Constipation in a 5-Month-Old Infant
Initial Management Approach
For a 5-month-old with constipation, start with fruit juices containing sorbitol (prune, pear, or apple juice) at 10 mL/kg body weight, followed by lactulose if juices are ineffective. 1
Virtual Exam and History Points
Critical History Elements
Feeding History:
- Type of feeding (breast milk vs. formula) and any recent formula changes 1
- Feeding frequency and volume - normal is every 3-4 hours at this age 1
- Signs of overfeeding or inadequate intake 1
Stool Pattern Details:
- Frequency, consistency, and pain with defecation 2
- Presence of screaming or stool-holding behaviors 2
- Any blood in stool or intermittent liquid stool passage (encopresis) 2
Red Flags to Rule Out Organic Disease:
- Constipation present since birth (suggests Hirschsprung's disease) 3, 4
- Failure to pass meconium within first 48 hours of life 4
- Poor weight gain or growth concerns 1
- Abdominal distension 4
- Vomiting, especially if bilious 5
Allergy Symptoms:
- Eczema, wheezing, or other signs suggesting cow's milk protein allergy 1
- Family history of allergies 1
Physical Examination Components (Virtual Assessment)
Visual Inspection:
- Observe perianal area for fissures, skin tags, or redness 5
- Look for abdominal distension through video 4
- Assess overall growth and development 1
Parent-Performed Gentle Abdominal Palpation:
- Guide parents to feel for palpable stool masses (if comfortable doing so) 4
Important Note: Digital rectal examination is typically not necessary for functional constipation in infants and should be reserved for cases with red flags 5, 4
Treatment Protocol
First-Line Dietary Interventions
Juice Therapy (Preferred Initial Treatment):
- Administer 10 mL/kg body weight of sorbitol-containing juices (prune, pear, or apple) 1
- These work by creating an osmotic load that increases stool water content 1
- Caution: Avoid excessive amounts as this can cause diarrhea, flatulence, and poor weight gain 1
Feeding Modifications:
- Continue breastfeeding on demand if breastfed 1
- Ensure adequate hydration with full-strength formula if formula-fed 1
- Consider 2-4 week trial of maternal milk and egg exclusion diet if breastfeeding and milk protein allergy suspected 1
- Consider extensively hydrolyzed or amino acid-based formula if formula-fed with suspected allergy 5
Second-Line Pharmacological Treatment
Lactulose:
- Recommended if fruit juices are ineffective 1, 6
- Dosing for infants: 2.5-10 mL daily in divided doses 7
- Adjust dose to produce 1-2 soft stools daily 8
- Important: If diarrhea develops, reduce dose immediately; if it persists, discontinue 7
Documentation Requirements
Document the Following:
- Detailed feeding history including type, frequency, and any recent changes 1
- Stool frequency, consistency, and associated symptoms (pain, blood, straining) 2
- Presence or absence of red flag symptoms 4
- Growth parameters and weight gain pattern 1
- Treatment plan initiated (specific juice type and amount OR lactulose dose) 1
- Parent education provided 8
- Follow-up plan established 8
Health Teaching for Parents
Education on Normal Bowel Patterns
- At 5 months, bowel movement frequency varies widely and can be normal anywhere from multiple times daily to once every few days 1
- Breastfed infants may have infrequent stools (even up to 7-10 days) if stools remain soft 1
- Straining alone without hard stools is normal (infant dyschezia) and does not require treatment 3
Treatment Expectations
- Improvement may take 24-48 hours or longer 7
- Constipation management is typically long-term and may require months of treatment 8
- Goal is 1 non-forced bowel movement every 1-2 days 8
When to Seek Urgent Care
- No bowel movement for more than 5-7 days with hard abdomen 4
- Vomiting, especially if bilious or forceful 5
- Blood in stool 4
- Severe abdominal pain or distension 4
- Poor feeding or lethargy 5
- Fever 5
Monitoring Instructions
- Track stool frequency and consistency 8
- Monitor for adequate weight gain 1
- Watch for signs of dehydration if using juices 1
- Report if treatment ineffective after 1-2 weeks 8
Follow-Up Plan
- Schedule follow-up in 2-4 weeks to assess treatment response 8
- Reassess for underlying causes if initial treatment unsuccessful 8
- Consider referral to pediatric gastroenterology if red flags present or treatment-resistant 3, 4
Critical Pitfall: Do not perform extensive laboratory or radiological investigations in the absence of red flags, as 90-95% of childhood constipation is functional 3, 6