What is the first line of treatment for constipation in an infant?

First-Line Treatment for Constipation in Infants

The first-line treatment for constipation in infants is dietary modification, which may include increased fluid intake, fruit juices containing sorbitol (such as prune, pear, or apple juice), and for formula-fed infants, consideration of formula changes if dietary intervention is unsuccessful.

Assessment and Diagnosis

Before initiating treatment, it's important to distinguish functional constipation from organic causes:

• Key symptoms: Infrequent stools (less than once every 2 days), hard stools, straining, discomfort during defecation
• Red flags requiring further investigation:
  • Delayed passage of meconium (>48 hours after birth)
  • Failure to thrive
  • Abdominal distention
  • Bloody stools
  • Perianal fistula
  • Abnormal position of anus
  • Absent anal or cremasteric reflex
  • Decreased lower extremity tone/strength

Treatment Algorithm for Infant Constipation

Step 1: Dietary Modifications

• For breastfed infants:

  • Continue breastfeeding (do not discontinue) 1
  • Consider maternal elimination diet (milk and eggs) for 2-4 weeks if symptoms persist 2

• For formula-fed infants:

  • Consider trial of formula with higher magnesium content and high β-palmitate to soften stool 1
  • Avoid switching from breastfeeding to formula solely for constipation 1
  • Ensure proper formula preparation (not too concentrated)

• For infants on solid foods:

  • Increase fruits and vegetables
  • Ensure adequate fluid intake

Step 2: Natural Remedies

• Fruit juices: Small amounts (1-2 oz) of prune, pear, or apple juice can help due to their sorbitol content 2

  • The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition recommends taking advantage of sorbitol in these juices to increase stool frequency and water content 2
  • For infants >4 months: 2-4 oz daily

• Increased water intake: Offer additional water between feedings

Step 3: Pharmacological Interventions

If dietary modifications are unsuccessful after adequate trial:

• First medication choice: Lactulose or lactitol-based medications for infants under 6 months 3

  • Dosage: 2.5 mL to 10 mL daily in divided doses 4
  • Reduce dose if diarrhea occurs; discontinue if diarrhea persists 4

• For infants over 6 months: Polyethylene glycol (PEG) is effective and well-tolerated 3, 5

Step 4: Management of Fecal Impaction

If fecal impaction occurs:

• Disimpaction using higher doses of PEG or glycerin suppositories may be needed 5
• After disimpaction, maintenance therapy is essential to prevent recurrence

Important Considerations

• Duration of treatment: Maintenance medications may be required for months as relapse is common 5
• Parental education: Explain the chronic nature of functional constipation and importance of consistent treatment
• Follow-up: Regular monitoring to adjust treatment as needed
• Warning signs for medical attention:
  • Persistent symptoms despite treatment
  • Development of new symptoms
  • Poor weight gain
  • Blood in stool

Caution

Despite widespread use, evidence supporting specialized formulas for functional gastrointestinal disorders including constipation is limited 1. Treatment should be supervised by healthcare providers, especially when using medications.

Only 50-70% of children with functional constipation demonstrate long-term improvement despite appropriate treatment 5, highlighting the importance of consistent management and follow-up.