Constipation: Signs, Causes and How to Help, An Expert's View

This article is for general health information only and does not constitute medical advice. The views expressed are those of the doctor and reflect his professional opinion. He contributed to this article in his independent professional capacity. The views expressed are his own and do not represent the views of Nestlé, nor do they constitute an endorsement of any Nestlé brand or product. Parents should consult their healthcare professional for personalised advice. Breastfeeding is best for infants.

Keeping track of your child's bowel movements is one of those less glamorous but genuinely important parts of parenting. Knowing what is normal for your child; how often they go, and what their poop looks like; means you are well placed to notice when something seems off. Here, Dr Lim Kwang Hsien explains the signs of constipation to watch for, and the practical steps that may help.

Q: What is constipation, and what causes it in babies and young children?

A: Constipation is a pattern of bowel movements in which stools are passed less frequently than usual and are often harder and smaller than normal. It is important to understand that frequency alone does not define constipation - a child who is pooping every day but passing hard, small, pellet-like stools is also constipated. Both texture and frequency matter equally when assessing whether your child's bowel movements are healthy.

Every child has their own natural rhythm. Some children have bowel movements two to four times a day, while others may go only once every two to four days. For breastfed babies, it is entirely normal to have large, soft bowel movements up to seven days apart without any discomfort. Constipation is really about a noticeable change from whatever is normal for your child – whether that is going less often, passing harder stools, or both.

Although majority of children with constipation do not have any underlying medical conditions, it is nevertheless important to rule out certain underlying diseases. To do this, it is useful to categorise these children according to age groups.

For babies under 6 months old:

A: Babies who present with true constipation especially in the first month of life will need to undergo several medical tests to rule out rare medical conditions that present with constipation and needs to be diagnosed early in life. Some examples would be a baby born with low thyroid hormones, or Hirschsprung Disease where the intestines are developed with no nerves. Should these tests be normal, these babies often respond to modification of milk formulas, and will improve once solids are introduced. Laxatives are usually not given in babies less than 6 months old.

For babies between 6 months and 1 year old:

A: Constipation sometimes occurs in this age group due to the weaning process where solids are introduced too quickly. A baby suddenly eating two to three solid meals a day may have stools that become bulkier and harder to pass. This may lead to a fear of passing motion and crying spells. Choices of solids, gradual weaning process and adequate fluid intake can make a meaningful difference. Sometimes laxatives may be needed to help these babies overcome their fear of passing motion. Persistent constipation despite adequate laxatives may warrant further evaluation. 

For one year onwards:

A: For older children, constipation is more commonly linked to diet and lifestyle, an excess of sweet or processed foods, poor bowel habits, or difficulties with toilet training. In some cases, small tears at the bowel opening can make passing stools painful, which can lead to a child  deliberately hold back the urge to pass poo. This will lead to bulkier stools after a few days of constipation and a vicious cycle ensues. These children will need a longer and adequate course of appropriate laxatives to retrain their bowel routine.

Sometimes, certain medications such as iron supplements can also cause constipation in this age group.

Constipation associated with vomiting and fever will need to be evaluated by a medical doctor and should not be treated with laxatives.

Q: How do I know if my child is constipated? What signs should I look out for? 

A: Constipation can show up in a number of ways, and it is worth knowing all of them so you can spot it early. 

Generally, it is texture and frequency. These two signs, together or separately, are the clearest indicators of constipation. Watch for hard, dry or pellet-like stools and the duration between bowel movements. Straining during a bowel movement is another sign. While some straining is normal for toddlers, a child who is crying or appearing to be in pain while trying to go may be constipated.

Streaks of blood in their poop are worth taking seriously. This can happen when straining causes small tears around the anus causing discomfort when your child tries to poo.  A hard, uncomfortable tummy or tummy ache that comes and goes can also point to constipation, as can general crankiness and holding-on behaviour such as fidgeting, crossing their legs, squatting, or refusing to sit on the toilet if they are toilet trained.

In some cases, severe constipation can also cause a child to lose some control of their bowel movements and overflow stools can soil their underclothes. This can be distressing for both the child and the parent, and is a sign that medical advice should be sought.

Seek medical assistance if your child's general health seems affected, if they are experiencing significant tummy pain, if there is blood in the stool, if they have not passed a bowel movement after four days despite increasing fluids and fibre in their diet, or if they begin soiling their underclothes.

Q: What can I do to help relieve my child's constipation and prevent it from coming back?

A: The right approach depends on your child's age and this is an important distinction that parents sometimes overlook.

For babies under one year:

A: In the first six months, when your baby is not yet on solids, the focus should be to rule out rare underlying medical conditions. Assuming all tests are normal, ensure that there are no milk issues causing constipation. If your baby is formula-fed, ensure the formula is always mixed correctly with enough water. Sometimes changing milk formula or adding supplements like probiotics might help. Also ensure adequate hydration with an appropriate amount of milk intake per day.

Between six and twelve months, as you begin introducing solids, how you wean matters as much as what you introduce. Introducing solids gradually gives your baby's digestive system time to adjust. Fibre-rich first foods such as pureed prunes, pears, peaches and vegetables can help support comfortable bowel movements during this transition. Always ensure fluid intake keeps pace with the introduction of solids.

For one year onwards:

A: For older children, it is important to balance adequate fluid intake and the introduction of fibre-rich foods such as cooked grains, whole-grain breads, fruits and vegetables. Keeping them physically active also helps, as movement can support the digestive process. For younger toddlers who are not yet mobile, gentle leg bicycle exercises and tummy massage can help stimulate the bowels.

One factor that is often underestimated in children aged one and above is the role of fear. If a child has experienced pain during a bowel movement particularly due to small tears at the bowel opening they may begin to hold back deliberately to avoid the discomfort. This creates a cycle that can significantly prolong constipation: the longer they hold back, the harder the stool becomes, and the more painful it is to pass. If you notice your child is actively avoiding going to the toilet, it is important to address this gently and with patience. Punishment or pressure will make the fear worse. A calm, encouraging approach works best. Your doctor may also recommend a short course of stool softeners or anaesthetic gel applied to the anus to break the cycle and allow the tears to heal.

For toilet-trained children, establishing a regular toilet routine can also help. Encourage them to sit on the toilet once or twice a day, ideally after meals, with their knees raised and feet supported on a footrest. A gentle reward system when they go successfully can build positive associations around toileting over time.

Always consult your doctor before giving any laxative. For older children where constipation is persistent, your doctor may recommend a laxative as part of a management plan. This is appropriate in some cases and nothing to be alarmed about. Do not use an enema or suppository unless specifically advised by your healthcare professional. 

Improvement from constipation can be slow. It may take several weeks or months of consistent effort before your child returns to their normal bowel pattern. Be patient, be encouraging, and involve your doctor if you are unsure.

Q: My baby is formula-fed. What should I know about supporting healthy digestion and bowel movements? 

A: Breastfeeding is the best source of nutrition for babies, and breast milk naturally supports healthy digestion. For mothers who are unable to breastfeed, or after breastfeeding ends, always ensure formula milk is mixed correctly with the right amount of water as stated on the label. Adequate hydration plays an important role in keeping stools soft and bowel movements comfortable. 

You may also notice that some formula milks contain certain ingredients that research suggests may play a role in supporting digestive health. It can be helpful to understand what these are. Probiotics are live microorganisms that may help support a healthy balance of bacteria in the digestive tract, and certain strains have been associated with softer stools and more regular bowel movements. Oligofructose, a soluble dietary fibre, may similarly support the presence of beneficial bacteria in the gut and has been linked to softer stools in some studies. Milk Oligosaccharides (MOs), a type of prebiotic that may also play a role in supporting gut health and digestive comfort. It is worth noting that the evidence behind these ingredients continues to evolve, and their effects can vary from child to child. As every child's needs are different, always speak to your doctor before making any changes to your child's formula milk or diet- especially if constipation persists despite general dietary measures.

Reference: 

Infant Constipation - What It Is, Signs/Symptoms - NUHS

Q&A: Is My Baby Constipated?

Chronic constipation in infants and children | SMJ

Infant Constipation | National University Hospital

Baby constipation - symptoms and treatment |Nestle FamilyNes 

The information in this article is for educational purposes only and does not constitute medical advice. It was reviewed by Dr Lim Kwang Hsien. Please consult a qualified healthcare professional for advice specific to your child.