Infant Stooling Patterns and Type of Feeding
by Anne Eglash MD, IBCLC, FABM
Parents are usually taught that frequent stool and voiding patterns are reassuring signs of adequate breastmilk intake, in addition to an accurate naked weight demonstrating appropriate growth. Parents perceive that a decreased stool frequency might indicate a drop in breastmilk intake. There is little research on normal stooling patterns in breastfed vs formula fed infants, so we decided to focus today’s CQW on a rather small study that investigated this topic. A group of French researchers evaluated 84 infants for their stooling patterns over a 3-month period, with 48% exclusively breastfed, 37% partially breastfed, and 15% exclusively formula fed. They only compared the exclusively formula fed and exclusively breastfed infants for the frequency of stooling, and the rate of infrequent stooling, defined by not pooping for at least 3 days. The interval growth charts for all infants were considered acceptable..
- Exclusively breastfed infants have more frequent stools with more liquid than exclusively formula fed infants.
- By 8-12 weeks of age, stool frequency was not different between the exclusively breastfed and formula fed infants.
- 28% of exclusively breastfed infants had at least one 3-day interval of no stool in the first 3 months, vs 8% in exclusively formula fed infants.
- Most cases of infrequent stools (more than 3 days without stooling) occurred in the first 5 weeks of age.
- The average number of stools per day begins to decline significantly in breastfed infants at approximately 3 weeks of age.
- By 3 months of age, breastfed infants have on average approximately 2 stools a day.
See the Answer
Breastfed infants pass more stools and more liquid stools than formula fed infants and some have no bowel movements or infrequent stools for several days or weeks. We compared exclusively breastfed and exclusively formula fed infants for the first three months.
This study of 118 infants was carried out in the maternity ward of the Lille University Jeanne de Flandre Hospital, France, in 2015. The outcomes were the number and consistency of stools and the prevalence of infrequent stools.
At three months, 84 infants remained and we compared 40 who were exclusively breastfed and 13 who were exclusively formula fed. Daily stool frequency was significantly higher in the breastfed than formula fed infants during the first (4.9 1.7 vs. 2.3 1.6, p < 0.001) and second (3.2 1.6 vs. 1.6 1.5, p = 0.003) months. Stools were more liquid in the breastfed infants during the first three months. Infrequent stools occurred in 28% of breastfed and 8% of formula fed infants at least once. (p = 0.25).
Exclusively breastfed infants produced more stools than exclusively formula fed infants during the first two months and more liquid stools during the first three. Infrequent stools were 3.5 times more likely in the breastfed infants.
This study found that infrequent stools are most likely to occur after 5 weeks of age. The authors state in their discussion that there is no well-understood physiologic mechanism for infrequent stools in an infant who is growing well.
The findings in this study are useful clinically. First, we can inform families that it is normal for their breastfed babies to decrease frequency of stooling by 3-4 weeks. In my practice, some families call concerned about this, since it happens between the 2 week and 2 month visit.
Secondly, we can counsel families that after the first week of age, approximately ¼-1/3 of breastfed infants have episodes of not pooping for 3 days in a row.
Thirdly, we can determine with some certainty that very frequent stools, such as 8-10 per day is not typical after 3 months of age, and this may be a sign of something else, such as sensitivity to a substance in mom’s diet or a reaction to a medication, such as an antibiotic.
Yvette Piovanetti says
In the past two weeks I have noticed that infants who had passed meconium in utero have shown delayed passage of stool. Has anyone else observed this?
I notice that some babies have little meconium. After 1 large meconium stool, they don’t have stool for a day, then the next stool is yellow seedy. So, if these same infants have one stool in utero, then they may not have stool for awhile after that. Perhaps this is related to your observation.
Diane Erdmann RN BSN IBCLC says
“Secondly, we can counsel families that after the first week of age, approximately ¼-1/3 of breastfed infants have episodes of not pooping for 3 days in a row.”
I have been an OB nurse for over 40 years and an IBCLC since 1990. I have worked with thousands of newborns and strongly disagree with the above the statement. I have found the vast majority of the time that a baby as young as 2 weeks old who has not stooled for up to 3 days is simply not getting enough breastmilk and probably is not gaining weight well. I would not expect a baby who is nursing well and gaining weight well to skip a day without stooling until they are at least a month old or older. The only exception I would possibly agree to the above statement is if the baby is getting formula but even then, most 2 week babies typically stool several times a day. I have often worked with breastfeeding mothers who have newborns who are not stooling and when they call the pediatrician office, they are told this is normal. This is only normal in an older breastfed baby or babies who are getting formula. I feel your readers could potentially have breastfeeding babies who are in severe trouble and think they are doing fine if given this advice if they do not get more information on how that baby is doing.
I agree that 3 days of no stool is less likely in a well-gaining infant. However, I do find that 2-3 days of no stool very commonly proceeds a growth spurt at 3 weeks and 6 weeks of age. In fact, when I mention this to families at well child exams, they will recall that their babies did have less or no stool preceding a growth spurt characterized by 2 days of intense eating. And, they never called with concerns about the drop in stools. Also, I certainly see babies who skip pooping for a day or 2 in the first month of life, who are gaining well.
I should have clarified in my comment that these study findings are meant to describe a population that is gaining well. If a family calls with concerns about infrequent stools, weight checks are imperative, not only for infant health but also for parental confidence.
Yvette Piovanetti says
Agree with you as a pediatrician I see the whole picture and therfore weight checks and evaluation for jaundice are done at that three day visit. I enphasize feeding on demand but after the second day usually the infant must feed 8-12 / q 24 hrs. Then we see the stools and avoid insufficient breast milk jaundice.
Erin O'Reilly says
It would be nice if stooling habits of breastfeeding babies were studied more! This is another example of how little research is done on breastfeeding related subjects. As Kate Hinde points out in her TED there is a lot more research on erectile dysfunction than on breastmilk or breastfeeding—so sad. I am surprised that you did not take this opportunity to discuss the stooling patterns in relation to the changes in the breastmilk composition; ie whey/casein content…Finally I would like to suggest that someone think about contacting the APP vendors for DATA on breastfeeding and stooling since it could be a good source of data! if course, they would have to remove the participant identification for privacy issues.
Patrice DeMarco says
LLL and the “Diaper Logs” state that we “count” the stool if it is the size of a quarter or larger or as big as the circle made by the “OK” sign.
Does anyone know the reference for this?
If an infant has only “smear” of stool and none as large as size of quarter, could this indicate that infant not getting enough to eat or other problem?