Constipation can be the most painful experience for a baby or young child – it is amazing how grumpy and unsettled a child can get when they are bunged up – and once they have finally passed a poo, their mood can switch in a heartbeat and they can be back to their cheery, happy self.
Up to about a third of children can get constipated at some time during their early years and around 40% develop symptoms during their first year of life which can persist for a long time. Paediatric wards have even had to open specialist constipation clinics to cope with the vast volumes of constipated kids.
A vast £162 million was spent by NHS England on treating constipation in both adults and children in 2017-18, £91 million of which was spent on laxatives!
Some people say it’s okay for a breastfed baby not to poo very often, but over the years I have found that these babies are better settled once they are pooing every day. Ideally, a baby would be having 1 to 3 dirty nappies a day.
The gut problems can often start when changing from breast milk to formula or when the baby is weaned onto solid food. If the symptoms are temporary, then that’s OK, as it is simply the baby’s tummy adjusting to the dietary changes. However, if it goes on more than a couple of weeks then this might be a sign that the baby is not tolerating the new milk or a specific food that well. Baby rice and white flour are quite constipating, and this is one of the main reasons I don’t recommend these for young babies.
Constipation can also kick in when a child is potty training between the ages of two and four years of age – many little ones are reluctant to poo in a potty and they often wait until they are wearing a nappy to do their number twos – often hiding in a corner to do it privately in their nappy.
If this happens, the golden rule is not to make a fuss as this will add a layer of stress and ingrain the behaviour even further. In time, and if the poo is soft enough/comfortable to pass, they will be happy to do it in the potty or loo.
Constipation can also develop when kids start at school in reception as the child can be too shy to “go” at school and will try to hold on for later – this can then make it harder and more painful to pass and thus setting up a negative association with passing a bowel movement.
Many children with constipation continue to have bowel problems as teenagers and adults. Since only 60 per cent of constipated children are successfully treated with laxatives, many still have lingering horrible symptoms as teenagers and adults which affect them every day.
Signs of Constipation
These can be standalone symptoms or found collectively together:
- Two or fewer bowel movements a week
- Bowel movements that are hard, dry and difficult to pass
- Stools are small and pebble like – also described as rabbit droppings or conkers
- History of excessive stool retention
- Large-diameter stools (bulky elephant poos…)
- Slim-diameter stools (thin finger-thickness snake like poos…)
- Abdominal pain & discomfort before or when passing a stool
- Excess bloating
- Strong smelling gas or wind
- Urgency (rushing to the loo)
- Incomplete stool evacuation
- Soiling and incontinence (known as encopresis)
When constipation becomes an ingrained pattern then it can really affect a child’s appetite as their little intestines can get blocked with so much old poo. Again, so many parents report that their bunged-up child with a tiny appetite is suddenly ravenous once they have done a number two. It makes sense as suddenly they feel more comfortable and there is now a little more space for food! If this happens quite regularly then they may be more bunged up than you think.
We learnt the hard way going through horrendous constipation with our eldest when he was a toddler (even though his tummy and poo were always soft – yes soft constipation really does exist!) and the final straw was when he started gagging and throwing up his food – we took him to A and E who carried out an X-ray to find he was extremely impacted and there was a blockage of poo the size of a small melon in his bowel. OUCH!!
It took us ages to clear his bowel entirely and to get his bowel unstretched so that he did not get backed up again. The prescribed laxatives were great at the start, but we realised quite quickly that they were not addressing the root cause and I knew instinctively that he needed more support to help him to gain 100% bowel control.
So, I went on a bit of a mission to try and fix this as potty training was also proving very hard at that point too! I have, over the years, developed some clever strategies to help address a long term sluggish painful bowel and this has kept our clinic very busy.
Why Do Kids Gets Constipated?
There are many factors contributing to why a child might get constipated and here are some of the key reasons that may help you to be your child’s detective and get a better understanding of why they are struggling so much to pass regular stools:
Babies who have been exposed to antibiotics directly or via their mother’s breast milk can become more constipated than those who have not taken antibiotics. This is because their gut microbiome has taken a big hit from the antibiotics and it can take time for the beneficial gut microbes to repopulate, especially before the baby is weaned onto solid food. If you or your baby need to take antibiotics, then consider adding in a lactobacillus rich probiotic for at least 6 weeks afterwards.
If mum’s gut microbes are depleted when pregnant or breastfeeding from taking antibiotics or proton pump inhibitors for reflux (omeprazole) then they may not pass on a diverse enough gut microbiome to their baby. Eating too many highly processed or “beige” refined foods (made from white flour or foods containing refined sugar) can contribute to creating a gut environment that allows stool to harden and dry up.
To remedy this, mum can eat cultured and fermented foods as well as fruit, vegetables, salads, nuts, seeds and pulses and the baby can do the same once they are weaned onto solids at around 6 months. Again, consider a lactobacillus probiotic to top up and there are specialist probiotic strains that can be given to mum and baby from birth.
Lack of prebiotics
Breast milk naturally contains prebiotics, however, the amount of prebiotic in the breast milk very much depends on mum’s diet and their own microbiome. If your baby is formula-fed, then most baby infant milk formulas do contain Galacto-oligosaccharides (GOS) which are prebiotics akin to breast milk and derived from cow’s milk.
They are added to the formula to help to feed the gut microbiome and to help digest milk, but sometimes this is not enough for the baby and other prebiotic and probiotic strains are needed to top things up. GOS is not added to every infant milk formula and the ones that do not contain GOS include Holle and Nannycare as well as some specialist formulas like Hipp Anti Reflux, Kendamil Medi+ and Aptamil Lactose Free. GOS is also not added to hypoallergenic formulas such as Nutrimigen LGG, Neocate and SMA Alfamino.
When you start weaning onto solid foods then you have the chance to feed your baby prebiotic rich foods such as bananas, apples, berries, barley, garlic, onions and leeks. See my weaning cookbook I Can’t Believe It’s Baby Food to find plenty of recipes containing these prebiotic foods. The best prebiotic supplement for babies and toddlers that we have found is Partially Hydrolysed Guar Gum (PHGG) which is super gentle on the developing gut and is suitable for those on the Low FODMAP diet or with overgrowth of bacteria in the small intestine (SIBO). Research had found it also reduces abdominal pain. PHGG has been found to cause less flatulence than lactulose, is tasteless and dairy free.
Need for probiotics
The two specific strains of probiotic that have been found to help constipation in children are lactobacillus (which you can consume in live yoghurt, kefir and other cultured foods) as well as bacillus coagulans which was trialled by a group of 141 children aged 4-12 with painful tummies and difficulty passing stool. In 8 weeks, those children taking the bacillus coagulans probiotic had a considerable reduction in abdominal discomfort, pain intensity, bloating, urgency, straining, incomplete stool evacuation and soiling. Diet-wise you can find bacillus coagulans strains in kimchi, sauerkraut and some live yoghurts.
Hypermobility & low muscle tone
Babies and children with low muscle tone, hypermobile joints and related collagen disorders such as Ehlers-Danlos syndromes (EDS) often have gut motility issues (I always say bendy on the outside-bendy on the inside) and can suffer from constipation more easily. This is something to work on in the longer term and I do advise one to one support from our paediatric clinical team.
Mast cell activation
We are increasingly seeing babies and toddlers in our clinic with mast cell activation (multiple non-classic IgE allergies) who are struggling with constipation. Histamine and other allergies can make the whole system quite dehydrated and gut motility slow, and this in turn can lead to harder to pass stools. Again, this needs to be assessed by a well experienced practitioner.
There are some very common and pesky gut amoeba that children can pick up from siblings, other children in nursery and school or when travelling abroad. The ones we often find in the stool tests that we run are Dientamoeba fragilis and Blastocystis hominis and usually do no harm. However, they can contribute to constipation and irritable bowel in some children and adults.
Too much milk
In 2020 some research on child constipation found that a key reason why children get constipated is that they drink too much milk and eat too much dairy. Once a child is over 12 months, they only really need to drink the equivalent of two cups of milk a day, so if your little one is consuming more and is getting constipated then swap any extra milk to water.
Many children simply do not drink enough water and it’s important to encourage the habit of drinking water from an early age – babies up to 12 months only need half to one cup of water in a day (best served at mealtimes) and 2-5 year olds can build up to one cup of water per year of life – 2 cups a day for two year olds and 5 cups of water a day for a five year old.
Higher magnesium need
Magnesium is responsible for 400 functions in the body and helps bowel muscles to stay toned and encourages peristalsis. You find magnesium in oily fish, nuts, seeds, green veg, pulses, buckwheat, cocoa, avocado and banana. Adding Epsom salts or magnesium flakes to the bath is soothing on the tummy and a child absorbs the magnesium in the bath water through the skin
Not enough fruit & veg
Five a day should be minimum once you have got into the swing of weaning. Not only do the fruit and veg provide extra hydration, but they also contain important fibre to feed the gut microbiome. If you have a constipated child then do your best to step up their intake of fruit and vegetables every day.
Not enough fibre
Butyrate is the primary source of energy for our colon cells and it is important for gut motility and can help to reduce pain in functional constipation. It decreases gut and systemic chronic inﬂammation and inhibits histamine production which is associated with allergies and mast cell activation. Butyrate is fed by fibre as well as butter and ghee. The best foods to provide fibre for little ones are apple, prunes, figs, apricots, kiwi fruits, papaya, mango, flax seeds (linseeds), chia and hemp seeds.
A sluggish bowel can have complex origins and can be difficult to manage – if you would like to speak to one of our paediatric nutrition team about how to get to the root cause of your little one’s sore tummies and straining then we would love to hear from you.