools each day. Formula-fed stools are often tan or yellow at this stage, and a little firmer than breast milk stools. Either way, there are many dirty diapers!
For most breastfed babies, the number drops to about 4 per day by 4 weeks old (although many kids have a different pattern). Formula-fed babies usually stool less often at this age, and the stools do not change much with time until solid foods are introduced (because unlike breast milk, formula doesn’t change over time).
By 8 weeks old, the average drops to 1 per day. Most formula-fed babies will not go less often than daily, but many breastfed kids will poop even less often than this. I know many babies who only go every three days. If a happy formula-fed baby goes 4 days, or a breastfed baby goes 7 days without a stool, I recommend checking in with a pediatrician (sooner if the child seems to be in pain). Still, it can be completely normal to go only once every eight days — as long as the stool is soft when it comes out. Breast milk is an amazing food that leaves very little in the way of waste.
Beginning solids usually produces a noticeable change in the character of the stools. They may be either softer or firmer, but they will likely smell worse (kids also smile and laugh more at this age, more than making up for the unpleasantness). Most children’s intestines are very responsive to the foods they eat.
Toilet learning may also result in a significant change in the timing and consistency of stools.
Also, at school-age, when children begin going to the bathroom alone (and parents are less aware of the frequency and consistency of stools), some children may go through another period of constipation.
When a child is constipated, the stool in the intestines has backed up more than it should. The longer stool sits in the colon, the more water is absorbed back into the body. When a child is constipated, the stool tends to be hard and passing it tends to be painful.
Anyone can become constipated. Common times include during the introduction of solid foods, during toilet training, or when fluid intake is decreased.
Babies will normally strain from time to time to move the stool along through the intestines. If you want to do something when babies grunt, push, or strain, try picking them up to get gravity to help them in their efforts, or try holding the knees against the chest to help them “squat” — the natural position for bowel movements. Straining is usually normal. Crying while straining may be a sign of constipation. Hard stools are often a sign of constipation.
A decrease in stool frequency might suggest constipation, but it may also be normal.
Constipation lasts until the hard stool is passed, and the intestines begin moving stool along at the normal rate.
Constipation can become a vicious cycle that lasts until treated.
I call this the D3 cycle (discomfort – dread – delay).
Children can enter the D3 cycle at any point. Sometimes it begins with an uncomfortable experience passing a hard stool created by a change in diet or a brief illness. Sometimes the starting point is simply the fear of sitting over the gaping hole in the potty to poop. Sometimes children are engaged in playing and choose to ignore the urge to poop, holding the stool in just to delay interrupting a vitally important game.
Whatever the starting point, they end up having a painful experience. When the next urge arrives, the child decides to delay pooping in order to avoid what happened last time. The longer he delays, the firmer the next stool becomes. When he finally does poop, the event is even more uncomfortable, which confirms his fears. What he dreaded was true!
He vividly learns from this experiment, but it’s the wrong lesson. So next time he is even more determined to hold the stool in. Discomfort leads to dread; dread leads to delay; delay leads to discomfort.
Constipation is diagnosed based on the history and physical exam. It can be seen on x-rays or ultrasound, but these are usually not needed. Children who have constipation that does not respond to treatment may need further evaluation to look for other possible causes of constipation, including Hirschsprung’s Disease, hypothyroidism, botulism, or food allergies.
The simplest first step is to give the child more to drink to soften the stools. At the same time, readjust the balance of the foods in the diet to help. Bananas, rice, soy, and products made from white flour tend to produce firmer stools. Papayas, pears, peaches, plums, apricots, peas, beets, and prunes make stools softer. By balancing the diet, you can often keep the stools comfortably mid-range.
If the stools are still too firm, juice is the gentlest medicine to soften them up. Apple juice twice a day is a good bet. If this doesn’t work, prune juice or baby food is even better.
In addition, when your daughter is straining you might want to put her in a tub of warm water. This will relax her muscles and make the stool easier to pass.
Glycerin suppositories can be very helpful if diet and juice don’t work, but overuse of suppositories can lead to dependence on them. Constipation stubborn enough to make suppositories necessary should be discussed with your pediatrician. The same holds true for baby laxatives. (Hint: If your pediatrician does recommend a laxative, 1/2 teaspoon of unprocessed bran, mixed with food twice a day, is about as effective as many laxatives and much cheaper).
In some children, the D3 cycle is so entrenched that in order to break free they need a stool softener to take the process out of their control. This is especially common if the stools have been hard enough to produce anal fissures.
If constipation is triggered by cow’s milk protein allergy, or other food allergy, then avoiding the offending food can make a big difference.
By staying familiar with a child’s normal stool patterns, parents can adjust the diet when the stools are starting to get too firm or too loose. Also, a high fiber diet can help to keep the stools regular for children who are drinking plenty of liquids.
For children who are learning to use the toilet, an effort should be made to avoid entering the D3 cycle. A relaxed attitude toward toilet learning and prompt attention to any discomfort, dread, or delay can prevent constipation problems.