The relationship between stool hardness and stool composition in breast- and formula-fed infants

"Constipation" and "hard stools" are associated with formula feeding of both term and preterm infants and, in the latter, can lead to life-threatening complications. This study tested the hypothesis that stool hardness is related to excretion of fatty acid (FA) soaps in term infants, and in the extreme to milk bolus obstruction in premature infants. Stools (n = 44) were collected from 20 formula-fed and 10 breast-fed infants aged 6 weeks and were classified using visual charts for stool hardness on a 5-point scale (1, watery; 5, hard). Stools were analysed for nitrogen, minerals, and lipid, the latter divided between the soap and nonsoap fractions. We explored the relationship between stool hardness or solids content and stool constituents, relative to both wet and dry weight. Calcium and FA soaps were the dominant factors significantly related to stool solids and hardness score across the breast- and formula-fed groups. An 8% increase in stool dry weight FA soap content corresponded to a 1-point change in stool hardness score. Stools from formula-fed infants had a higher solids content and were classified as significantly harder than those from breast-fed infants (hardness scores, 4.0 +/- 0.5 versus 2.6 +/- 0.7, mean +/- SD) and on both a wet- and dry-weight basis contained severalfold higher levels of minerals and lipid and considerably less carbohydrate. Differences in lipids between formula- and breast-fed infants' stools were due almost entirely to FAs (mainly C16:0 and C18:0) excreted as soaps (27.7 +/- 7.5% compared to 3.1 +/- 4.1% of dry weight), suggesting the groups differed markedly in their handling of saturated FAs. An inspissated stool sample from a premature infant requiring surgical disempaction of an obstructed small intestine was found to be enriched in FA and calcium relative to the preterm formula. FA soaps, predominantly saturated, accounted for one third of the stool dry weight. These data support the hypothesis that calcium FA soaps are positively related to stool hardness; we speculate that this may, at least in part, explain the greater stool hardness in formula- versus breast-fed infants and milk bolus obstruction in preterm infants. This conclusion is consistent with the physical properties of calcium FA soaps.