What can I do if my baby strains to have a bowel movement but no stool is passed?

Infant Straining Without Stool Production

This is most likely normal infant behavior called "infant dyschezia" – straining is common in babies under 6 months as they learn to coordinate their muscles, and no treatment is needed if your baby is otherwise well, feeding normally, and gaining weight appropriately. 1

First: Distinguish Normal from Constipation

Key assessment points:

• Normal bowel patterns vary dramatically by age and feeding type – newborns typically have bowel movements after most feedings (8-12 times daily), but by 2 months this decreases to every 3-4 hours or less frequently 1
• Breastfed infants can go 7-10 days without stool and still be completely normal if the stool is soft when it comes 1
• Straining alone does not equal constipation – babies often grunt, turn red, and appear to strain because they haven't yet learned to relax their pelvic floor while pushing 1

True constipation requires:

• Hard, pellet-like stools (not just infrequent stools)
• Pain or crying during bowel movements
• Blood on stool surface from anal fissures
• Abdominal distension or decreased appetite 2, 3

When Reassurance Is Appropriate (Most Cases)

If your baby has the following, no intervention is needed:

• Straining but eventually passes soft stool (even if days apart)
• Normal feeding and weight gain
• No signs of distress between episodes
• No hard, painful stools 1, 4

Continue breastfeeding on demand without any changes – switching from breast milk to formula is not recommended for normal straining or functional GI concerns 4

When to Consider Treatment (True Constipation)

For Infants Under 6 Months

First-line treatment options:

• Fruit juices containing sorbitol (prune, pear, or apple juice) at 10 mL/kg body weight – these create an osmotic load that softens stool 1
• Lactulose is the recommended medication if juice is insufficient, dosed at 2.5-10 mL daily in divided doses for infants 1, 5
• Avoid excessive juice (can cause diarrhea, flatulence, and poor weight gain) 1

Dietary considerations:

• For breastfed infants: Consider a 2-4 week maternal elimination diet (removing milk and eggs) if milk protein allergy is suspected (symptoms include excessive fussiness, blood in stool, poor weight gain) 1
• For formula-fed infants: Consider switching to extensively hydrolyzed or amino acid-based formula if milk protein allergy suspected 1
• Ensure adequate hydration and avoid overfeeding 1

For Infants 6 Months and Older

• Polyethylene glycol (PEG) becomes the preferred option after 6 months of age 6, 7
• Continue lactulose as alternative if PEG unavailable or poorly tolerated 7
• Introduce age-appropriate solid foods with adequate fiber when developmentally ready 1

Red Flags Requiring Immediate Medical Evaluation

Seek urgent care if your baby has:

• Delayed passage of meconium (first stool after birth) 7
• Bilious (green) vomiting 1
• Ribbon-like stools (suggests anatomic obstruction) 7
• Failure to thrive or poor weight gain 1, 7
• Severe abdominal distension 7
• Absent anal wink reflex 7
• Explosive stool/gas after rectal exam (suggests Hirschsprung disease) 7
• Sacral dimple, hair tuft, or skin abnormality over spine 7

These may indicate serious organic causes like Hirschsprung disease, spinal cord abnormalities, hypothyroidism, or anatomic malformations that require specialized evaluation 2, 7.

Common Pitfalls to Avoid

• Do not stop breastfeeding in favor of formula for normal straining or functional constipation 4
• Do not use stimulant laxatives in infants – safety data are conflicting and they should be avoided 8
• Do not perform routine rectal stimulation (like thermometer insertion) – this can create dependency and doesn't address the underlying issue 1
• Do not diagnose lactose intolerance based solely on stool pH or reducing substances without clinical symptoms 8