Management of Constipation in Infants
For infants with constipation, the recommended approach includes dietary modifications, adequate hydration, and when necessary, osmotic laxatives such as lactulose for infants under 6 months and polyethylene glycol (PEG) for those over 6 months of age. 1, 2
Definition and Risk Factors
- Constipation in infants is defined as a delay or difficulty in defecation present for 2 or more weeks 3
- Common triggers include weaning, toilet training, transitions to kindergarten/school, febrile illness, and travel 4
- Infrequent defecation (≤2 per week), painful or hard bowel movements, or large diameter stools suggest functional constipation 4
Initial Management Approach
For Breastfed Infants
- Continue breastfeeding on demand - breastfeeding should never be discontinued due to constipation 5, 1
- Reassure parents that functional gastrointestinal disorders are typically normal and often do not require treatment 5
For Formula-Fed Infants
- Consider specialized formula with high β-palmitate and increased magnesium content to soften stool 5
- A partially hydrolyzed infant formula with prebiotics and β-palmitate may be beneficial for functional constipation 1
- Ensure adequate hydration by offering appropriate amounts of formula 6
Pharmacological Management
For Infants Under 6 Months
- Lactulose is effective and safe for infants younger than 6 months 1, 2
- Initial daily oral dose in infants is 2.5 mL to 10 mL in divided doses 7
- If the initial dose causes diarrhea, reduce the dose immediately; if diarrhea persists, discontinue lactulose 7
For Infants Over 6 Months
- Polyethylene glycol (PEG) is preferred over lactulose for infants older than 6 months 1, 2
- PEG dosing should be adjusted based on symptom response and side effects 6
- Common side effects of PEG include bloating, abdominal discomfort, and cramping 6
Dietary Interventions
- Increase water and fiber in the diet as first-line intervention 6
- For older infants receiving solid foods, recommended foods include fruits, vegetables, and whole grains 6
- Some fruit juices (prune, pear, and apple) contain sorbitol and other carbohydrates that can help increase stool frequency and water content 6
When to Refer to a Specialist
- Red flags requiring specialist referral include:
- Delayed passage of meconium beyond 48 hours of life
- Associated intestinal obstruction symptoms
- Developmental delays
- Behavioral problems
- Frequent soiling of underwear 4
- Persistent constipation despite appropriate management 3
Common Pitfalls to Avoid
- Avoid prolonged use of stimulant laxatives in infants as safety data for long-term use is limited 6
- Do not use adult-strength enemas or suppositories in infants due to risk of electrolyte disturbances 6
- Avoid assuming that all hard stools indicate constipation - infrequent but soft stools may be normal, especially in breastfed infants 5
- Do not discontinue breastfeeding in favor of formula feeding for management of constipation 5, 1