Typical Stool Frequency in Breastfed Infants
by Anne Eglash MD, IBCLC, FABM
What are normal stooling patterns for infants?
Lactation specialists are often asked about expected stool frequency. The authors of this systematic review and meta-analysis sought to identify what typical stooling patterns are for children ages 0-4 years of age, to avoid overdiagnosis or underdiagnosis of GI disorders.
They included 75 of 3756 studies from 43 different countries that reported on stool frequency and/or consistency among healthy children ages 0-4 years of age. Their exclusion criteria included infants less than 37 weeks gestation, children on medication or with illness.
The authors categorized the children into 2 groups-9875 infants who were under 14 weeks of age, and 5747 children aged 14 weeks-4 years.
They found that average stool frequency among all infants 0-14 weeks of age ranged from 0.6-5 stools a day. But what about breastfed vs formula fed? See the question!
- Among infants under 14 weeks of age, those who breastfed stooled more often each day than those who were fed formula.
- Approximately 5% of all infants under 14 weeks of age had hard stools.
- Approximately 10% of formula fed infants under 14 weeks of age had hard stools.
- Approximately 10% of children aged 14 weeks-4 years of age had hard stools.
- Changes in infant formula with the addition of prebiotics such as oligosaccharides are associated with less frequent stooling.
- There was no difference in defecation patterns among children based on geographic location.
See the Answer
Abstract
Objective
To summarize available data on defecation frequency and stool consistency of healthy children up to age 4 in order to estimate normal references values.
Study design
Systematic review including cross-sectional, observational, and interventional studies published in English, that reported on defecation frequency and/or stool consistency in healthy children 0-4 years old.
Results
Seventy-five studies were included with 16 393 children and 40 033 measurements of defecation frequency and/or stool consistency. Based on visual inspection of defecation frequency data, a differentiation was made between two age categories: young infants (0-14 weeks old) and young children (15 weeks-4 years old). Young infants had a mean defecation frequency of 21.8 per week (95 % CI, 3.9-35.2) compared with 10.9 (CI,5.7-16.7) in young children (P < .001). Among young infants, human milk-fed (HMF) infants had the highest mean defecation frequency per week (23.2 [CI, 8.8-38.1]), followed by formula-fed (FF) infants (13.7 [CI 5.4-23.9]), and mixed-fed (MF) infants (20.7 [CI, 7.0-30.2]). Hard stools were infrequently reported in young infants (1.5%) compared with young children (10.5%), and a reduction in the frequency of soft/watery stools was observed with higher age (27.0% in young infants compared with 6.2% in young children). HMF young infants had softer stools compared with FF young infants.
Conclusions
Young infants (0-14 weeks old) have softer and more frequent stools compared with young children.
This scoop on infant poop provides some clinical guidance to share with families. The authors found that among infants under 14 weeks of age, the average number of daily stools was 3.3, 3.0, and 2.0 for breastfed, mixed-fed, and formula fed infants respectively.
Among infants under 14 weeks of age, approximately 0.3% of breastfed infants had hard stools (hard to imagine!) vs 1.8% among formula fed infants.
Among children aged 14 weeks-4 years 10.5% had hard stools, with increased risk of hard stools with increased age. The authors found a very slight increased frequency of stooling associated with formula with prebiotics such as oligosaccharides.
Allison
My fourth child had thick (peanut butter like) stools several times around 3-4 months of age, and struggled to pass them, before any introduction of any substance other than breastmilk.
It was so bizarre that I consulted our physician, and we monitored her for a while, and tried to see if my diet/medication correlated. We never found a correlation, but it did resolve.
It was however alarming how many nurses I spoke with that dismissed my concern. Every one of them told me it was common. We reside in an area of the US with incredibly low exclusive breastfeeding rates.
Kallyn Lang
My son also presented like this. It was a gut motility issue, related to congenital hypotonia that was not picked up on. I, too, was dismissed until he was diagnosed at 10 months of age with 22q Deletion Syndrome.
Shyamala Sathiaseelan
There is something that I want to share. Whenever a mother posts in forums asking her baby poops after or during every feed, people come back and say it is normal. Actually it is a sign of lactose overload or lactose intolerance. Two very different reasons but they are not normal. Both of them can be dealt with and the issues sorted.
IABLE
I agree that for a child after the first few weeks, stooling with each feeding can be a sign of lactose overload. However I would not say lactose intolerance, as that is a very, very rare situation in a newborn.
Shyamala Sathiaseelan
I have seen many cases of secondary/temporary lactose intolerance In my practice, confirmed by a stool test for reducing substances positive. this happens in case of antibiotics given to baby or mother or in case of a stomach infection
IABLE
Thanks for clarifying. Yes, infants who have injury to their intestinal brush border due to illness/meds lose the lactose digesting enzyme called lactase for a limited time, until their gut heals.
Shyamala Sathiaseelan
Yes, and the gut heals better by intake of probiotics and lactase enzyme.
Njoku Faustina
My experience with exclusive breastfeeding was that my baby was having frequent loose stools, this was ok with me and my baby was doing well on breastmilk.
Another breastfeeding mother I interviewed said that her baby on exclusive breastmilk opened her bowel at 3-4 days intervals, when she reported to her physician, she was told that not a problem, and that her baby was having a balanced diet with breastmilk.
The defecation pattern of breastfed babies in our geographical location is usually associated to the feeding habit of the mother and that is why it is believed in our culture that a breastfeeding mother should avoid certain meals.
Karolina Chojnacka-Przekwas
It’s very interesting to me. As a lactation consultant should I send every newborn who poops once for 3-4 days to a pediatrician if they seem to be healthy otherwise? I don’t want to miss anything but at the same time I don’t want to unnecessarily stress already stressed parents… I really rarely see newborns and babies who poop 3-4 times a day even if they eat good amounts of breastmilk or formula. Any hint would be highly appreciated.