Treatment of Infant Constipation
For infants with constipation, start with fruit juices containing sorbitol (prune, pear, or apple juice at 10 mL/kg body weight), continue breastfeeding if applicable, and consider switching to lactose-free formulas for bottle-fed infants if symptoms persist. 1
First-Line Dietary Interventions
For Breastfed Infants
- Continue breastfeeding on demand without interruption, as breastfeeding should never be discontinued in favor of formula feeding 1, 2
- Consider a maternal exclusion diet restricting milk and eggs for 2-4 weeks if constipation persists 1
- Reassure parents that functional gastrointestinal disorders are normal physiological phenomena that typically do not require treatment 2
For Formula-Fed Infants
- Administer full-strength, lactose-free or lactose-reduced formulas if constipation continues 3, 1
- Consider formulas enriched with high β-palmitate and increased magnesium content to soften stool 2
- Avoid the practice of diluting formulas, as full-strength formulas should be given immediately 3
- A trial of withholding cow's milk may be considered, as it can promote constipation in some children 4
For Infants on Solid Foods
- Offer fruit juices with sorbitol (prune, pear, apple) at 10 mL/kg body weight as a first-line intervention 1
- Include starches, cereals, fruits, and vegetables in the diet 3
- Avoid foods high in simple sugars and fats, which can worsen constipation 3, 1
- Adding fiber to the diet may improve constipation 4
Pharmacological Options
For Infants Under 6 Months
- Lactulose or lactitol-based medications are authorized and effective 5
For Infants Over 6 Months
- Polyethylene glycol (PEG) is the preferred medication for established constipation 5
- Alternative maintenance medications include mineral oil, lactulose, milk of magnesia, and sorbitol 4
- For fecal impaction, use high-dose PEG for the first few days or repeated phosphate enemas for disimpaction 5
Important Caveat
- Hyperosmotic mineral water, diet alone, and endoanal medications are not effective treatments for established constipation at any age 5
- The key principle is using a sufficient dose for a prolonged duration, as treatment may be required for months to years due to high relapse rates 5, 4
Red Flags Requiring Immediate Evaluation
Watch for these warning signs that indicate potential organic causes requiring specialist referral:
- Delayed passage of meconium beyond 48 hours after birth 1, 6
- Failure to thrive 1
- Abdominal distension 1
- Bloody stools 1
- Vomiting 1
- Abnormal neurological findings 1
- Developmental delays or behavioral problems 6
These may indicate serious conditions such as Hirschsprung's disease, hypothyroidism, cystic fibrosis, spinal cord abnormalities, or congenital anorectal malformations 4.
Treatment Principles
- Education of parents is instrumental in improving functional constipation outcomes 4
- Behavioral modifications and education regarding toilet adaptation should be implemented to restore colonic motility 5
- Maintain adequate hydration, as fluid restriction and dehydration increase constipation 7
- Only 50-70% of children demonstrate long-term improvement despite treatment, so realistic expectations should be set 4