What is the best approach to manage constipation in a 2-month-old infant presenting to the emergency department?

Management of Constipation in a 2-Month-Old Infant in the Emergency Department

For a 2-month-old infant with constipation presenting to the emergency department, the initial approach should focus on ruling out serious organic causes, ensuring adequate hydration, and using glycerin suppositories as first-line intervention.

Initial Assessment

• Rule out red flags that may indicate serious organic causes:

  • Delayed passage of meconium (>48 hours after birth)
  • Failure to thrive
  • Abdominal distension
  • Vomiting
  • Blood in stool
  • Family history of Hirschsprung's disease
  • Abnormal anorectal examination

• Assess hydration status:

  • General appearance
  • Mucous membranes
  • Capillary refill time
  • Urine output
  • Vital signs (heart rate, blood pressure) 1

Management Algorithm

Step 1: Determine if Impaction is Present

• Physical examination to assess for fecal impaction
• If impaction is suspected, consider abdominal X-ray

Step 2: Initial Interventions

• For mild constipation without impaction:
  • Ensure adequate fluid intake
  • For exclusively breastfed infants:
    • Continue breastfeeding
    • Reassure parents that infrequent stools (even up to 7-10 days) can be normal in exclusively breastfed infants if stool is soft
  • For formula-fed infants:
    • Consider small amount of apple or pear juice (1-2 oz diluted with equal amount of water)
    • Ensure proper formula preparation (not too concentrated)

Step 3: Medical Interventions

• For moderate constipation:

  • Glycerin suppository (infant size) - safest option for this age group 2
  • If suppository ineffective, consider:
    • Small volume (5-10 mL/kg) warm saline enema

• For severe constipation with impaction:

  • Glycerin suppository followed by gentle manual disimpaction if necessary (with appropriate analgesia) 3

Important Considerations

Medications to Avoid in 2-Month-Olds

• Oral laxatives like lactulose should be used with caution in infants due to risk of electrolyte disturbances and dehydration 4
• Polyethylene glycol is generally not recommended as first-line therapy in infants under 6 months
• Stimulant laxatives (senna, bisacodyl) are not appropriate for this age group

Follow-up Care

• Educate parents about:
  • Normal stooling patterns in infants
  • Proper feeding techniques
  • Signs of dehydration
  • When to return for care
• Arrange follow-up within 1-2 weeks to ensure resolution

When to Consider Specialist Referral

• No response to initial interventions
• Recurrent episodes requiring emergency care
• Concerning physical findings suggesting anatomic abnormality
• Failure to thrive
• Persistent abdominal distension

Prevention

• Maintain adequate hydration
• For formula-fed infants, ensure proper formula preparation
• Avoid constipating formulas if problem recurs
• Consider probiotic supplementation in formula-fed infants with recurrent constipation

Remember that in most cases, infant constipation is functional and self-limiting, but careful assessment is needed to rule out more serious conditions, especially in this young age group.