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202 Jornal de Pediatria - Vol. 78, Nº3, 2002
202
0021-7557/02/78-03/202
Jornal de Pediatria
Copyright
©
2002 by Sociedade Brasileira de Pediatria
ORIGINAL ARTICLE
Abstract
Objective: to study the relationship between breast-feeding, dietary fiber intake and constipation in
infants.
Methods: the study population consisted of 275 infants consecutively enrolled in two Primary Care
Clinic in the city of Embu, in the Great São Paulo. The feeding pattern were classified in predominantly
breast-feeding, partially breast and cow’s milk feeding and artificial feeding. Constipation was defined by
the elimination of hard stool associated with one of the following: painful or difficult defecation, hard or
round cracked stools and less than three defecations a week. False constipation was defined by the
elimination of soft stools without pain or difficulty but with less than three defecations a week.
Results: constipation was found in 25.1% (69/275). False constipation was found only in the first
semester of life in 5.1% of 159 infants. The prevalence of constipation was higher between 6 and 24 months
(38.8%, 45/116) than in the first semester of life (15.1%, P=0.000). A model of logistic regression
demonstrated that infants under artificial feeding were 4.53 times more liable to develop constipation than
infants who were predominantly breastfed. The daily dietary fiber intake (g/day) was similar (P=0.57)
among the constipated (median=9.0 g; 25th and 75th percentiles: 6.9-13.1g) and non-constipated (median
= 8.8 g; 25th and 75th percentiles: 6.1-12.9 g).
Conclusions: dietary fiber intake was similar in constipated and non-constipated infants. Breast-
feeding serves as a protection factor against the development of constipation in the first semester of life.
J Pediatr (Rio J) 2002; 78 (3): 202-08: constipation, breast-feeding, dietary fiber.
Constipation in infants: influence of type of feeding
and dietary fiber intake
Andrea Nogueira de Campos Aguirre,
1
Márcia Regina Vítolo,
2
Rosana Fiorini Puccini,
3
Mauro Batista de Moraes
4
1. Master’s degree in Nutrition from Universidade Federal de São Paulo -
Escola Paulista de Medicina.
2. Supervisora de Nutrição do NUNADI - Doutora em Ciências pela Escola
Paulista de Medicina.
3. Associate Professor, Department of Pediatrics, Universidade Federal de
São Paulo.
4. Professor of Pediatric Gastroenterology, Department of Pediatrics, Escola
Paulista de Medicina (EPM), Universidade Federal de São Paulo.
Manuscript received Oct 05 2001. Accepted for publication Mar 27 2002.
Introduction
The etiopathogenesis of chronic functional constipation
in infants is not fully known. The cause of constipation may
involve body composition, genetic, nutritional,
psychological or emotional factors, associated or not with
intestinal motility disorder.
1-3
Studies carried out at pediatric gastroenterology clinics
in Brazil
4,5
and abroad,
6
agree that constipation often has
an early onset, sometimes in the first six months of life or
even at birth. In two studies
4,5
conducted in Brazil with
patients aged between four and six years assisted at
specialized clinics, approximately 20% of parents or
guardians said constipation had developed during exclusive
breastfeeding. However, the possibility of constipation
during this period is questioned
7
. In a previous study
5
we
observed that the median for exclusive breastfeeding time
Jornal de Pediatria - Vol. 78, Nº3, 2002 203
was lower in constipated infants than in the control group,
which makes us speculate whether breastfeeding can have
a protective role against constipation. Nevertheless, this
should be carefully analyzed, due to the long interval
between the application of the questionnaire and weaning.
5
In infants, a diet low in fibers is a risk for chronic
constipation.
8,9
To our knowledge, there is no reference in
literature that relates bowel habit to the amount of fiber
intake in infants.
The present study aimed at evaluating the relationship
between the type of breastfeeding, fiber intake and
occurrence of constipation in infants.
Methods
The study was carried out at two basic health units in the
town of Embu, in the Metropolitan Region of São Paulo,
Brazil. The Universidade Federal de São Paulo - Escola
Paulista de Medicina (UNIFESP-EPM) has provided the
local community with medical assistance through an
integrated program since the 1970’s. All infants younger
than 24 months, without acute or chronic diseases,
consecutively assisted from December 1996 to December
1997 were included in the study. The exclusion criteria
were presence of delayed neuropsychomotor development,
hypothyroidism, anorectal malformations and use of
antacids, anticholinergics and codeine. No infants with
such characteristics were found among the assisted patients.
As a result, 275 infants were included in the study.
To determine whether or not the infant presented with
constipation, a standardized questionnaire including
questions related to bowel habits was used. The shape and
consistency of stools, as well as pain, difficulty or fear
during stool passage were registered. A catalog with 12
pictures of infant’s stools, with different characteristics,
was used to help identify their shape and consistency.
Constipation was characterized by necessarily hard
stools and by the presence of at least one of the following
characteristics: painful stools or difficult stool passage,
scybalous stools, cylindrical stools with cracks or thick
cylindrical stools, or interval between bowel movements
greater than or equal to three days. Intestinal
pseudoobstruction occurred when stools were soft, and no
painful stools or difficult stool passage were present, at an
interval greater than or equal to three days.
3
Normal bowel
habit was defined as the absence of all characteristics
outlined above.
In terms of breastfeeding practice, infants were placed
into three categories:
10
– predominant breastfeeding: infants who were
exclusively fed breastmilk, or who were fed breastmilk,
water and/or tea;
– mixed breastfeeding: infants who were fed breastmilk
and other complementary foods, including cow’s milk,
milk-based formulas, or any other kind of food; and
– artificial breastfeeding: infants who were no longer fed
breastmilk.
Infant feeding was assessed by the usual daily food
intake in infants older than six months.
11
The analysis of
diet information was made using the Nutrition Support
program.
12
The amount of dietary fiber intake was assessed
through the AOAC (Association of Official Analytical
Chemists) table.
13
Weight and height measurements were obtained
according to the recommended techniques.
14
The
comparison between anthropometric parameters of
constipated and control infants was performed by z scores,
calculated by the EPI-Info program,
15
taking into
consideration the NCHS (National Center for Health
Statistics) weight and height tables.
16
The statistical analysis was made by the EPI-Info
program.
15
A logistic regression model was used for the
multivariate analysis of constipation, using the Stata program
(Stata Corporation, Texas, USA).
17
The study was approved
by the Ethics and Research Committee of Universidade
Federal de São Paulo – Escola Paulista de Medicina, and a
written consent form was obtained from parents or guardians.
Results
The infants were classified into two age groups: less
than six months and six to 24 months. Table 1 shows the
bowel habit pattern and the occurrence or not of constipation.
Constipation was present in 25.1% (69/275) of the study
population. Scybalous stools were more frequent in
constipated infants, representing 63.4% (44/69) of the
cases. Stool frequency lower than three times a week was
observed in only 5.8% of 69 constipated infants. Constipation
was more frequent between the sixth and 24th months
(38.8%; 45/116) than in the first six months of life (15.1%),
with statistically significant difference (P=0.0000). Mothers
noticed their children presented with painful stools or
difficult stool passage in 65.2% (15/23) and 25.2% (30/119)
of the cases, in the first six months and between the sixth and
24th months of life, respectively. On the other hand, painful
stools or difficult stool passage were present in 25.2%
(30/119) of the infants with normal bowel habit in the first
six months of life and in none of the infants between the
sixth and 24th months of life.
The association between breastfeeding practice and
occurrence of constipation was analyzed by considering the
information obtained from 159 infants in the first six months
of life. In this group, 66 (41.5%) were on predominant
breastfeeding, 49 (30.8%), on mixed breastfeeding and 44
(27.7%), on artificial breastfeeding. Eight percent (5.1%)
of 159 infants had intestinal pseudoobstruction, that is, they
passed amorphous stools, with liquid or pasty consistency,
at an interval greater than three days; among these infants,
Constipation in infants: influence of type of feeding... - Aguirre ANC
et alii
204 Jornal de Pediatria - Vol. 78, Nº3, 2002
six received predominant breastfeeding and two were on
mixed breastfeeding. Stool frequency was twice a week in
four infants with intestinal pseudoobstruction, once a week
in three and once every 15 days in one infant.
Constipation was less frequent in infants on predominant
breastfeeding (4.5%) than in those on mixed breastfeeding
(18.4%) or on artificial breastfeeding (27.3%; 12/44;
P<0.05). In the first six months of life, the incidence of
constipation increased with age (5.5% in the first two
months, 16.3% in the subsequent two months, and 23.0% in
the last two months; P<0.05). Considering that the frequency
of constipation increased with age, and that the frequency of
predominant breastfeeding decreased; the relationship
between these two variables and the occurrence of
constipation was analyzed by a logistic regression model,
employing three categories for age (first two months,
subsequent two months, and last two months of life) and for
the type of breastfeeding (predominant, mixed and artificial).
Table 2 presents the result of the logistic regression analysis,
showing that age is not associated with constipation, in
opposition to what was indicated by the statistical test used
for separately assessing the association of these variables.
On the other hand, the association between type of
breastfeeding and constipation (P=0.02) was confirmed.
Table 1 - Pattern of bowel habits of breastfed infants seen in basic health unit
Stool Painful and/or Age group
difficult
Consistency Shape defecation Conclusion 0 |– 6 m 6 |– 24 m Total
Liquid, soft or paste-like shapeless No Normal 83 (52.2%) 40 (34.5%) 123 (44.7%)
Liquid, soft or paste-like shapeless Yes Normal 29 (18.2%) 0 (0.0%) 29 (10.5%)
Liquid, soft or paste-like round No Normal 6 (3.7%) 16 (13.7%) 22 (8.0%)
Liquid, soft or paste-like round Yes Normal 1 (0.6%) 0 (0.0%) 1 (0.4%)
Hard round without crack No Normal 8 (5.0%) 15 (12.9%) 23 (8.4%)
Hard coprolite Yes Constipation 11 (6.9%) 18 (15.5%) 29 (10.5%)
Hard coprolite No Constipation 4 (2.5%) 11 (9.4%) 15 (5.5%)
Hard round without crack Yes Constipation 2 (1.2%) 6 (5,1%) 8 (2.9%)
Hard round with crack Yes Constipation 3 (1.89%) 5 (4.3%) 8 (2.9%)
Hard round with crack No Constipation 4 (2.5%) 5 (4.3%) 9 (3.3%)
Liquid, soft or paste-like stool defecated
in intervals of 3 days or longer False constipation 8 (5.0%) 0 (0.0%) 8 (2.9%)
Total 159 (100.0%) 116 (100.0%) 275 (100.0%)
Table 2 - Result of the logistic regression analysis with proportional adjacent categories
about the relation between constipation, age and feeding type in 159 breastfed
infants during the first semester of life
Relation between constipation and Odds-ratio P
(confidence interval-95%)
Age 0 - 2 months 1.00 0.18
2 - 4 months 1.55 (0.82 - 2.92)
4 - 6 months 2.40 (0.67 - 8.53)
Feeding type Predominant 1.00 0.02
Mixed 2.13 (1.13 - 4.01)
Artificial 4.53 (1.24 - 16.08)
Constipation in infants: influence of type of feeding... - Aguirre ANC
et alii
Jornal de Pediatria - Vol. 78, Nº3, 2002 205
Therefore, according to the odds ratio, artificial versus
mixed breastfeeding and mixed versus predominant
breastfeeding showed an odds ratio 2.1 times higher for
constipation. Artificial breastfeeding, on its turn, showed
an odds ratio 4.5 times higher.
The study on the association between the intake of
nutrients and dietary fibers, and other information about the
diet was carried out with infants older than six months. The
food intake was assessed according to the usual daily food
intake questionnaire, using the information obtained from
75 infants older than six months, who were no longer fed
breastmilk. Six (8.0%) questionnaires were not included in
the study for having inadequate information. Therefore, the
results shown in Table 3 correspond to 31 constipated
infants and 38 infants with normal bowel habit. Age and the
estimated amounts of food, water and milk volume, energy
and protein requirements, and the amounts of protein,
carbohydrate, and lipids did not show statistically significant
difference between constipated and nonconstipated infants.
The intake of dietary fiber was estimated according to
the AOAC table. This evaluation also included infants who
were fed breastmilk, which is not a source of dietary fiber.
Among the questionnaires of the 116 infants aged between
six and 24 months, nine (7.8%) were not included in the
study for having inadequate information. Therefore, the
results of 107 questionnaires were considered. Table 4
shows that there was no statistical difference in the intake of
dietary fiber by constipated in comparison with
nonconstipated infants.
Table 5 shows the anthropometric parameters that did
not have statistical difference according to the presence or
absence of constipation.
Discussion
In Brazil, several recently reviewed studies
3
showed
that constipation frequently occurs in infants, with a rate of
25.1% in infants younger than two years – an age group that
was not much investigated in previous studies. In the
present study, the incidence of constipation increases
progressively in the first six months of life. However, the
prevalence of constipation between the sixth and 24th
months is statistically higher than that observed during the
first six months. A study
18
conducted with a community in
northeastern Brazil showed a 21.8% prevalence of
constipation in infants, which is similar to the result obtained
in the present study. It is not easy to compare the results of
different studies on the prevalence of constipation due to
the different concepts adopted in each one of them. In the
present study, constipation is characterized by the elimination
of necessarily hard stools and by at least one of the following
Table 3 - Age (months) and dietary data according to the usual daily diet of breastfed infants
with or without constipation
* Median and 25th and 75th percentils, Mann-Whitney’s test for all variables
Constipation
Yes No P*
(n=31) (n=38)
Age (months) 12.09 11.04 0.34
(8.77 - 16.23) (8.97 - 14.13)
Food amount (g) 1,429.5 1,400.9 0.91
(1,188.2-1,955.5) (1,224.5-1,858.4)
Water volume (ml) 300 240 0.91
(120 - 450) (100 - 450)
Milk volume (ml) 720 710 0.52
(600 - 690) (480 - 900)
Energy requirements (%) 146.8 160.5 0.21
(131.5 - 171.5) (136.9 - 195.1)
Protein requirements (%) 410.0 406.4 0.79
(293.1 - 509.0) (271.1 - 502.0)
Proteins (g) 62.1 56.9 0.56
(46.9 - 82.0) (43.4 - 78.8)
Carbohydrates (g) 196.8 217.6 0.28
(156.1 - 271.6) (172.0 -250.6)
Lipids (g) 45.5 45.9 0.97
(37.7 - 54.9) (37.0 - 59.9)
Constipation in infants: influence of type of feeding... - Aguirre ANC
et alii
206 Jornal de Pediatria - Vol. 78, Nº3, 2002
Table 4 - Estimate of the total fiber intake (g), percentage of adherence to the recommended
daily fiber intake (5 g/day) and fiber per 1,000 kcal of diet, according to the usual
food intake of breastfed infants with or without constipation
* Median and 25th and 75th percentils between parentheses, Mann-Whitney’s test for all variables.
Constipation
Yes No P*
(n=44) (n=63)
Daily intake (g/day) 9.00 8.76 0.57
(6.88 - 13.13) (6.07 - 12.94)
Percentage of minimal recommendation 180.0% 175.2% 0.57
(5 g/day) (137.6% - 262.6%) (121.4% - 258.8%)
Total fiber (g) per 1,000 kcal of diet 7.64 6.50 0.32
(4.49 - 10.38) (5.50 - 8.76)
characteristics: painful stools or difficult stool passage,
scybalous or cylindrical stools with cracks, or still, interval
between bowel movements greater than or equal to three
days. This concept is in agreement with the proposition of
a workgroup that included representatives from different
continents.
19
Our results showed that constipation in infants was
usually characterized by the passage of hard, scybalous
stools, followed by painful stools or difficult stool passage.
A reduction in stool frequency occurred in only 5.8% of
constipated infants. On the other hand, painful stools and/
or difficult stool passage was reported by 25.2% of the
mothers whose children were younger than six months,
without constipation, showing that this diagnostic
information is not so specific in this age group. With regard
to intestinal pseudoobstruction, there are no references in
literature on its frequency, which was 5.1% in the 159
infants younger than six months, who corresponded to 7.3%
(8/110) of the infants on predominant breastfeeding. It is
important to emphasize that intestinal pseudoobstruction is
not a pathological condition, and therefore, it requires no
treatment, but only some guidelines or instructions to the
family and maintenance of breastfeeding. The constipated
infants included in this study were not receiving any specific
treatment. This is different from the practice used in pediatric
gastroenterology clinics which, in general, treat older
children and more severe conditions, of which constipation
is the major complaint. Constipation complications, such as
fecal soiling, stool retention, painful and sporadic passage
of bulky stools, and chronic abdominal pain are commonly
observed in these specialized clinics.
4-6
In patients with
chronic constipation assisted at specialized services, the
problem is often observed in the first year of life. For that
reason, infants are investigated for the association between
constipation and two dietary aspects that might be related to
its onset: type of breastfeeding and amount of dietary fiber
in the weaning diet.
The absence of breastfeeding in the first six months of
life is associated with constipation, according to the logistic
regression test. In other words, the chances of an infant on
artificial breastfeeding presenting constipation is 4.5 times
higher than in infants on predominant breastfeeding.
Table 5 - Median and 25th and 75th percentils (between
parentheses) of weight-for-age, weight-for-height
and height-for-age z scores of children with and
without constipation
Note: weight-for-height z scores were calculated for 68 children with
constipation and 203 without, since four children presented height
below the lowest value of the NCHS table.
Constipation
z score Yes No Mann-Whitney's
(n=69) (n=206) Test
Median 0.0 0.0 0.51
weight/age (-0.7 +0.6) (-0.6 +0.5)
(25th P 75th P)
Median +0.5 +0.2 0.12
weight/height (-0.5 +1.1) (-0.4 +0.8)
(25th P 75th P)
Median -0.4 -0.3 0.77
height/age (-1.0 +0.3) (-0.9 +0.3)
(25th P 75th P)
Constipation in infants: influence of type of feeding... - Aguirre ANC
et alii
Jornal de Pediatria - Vol. 78, Nº3, 2002 207
According to literature,
20,21
stool frequency is higher in the
first year of life, decreasing with age. Stool frequency in
infants on natural breastfeeding is higher than in infants on
artificial breastfeeding. Motilin can be responsible for
altered bowel habits.
20
Another aspect to be considered is
the good digestibility of lipids contained in human milk
versus milk-based formulas, which produces softer stools.
22
After weaning, some cases of constipation can be attributed
to intolerance of or allergy to cow’s milk protein.
23-25
If we
add these physiological.
20,21
and pathological.
21-23
evidence
to the results obtained through our study, natural
breastfeeding should be considered a protection factor
against constipation.
Another diet-related factor that can influence the
development of constipation in infants is the content of
dietary fibers in weaning foods. However, there is no
reference in literature that relates the intake of dietary fiber
to bowel habits in this age group. The information on the
intake of dietary fiber in infants is scarce. There is some
concern that the high intake of dietary fiber may have
negative effects on growth for causing early satiation or for
interfering with mineral uptake.
The only recommendation for dietary fiber intake
involving infants found in literature was proposed by
Agostoni et al.,
26
who suggested the daily intake of at least
five grams of dietary fibers a day. In the present study, there
was no association between constipation and reduced fiber
intake, which is different from the results obtained from
other studies carried out in Brazil
8
and abroad,
9
whose
study population consisted of children older than two years.
Although there is some reference in literature
27-30
that
a high intake of dietary fiber can cause anorexia, thus
interfering with the amount of energy intake, in our study,
the infants had a median intake of energy and fiber greater
than the minimal recommendation, and the weight and
height values showed that the nutritional status of the study
population was satisfactory. The fact that constipated and
nonconstipated infants did not have different estimates for
fiber intake does not mean that the administration of fibers
to those who are prone to constipation does not normalize
bowel habits.
Our study showed that the estimated intake of dietary
fiber was not different between constipated and
nonconstipated infants. With respect to natural breastfeeding,
we can affirm that its protective role against constipation in
the first six months of life is one more advantage in relation
to artificial breastfeeding.
Acknowledgements
We thank all the support received from the State of São
Paulo Research Foundation (FAPESP). We also thank Mr.
Fernando A.B. Colugnati for carrying out the statistical
analysis and the logistic regression test.
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Correspondence:
Dr. Andrea Nogueira de Campos Aguirre
R. Coronel Amazonas Marcondes, 1115/203 C2
CEP 80035-230 – Curitiba, PR, Brazil
Telephone: +55 41 3534839
E-mail: andrea.aguirre@utp.br
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