Constipation

It can be difficult to know what’s ‘normal’ when it comes to an infant’s bowel movements. The frequency and consistency of stools can vary, but symptoms of constipation are easy to spot

Like adults, babies and infants are all different in terms of how often they normally pass stools – for some, it will be a few times a day, whereas others will only go a few times a week. Parents may ask you for advice if their baby hasn’t passed stools as often as normal.

Symptoms

The criteria used to diagnose constipation in infants up to four years of age is that two of the following symptoms must be present for one month:

  • Two or fewer defaecations per week
  • History of excessive stool retention
  • History of painful or hard bowel movements
  • Presence of large faecal mass in the rectum
  • History of large stools, which may obstruct the toilet.

Accompanying symptoms may include being irritable and unhappy, loss of appetite, tiredness, excessive flatulence, foul smelling wind and stools, and abdominal discomfort and pain. These symptoms may disappear after a bowel movement.

Constipation is common among babies and infants, although it doesn’t usually occur in babies who are exclusively breastfed

Causes

Constipation is common among babies and infants, although it doesn’t usually occur in babies who are exclusively breastfed. The cause of the problem can vary, and may include:

  • Diet and dehydration, if lacking in fluid, fruit or vegetables
  • Toilet training
  • Emotional causes (e.g. starting nursery or a new sibling arriving)
  • Medication side effects
  • Not being very active.

Top tip for managing constipation

The best way to avoid constipation is to make sure that an infant eats plenty of fibre. Fruit, which can be chopped or puréed depending on the baby’s ability to chew, is a suitable option. The best fruits for managing constipation are apples, apricots, grapes, peaches, pears, plums, prunes, raspberries and strawberries.

Treatment

If a baby has constipation and has not yet been weaned onto solid foods, the first course of action is to give them cooled, boiled water between their normal milk feeds. Advise parents to continue making up formula milk as usual – it should never be diluted or over-concentrated. Also suggest parents gently massage their baby’s abdomen or move their legs in a ‘cycling’ action to help stimulate the bowels.

For babies who have already been weaned, recommend that parents give them plenty of water (a small amount of diluted fruit juice can also be given to infants over 12 months) to drink and include more fruit and vegetables in their diet. Fruits that are good for constipation include apples, pears, peaches, apricots, prunes, grapes, raspberries and strawberries. Toddlers who experience constipation should be given regular, frequent meals and should try to stay active. Parents should also encourage good toilet habits to teach the child to go when they feel they need to.

If the problem hasn’t improved after trying any of the above suggestions, the infant may need an osmotic or stimulant laxative (e.g. lactulose or senna).

Clinical summary:

Early diagnosis and management of constipation is important in order to prevent it causing complications, such as a painful anal fissure or embarrassing continence issues such as soiling, or becoming chronic. Additional obstacles exist in the form of a reluctance to seek advice in the first place because of embarrassment, and the conflicting information that many people receive. Both can impact on the effectiveness of treatments and lead to a great deal of frustration.

In its clinical guidance on the topic, NICE states that a full assessment should be conducted before constipation is diagnosed. Underlying causes and red flag symptoms, such as abdominal distension with vomiting which could indicate intestinal obstruction, should be excluded at this time.

First-line treatment for impaction is with an oral macrogol (polyethylene glycol 3350 plus electrolytes). If this product isn’t tolerated, a stimulant laxative (sodium picosulfate, senna or docusate sodium) may be given either on its own or with the osmotic laxative lactulose. All infants should be reviewed within a week, and rectal medication is only recommended if oral treatments fail.

If the infant doesn’t have faecal impaction, or once it has been relieved, maintenance therapy should be started (under the advice of a doctor). First-line treatment is with a macrogol, the dose adjusted according to symptoms and response. A stimulant agent may be added or substituted if the macrogol does not work or is not tolerated. The regimen should be followed for several weeks after regular bowel habits are restored, which may take several months. Frequent reassessments should be conducted, ideally by the same healthcare professional, in order to ensure that re-impaction has not occurred and to provide advice on any issues that occur. Medication should not be stopped abruptly, but instead gradually reduced over a period of months while keeping an eye on stool consistency and frequency. Therapy may be required for several years or on an ongoing basis.

Information on diet and lifestyle interventions should be provided, but are not considered first line treatments on their own.

 



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