26. Jan, 2021
Let's Talk About Poop! What is normal in the first 6 weeks of life
Poop: new parents’ favourite topic. It is true that, as healthcare professionals, we are very interested about their baby’s poopy nappies: colour, consistency, frequency, especially in the early days as it is a good way for us to know if milk transfer is occurring.
The first 10 days of your baby's life:
From birth, your baby should pass stools every day, many times a day, often having a dirty nappy during/ after each feed.
The first poo is called meconium and contains debris from your baby's life in the womb. It is cleared progressively over the first couple of days of life.
This tar-like poop is then changing colour and becoming green then yellow (mustard or curry paste).
Between 4 and 6 weeks:
Your baby should continue to pass stools many times every day. If it has been more than 24h without stools, breastfeeding (or formula feeding) should be assessed.
- In breastfed babies: is there sufficient milk transfer?
- What is the weight gain?
- How is the baby behaving?
- Full breastfeeding assessment
In formula-fed babies:
- How much milk is the baby taking?
- What is the weight gain?
- How do parents make bottles: you can never assume that parents know how to make formula bottle? *
- Are they using a "prep machine" and if so, is it calibrated correctly?
This period's lack of stools is often linked with low calorific intake, particularly in the breastfed baby.
Therefore, the feeds should be pushed and if you are breastfeeding, applying breast compressions can help during the feed (or while pumping) to push further hindmilk, (hindmilk, also known as fatty milk, sticks to the walls of the milk ducts. By applying breast compressions, you are dislodging the fat faster and pushing a higher amount into the breast milk. It is a good tip for those babies who are slow to put on weight, premies, babies with tongue ties and SGA).
If your baby still has not passed stools in that 24h period despite adjustment made to latch/ bottle making, etc., the baby should be seen by a G.P.
After 6 weeks:
When caring for older babies (6 weeks on), parents will often worry that their baby is no longer passing stools every day. It is completely normal in both breastfed and formula - fed babies (however, in the formula fed baby, constiaption should be over-ruled). We often tell parents that a breastfed baby can go one week to 10 days without a poo and be completely fine. In his book, paediatrician Jack Newman mentions a baby going for 28 days without a poo and perfectly happy!
Note that paediatricians do not see babies if they have not pooped for 7 days or less. It is considered normal, unless the baby is unwell, has a medical condition or is extremely uncomfortable.
In breastfed babies: why is this ok?
Amongst an almost endless list of ingredients, breastmilk contains casein and whey (all mammal milk do but in different proportions).
In the early weeks post-partum, the whey-casein ration in human milk is 90:10 (90% whey, 10% casein).
At around 6 weeks post-natally, the whey-casein ratio in maternal milk changes to about 80:20 (80% whey, 20% casein). This slight increase in casein is designed to answer the baby’s metabolic need for calcium and mineral (which, interestingly, coincides with the famous “6 weeks growth spurt” or “wonder week”). It becomes less laxative.
Parents will note a change in consistency of the stools (toothpaste-like) and frequency (less dirty nappies).
By 6 months, the whey: casein ration has been altered once more to answer the baby’s needs: 60:40 to 50:50.
Again, breastmilk’s altered composition is designed to answer the baby’s growing needs. By 6 months, the baby is more mobile, rolling over and developing better musculoskeletal coordination. The change in the whey: casein ratio then meets the baby’s muscle-skeletal demands.
Where is the poo, then?
Most parents will be taken back when told that their baby can go for ten days without pooping and wonder where all that poop is going.
Some will say that “breastmilk is perfect and produces little or no waste”. This statement is not exactly accurate. Yes, breastmilk is perfect, but if anyone has ever been a victim of a “poonami”, they can tell the poo was obviously “somewhere”!
To understand why we must look even closer to the constituency of breast milk.
Breastmilk contains around 90% water. Most of it is excreted as urine, but some are left over for the stools. After all, a dehydrated baby (and adult), will poop less.
Breastmilk also contains a large amount of sugars (the second most abundant ingredient): one of them is lactose (galactose), another is the Human Milk Oligosaccharides or HMOs.
HMOs is the 3rd most abundant ingredient in breastmilk and cannot be digested by the baby’s lower G.I. tract.
As always, Mother Nature was clever about this: HMOs seems to be solely responsible for the growth of “good bacteria” in the baby’s gut and promote an ideal Microbiome.
HMOs cannot be digested as babies lack the enzyme needed to do so. Therefore it passes undigested into the lower intestinal tract where gut bacteria feast on it! (Jantscher- Krenn & Bode, 2012).
Many HMOs that weren’t consumed by the gut bacteria are then excreted in the stools. But not only do they allow colonisation of the gut by good bacteria, but they also protect it by removing pathogens by blocking their adhesion to epithelial surfaces of the bowels.
As they are the body’s natural pre-biotic, breastfed babies do not need additional pre/pro-probiotics. Maternal milk provides the best culture their microbiome needs!
HMOs, collect nasty pathogens, good bacteria that were not needed and exit the body via the stools.
Back to the question: where is the poo?
One logical answer is, in the bowels, of course. While in adults, having no bowel movement for 10 days would lead to extreme discomfort and very hard stools, breastfed babies experience things differently.
In the bowels, the fermentation of oligosaccharides (HMOs) leads to an increased microbial mass which draws up water and increases stool mass. Additionally, the fermentation and growth of “good bacteria” such as Lactobacillus and Bifidobacteria can increase the stools' water content.
Finally, HMOs are a type of fibre. Therefore they bind to water which increased the stool volume.
In short, it does not matter how long the poo has been sitting in the bowels, as the stools keep filling up with water, it increases the mass and volume until it is ready to be excreted which is why it is not called constipation.
Very if any, discomfort is felt by the baby.
Constipation is categorised not only by a lack of bowel movement as well as hard stools difficult to pass, which can be seen in the formula-fed baby, unlike in the breastfed baby (unless there is an underlying medical issues).
Episodes of hard stools in the exclusively, healthy breastfed baby are unheard of and usually coincide with the introduction of solid food.
But my baby is straining, why?
Parents often worry that their baby is straining, becoming red and look in pain when trying to poo.
Most babies will, at some point, experience straining without being constipated. The medical term for this is dyschezia or uncontrolled stooling reflex.
As the baby’s nervous system is still developing, there is poor coordination due to the nervous system's immaturity.
There has to be a coordination between the diaphragm, the abdominal muscles, and the anal sphincters for the bowels to empty. In babies, this coordination can be all over the place and result in a straining baby, becoming red, but the anal sphincters remain close.
Crying is often associated with this episode. It is not because the baby is in pain as it is often interpreted by some healthcare professionals and parents. It has a physiological value: crying increases pressure on the diaphragm and the abdominal muscles in order to give more force to push the stools into the rectum, apply pressure on the internal anal sphincter and eventually: poop!
Unaware of this physiological phenomenon, parents often seek medical treatment. G.Ps should be knowledgeable about this physiological development. However, I have met parents given the wrong advice by their family practitioner (non-evidence, obsolete advice such as orange juice, prune juice, sugared water, warm water. In other cases, glycerine suppositories or Lactulose are prescribed.)
Juices are not only irritant to the G.I. tract of the baby, but they also disturb the clever microbiome of the baby’s gut, glycerine suppositories should only be used if there is a true case of constipation, while offering water to a breastfed baby is pointless.
Not only does water take up space in the stomach with zero calorific value, breastmilk is 90% water! Same goes with sugar: why offering sugared water when breastmilk contains its own very special ones! The lack of education in breastfeeding sadly leads to parents receiving poor advice from some trusted healthcare professional.
For more information on constipation in babies and what is normal, you can visit: Constipation | The GP Infant Feeding Network (UK) (gpifn.org.uk) (this link also has explanation on dyschezia).