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What’s the source of my 4-month-old’s constipation?
Q: My 4-month-old son seems to be constipated most of the time. I feed him both breast milk and formula. What would be the cause, and is it OK to use an enema on him?
A: Hildah, it can be confusing to know what’s normal and what’s not for babies’ bowel movements. Every baby develops his own pattern of bowel movements—how often, what colour, how soft or hard—that’s normal for him. This can also change over time, depending on what your baby drinks and eats.

Breastfed babies tend to have more frequent, yellowish and watery stools. Formula-fed babies tend to have less frequent, brownish and firmer stool, but they should still be as soft as peanut butter. Since your baby drinks breast milk and formula, his bowel movements could be like either of these.

It would help to understand what you mean by “constipation.” Although many parents think that a baby is constipated if he doesn’t poop every day, that’s not true. Some babies poop many times a day, some once a day and others only once or twice a week. These can all be normal. Doctors don’t define constipation by how often a baby poops, but rather by how hard the stool is and how difficult it is for the baby to push it out. If your baby’s stools are hard like pebbles, he could be constipated. Also, although it’s normal for infants to strain, grunt and turn pink in the face when they have a bowel movement, if your baby has to strain so much that he cries, or his stool is so hard that it causes cracking around his anus and blood streaks on his stool, then he may be constipated.

If your baby is truly constipated, you don’t need to rush to give him an enema right away. Here are some general tips for dealing with it:

1. Feeding your baby:
  • At 4 months of age, you should still be feeding your baby only breast milk or formula. Although doctors recommend starting solid foods, such as baby cereal, between 4 and 6 months and when the baby shows he’s ready, feeding him cereal now could increase his constipation. It might be best to wait until he’s 6 months old to start baby cereal. And don’t put cereal in your baby’s bottle. Feed it to him only by spoon.

  • After 4 months of age, you could try giving your baby a few ounces of juice each day. Apple, pear and grape juice can help loosen the stool.

  • In some hot climates, babies can lose fluids by sweating, which can make their stools harder. During the hot weather, you can give your baby a few ounces of water in a bottle each day. But be sure the water is boiled for 20 minutes to prevent giving your baby an intestinal infection, and then cool it before giving it to him.

    2.Helping the bowels move:
    In older children and adults, getting physical activity every day can help the bowels move. This is true for babies, too. You can try the following every day:

  • Give your baby a massage. Lay your baby on his back. Take his legs in your hands and gently bring them up toward his abdomen or make bicycle motions with his legs. Massage his tummy by gently moving your hands from your baby’s lower right abdomen, clockwise to the upper right, upper left and then lower left abdomen (this is the direction the stool moves in your baby’s intestines).

  • Encourage your baby to move on his own. Lay him down on a blanket on his back. Dangle interesting objects (such as rattles, balls, blocks and scarves) in front of him to encourage him to reach out to grab or kick at the objects. Lay him on his tummy and put your face or interesting objects in front of him for him to reach out to.

    3. Talk with your baby’s doctor about the constipation.
    If these tips don’t resolve the constipation, your doctor might prescote a stool softener such as mineral oil for a few months. Sometimes the doctor will prescote a rectal suppository or enema to clear out the hard stool before starting on a stool softener.
Karen Sokal-Gutierrez M.D., M.P.H. Pediatrician