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How to manage a constipated infant. -&- Child a picky eater? Anxiety, depression

Written by Rotimi Adesanya - Nigeria

Dr. Rotimi Adesanya
A mother made this comment and asked a question through the feedback platform, in response to an article I wrote two years ago on infant constipation.
Hello, My baby is having a serious problem which is constipation. She has a hard belly and sometimes has some foul smelling wind and poo.

I have tried a few solutions such as adding extra water in-between feeds, I give her plenty of water or diluted fruit juice and even give her some leg exercises. Yet, everything makes no difference. Does anyone have better idea to suggest to me?

I have seen several mothers of neonates and infants with the same complaint of their babies' inability to move bowel for up to 10 days. The babies are without any abnormality and they will start moving their bowels after examining their rectum.
This is partly due to the stimulation of the nerves innervating the rectum and they will not need any medication; while very few (about two per cent) may have an underlying medical condition and may need to be sent for further tests such as X-ray and ultrasound scan of the abdomen.

It is advisable for mothers of newborns with constipation to contact their doctors for advice and not assume that all is right.
During the first week of life, infants pass approximately four soft or liquid bowel movements per day (generally more in breast-fed, compared with bottle-fed, infants).
During the first three months of life, breast-fed infants have about three soft bowel movements per day. Some breast-fed infants have a bowel movement after each feeding, whereas others have only one or two bowel movements per week. Infants who breastfeed are rarely constipated.

Most formula-fed infants have two to three bowel movements per day, although this depends on which infant formula is given. Some soy and cow's milk-based formulas cause harder bowel movements; while other formulas that contain partially or completely hydrolysed milk proteins can cause loose bowel movements.
Constipation in infants less than one year of age is common, but it can be a source of concern for parents. Sometimes, the baby is not really constipated, but must be given time to set his own schedule for having a bowel movement.

Infant constipation is the passage of hard, dry bowel movements – not necessarily the absence of daily bowel movements. Infant constipation may begin when a baby transitions from breast milk to formula or when s/he begins eating solid foods.
In rare cases, constipation may be caused by a lack of nerves or by structural problems in the lower large intestine.

Signs and symptoms
  • An infant who is constipated usually strains more than other babies to have a bowel movement.
  • The stool may be formed and hard like small pebbles, or it may be soft and mushy. Stool may even be wide and large.
  • Sometimes, solid stool stays inside and liquid stool (like diarrhoea) may pass out around it.
  • Other signs of constipation are infrequent stools that are difficult to pass.
  • The child's abdomen can become swollen with gas, and painful cramps can result from constipation.
  • The child may be restless and cranky.

  • Digital rectal examination: In this procedure, a doctor or other health care provider inserts a gloved finger into the rectum to feel for anything unusual or abnormal.
  • Abdominal X-ray: This is a diagnostic test to evaluate the amount of stool in the large intestine.
  • Abdominal scan may be helpful in some cases.

  • You may give fruit juices (prune, pear, cherry, orange or apple). If the stool becomes too loose, just give less juice to your baby.
  • If the baby is eating rice cereal, it may help to switch to oatmeal or barley cereal. Rice cereal can cause constipation in some children.
  • To ease the passage of hard stools, consider applying a small amount of water-based lubricant to your baby's anus.
  • It might help to place an infant glycerin suppository into your baby's anus. Glycerin suppositories are available without a prescription. They are only meant for occasional use when dietary changes are not effective.
  • If your baby is old enough to eat strained foods, you may give him fruits and vegetables.
  • A warm bath, at least once a day, can help relax his rectum. This can make it easier for him to have a bowel movement.
  • Proper toilet training/bowel habits for older infants: Have your child sit on the potty at least twice a day for at least 10 minutes, preferably shortly after a meal.
The treatment listed above is applicable to infants above three months only. Those that are less will need a doctor's review.
In conclusion, most of the time, constipation is a temporary situation. However, some children may have diseases of the intestine, such as Hirschsprung's disease (a blockage of the large intestine).
Child a picky eater? Anxiety, depression

Anxiety in children
Picky eating among children is a common but burdensome problem that can result in poor nutrition for kids, family conflict, and frustrated parents.
Although many families see picky eating as a phase, a new study from Duke Medicine finds moderate and severe picky eating often coincides with serious childhood issues such as depression and anxiety that may need intervention.

According to the study, published August 3 in the journal Pediatrics, more than 20 percent of children ages 2 to 6 are selective eaters. Of them, nearly 18 percent were classified as moderately picky. The remaining children, about 3 percent, were classified as severely selective — so restrictive in their food intake that it limited their ability to eat with others.

"The question for many parents and physicians is: when is picky eating truly a problem?" said lead author Nancy Zucker, Ph.D., director of the Duke Center for Eating Disorders. "The children we're talking about are not just misbehaving kids who refuse to eat their broccoli."
Children with both moderate and severe selective eating habits showed symptoms of anxiety and other mental conditions. The study also found that children with selective eating behaviors were nearly twice as likely to have increased symptoms of generalized anxiety at follow-up intervals during the study, which screened an initial 3,433 children.

"These are children whose eating has become so limited or selective that it's starting to cause problems," Zucker said. "Impairment can take many different forms. It can affect the child's health, growth, social functioning, and the parent-child relationship. The child can feel like no one believes them, and parents can feel blamed for the problem."
The study found that both moderate and severe selective eating were associated with significantly elevated symptoms of depression, social anxiety and generalized anxiety.
Although children with moderate picky eating did not show an increased likelihood of formal psychiatric diagnoses, children with severe selective eating were more than twice as likely to also have a diagnosis of depression.

Children with moderate and severe patterns of selective eating would meet the criteria for an eating disorder called Avoidant/Restrictive Food Intake Disorder, a new diagnosis included in the most recent Diagnostic and Statistical Manual of Mental Disorders.
The findings also suggest that parents are in conflict with their children regularly over food- which does not necessarily result in the child eating - and families and their doctors need new tools to address the problem, Zucker said.
"There's no question that not all children go on to have chronic selective eating in adulthood," Zucker said. "But because these children are seeing impairment in their health and well-being now, we need to start developing ways to help these parents and doctors know when and how to intervene."

Zucker said some children who refuse to eat might have heightened senses, which can make the smell, texture and tastes of certain foods overwhelming, causing aversion and disgust. Some children may have had a bad experience with a certain food, and develop anxiety when trying another new food or being forced to try the offensive food again, she said.
"What's hard for physicians is that they don't really have data to help predict which children will age out of the problem and which children won't, and so they're trying to do the best they can with limited information and interventions," Zucker said.

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