Newborn Series: Gas/ Stools & Constipation

Stools and Constipation
Once the thick, black meconium stools have passed, stool frequency and consistency are variable depending on the type of feeding.

With breastfeeding, stool color transitions over to a yellow, seedy color with a loose consistency sometimes just as thin as water. Color of stool is variable and can be green, yellow, brown, or just watery. Frequency can also vary from every diaper change to every 3-5 days.  Yes, it can be normal with breastfeeding to have bowel movements as infrequent as every 3-5 days.  Breast milk is often so well absorbed that sometimes nothing is left after digestion.  It is rare to have true constipation with breast feeding.  As long as the stools are not hard and there is no pain with bowel movements, we would not recommend giving anything extra to stimulate more bowel movements.  Just enjoy it – things will change once solids are added!

With formula, constipation can be an issue.  Formula is thicker than breast milk, not as rapidly absorbed, and contains iron which, for some babies, can cause constipation. With formula, the stool pattern should be, at a minimum, every 1-2 days.  Also remember, it is normal for babies to push and strain during bowel movements, but it is not normal to have pain or hard stools.  If your baby is having infrequent or hard, painful bowel movements, you should consider several options:

• Start with a glycerin suppository up to twice per day to stimulate the rectum.  Along with this, you can try organic prune juice (mixed into the bottle) 1-2 tsp up to twice daily as needed.  Sometimes, it is just a matter of giving the digestive tract time to get used to the formula.
• If the above does not work, start adding fiber to the formula.  We recommend Benefiber 1 tsp mixed in formula once per day (up to twice per day as needed) and probiotics (can be purchased as Sprouts market or Whole Foods) mixed in formula once daily.
• If the above does not work, then switch the formula.  We would not recommend going to a low iron formula although this usually solves the problem short term.  Instead, we recommend switching to a soy-based formula (Isomil or Prosoybee) or trying Nestle Good Start (this has probiotics added in and often times aids in digestion).
• If all of the above is unsuccessful, we would recommend prescription stool softeners.  A stool softener called Colace can be mixed into the formula at this point.  However, it is rare that it comes to this step.

If you child has had chronic constipation since birth, other tests to rule out anatomic abnormality may also be indicated.  Blood in the stools is never normal and most commonly an indicator of a food allergy or local trauma from an anal fissure.

Gas
All babies have gas, some more than others.  Factors associated with breastfeeding usually have to do with the mother’s food intake.  The most common foods associated with increased gas production for infants are:

• milk products
• caffeine
• spicy foods
• peppers
• onions
• cruciferous vegetables (broccoli, cauliflower).
• Rarely, wheat or gluten products can bring on gas too.

Keep a food diary and see if you can diagnose which foods are the culprit.  With formula, it is more common to have gas as formula is not as readily absorbed.  Switching from a cow milk-based formula (Enfamil, Similac) to a soy-based formula (Isomil, Prosoybee) may help.  Mylicon (or simethicone) drops are also safe to use and can help in some instances.

Normally, gas is not painful.  If gas is painful and associated with excessively loose bowel movements, this probably represents an intolerance to either lactose or a food allergy.  Milk protein allergy is the most common and is associated with blood in the stool and/or a diffuse rash.  In this instance, we recommend first changing from the milk-based formula to a soy formula (or if breastfeeding, avoiding all dairy).  Soy formula contains a different sugar (not lactose) and a different protein (soy protein instead of cow milk protein) so this change usually solves both problems of lactose intolerance and milk protein allergy.

Twenty percent of children with true milk protein allergy can also be allergic to soy.  The next step if the soy formula does not help is to switch to a hydrosylated formula (such as Nutramigen or Alimentum) in which all the milk proteins have been broken down.