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Original Article
Infrequent Stools in Exclusively Breastfed Infants
Marie Courdent,
1
Laurent Beghin,
2
James Akre´,
3
and Dominique Turck
4
Abstract
Background: Few data are available on the number of stools in exclusively breastfed infants. Two studies
aimed to assess the stool pattern in exclusively breastfed infants and to evaluate the reactions of mothers in the
case of infrequent stools and the decisions of healthcare providers.
Materials and Methods: Infrequent stools were defined as an interval of >24 hours between bowel movements.
Study 1 concerned 198 infants. Mothers responded to a questionnaire where they described their knowledge and
attitude toward infrequent stools. Study 2 was performed using the Internet with 85 French-speaking mothers
worldwide responding to a questionnaire on bowel movements and reactions of mothers and healthcare pro-
viders. Using the scale provided, mothers evaluated their anxiety and the discomfort of their infants.
Results: In Study 1, 37% of exclusively breastfed infants experienced at least one episode of infrequent stools
that occurred at <1 month of age in 19% of cases. Mothers who were aware of infrequent stools intervened less
frequently (17%) than mothers who were unaware of this condition (79%) ( p<0.0001). In Study 2, the median
duration of all combined episodes of infrequent stools was 10 weeks (range, 1–34 weeks) with a maximal
duration of 28 days. The most frequent action for infants was abdominal massage (79%), whereas in mothers it
was consumption of fruit juice/mineral water rich in magnesium/vegetables (73%). There was a correlation
between the maternal anxiety score and the infant’s discomfort score ( p=0.0001).
Conclusions: Parents/health professionals should be informed of the prevalence of infrequent stools in ex-
clusively breastfed infants and adopt a wait-and-see attitude.
Background
Breastfed infants usually pass more stools, and more
liquid stools, than formula-fed infants. Mothers are ad-
vised that their breastfed infant should have at least three soft
stools daily during the first 4–6 weeks of life.
1
Fewer than
three soft stools per day at that age is considered a signal of
insufficient milk intake. After 4–6 weeks of life the number of
stools decreases progressively.
2
A few infants may even have
no bowel movements for several days or even weeks.
Healthcare providers usually refer to this situation as ‘‘con-
stipation,’’ ‘‘false constipation,’’ ‘‘infrequent bowel move-
ments,’’ or ‘‘scarce stools’’ of the breastfed infant despite the
absence of discomfort (i.e., no hard stools and no crying or
distress during defecation).
Mothers are given many recommendations for themselves
and their babies, for example, ‘‘drink orange juice,’’ ‘‘eat
more vegetables and fiber,’’ ‘‘drink mineral water with lax-
ative properties,’’ etc. Some breastfed infants with so-called
constipation may even undergo medical examination in-
cluding large bowel enema, rectal manometry, and rectal
biopsy. It is surprising that very few data are available in the
medical literature concerning the number of stools of healthy
breastfed infants.
The objectives of the present study were as follows: (1) to
assess the prevalence of the infrequent stools in healthy ex-
clusively breastfed infants; (2) to study the characteristics of
these infants (age at onset, duration, underlying medical
conditions); and (3) to evaluate the reactions of mothers and
the decisions made by healthcare providers.
Materials and Methods
Two studies were conducted consecutively. The first study
aimed at assessing the prevalence of infrequent stools and
mothers’ knowledge of the condition and their reaction to it.
The second study aimed at describing the characteristics of
infants and evaluating the attitudes of parents and healthcare
1
Mother and Child Welfare, General Council of the Nord Department, Lille, France.
2
Clinical Investigation Center, Pediatric Branch, CIC-PT-1403 INSERM and INSERM U995, Lille University Hospital, Lille, France.
3
Geneva, Switzerland.
4
Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Jeanne de Flandre Lille University Children’s
Hospital and INSERM U995, Lille, France.
BREASTFEEDING MEDICINE
Volume 9, Number 0, 2014
ªMary Ann Liebert, Inc.
DOI: 10.1089/bfm.2014.0050
1
providers. Infrequent stools of the exclusively breastfed in-
fant were defined as an interval of more than 24 hours be-
tween bowel movements.
Study 1
Mothers and infants were recruited for the study during La
Leche League meetings. Mothers filled out a short ques-
tionnaire.
Study 2
Study 2 was based on a structured questionnaire on bowel
movements and the reactions of mothers and healthcare
providers. The study was performed using the Internet, based
on information provided on the La Leche League France
Web site www.lllfrance.org/ and other Web sites related to
breastfeeding by 85 French-speaking mothers from Algeria,
Belgium, Canada, France, Greece, The Netherlands, Singa-
pore, and Sweden. Inclusion criteria were infant age from 10
days to 8 months, exclusive breastfeeding from birth, daily
vitamin D and weekly vitamin K supplementation, and re-
covery of birth weight at a maximal age of 10 days. Growth
was considered normal if consistent with the World Health
Organization child growth standards.
3
All infants included in
Study 2 had experienced at least one episode of infrequent
stools during the month preceding the questionnaire. Mothers
were responsible for evaluating their anxiety and the dis-
comfort of their infants on a scale ranging from 1 (‘‘relaxed’’
for the mother and ‘‘quiet’’ for the baby) to 6 (‘‘very anx-
ious’’ for the mother and ‘‘disturbed’’ for the baby).
Statistics
In this study, given the high number of included/analyzed
subjects (n=198), we used parametric testing. Association
between two groups was assessed using chi-squared tests.
4
A
value of p<0.05 was considered significant.
5
Regulatory requirements
Because this study consisted of a retrospective evaluation
and was both noninterventional and anonymous, in accor-
dance with French medical research regulations it required no
advance agreement from an independent ethical committee
or any declaration to a competent authority concerning per-
sonal information technology data.
Results
Study 1
Of the 198 infants recruited during the La Leche League
meetings (Fig. 1), 74 (37%) had experienced at least one
episode of infrequent stools, which had occurred before 1
FIG. 1. Flowchart of screening, inclusion, and analysis rate in Study 1. IS, infrequent stools.
2 COURDENT ET AL.
month of age in the case of 14 infants (19%). Seventy-two of
the 74 mothers (97%) of infants with infrequent stools filled
in the short questionnaire. Of 48 mothers (67%) who were
aware of this condition, 40 (83%) did not intervene; these
mothers said that they were not anxious and waited patiently
for the next stool. Of 24 mothers (33%) who were unaware of
this condition, only five (21%) did not intervene; the other 19
mothers sought additional information (for example, search
for documentation, phone call to a breastfeeding associa-
tion or healthcare provider, or consultation with a healthcare
provider). Mothers who were aware of infrequent stools in-
tervened less frequently than mothers who were unaware of
this condition ( p<0.0001).
Study 2
The median age of the 85 infants was 16 weeks, with a
range from 10 days to 8 months. The median age at the first
episode of infrequent stools was 6 weeks (range, 1–22
weeks). The median daily number of stools before the first
episode of infrequent stools was three (range, one to eight).
The median duration of the first episode of infrequent stools
was 4 days (range, 1–10 days), whereas the median duration
of the other episodes was 6 days (range, 2–28 days). The
median duration of all combined episodes of infrequent stools
was 10 weeks (range, 1–34 weeks). A few mothers sponta-
neously called the return of stooling ‘‘back stools.’’ The
median number of diapers used for stool collection on the day
when bowel movements returned was two (range, one to
four), with the stools being most frequently described as soft,
yellow, and large. No infant experienced hard ‘‘back stools.’’
No specific action was undertaken in the case of 52 (61%)
of the 85 infants, and stools returned to a normal pattern.
Specific action was undertaken for 33 infants (39%). The
most frequent action for infants (because there are several
possibilities for the same infant, the total exceeds 100%) was
as follows: (1) abdominal massage, n=26 (79%); (2) use of
suppositories and/or anal stimulation and/or enema, n=21
(64%); and (3) consumption of fruit juice and/or mineral
water rich in magnesium, n=11 (33%).
The most frequent action for mothers (several possibilities
for the same mother) was as follows: (1) consumption of fruit
juice/mineral water rich in magnesium/vegetables, n=24
(73%); and (2) miscellaneous (e.g., prokinetics, laxatives,
homeopathy, osteopathy, foot massage), n=16 (48%).
The median anxiety score of the mothers during the in-
frequent stools episodes was 2 (range, 1–6), whereas the
median discomfort score of the infants was 1 (range, 1–6).
There was a correlation between the maternal anxiety score
and the infant’s discomfort score (r=0.0001). Mothers who
took specific action for either themselves or their baby or both
had a higher median anxiety score (3.65) than those not
taking specific action (1.78) ( p=0.001). Infants undergoing
specific action had a higher median discomfort score
(2.39 –1.59) than those who did not (1.5 –1.0) ( p=0.02).
Discussion
Our first study showed a high prevalence (37%) of infre-
quent stools in the exclusively breastfed population.
Awareness of this condition was associated with a lower rate
of intervention compared with mothers who were unaware of
it. Our second study allowed us to better characterize the
epidemiological and clinical features of infrequent stools. It
occurred as early as 10 days and as late as 8 months of age;
the median duration of an episode of infrequent stools was
less than 1 week with a maximum of 4 weeks. The median
duration of all combined episodes with infrequent stools was
2.5 months with a maximum of 8 months. It is not surprising
that the more anxious mothers were more prone to intervene
than the less anxious mothers.
Weaver et al.
2
showed that breastfed infants had a higher
mean frequency of defecation than formula-fed infants at 2,
4, and 8 weeks of age; by 16 weeks, the mean frequency of
bowel movements per day was two for infants of both feeding
groups. Breastfed infants passed larger, softer stools than
formula-fed infants until the introduction of complementary
foods. In their description of the feces patterns of breastfed
infants, Lawrence and Lawrence
6
pointed out that after 1
month of age, a breastfed infant should have at least one stool
a day. If this does not happen, the healthcare provider should
determine whether growth and urine output are adequate (i.e.,
six to eight wet diapers a day and at least one that is heavily
soaked). Other sources focusing mainly on parents state that,
at around 6 weeks of age, some infants cease having the
several daily bowel movements expected up to this point.
Some start stooling once a day, whereas others wait several
days, and still others may have a week of stool-free days.
There are very few data on the prevalence and character-
istics of infrequent stools. Moreover, the definition of infre-
quent stools varies among studies and the names being used
for constipation or intestinal pseudo-obstruction or infre-
quent bowel movements. We were unable to identify any
study assessing the prevalence of infrequent stools, how-
ever defined, in a population of healthy exclusively breastfed
infants.
Aguirre et al.
7
observed in Sao Paulo, Brazil, a prevalence
of 9% among predominantly breastfed infants <6 months of
age. Constipation was characterized by necessarily hard
stools and by the presence of at least one of the following
features: painful stools or difficult stool passage, scybalous
stools, cylindrical stools with cracks or thick cylindrical
stools, or intervals between bowel movements ‡3 days.
Choe et al.
8
observed that out of 416 children attending
their tertiary referral center in Seoul, South Korea, for con-
stipation (defined as the absence of stools on 3 consecutive
days) during a 1-year period, 28 (6.7%) were exclusively
breastfed and had no organic abnormality. In this study, mean
age at onset of constipation was 1.9 months (range, 0.5–3.5
months), and the condition spontaneously resolved at a mean
age of 3.9 months (range, 1–7 months).
In some cases, the absence of defecation can last up to 4
weeks as in our study, or even longer (45 days) (G. Gremmo-
Fe
´ger, Brest University Hospital, Brest, France, personal
communication). Weaver et al.
2
described a breastfed infant
who passed no stools for 27 days between 7 and 11 weeks of
age. The infant remained visibly well, displayed no clinical
signs of gastrointestinal or systemic disease, and passed a
vast stool at the end of this period. She had only 14 bowel
movements during the first 16 weeks of life. The pathophys-
iology of the condition remains unknown and unresolved.
Our studies have several strengths and weaknesses. The
strengths include the high number of children in the prevalence
study, the strict definition of exclusive breastfeeding, weight
gain consistent with World Health Organization growth
STOOL PATTERN AND EXCLUSIVE BREASTFEEDING 3
standards, and exclusion of infants with hard stools or stooling
problems. However, the weaknesses include the arbitrary
definition of infrequent stools, the study samples of infants who
are not necessarily representative of the general population of
breastfed infants, and recruitment bias from the Internet.
Conclusions
Because up to 37% of exclusively breastfed babies may
pass infrequent stools, parents and health professionals
should be aware of this possibility. As there are no estab-
lished standards regarding defecation, the term ‘‘infrequent
stools’’ seems the most appropriate. In most cases infrequent
stools are very well tolerated, and parents and health pro-
fessionals have only to monitor infant growth and develop-
ment. Because the priority is to do no harm, it is of paramount
importance to avoid unnecessary tests. As Eggermont
9
has
pointed out, ‘‘the clinical evaluation of these patients is of
paramount importance. As a rule, the infant is happy and
thriving. Abdominal ballooning is exceptional and rarely
causes crying and flatus. Neither abdominal palpation nor
rectal examination reveals retention of excessive fecal ma-
terial.’’
9
Health professionals need to learn when to do
nothing, while adopting a wait-and-see attitude and bearing
in mind the possibility of Hirschsprung’s disease developing
with the onset of complementary feeding.
Disclosure Statement
No competing financial interests exist.
References
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Address correspondence to:
Marie Courdent, RN
10 rue Parrayon
59000 Lille, France
E-mail: marie.courdent@wanadoo.fr
4 COURDENT ET AL.
