What is the best treatment approach for constipation in a 10-month-old infant?

Treatment of Constipation in a 10-Month-Old Infant

For a 10-month-old infant with constipation, start with fruit juices containing sorbitol (prune, pear, or apple juice) to increase stool frequency and water content, and if this fails, escalate to polyethylene glycol as the first-line pharmacologic treatment. 1

Initial Dietary Management

• Ensure adequate fluid intake as the foundation of treatment, particularly for breastfed infants who should continue nursing on demand 2
• Administer small amounts of fruit juices containing sorbitol such as prune, pear, or apple juice, which create an osmotic effect to soften stools and increase bowel movement frequency 1
• The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition specifically recommends taking advantage of the sorbitol and other carbohydrates in these juices for infant constipation 1
• Avoid increasing dietary fiber at this age unless adequate fluid intake is already established 2

First-Line Pharmacologic Treatment

• Polyethylene glycol (PEG) is the recommended first-line medication for infants over 6 months of age with constipation 2, 3
• PEG is effective, well-tolerated, and should be administered at age-appropriate doses to achieve soft, painless bowel movements 2, 4
• For infants under 6 months, lactulose or lactitol-based medications are authorized and effective alternatives 3

Lactulose Dosing for Infants

• The recommended initial daily oral dose for infants is 2.5 mL to 10 mL in divided doses 5
• If the initial dose causes diarrhea, reduce the dose immediately; if diarrhea persists, discontinue lactulose 5
• The goal is to produce 2-3 soft stools daily 5

Management of Fecal Impaction (If Present)

If the infant has developed fecal impaction, a more aggressive approach is needed:

• Start with glycerin suppository as the initial intervention 2
• If glycerin fails, escalate to bisacodyl suppository (one rectally daily to twice daily) 2
• Mineral oil retention enema can be used to lubricate and soften impacted stool 2
• High-dose PEG (1 capful/8 oz water twice daily) for disimpaction if suppositories are insufficient 2

Critical Contraindications

• Do not use enemas in infants with neutropenia, thrombocytopenia, recent surgery, intestinal obstruction, or undiagnosed abdominal pain 2
• Rule out mechanical obstruction with physical examination before aggressive treatment 2

Red Flags Requiring Further Evaluation

Before assuming functional constipation, evaluate for these warning signs that suggest organic causes 4:

• Delayed passage of meconium (>48 hours after birth)
• Failure to thrive
• Abdominal distension
• Abnormal position of anus
• Absence of anal or cremasteric reflex

These findings may indicate Hirschsprung's disease, hypothyroidism, or other serious conditions requiring specialized evaluation 6, 4

Maintenance Therapy

• Continue treatment for months as functional constipation commonly relapses 7, 4
• Regular reassessment of bowel habits is essential to monitor effectiveness 2
• The goal is one non-forced bowel movement every 1-2 days 2
• Only 50-70% of children demonstrate long-term improvement despite treatment, so set realistic expectations with parents 4

Common Pitfalls to Avoid

• Do not delay treatment as chronicity significantly interferes with emotional growth and development 8
• Do not use mineral water, endoanal medications, or dietary changes alone for established constipation—these are ineffective 3
• Do not withhold cow's milk routinely, but a trial of elimination may be considered if other measures fail 4
• Ensure sufficient dosing for adequate duration—the most common treatment failure is inadequate dose or premature discontinuation 3