What is the approach to managing constipation in infants under 6 months?

Management of Infant Constipation Under 6 Months

For infants under 6 months 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

Understanding Normal Bowel Patterns in Infants

• Newborns typically feed every 2-3 hours (8-12 times per day), with bowel movements often occurring after feedings 2
• By 2 months, feeding patterns change to every 3-4 hours, which can affect stool frequency 2
• Parents should be educated that normal bowel patterns in infants vary widely - some breastfed infants may have a bowel movement after each feeding while others may go several days without a stool 1

Assessment of Infant Constipation

• Rule out other causes of hard stools or infrequent bowel movements, including anatomic, endocrinologic, metabolic, or neurologic causes 3
• Assess for signs of discomfort during defecation, such as crying, straining, or stool-holding behaviors 3
• Evaluate feeding history, including type of feeding (breast milk vs. formula) and any recent changes 2
• Check for associated symptoms like abdominal distention or blood in stool that might indicate more serious conditions 4

First-Line Management Strategies

For Breastfed Infants:

• Continue nursing on demand as the primary nutritional source 1
• Consider maternal diet modification if infant shows signs of milk protein allergy (which can mimic constipation symptoms) 2
• A 2-4 week trial of maternal exclusion diet that restricts at least milk and egg may be beneficial 2

For Formula-Fed Infants:

• Ensure adequate hydration and consider using full-strength formula 1
• Consider changing to a protein hydrolysate formula if milk protein allergy is suspected 2
• Small feeding changes may help - avoid overfeeding while ensuring adequate intake 2

Dietary Interventions

• Introduce small amounts (10 mL/kg body weight) of fruit juices containing sorbitol, such as prune juice, pear juice, or apple juice 1
• These juices create an osmotic load in the gastrointestinal tract, helping increase stool water content and frequency 1
• For infants approaching 6 months, consider introducing appropriate solid foods when developmentally ready 2

Medication Options

• For infants under 6 months who don't respond to dietary interventions, lactulose/lactitol-based medications are authorized and effective 5
• For infants over 6 months, polyethylene glycol (PEG) can be considered 5
• Important principle: use sufficient dosing for an adequate duration to achieve and maintain regular bowel movements 5

Important Cautions

• Avoid excessive juice consumption as it may lead to diarrhea, flatulence, abdominal pain, and poor weight gain 1
• Hyperosmotic mineral water is not recommended as treatment for established constipation 5
• Avoid mineral oil in infants due to risk of aspiration 5
• Treatment of constipation should not be delayed, as this can lead to psychosocial and digestive consequences 5

When to Consider Further Evaluation

• Failure to respond to first-line treatments 6
• Signs of bowel obstruction or concerning symptoms like significant abdominal distention 4
• Poor weight gain or growth concerns 2
• Blood in stool not explained by anal fissures from hard stools 4

Parental Education

• Reassure parents that functional constipation is common and typically resolves with appropriate management 3
• Emphasize the importance of maintaining adequate hydration 1
• Explain that treatment may be needed for several months to establish healthy bowel patterns 3