What are the treatment options for infant constipation?

Treatment Options for Infant Constipation

For infant constipation, dietary interventions should be the first-line approach, including fruit juices containing sorbitol, appropriate formula changes, and increased fluid intake, before considering medications like lactulose. 1

Dietary Interventions

Breastfed Infants

• Continue breastfeeding on demand as this is well-tolerated and advantageous for infants with gastrointestinal issues 1
• Consider implementing a maternal exclusion diet (restricting milk and eggs) for 2-4 weeks if constipation persists 1
• Breastfed infants typically have higher stool frequency compared to formula-fed infants during the first 5 months 2

Formula-Fed Infants

• Consider switching to lactose-free or lactose-reduced formulas if symptoms persist 1
• Administer full-strength formulas rather than diluted formulas 1
• Formulas enriched with high β-palmitate and increased magnesium content may help soften stools 3
• Adding formula to a breastfed infant's diet may actually decrease stool frequency and should not automatically be diagnosed as constipation 2

Older Infants on Solid Foods

• Introduce fruit juices containing sorbitol, such as prune, pear, and apple juices (10 mL/kg body weight) 1
• Include fruits and vegetables in the diet 1
• Avoid foods high in simple sugars and fats 1

Fluid Intake

• Ensure adequate hydration as dehydration is a risk factor for constipation 4
• Magnesium sulfate-rich mineral waters have been shown to improve constipation in healthy infants 4

Medication Options

For Infants Under 6 Months

• Lactulose-based medications are authorized and effective for infants under 6 months 5
• Initial daily oral dose for infants is 2.5 mL to 10 mL in divided doses 6
• If the initial dose causes diarrhea, reduce the dose immediately; if diarrhea persists, discontinue lactulose 6

For Infants Over 6 Months

• Polyethylene glycol (PEG) is recommended for infants over 6 months of age 5
• For older children, the total daily dose of lactulose is 40 mL to 90 mL 6

Treatment Algorithm

1. First-Line: Dietary Modifications

   • For breastfed infants: Continue breastfeeding, consider maternal dietary changes 1
   • For formula-fed infants: Consider lactose-free formulas or formulas with increased magnesium content 1, 3
   • For infants on solids: Add fruits and vegetables, try fruit juices with sorbitol 1

2. Second-Line: Medications

   • If dietary modifications fail after 2-4 weeks:
     • For infants under 6 months: Lactulose 2.5-10 mL daily in divided doses 6, 5
     • For infants over 6 months: Polyethylene glycol or lactulose 5

3. For Severe Cases with Fecal Impaction

   • Fecal disimpaction using a high dose of PEG for the first few days or phosphate enemas 5
   • Follow with maintenance therapy to prevent recurrence 5

Red Flags Requiring Further Investigation

• Delayed passage of meconium (>48 hours after birth) 1
• Failure to thrive 1
• Abdominal distension 1
• Bloody stools 1
• Vomiting 1
• Abnormal neurological findings 1

Important Considerations and Pitfalls

• Avoid diagnosing constipation based solely on defecation frequency, especially in formula-supplemented breastfed infants who may normally defecate less than once per day 2
• Lactulose contains small amounts of galactose and lactose, so use with caution in infants with diabetes 6
• Infants receiving lactulose may develop hyponatremia and dehydration, so monitor hydration status 6
• Despite appropriate treatment, only 50-70% of children with functional constipation demonstrate long-term improvement, so persistence with the treatment plan is essential 7
• Never discontinue breastfeeding in favor of formula feeding for managing constipation 3