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Constipation

Constipation is a common functional gastrointestinal disorder in infancy and early childhood. Under Rome IV criteria, functional constipation is defined by infrequent, hard or painful stools in the absence of structural or metabolic disease. Prevalence varies by age. In infancy, reported rates are generally lower (approximately 3-12%), whereas prevalence increases in the toddler years to around 10–18% in children aged 1-4 years.1-3

Stool patterns differ by feeding type. Breastfed infants typically have softer, more frequent stools, while formula-fed infants may have firmer stools. Key transition periods, including the introduction of complementary foods and later cow’s milk as a main drink, are recognised times when constipation may emerge in susceptible children.

During the toddler years, when constipation becomes particularly common, greater solid food intake, higher consumption of cow’s milk, and toilet training may all be contributing factors. Stool frequency often decreases after solids are introduced, and excessive cow’s milk intake (>500-600 mL/day) may displace fibre-rich foods in some children. Behavioural stool withholding – often triggered by a previous painful bowel motion or toilet training stress – is a major contributor. Early recognition helps prevent the cycle of withholding, rectal distension and progressively harder stools.4,5

Guidelines emphasise clinical assessment, confirming there are no clinical features requiring further investigation, caregiver education, behavioural strategies and the use of stool-softening therapies where indicated.4,5

When breastmilk is not the sole source of nutrition, formula composition may influence stool characteristics (softness, consistency and pattern). Prebiotic oligosaccharides such as GOS and FOS have are supported by consistent evidence for promoting softer stool consistency in formula-fed infants.6

The probiotic strain Bifidobacterium animalis subsp. lactis (BB-12™) has been associated with improvements in bowel movement frequency in adults with low stool frequency.7 However, in early life, BB-12 has been studied primarily in the context of microbiota modulation, immune outcomes and infantile colic.8,9 Evidence to support improvements in bowel movement frequency in infant and toddler populations remains limited, and it is unclear whether findings observed in adults translate to early life.

Milk containing only A2 beta-casein has shown differences in digestive comfort measures in some cohorts, although constipation-specific outcomes are less consistently reported.10,11

In the management of constipation, dietary and lifestyle measures remain central, particularly in toddlers. Adequate intake of fruits, vegetables and whole grains, appropriate fluid intake and regular toileting routines are important for maintaining normal stool patterns. Persistent constipation should be managed according to established paediatric guidelines.4,5

References

  1. Robin SG, Keller C, Zwiener R, Hyman PE, Nurko S, Saps M, et al. Prevalence of pediatric functional gastrointestinal disorders utilizing the Rome IV criteria. J Pediatr. 2018;195:134–139. doi:10.1016/j.jpeds.2017.12.012
  2. Steutel NF, Zeevenhooven J, Scarpato E, Vandenplas Y, Tabbers MM, Staiano A, et al. Prevalence of functional gastrointestinal disorders in European infants and toddlers. J Pediatr. 2020;221:107–114. doi:10.1016/j.jpeds.2020.02.076
  3. Vernon-Roberts A, Alexander I, Day AS. Systematic review of pediatric functional gastrointestinal disorders (Rome IV criteria). J Clin Med. 2021;10(21):5087. doi:10.3390/jcm102150887
  4. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150(6):1443–1455.e2. doi:10.1053/j.gastro.2016.02.016
  5. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258–274. doi:10.1097/MPG.0000000000000266
  6. Vandenplas Y, De Greef E, Veereman G. Prebiotics in infant formula. Nutrients. 2023;15(6):1313. doi:10.3390/nu15061313
  7. Effect of the probiotic strain Bifidobacterium animalis subsp. lactis, BB-12®, on defecation frequency in healthy subjects with low defecation frequency and abdominal discomfort: a randomized, double-blind, placebo-controlled, parallel-group trial. Br J Nutr. 2015;114(10):1638–1646. doi:10.1017/S0007114515003347.
  8. Collins FWJ, Vera-Jiménez NI, Wellejus A. Understanding the probiotic health benefits of Bifidobacterium animalis subsp. lactis BB-12™. Front Microbiol. 2025;16:1605044. doi:10.3389/fmicb.2025.1605044
  9. Nocerino R, De Filippis F, Cecere G, Marino A, Micillo M, Di Scala C, et al. The therapeutic efficacy of Bifidobacterium animalis subsp. lactis BB-12® in infant colic: a randomized, double-blind, placebo-controlled trial. Aliment Pharmacol Ther. 2020;51:110–120. doi:10.1111/apt.15561
  10. Sheng X, Li Z, Ni J, Yelland GW. Effects of conventional milk versus milk containing only A2 β-casein on digestion in Chinese children: a randomized study. J Pediatr Gastroenterol Nutr. 2019;69(3):375–382. doi:10.1097/MPG.0000000000002437
  11. Yu W, Wang W, Sheng X. Effect of A1 protein-free formula versus conventional formula on digestive tolerance: a randomized controlled trial. J Pediatr Gastroenterol Nutr. 2025;80(4):705–713. doi:10.1002/jpn3.12473