Treatment of Infant Constipation
For infants under 6 months with constipation, start with fruit juices containing sorbitol (prune, pear, or apple juice) at 10 mL/kg body weight, followed by lactulose if dietary measures fail. 1, 2
Initial Assessment
Before treating, evaluate these key factors:
- Feeding history - Document whether the infant is breastfed or formula-fed, and note any recent changes in feeding patterns 1, 2
- Red flag symptoms - Look for bilious vomiting, which may indicate serious underlying conditions requiring immediate evaluation 1
- Physical examination - Perform visual inspection of the perianal area for fissures, skin tags, or redness; digital rectal examination is typically unnecessary for functional constipation 1
- Growth parameters - Poor weight gain or growth concerns warrant further evaluation for organic causes 1
Understanding Normal Patterns
- Newborns typically have bowel movements after most feedings (8-12 times daily), while by 2 months this decreases as feeding intervals lengthen to every 3-4 hours 1
- Parents often misinterpret normal variations in stool frequency as constipation 1
Treatment Algorithm by Age
Infants Under 6 Months
First-line dietary interventions:
- Breastfed infants - Continue nursing on demand as the primary intervention 1, 2
- Formula-fed infants - Ensure adequate hydration with full-strength formula 1
- Fruit juices - Introduce small amounts (10 mL/kg body weight) of sorbitol-containing juices (prune, pear, or apple juice) to increase stool water content 1, 2
- Maternal diet modification - Consider a 2-4 week trial eliminating milk and egg from the maternal diet if milk protein allergy is suspected (can mimic constipation) 1, 2
Second-line pharmacological treatment:
- Lactulose - Use initial daily oral doses of 2.5 mL to 10 mL in divided doses if dietary measures are insufficient 2, 3
Infants 6-12 Months
- Fruit juices remain first-line treatment at 10 mL/kg body weight 1, 2
- Lactulose can be used if juices are inadequate 1, 3
- Polyethylene glycol (PEG) becomes an option after 6 months of age, though it is not FDA-approved for children under 17 years without physician guidance 4, 3
- Solid foods - For infants approaching 6 months who are developmentally ready, introducing appropriate solid foods may help 1
Special Considerations for Milk Protein Allergy
If milk protein allergy is suspected (which can present with constipation-like symptoms):
- Consider switching to an extensively hydrolyzed or amino acid-based formula for formula-fed infants 1
- For breastfed infants, implement maternal dietary restriction of milk and egg for 2-4 weeks 1, 2
Critical Warnings
- Avoid excessive juice consumption - This can lead to diarrhea, flatulence, abdominal pain, and poor weight gain 1, 2
- Avoid overfeeding - Small feeding adjustments may help while ensuring adequate intake 1
- Duration of treatment - Do not use over-the-counter laxatives for more than 7 days without physician guidance 5
Common Pitfalls
The evidence shows that primary care physicians tend to undertreat childhood constipation, with nearly 40% of children remaining symptomatic after 2 months 6. The key mistakes include:
- Prescribing fixed doses without instructing parents to titrate based on response 6
- Failing to address disimpaction when fecal impaction is present 6
- Inadequate duration of maintenance therapy 4, 7