Constipation: A-to-Z Guide from Diagnosis to Treatment to Prevention

Child making a funny face. Could it be constipation?


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 that he or she be checked by 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.

What is 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.

Who gets constipation?

Anyone can become constipated. Common times include during the introduction of solid foods, during toilet training, or when fluid intake is decreased.

What are the symptoms of constipation?

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.

Is constipation contagious?


How long does constipation last?

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.

How is constipation diagnosed?

Constipation is diagnosed based on the history and physical exam. It can be seen on x-rays, 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.

How is constipation treated?

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. Pears, peaches, plums, apricots, peas, 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.

How can constipation be prevented?

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.

Dr. Alan Greene

As a father of four himself, Dr. Greene has devoted himself to freely giving real answers to parents' real questions -- from questions about those all too common childhood conditions to those that address the most recent and rare pediatric illnesses. His answers combine cutting edge science, practical wisdom, warm empathy, and a deep respect for parents, children, and the environment. He is also an electrifying public speaker, and has personally touched many during his talks in North America, Europe, Asia, and the Middle East.

Dr. Greene is a graduate of Princeton University and the University of California at San Francisco. Upon completion of his pediatric residency program at Children's Hospital Medical Center of Northern California he served as Chief Resident. He entered primary care pediatrics in January 1993.

Dr. Greene is the Past President of The Organic Center and on the Board of Directors of Healthy Child Healthy World. He is a founding partner of the Collaborative on Health and the Environment. He also consults for the Environmental Working Group.

In 1995, he launched, cited by the AMA as “the pioneer physician Web site” on the Internet. His award-winning site has received over 80 million Unique Users from parents, concerned family members, students, and healthcare professionals. In addition to being the founder of, he is the Medical Director for HealthTap.

In 2010 Dr. Greene founded the WhiteOut Movement to change how babies in the United States are fed. In 2012 he founded TICC TOCC - Transitioning Immediate Cord Clamping To Optimal Cord Clamping. He is also the founder of KidGlyphs, a free iPhone app that provides a tool for young children to express themselves beyond their verbal skills while teaching them important language skills.

Dr. Greene is the Founding President of the Society for Participatory Medicine and has served as both President and Board Chair of Hi-Ethics (Health Internet Ethics. He is on the Board of Directors for Healthy Child Healthy World, The Lunchbox Project, and The Society for Participatory Medicine. He has also served as an advisor to URAC for both their inaugural and their updated health web site accreditation program. He is a founding member of the e-Patient Scholars Working Group, and a founding board member of the Center for Information Therapy.

Dr. Greene is a regular columnist for Parenting Magazine. He is also the Pediatric Expert for The People’s Pharmacy (as heard on NPR) and Healing Quest (seen on PBS stations). He was the original Pediatric Expert for both Yahoo! and iVillage.

Dr. Greene is the author of Feeding Baby Green (Wiley, 2009), Raising Baby Green (Wiley, 2007), From First Kicks to First Steps (McGraw-Hill, 2004), The Parent's Complete Guide to Ear Infections (People's Medical Society, 1997), and a co-author of The A.D.A.M. Illustrated Family Health Guide (A.D.A.M., Inc., 2004). He is the medical expert for three additional books, The Parent's Soup A-to-Z Guide to Your New Baby, (Contemporary Books, 1998) The Parent's Soup A-to-Z Guide to Your Toddler, (Contemporary Books, 1999), and The Mother of All Baby Books, (Hungry Minds, Inc., 2002).

Dr. Greene is a frequent keynote speaker at important events such as Health 2.0 2011 held in San Diego, CA, IFOAM 2008 (International Federation of Organic Agriculture Movements), held in Modena Italy, the first European Internet health conference, held in Maastricht, the first International eHealth Association Conference, held in Jeddah, and the largest e-Healthcare World Conference, held in Las Vegas, and the first Green Power Baby Shower, held in Hollywood. Dr. Greene also appears frequently on TV, radio, websites, and in newspapers and magazines around the world, including such venues as the TODAY Show, Good Morning America, Fox and Friends, The Dr. Oz Show, CNN, ABC, CBS, and NBC network news, NPR, The New York Times, The Wall Street Journal, USA Today, Time Magazine, Parade, Parenting, Child, Baby Talk, Working Mother, Better Home's & Gardens, and the Reader's Digest.

Dr. Greene loves to think about challenging ideas, he enjoys being where nothing manmade can be seen, and he wears green socks.

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