Acta Pædiatrica ISSN 0803-5253

REGULAR ARTICLE

The bowel movement characteristics of exclusively breastfed and

exclusively formula fed infants differ during the first three months of life
Emilie Moretti (emiliemoretti@hotmail.com)1 , Thameur Rakza2, Beatrice Mestdagh2, Julien Labreuche3, Dominique Turck4
1.Neonatal Intensive Care Unit, Lille University Jeanne de Flandre Hospital and Faculty of Medicine, Lille, France
2.Division of Pediatrics, Maternity Ward, Lille University Jeanne de Flandre Hospital and Faculty of Medicine, Lille, France
3.Department of Biostatistics, Lille University Hospital and Faculty of Medicine, Lille, France
4.Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lille University Jeanne de Flandre Hospital and Faculty of Medicine, Lille, France

Keywords ABSTRACT
Bowel movements, Exclusive breastfeeding, Aim: Breastfed infants pass more stools and more liquid stools than formula fed infants
Formula fed infants, Infrequent stools, Loose stools
and some have no bowel movements or infrequent stools for several days or weeks. We
Correspondence compared exclusively breastfed and exclusively formula fed infants for the first three
E Moretti, MD, Service de Ne onatologie, Centre
Hospitalier d’Arras, 3 boulevard Georges Besnier, months.
62000 Arras, France. Methods: This study of 118 infants was carried out in the maternity ward of the Lille
Tel: +33321211323 |
University Jeanne de Flandre Hospital, France, in 2015. The outcomes were the number
Fax: +33321211731 |
Email: emiliemoretti@hotmail.com and consistency of stools and the prevalence of infrequent stools.
Received
Results: At three months, 84 infants remained and we compared 40 who were exclusively
22 May 2018; revised 31 July 2018; breastfed and 13 who were exclusively formula fed. Daily stool frequency was significantly
accepted 9 October 2018. higher in the breastfed than formula fed infants during the first (4.9  1.7 vs. 2.3  1.6,
DOI:10.1111/apa.14620 p < 0.001) and second (3.2  1.6 vs. 1.6  1.5, p = 0.003) months. Stools were more
liquid in the breastfed infants during the first three months. Infrequent stools occurred in
28% of breastfed and 8% of formula fed infants at least once. (p = 0.25).
Conclusion: Exclusively breastfed infants produced more stools than exclusively formula
fed infants during the first two months and more liquid stools during the first three.
Infrequent stools were 3.5 times more likely in the breastfed infants.

BACKGROUND infrequent stools in exclusively breastfed and exclusively

The bowel habit of young infants is strongly influenced by
their feeding mode. Breastfed infants pass more stools and
more liquid stools than formula fed infants, and breast-
feeding is considered to prevent constipation (1–3). The
adequacy of the breast milk transferred from the mother
to her infant is reflected by normal weight gain, regular
urine emissions and stool evacuations (4). Parents are
usually advised that their breastfed infant should have at
least three soft stools daily during the first four to six
weeks of life. However, some breastfed infants may have
no bowel movements for several days or even weeks.
Healthcare providers usually refer to this situation as
infrequent stools or infrequent bowel movements (5–8) in
breastfed infants, despite the absence of discomfort, such
as no hard stools and no crying or distress during
defecation. Surprisingly, there has been very little research
on the stool patterns of exclusively breastfed infants,
namely the number and consistency of stools, over the
first months of life.
The aims of the present study were twofold: firstly to
describe the bowel habits, number and consistency of stools
of exclusively breastfed infants during the first three months
of life, as compared to exclusively formula fed infants, and
secondly to assess the prevalence and characteristics of
formula fed infants over the same period.
METHODS
This monocentric cohort study with prospective data
collection was carried out in the maternity ward of the
Lille University Jeanne de Flandre Hospital, France. Our
study included infants born in the maternity unit and
admitted to the ward, irrespective of their diet. Infants born
elsewhere or transferred to another ward and infants born
Key Notes
 This French study compared 40 exclusively breastfed
and 13 exclusively formula fed infants for the first three
months of life.
 Exclusively breastfed infants produced more stools than
exclusively formula fed infants during the first two
months and more liquid stools during the first three
months of life.
 The study also found that infrequent stools were 3.5
times more likely in the breastfed infants (28%) than
formula fed infants (8%).

©2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 1
Stool patterns by feeding mode in early infancy
prematurely before 34 weeks of gestation and weighing less
than 1500 g were not included.
Exclusive breastfeeding was defined according to the
World Health Organization criteria (9). Infrequent stools
were defined as at least one episode with an interval of
more than three consecutive days between bowel move-
ments in an infant with no symptoms that suggested
underlying disease or distress. Stool consistency was rated
from one for solid to five for liquid, according to a simplified
and validated version of the Bristol scale (10).
The characteristics of the study population were collected
using a questionnaire filled in by the mothers on the ward
and the medical records of the mothers and infants. The
duration of the follow-up period was the first three months
of life. Every week, on a fixed day of the week, the parents
recorded the number and consistency of stools and the
number of consecutive days during the preceding week with
no stool evacuation. Anthropometric measurements, such
as weight, length and head circumference, were performed
by healthcare providers and recorded. Only infants who
were exclusively breastfed for the whole duration of the
study and infants who were exclusively formula fed from
birth were analysed and compared in order to avoid bias
linked to partial breastfeeding.
The primary outcome was the infants’ stool pattern: the
daily number and consistency of stools during the three-first
months of life. The secondary outcome was the prevalence
of infants presenting with at least one episode of infrequent
stools, defined as three or more consecutive days with no
stool evacuation, during the study period.
All the quantitative variables are expressed as means,
standard deviations and median ranges and categorical
variables are expressed as numbers and percentages. The
normality of the distributions was assessed graphically and
using the Shapiro–Wilk test. To assess any selection bias
related to the loss of the follow-up, the main maternal and
neonatal characteristics were compared between infants lost
and not lost to follow-up using the Student t-test for
quantitative variables or the chi-square test for categorical
variables. To evaluate the magnitude of differences, we
calculated the absolute standardised differences and any
difference that was greater than 20% was meaningful. We
looked at the infants with three-month follow-up data
available and compared the maternal and neonatal charac-
teristics between the three feeding groups as follows: exclu-
sively breastfed, partially breastfed and exclusively formula fed
using analysis of variance for quantitative variables and using
chi-square or Fisher’s exact tests for categorical variables.
The main analysis compared the monthly average values
of the daily number of stools and stool consistency score
assessed on a fixed day of each week between exclusively
breastfed and exclusively formula fed infants using the
Mann–Whitney U test. The weekly values were also com-
pared using Mann–Whitney U tests as a secondary analysis.
The percentage of infants with at least one episode of
infrequent stools during the three-month follow-up period
was compared between the exclusively breastfed and
exclusively formula fed infants using Fisher’s exact test.
2 ©2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd
Moretti et al.
We used Student t-tests or the Mann–Whitney U test for
non-normal variables to analyse infrequent stools as a binary
variable, based on the presence of at least one episode during
the follow-up period. Spearman’s rank coefficients were used
to analyse infrequent stools as the quantitative variable,
based on the number of weeks with infrequent stools.
Because of the exploratory nature of this study and small
study sample size, we did not adjust for multiple compar-
isons. Statistical testing was carried out at the two-tailed
alpha level of 0.05. Data were analysed using SAS software,
version 9.4 (SAS Institute, Cary, NC, USA).
RESULTS
A total of 118 infants were included in the present study. As
shown in Table 1, no significant differences were found in
the main maternal and neonatal characteristics according
to the feeding groups. Out of the 118 infants we included,
34 infants were lost to follow-up (Fig. 1). The maternal and
neonatal characteristics did not differ significantly between
the infants lost and not lost to follow-up (Table S1). The
absolute standardised difference for these characteristics is
also mentioned in Table S1. Of the 84 infants with three
months of follow-up data, 40 infants (48%) were exclusively
breastfed, 31 (37%) were partially breastfed and 13 (15%)
were exclusively formula fed. Further analyses during the
first three months of life were performed among exclusively
breastfed and exclusively formula fed infants (Fig. 1).
Stool frequency
As shown in Table S2, stool frequency was significantly
higher in exclusively breastfed infants than exclusively
formula fed infants during the first and the second months
of life, but not the third month of life. The weekly analysis
showed that the difference in stool frequency between the
two exclusive feeding groups decreased during the follow-
up period and was not significant from the eighth week of
life onwards (Fig. 2) (all p values >0.09). During the first
week of life, the mean number of daily number of stools was
4.8, the median was five and the range was 1–8 for the
exclusively breastfed infants versus 2.7, two and 1–6 for the
exclusively formula fed infants (p < 0.001). The figures for
the 12th week of life were 1.8, one and 0–5 versus 1.1, one
and 0–3 (p = 0.15).
Stool consistency
Regardless of the study month, the stool consistency was
significantly more liquid in exclusively breastfed than
exclusively formula fed infants during the first three months
of life (Table S2).
Infrequent stools
At least one episode of infrequent stools occurred during
the first three months of life in 11 exclusively breastfed
infants (28%) as compared to one exclusively formula fed
infant (8%) (p = 0.25). As shown in Figure S1, most of the
cases of infrequent stools in the exclusively breastfed infants
occurred after five weeks of age.
Moretti et al. Stool patterns by feeding mode in early infancy

Very few data are available on the stool patterns,

Table 1 Main maternal and neonatal characteristics of the study population
numbers, consistency and prevalence of infrequent stools
(N = 84) according to feeding groups
in breastfed infants.
Characteristics EBF (n = 40) EFF (n = 13) p Value
Weaver et al. showed that the mean number of daily
Maternal stools was higher in breastfed infants than in formula fed
Mothers’s age (years) infants at two weeks of age (approximately 4 vs. 2.5,
Mean (SD) 32.0 (4.1) 31.8 (4.3) 0.94* p < 0.002) and at eight weeks of age (approximately three
Median (range) 32 (25–40) 32 (26–39) vs. two, p < 0.02) (3). The difference was no longer
Educational level, n (%) significant at 12 weeks. Weaver et al. also showed that
College 2 (5.0) 4 (30.8) 0.32‡
breastfed infants passed softer stools during the first
University 7 (17.5) 3 (23.1)
20 weeks of life, even after the introduction of comple-
(2–3 years)
University 18 (45.0) 3 (23.1)
mentary foods. With regard to infrequent stools, the authors
(4–5 years) reported a case of a breastfed infant with no bowel
University 13 (32.5) 3 (23.1) movement for 27 consecutive days between weeks 7 and
(>5 years) 11. This child was fine, did not present any symptoms of
Primipara, n (%) 24 (60.0) 8 (61.5) 0.93† gastrointestinal or systemic disease and had a bowel
Neonatal movement at the end of this period. This child only passed
Gestational age, n (%) 14 stools during the first 16 weeks of life (3). In a series of
<37 weeks 3 (7.5) 0 (0.0) NA 416 infants with constipation in Seoul, South Korea,
37–41 weeks 30 (75) 13 (100)
defined as three consecutive days without a bowel move-
>41 weeks 7 (17.5) 0 (0.0)
ment, Choe et al. described a subgroup of 28 exclusively
Male, n (%) 15 (37.5) 8 (61.5) 0.20†
Birth weight (g) breastfed infants, which comprised 7% of the whole study
Mean (SD) 3330 (468) 3538 (425) 0.30* population. No underlying organic cause was found, con-
Median (range) 3303 (1870–4195) 3470 (2790–4300) stipation started at a mean age of 1.9 months (range 0.5–
Birth length (cm) 3.5 months) and spontaneously resolved at a mean age of
Mean (SD) 49.7 (1.9) 50.3 (1.3) 0.53* 3.9 months (range one to seven months) (6).
Median (range) 50.0 (45.0–53.0) 50.0 (48.0–53.0) The underlying mechanisms of the infrequent stools
Birth head circumference (cm) syndrome in exclusively breastfed infants are unknown.
Mean (SD) 35.0 (1.7) 35.0 (0.8) 0.74*
Many hypotheses have been put forward, from better
Median 35.0 (32.0–38.5) 35.0 (33.5–36.0)
digestion of the fat in mother’s milk than formula milk to
(range)
a greater number of saccharolytic bacteria that can degrade
EBF = Exclusively breastfed; EFF = Exclusively formula fed; NA = Not appli- unabsorbed and unabsorbable sugars (6). The pathophysi-
cable; SD = Standard deviation; wk = Weeks. ology of this syndrome, where exclusively breastfed infants
p-values calculated using: *ANOVA, †Chi-square test, ‡Fisher’s exact test. may experience the absence of bowel movements for
several consecutive weeks, has not yet been resolved.
Infrequent stools should be brought to the attention of
Tolerance of infrequent stools in exclusively breastfed healthcare providers in order to avoid unnecessary medical
infants investigations that may be harmful and expensive. How-
The infant’s growth patterns, such as weight, length and ever, careful history taking and clinical examination of the
head circumference, were within the normal ranges accord- infant are of paramount importance, so that clinicians can
ing to World Health Organization growth charts in exclu- rule out any underlying organic diseases, such as Hirsch-
sively breastfed infants with or without infrequent stools sprung’s disease. Adequate mother’s milk transfer should
during the first three months of life (data not shown). also be confirmed by checking reviewing breastfeeding
patterns. Clinicians should also check that the infants are
urinating well and producing at least three to four wet
DISCUSSION diapers a day and that they are following a normal growth
In this monocentric prospective cohort study, the number trajectory for their age.
of stools was higher in exclusively breastfed infants than in
exclusively formula fed infants during the first two months Strengths and limitations
of life, whereas the stool consistency was more liquid during One of the strengths of our study was that it was prospective
the first three months of life. The number of stools in and this decreased the memorisation bias that can occur in
exclusively breastfed infants matched that of exclusively retrospective studies. The same cohort was also followed
formula fed infants from the eighth week onwards. longitudinally on a weekly basis for three consecutive
Although the difference was not significant, the prevalence months, whereas Weaver et al. (3) studied six different
of infrequent stools was 3.5 times higher in exclusively cohorts of 40 children at different ages, namely 2, 4, 8, 12,
breastfed infants than exclusively formula fed infants (28% 16 and 20 weeks.
vs. 8%). Most cases of infrequent stools in exclusively One limitation was that 29% of the children were lost to
breastfed infants occurred after five weeks of age. follow-up in our study, despite e-mail and telephone

©2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 3
Stool patterns by feeding mode in early infancy Moretti et al.

118 included infants

34 lost to 3-month follow-up

84 infants followed for the first 3 months of life

31 PBF infants
secondarily
excluded

53 analysed infants

40 EBF infants 13 EFF infants

Abbreviations:
EBF= exclusively breastfed;
EFF= exclusively formula fed;
PBF= partially breastfed.
Figure 1 Flow chart of the infants (N = 118) included in the study.

Figure 2 Mean daily number of stools during the first three months of life in exclusively breastfed infants (N = 40) and exclusively formula-fed infants (N = 13). p-
value for comparison between the two feeding groups <0.005. Standard error of means is plotted.

4 ©2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd
Moretti et al.
reminders, and this is probably because some of the parents
found the follow-up long and tedious. The small sample size
of the exclusively formula fed infants also needs to be
mentioned. Daily data collection of the number and
consistency of stools during the whole follow-up period
would have been preferable, but we felt this would be
unrealistic in practice and lead to a higher risk of infants
being lost to follow-up. Therefore, our results should be
interpreted with caution and should be replicated in further
large studies, with daily data collection. Taking into account
the results of the present study, and assuming alpha = 0.05
and power = 0.8 as well as a dropout rate of 50% in
exclusively breastfed infants, a total sample size of 172
would be necessary, namely 86 exclusively breastfed and 86
exclusively formula fed infants.
CONCLUSION
The exclusively breastfed infants in our study had more
bowel movements during the first two months of life and
more liquid stools during the first three months of life than
the exclusively formula fed infants. Infrequent stools mainly
occurred after one month of age and were observed 3.5
times more often in exclusively breastfed infants than in
exclusively formula fed infants.
FUNDING
This study did not receive any external funding.
CONFLICT OF INTEREST
The authors have no conflict of interests to declare.
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SUPPORTING INFORMATION
Additional Supporting Information may be found online in
the Supporting Information section at the end of the article:
Figure S1. Prevalence and number of infants (week by
week) who presented at least one episode of infrequent
stools during the first three months of life.
Table S1. Maternal and neonatal characteristics of the
included infants (N = 118) according to lost or not of first
three-month of life follow-up.
Table S2. Stools frequency and consistency in EBF infants
(N = 40) and EFF infants (N = 13) at first, second and third
month of life.
5