Newborn constipation
No one-size-fits-all remedy
But a rich set of options

Newborn constipation is as painful for the parents as it is for the infant. As the father of three, I speak from experience.

If your baby is constipated at this moment, you are probably feeling powerless. Baby’s tummy has been aching for a few days, and she has only produced a few dry pellets. You don’t know what to try next.

And if you are giving her formula, the last thing in the world you want to hear is “you should have breastfed her”. I talk from personal experience. Plus, this is beside the point.

But you have options. Millions of parents around the world have dealt with this situation. If they have gone through that frustrating episode, you can survive it, too.

So let’s talk about this touchy subject. After presenting the reasons behind newborn constipation, we will get into the possible remedies available to you.

Gastrointestinal functions after birth

There are 2 very important processes being put into place in the first few days of baby’s life.

Gut flora

Baby’s gastrointestinal tract needs to be inoculated with friendly bacteria at birth. Those bacteria form her colonic flora. On this website, we have often discussed the important role of the gut flora for a healthy transit.

While in her mother’s belly, the gut of the baby is void of any bacterial life. As soon as she comes into contact with the outside world, the inoculation starts.

The fastest way to get loads of those friendly bugs is through vaginal delivery. The mother’s vagina is full of bacterial life, and those bacterial strains will be transferred to the baby.

The mother’s fecal flora also plays a big role in the establishment of the baby’s friendly bug colonies(1), and here again vaginal delivery is determinant.

This point is important: as we will see further down, probiotics and prebiotics are more relevant in the context of a C-section. If there has been a vaginal delivery, there are fewer reasons to think that the baby’s flora might be deficient.

Meconium passage

The second important process is a timely passage of meconium. During pregnancy, the baby absorbs amniotic fluid and other miscellaneous substances present in the uterine environment. At birth, those will be eliminated as waste, and will constitute baby’s first defecation.

Meconium is dark green and quite sticky. Usually, baby will pass meconium in the first 24 to 48 hours of her life. The later meconium comes out, the more abdominal distention baby may have.

At this stage, a baby is not in touch with her body. New and uncomfortable bodily sensations are taking place. The defecation reflex is one of them. As baby tries to expel meconium, you may see marked straining, tossing, legs moving, and curled up toes. This exaggerated response may not necessarily be a sign of newborn constipation.

Note that if meconium takes too long to come out in a full term newborn, it raises the suspicion of Hirschsprung’s disease. We will talk about Hirschsprung’s further down in this article.

Some studies(2) show that a delayed passage of meconium is linked to constipation issues later on in the child’s life. This is just a statistical correlation of course. If your child has delayed passage of meconium, it may not mean anything.

But on the other hand knowing the predisposition of your child is a great way to take proactive measures later in his life to make sure he has a good transit.

Defecation patterns

After those first life events, be aware of the defecation patterns you should expect.

One study(3) performed on more than 1000 children gives a good idea of the average pattern:

  • In the first month, the average number of defecations per day is 6;
  • In the second month, this number decreases to about 1 a day, and this remains so for most babies until the end of their 24th month;
  • In the second month, about 40% of infants pass stools less than once a day. This pattern of rare defecation holds until the end of the sixth month, when supplemental foods are started;
  • Stool frequency is higher in exclusively breast-fed infants;
  • Babies who had colic in their first 2 months have less frequent defecation during their first 2 years.

Another study(4) gives a slightly different view:

  • During the first week of life, babies have an average of 4 defecations per day;
  • This number gradually declines to 1.7 defecations per day at 2 years of age;
  • Further declining to 1.2 defecations per day at 4 years of age;
  • The study also notes that some breast-fed babies do not have stools for several days, and this is normal.

Of course, these are average numbers and should be taken as such. Your baby is a very unique individual who may vary from this average, and this does not necessarily means she has newborn constipation.

When is baby constipated?

Forget about the number of defecations per day or per week. Certain babies will pass stools several times a day, some others will do so once every 48 hours without having newborn constipation.

There could be days between bowel movements of a healthy breast-fed baby (weeks in rare instances), the key here being that the stools remain soft when they finally come out.

If your baby has newborn constipation, you will observe one of the following symptoms:

  • Dry hard stools or “pellets”, sometimes looking like drying playdough;
  • Stools passed with difficulty, accompanied with lots of agitation and unrest;
  • Distention of the belly (looking like an inflated balloon);
  • Sometimes traces of fresh blood in the diaper, since dry stools may create small tears in the fragile mucosa of baby’s colon;
  • Rarely hemorrhoids, although unfortunately this condition is not reserved for adults;
  • Sometimes liquid being passed between hard stools, which may indicate fecal impaction (liquid stools manage to squeeze past the hard plug), or Hirschsprung’s disease.

One of the main complications of newborn constipation may be anal fissures, which are small tears in the colon mucosa due to the passage of hard, dry stools.

When fissures occur (may be signaled by traces of blood in the diaper), the baby will be in pain each time she tries to pass stools. As a reflex, she will try to hold it in, further aggravating the situation.

RED FLAGS
If you observe any of the following red flags, promptly contact your doctor:

  • Fever
  • Vomiting
  • Bloody diarrhea
  • Excessive sleepiness
  • Refusal to feed
  • Weight loss or poor weight gain

According to the medical literature, other red flags could be excessive crying and restlessness. But as a parent, I know this is very hard to gauge. Some babies simply cry and fuss a lot, how do you know when you enter the realm of “excessive crying”?

At the end of the day, use common sense: when in doubt, contact your doctor.

The reasons behind newborn constipation

Most of the time, newborn constipation does not have any organic cause; it is purely functional. This means the transit functions are affected, but the organs themselves are healthy.

Causes of newborn constipation may include the following manifestations.

Food allergy or intolerance
Today, more and more babies have either allergies (marked allergic reaction) or food intolerances (less obvious signs) related to formula milk.

Formula milks are becoming increasingly complex in their constituents and manufacturing processes, so it is hard to pinpoint exactly the newborn constipation trigger.

I am not going to tell you why you should have breastfed your baby. For whatever reason you chose formula, things will be alright. We are here to discuss solutions.

No, we are here to discuss solutions.

This is what we know today about formula milk upsets:

If you have food intolerances or food allergies in your family, there is a high probability that your baby will inherit that trait.

Part of the solution to newborn constipation will be identifying the right formula for your baby. This will be covered further down.

Lack of fluids
Sometimes baby lacks fluids. This could happen for several reasons.

First is the change to hotter weather. Babies sweat a lot during the heat of summer, and they need to drink on a regular basis, through breast milk or formula.

Second, a bout of diarrhea or fever may trigger dehydration.

Third, some parents may not be adding enough water to the formula powder. Read the instructions on the box again just to make sure you have the proportions right.

If your newborn constipation is due to dehydration, you may be able to see signs such as a dry tongue and mouth, dry irritated eyes and dry skin.

The best way to rehydrate your baby is through formula or breastfeeding. Between birth and 6 months of age, babies should not be given water. They need a perfect balance of different minerals and electrolytes in their drink, and formula or breast milk provides that. Plain or mineral water is too harsh on their kidneys and makes them lose some precious minerals like sodium.

Talk to your doctor or pediatrician if you suspect dehydration.

A lack of good gut flora
As discussed previously, we all need balanced gut flora to digest food properly. When a baby does not go through vaginal birth, she will not get inoculated with the mother’s vaginal and rectal flora, which may delay the development of her own flora.

The study mentioned previously(4) observed that 5% of the cases of chronic constipation in children was dysbacteriosis of the digestive system, an imbalance in gut flora.

Other studies have shown differences between the flora of constipated and non-constipated people, and improvement of transit when pro-biotic supplements of certain strains were given(5). Bacteria in our gut produce short-chain fatty acids, and those acids lower the pH in the colon. This lower pH enhances peristalsis, the wave-like forward motion that gets stools moving.

We will see further down how we can help reestablish the flora of babies who have been delivered by Caesaeran.

The use of thickening agents
Certain parents use thickening agents such as rice flakes or other type of cereals in baby’s bottle. They usually do this to prevent spitting, but sometimes because they believe it will provide better nourishment (this is one piece of advice I heard from my mom).

If your baby has newborn constipation, do not use thickening agents.

Newborn constipation and organic causes

If the constipation is stubborn, does not respond to dietary changes and simple approaches, or show specific signs (constipation alternating with diarrhea for instance), an organic cause or metabolic imbalance may be responsible.

These causes are fairly rare, but the possibility exists. Organic here means that the baby was born with a defective organ.

Hirschsprung’s disease

One of the most common organic cause of newborn constipation is Hirschsprung’s disease.

Hirschprung’s is a birth defect characterized by a complete lack of nerve connections for a portion of the baby’s colon. This portion is not getting any signals from the nervous system.

When the nervous system sends out orders to get the stools to move forward (peristalsis), that portion will not respond. Stools move in the colon until they get to that portion, where they get stuck. This leads to fecal impaction and, in the long run, failure to thrive (baby not gaining enough weight, etc).

As we have seen, a delayed passage of meconium, followed by certain signs like constipation alternating with diarrhea, indicate this condition to your doctor. From 50% to 90% of newborns with Hirschsprung’s disease do not pass meconium in the first 48 hours of their life(6).

The incidence of Hirschsprung is about 1 case in 5000 births(6).

Your doctor will discuss diagnosis and treatment options with you. Diagnosis may involve doing a biopsy to confirm that there is indeed something wrong with a portion of the baby’s colon.

There aren’t tons of options from that point on. Your doctor will explain to you the surgical procedure, which is a “resection”. The non-responsive portion of the colon will be cut, and the two functioning ends will be put together.

Risks and long-term implications of such a procedure depend on how much of the colon needs to be removed.Without surgery, the baby risks serious complications.

Other possible health causes

Describing all the possible causes of newborn constipation, however obscure, would take too long and is not the purpose of this page. Our aim is to provide solutions.

But for the sake of completeness, here’s a list of other possible causes that your doctor may need to investigate if your newborn constipation remains intractable:

  • An anomaly of the anus (stenosis for instance, which is a narrowing of the anal canal due to repeat scarring from recurrent fissures);
  • An anomaly of the spinal cord (spina bifida for instance);
  • Hypothyroidism (thyroid is not active enough);
  • Coeliac disease (allergy to gluten);
  • Hypercalcaemia (too much calcium in the system).

Newborn constipation remedies

In this section, we will look at a seven-step approach to help you with newborn constipation.

Step 1: picking the right formula

First things first. Nutrition is fundamental to treating newborn constipation. What goes in determines what comes out, and how it comes out.

If you search the blogs for "newborn constipation", you will find as many opinions as blog posts. For baby Kile, only Enfamil cured his newborn constipation. For baby Sarah, it was Similac. For baby Cinthia, soy formula constipated her whereas a hypoallergenic formula solved her problems. For baby Kevin, soy formula saved the day. It is pretty mind-boggling.

This is your quest, and you will find what works and what doesn’t work for your baby. There will be costs, but your baby’s well-being is worth it.

Here are the choices available to you, from simplest to most refined in terms of the main protein constituents:

  1. The traditional cow’s milk based formulas (Enfamil LIPIL, Similac ADVANCE, equivalent Target and Costco brands, etc). You can use those if you do not suspect any intolerance to either cow’s milk proteins or lactose.However, pick the one that has the highest magnesium content. Studies(7) show that a magnesium-enriched formula relieves constipation in newborns. Novalac IT was the brand used for that study, and is rich in magnesium.
  2. If you suspect that your baby is lactose intolerant, you will have to play with the lactose-free formulas (Enfamil Lactofree, Similac Lactose Free, etc). Those are still based on cow’s milk, but the lactose has been removed (the cow’s milk proteins stay). Again, pick the one with the highest magnesium content.
  3. If you suspect your baby is intolerant to cow’s milk proteins, you can try the soy-based formulas (Enfamil ProSobee, Similac Isomil, etc). Again, pick the one that has the highest magnesium content.
  4. If you suspect your baby is intolerant to both cow’s milk and soy proteins, you will have to play with the hypoallergenic, also called “elemental” formulas. Those are almost double the price of the traditional formulas. They include Enfamil Nutramigen, Similac Alimentum and the like. Those formulas contain proteins that are already broken down into fragments, and those fragments are less recognized as allergens and more digestible.One sub-category of the elemental formulas goes one step further, breaking down the proteins into individual amino-acids so that they don’t provoke allergic reactions and are better assimilated. Those include Enfamil Nutramigen AA and Neocateand are even more expensive.

How do you pick the right formula? By trial and error, which can be costly. Here are the main levers you can play with:

Regarding prebiotics, we will see further down that there is an alternative to having them in the formula – you can add prebiotics to each bottle in a very simple way.

All in all, this is a pretty complex choice to make.

And if you haven’t found the optimal formula yet, the next sections could just do the trick.

Step 2: picking the right water

To prepare baby’s milk, you obviously need water. Some pediatricians recommend boiled tap water, some filtered tap water, and others distilled water. In certain countries, the standard is to use mineral water, and pediatricians recommend specific brands (in France, Evian and Volvic for instance).

Different waters have different amounts of magnesium. Magnesium has a laxative effect.

So if you are dealing with newborn constipation, try to use a mineral water that has a high level of magnesium. Look at the labels and compare, and check with your pediatrician to see if the levels are acceptable.

Revert back to your pediatrician's guidelines when your newborn constipation has abated, as high levels of minerals in the water makes the baby’s kidneys work harder.

Also, use the recommended formula dilution. Diluting the formula too much, or giving your newborn water to drink can result in “water intoxication” (and of course not diluting it enough can lead to newborn constipation).

Step 3: some useful additions to the bottle

Sometimes, the powder and the water just won’t be enough to relieve newborn constipation. So here are some useful bottle additions you can try.

Baby food
We talked earlier on about the benefits of prebiotics (not to be confused with probiotics) for constipation(9). Prebiotics can be found naturally in plant food, such as asparagus, artichokes, onion, apples, etc.

You don’t need to look very far to find them, a teaspoon of baby food mixed with baby’s bottle once or twice a day may be helpful. Wait till your baby is a couple of months old for this approach, or talk to your pediatrician to see if he or she is OK with it for a younger baby suffering from newborn constipation.

The different types of sugar
Just like salt, sugar attracts water. When sugar enters your baby's bowel, extra water is attracted from the bowel mucosa and will soften up the stools. You can try to add half a teaspoon of brown or white sugar to 1 ounce of the water you use to prepare the formula.

This should not become a long term solution, as baby could get used to the sugary taste, leading to tooth decay if she still demands her sugary bottle later when she starts teething. Not to mention the metabolic effect of too much sugar in the long run.

Lactulose is another type of sugar, non-digestible, that draws water in the intestinal tract. Lactulose can be prescribed by your doctor and typical doses may vary from 1ml to 2ml, once to twice a day, depending on the severity of constipation.

Fruit juices
Fruit juices contain fructose and sorbitol, two types of sugar that will help draw water into the stools. Prune and pear juice are recommended by some specialists(10).

Some other specialists recommend not to use juice before 2 months of age. Check with your pediatrician. If you pediatrician is OK, you can start with pear juice which is a little less laxative. If this is not effective, you can try prune juice.

Step 4: abdominal massage

Abdominal massages can help to get the stools moving through the colon. Here is how to proceed:

I personally like to use a sweet almond oil infused with chamomile flowers (Roman or German chamomile is fine). Chamomile is anti-inflammatory and soothing to painful bellies.

Step 5: movement and physical activity

Sometimes physical activity can also help get things moving in the baby’s colon, especially those exercises encouraging her to move her legs up and down.

You can try to install a play mat or play gym with different toys hanging. Some babies like to reach for the hanging toys with their legs, encouraging them to go through a pedaling movement.

Some babies like to stand on their legs if you hold them by their hands. Even though they cannot do this for long and get tired rapidly, the pumping exercises may help their transit.

You can also try to hold your baby’s legs up, gently pressing against her belly with her knees, then relaxing her legs, then pressing again, etc. Try this pumping motion for a few minutes and see if it helps trigger a defecation.

Step 6: glycerin suppositories

Glycerin suppositories can be quite helpful for newborn constipation that doesn’t respond to dietary measures and exercise, but should only be used occasionally. There is a risk of dependency when used regularly. The colon gets lazy and expects a suppository to expel feces.

Make sure you buy the proper suppository size for your newborn (ask your pharmacist) and use a bit of Vaseline to insert the suppository easily. It should work fairly rapidly, within 10 to 15 minutes.

The size for infants is usually 1 gram per suppository.

Step 7: anal stimulation

Another method is to dip the end of a Q-tip in Vaseline and gently rub the baby’s rectum with it. Do not insert the Q-tip in the anus, nor any other object like a thermometer.

Most of the time rubbing the outside area should be sufficient to trigger the defecation reflex.

Conclusion

In this article, we have reviewed the different methods to relieve newborn constipation.

We have seen that even though there is not a one-size-fits-all approach, there is a logic to follow: first nutrition and what goes in the bottle (which formula, which mineral water, which additional ingredient), then massage and physical stimulation.

Being a parent is a work of patience, and this starts at birth. If you are dealing with newborn constipation, do not give up.

With patience, you should be able to build your own newborn constipation remedies toolkit, using the suggestions given on this web page. But only you can, through experimentation, arrive at the right options (and yes, trying to “find the truth” in blogs will numb your mind).

As a father of three, my heart goes out to you. Good luck!


References

(1) Tannock GW, Fuller R, Smith SL, Hall MA. "Plasmid profiling of members of the family Enterobacteriaceae, lactobacilli, and bifidobacteria to study the transmission of bacteria from mother to infant". J Clin Microbiol. 1990 Jun;28(6):1225-8

(2) Croaker GD, Pearce R, Li J, Nahon I, Javaid A, Kecskes Z. "Idiopathic slow transit constipation is rare. But delayed passage of meconium is common in the constipation clinic". Pediatr Surg Int. 2007 Dec;23(12):1153-9.

(3) Tunc VT, Camurdan AD, Ilhan MN, Sahin F, Beyazova U. "Factors associated with defecation patterns in 0-24-month-old children". Eur J Pediatr. 2008 Dec;167(12):1357-62. Epub 2008 Feb 9.

(4) Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. "Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition". J Pediatr Gastroenterol Nutr. 2006 Sep;43(3):e1-13.

(5) Picard C, Fioramonti J, Francois A, Robinson T, Neant F, Matuchansky C. "Review article: bifidobacteria as probiotic agents -- physiological effects and clinical benefits". Aliment Pharmacol Ther. 2005 Sep 15;22(6):495-512. Review.

(6) Parisi MA. "Hirschsprung Disease Overview". 2002 Jul 12 [updated 2011 Nov 10]. In: Pagon RA, Bird TD, Dolan CR, Stephens K, editors.

(7) Yvan Vandenplasa, Hsun-Chin Chaob. "Therapeutic effect of a magnesium-enriched formula on infants with constipation" PEDIATRICS Vol. 121 No. Supplement 2 January 1, 2008 pp. S113

(8) Iacono G, Cavataio F, Montalto G, Floren A, Tumminello M, Soresi M, Notarbartolo A, Carroccio A, " Intolerance of Cow's Milk and Chronic Constipation in Children" N Engl J Med 1998; 339:1100-1104

(9) Sabater-Molina M, Larqué E, Torrella F, Zamora S. "Dietary fructooligosaccharides and potential benefits on health". J Physiol Biochem. 2009 Sep;65(3):315-28. Review.

(10) Rasquin-Weber A, Hyman PE, Cucchiara S, Fleisher DR, Hyams JS, Milla PJ, Staiano A. "Childhood functional gastrointestinal disorders". Gut. 1999 Sep;45 Suppl 2:II60-8. Review.


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