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This case report describes an exclusively breastfed (EBF) infant who did not defecate for over two weeks but remained healthy and resumed regular bowel movements without medical intervention. The goal is to highlight the importance of recognizing normal variations in stooling patterns among breastfed infants and to emphasize pediatricians' role in carefully assessing abnormal stool changes during routine well-baby visits. Although similar benign cases of infrequent stooling in EBF infants have been reported, they remain rare. This report provides a detailed description of the full clinical course, reinforcing that careful observation and reassurance are often enough when there are no warning signs. Awareness of such benign presentations helps healthcare providers distinguish harmless stooling delays from early signs of true gastrointestinal disorders, thereby avoiding unnecessary investigations and reducing caregiver anxiety. Overall, the report emphasizes that infrequent stooling in healthy, exclusively breastfed infants can occur without an underlying illness.
Healthy bowel movements are a key indicator of infant well-being and can reassure caregivers. However, variations in stool patterns, especially in breastfed infants, often cause concern when they deviate from expectations. Research shows that defecation frequency varies widely among neonates and infants [1]. Most pass their first meconium within 48 hours, and frequent stooling in the first week usually indicates sufficient breast milk intake. Typically, breastfed infants tend to have more frequent bowel movements compared to those who are formula-fed, averaging between one and eight times a day [1,2].
This case report describes an exclusively breastfed (EBF) infant who remained asymptomatic and well-fed despite a prolonged absence of bowel movements. This condition, termed infrequent stooling or pseudo-constipation, is benign and often underrecognized in medical literature [3]. It can be misunderstood by caregivers or less experienced healthcare providers, resulting in unnecessary testing or treatments. To our knowledge, this is the first detailed report documenting the full clinical course of an EBF infant with infrequent stooling, demonstrating its benign nature and spontaneous recovery.
Unlike earlier reports with limited clinical details, our report underscores the importance of distinguishing normal variations in stooling from pathological constipation in otherwise healthy infants. It provides practical insights into clinical assessment, continuous observation, and the importance of clear communication and reassurance in pediatric care, especially when managing atypical yet benign stooling patterns.
Case Presentation
A 65-day-old male infant was brought to our pediatric outpatient clinic due to a lack of stool passage for one week. He is the second child in his family, born at term, with a weight of 2800 grams, following an uncomplicated spontaneous vaginal delivery. He was discharged from the nursery in good condition and passed meconium within the first forty- eight hours of life. Since then, his stool has been soft and regular daily. He occasionally spat up once a day, but never had a history of frequent vomiting, abdominal distention, or rectal bleeding.
At the time of the visit, he weighed 4600 grams and had been gaining weight appropriately, averaging 30 grams per day. His developmental assessment was appropriate for his age. He has been exclusively breastfed (EBF) since birth, and the mother has consumed regular dairy products. His only medication includes vitamin D drops. There is no family history of cow's milk protein or other food allergies.
During his physical examination, he appeared healthy and was not in distress. There were no dysmorphic features or signs of jaundice. The abdomen was soft and relaxed, showing no signs of distention, masses, or hernias. He had a patent anal opening in the normal position, with good sphincter tone and no anal fissures. Both the neurological examination and developmental assessment were normal. Additionally, there were no dermatologic lesions on his back that would suggest spinal dysraphism.
A pediatrician prescribed glycerin rectal suppositories, considering the possibility of functional constipation, and he had a bowel motion the same day. However, during a follow-up appointment one week later, it was noted that the baby had not had a bowel movement since then. The parents were reassured, and another follow-up visit was scheduled for the following week. At that appointment, it was observed that the baby still had not passed stool. Despite this, the parents were reassured, as no concerning signs were present. A phone follow-up three days later confirmed that the infant passed stool on day 15. The stool was normal, soft to loose, with an adequate amount, with no reports of distress such as crying or screaming during stooling (Figure 1). Weekly follow-ups with the parents took place over the next month. The infant remained exclusively breastfed, with no changes to the feeding schedule. During this time, the infant began passing at least one normal, soft stool each week.
Figure 1: Stool Output Following Delayed Passage in the Reported Infant
This case underscores that an extended period of stool absence in an EBF infant may occur without an underlying pathology, provided the infant remains healthy, well-nourished, and comfortable. Such observations emphasize the significance of interpreting stooling patterns within the broader context of feeding adequacy, growth progression, and overall health, rather than relying solely on stool frequency. In clinical practice, reassurance and counseling are paramount, as meticulous observation often proves more appropriate than unwarranted diagnostic or therapeutic interventions when no clinical warning signs are evident.
While previous studies have noted similar cases of infrequent stooling in healthy breastfed infants, such reports remain relatively scarce [3-6]. This case provides important evidence by carefully describing growth metrics, examination results, and long-term follow-up, confirming that a stool-free interval exceeding 2 weeks can sometimes be a benign physiological variation. Unlike earlier reports, this case offers a comprehensive clinical interpretation and highlights the importance of a patient-centered approach rather than strictly protocol-based interventions in pediatric care.
Many pediatricians rely on the Rome IV criteria as the main standard for diagnosing functional constipation, emphasizing stool consistency and frequency [7]. To assess stool consistency, a modified version of the Bristol Stool Form Scale, originally made for adults, is recommended. This scale classifies stools into seven types based on shape and consistency. However, a newer, more sensitive tool, the Brussels Infant and Toddler Stool Scale (BITSS) [8], has been created explicitly for non-toilet-trained children and infants, offering a better alternative. This validated scale sorts stools into four types (watery, loose, formed, or hard), making it easier for caregivers to identify the stool type.
The Rome criteria define abnormal stool frequency as fewer than two bowel movements per week. However, caution should be exercised when applying these criteria to young infants, as infrequent stooling with loose stools may not be deemed abnormal if there are no other alarm symptoms. Acknowledging this variation is crucial for pediatricians, as misapplication could lead to overdiagnosis and unnecessary interventions. By understanding the normal physiological differences among infants, pediatricians can reassure caregivers and provide appropriate guidance, thereby alleviating parental anxiety and preventing unwarranted diagnostic or therapeutic measures. Often, a watchful waiting approach combined with ongoing clinical observation is the most appropriate course of action.
The exact causes of infrequent stools in these infants are not fully understood; however, several theories offer insights into this condition. Breastfeeding and breast milk can significantly influence an infant's gut microbiota [9,10], leading to greater microbial diversity than in formula-fed infants [11]. This distinction is closely related to differences in stool characteristics and patterns [12]. Additional factors may include the infant's age, genetic variations, the mother's dietary intake, and any supplements the mother takes [13]. Furthermore, the macronutrients in breast milk, particularly fats, tend to be easier for infants to digest and absorb than those in formula [14]. This efficient absorption may result in a decreased overall stool output, although this outcome is not guaranteed. These interesting hypotheses present a valuable opportunity for future research to explore the underlying pathophysiology and specific mechanisms involved.
In the same vein of clinical research, it is essential to acknowledge that this report has its limitations, as it centers on a single case. Consequently, larger prospective studies could yield important insights into these atypical stool patterns. Such research would assist clinicians and researchers in establishing upper limits for normal stooling intervals and in refining clinical recommendations and guidelines.
This case affirms that stool infrequency in an otherwise thriving, exclusively breastfed infant should be interpreted within the context of the entire clinical picture, rather than based solely on stool frequency. The primary message for pediatric practitioners is to prioritize reassurance, parental guidance, and diligent observation over unnecessary investigations or treatments when the infant is well, feeding effectively, and demonstrating normal growth. Simultaneously, this report identifies a knowledge gap, underscoring the need for larger, prospective studies to delineate the physiological limits of normal stooling patterns in early infancy and to establish more accurate, evidence-based clinical guidelines.
Ethical Considerations
Institutional review board approval was not required for this case report, as it involves a single patient and no experimental procedures. Written informed consent was obtained from the patient’s parents for publication of the case details. No identifiable images or personal information have been included in this report.
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