stool, infant

New parents often express concerns to the doctor about the number, consistency or frequency of their infants' stools, and are sometimes quite distressed by the effort the Baby has to expend to expel what is often quite normal stool. Most babies with apparent stooling problems are either perfectly normal or have minor, temporary difficulties that will pass with time. Rarely, stooling problems are more significant. This article will discuss a few of these issues and perhaps shed some light on the subject for you.

First, let us discuss stool frequency. Here is a table of normal stool frequency for breast milk and various formulas:

Normal stool frequency on various formulas:
breast fed average 27 stools per 7 days (range 2-67)
Enfamil® (or) Enfamil® with Iron 15-16 per 7 days
ProSobee® (soy formula) 15 stools per week, with 30% described as hard or firm
Nutramigen® 25 stools per 7 days; 60% described as watery
Source: Dr. Jeffrey Hyams, Chief of Digestive Diseases and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut, quoted in Pediatric News September 2000, p. 28

Apparently painful pooping - straining and screaming, only to pass soft stool - is technically termed infant dyschezia. The problem is that the baby has an uncoordinated stooling reflex; the anus does not relax at the proper time, so the baby pushes hard with the diaphragm and abdominal muscles while holding the anus tightly closed. Rectal stimulation with suppositories and rectal thermometers may give temporary relief in a pinch, but actually seem to interfere with the baby's learning of how to let go of the stool. In any event, this is a self-limited problem, for all babies seem to get the hang of it after a while.

Hard, dry, constipated stools in young babies are almost exclusively a product of

  • cow milk or soy formula use
  • too early or too enthusiastic introduction of cereal

Breast milk makes a naturally looser and less voluminous stool by its nature. Breast milk is more or less completely absorbed by the baby. Little residue is left - a few curds of protein, water, and nitrogen gas which is all that remains of swallowed air (the swallowed oxygen and CO2 are rapidly absorbed into the bloodstream). Conversely, infant formulas always leave more residue to be excreted by the colon, so the bottle baby has more bulky stools. Also, the natural function of the colon is to dry and compact the feces, and this process may work too well at times, leading inevitably to stools that are more firm and bulky than the average baby's rectum is designed to handle, at least in the early period after birth.

At least in my view, this type of formula-induced constipation is best treated by the addition of corn syrup (Karo®) to the formula (white or dark matters not). I start with about 2 teaspoons of Karo in every bottle, and tell the parents to adjust the amount up or down depending upon how things come out. So to speak.

Offering corn syrup in water between milk bottles, although often recommended, makes no sense whatsoever. This is because the idea is to overwhelm the absorptive capacity for sugar of the small intestine by adding more total sugar than can be absorbed. The excess passes through the small intestine into the large bowel, where it causes a natural and harmless looseness to the stool.

Prune or apple juice contain sorbitol, a non-absorbable sugar that also has laxative properties for just the same reason. Your doctor may not advise using juice for very young infants for allergy avoidance reasons, and you should consult your physician about his or her views on the subject before using juice.

Constipation due to cereal occurs especially with cereal added to the formula bottles ("cereal + formula = concrete"). This may be done in an effort (usually futile) to coax the infant to sleep longer. (Interval training of feedings is much more effective.) Parents can easily misjudge how much cereal the baby is receiving via the bottles. A good rule to follow is that if the baby is too young to be fed with a spoon, he or she is probably too young for routine cereal use.

The exception to the discouragement of early cereal use concerns babies under care for gastroesophageal reflux disease. In that circumstance, we give the cereal and treat the resulting constipation as warranted.

However, not all stooling problems in young infants are benign. What should parents look for? Signs of significant medical problems related to infant defecation would include:

  • absence of stool in the first 48 hours of life
  • constipation from birth
  • failure to thrive
  • abdominal distention
  • abnormal rectal anatomy - the anus is displaced or malformed
  • abnormal neurological signs such as floppiness
Any of these signs should prompt aggressive evaluation to discover or rule out significant medical problems.
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