What is the management of constipation in a child less than 1 year?

Management of Constipation in Children Less Than 1 Year

For infants under 1 year with constipation, fruit juices containing sorbitol such as prune, pear, and apple juices are recommended as first-line treatment, followed by lactulose if necessary. 1

Assessment and Diagnosis

• Constipation in infants should be identified through careful history taking, focusing on frequency and consistency of stools, presence of pain during defecation, and any associated symptoms 2
• Rule out underlying medical conditions, which account for less than 5% of childhood constipation cases 2
• Assess for warning signs that might indicate an organic cause, including delayed passage of meconium, ribbon-like stools, or failure to thrive 2

First-Line Treatment Options

Dietary Interventions

• For breastfed infants, continue nursing on demand as the primary nutritional source 1
• For formula-fed infants, ensure adequate hydration and consider using full-strength formula 1
• Introduce small amounts (10 mL/kg body weight) of fruit juices containing sorbitol and other carbohydrates, such as:
  • Prune juice
  • Pear juice
  • Apple juice 1

Mechanism of Action

• Sorbitol and certain carbohydrate ratios in these juices are poorly absorbed, creating an osmotic load in the gastrointestinal tract 1
• This osmotic effect helps increase stool water content and frequency, particularly beneficial for infants with constipation 1
• The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition specifically recommends these juices for constipation treatment in infants 1

Second-Line Pharmacological Treatment

Lactulose

• For infants under 1 year, lactulose is the recommended first-choice laxative treatment when dietary interventions are insufficient 2
• Initial daily oral dose for infants: 2.5 mL to 10 mL in divided doses 3
• If the initial dose causes diarrhea, reduce the dose immediately 3
• If diarrhea persists despite dose reduction, discontinue lactulose 3

Polyethylene Glycol (PEG)

• Not recommended as first-line treatment for infants under 6 months 4
• Can be considered for infants over 6 months of age if lactulose is ineffective 4

Treatment Approach Algorithm

1. Start with dietary modifications:

   • Continue normal feeding (breast milk or formula)
   • Add small amounts of sorbitol-containing fruit juices 1

2. If dietary modifications are insufficient after 1-2 weeks:

   • Initiate lactulose at 2.5-10 mL daily in divided doses 3, 2
   • Monitor for response and adjust dose to achieve 2-3 soft stools daily 3

3. For persistent constipation:

   • For infants >6 months: Consider PEG as an alternative 4
   • Evaluate for possible underlying conditions if constipation persists despite appropriate treatment 2

Important Considerations and Pitfalls

• Avoid excessive juice consumption as it may lead to diarrhea, flatulence, abdominal pain, and poor weight gain 1
• Do not use adult doses of laxatives in infants; always use age-appropriate dosing 3
• Chronic constipation requires long-term management; approximately 30% of children may continue to have symptoms beyond puberty 5
• Avoid using enemas in infants except under specific medical supervision 6
• Early and adequate treatment is essential to prevent complications such as anal fissures, which can create a painful defecation cycle 2
• Treatment success correlates with how appropriately the condition is managed; undertreatment is common and leads to persistent symptoms 6

Follow-up

• Regular follow-up is essential to monitor treatment response and adjust therapy as needed 2
• Parents should be educated about normal bowel patterns in infants and the importance of maintaining adequate hydration 1
• If constipation persists despite appropriate treatment for 2 months, consider referral to a pediatric gastroenterologist 6