What is the treatment for constipation in a 5-day-old newborn?

Treatment of Constipation in a 5-Day-Old Newborn

In a 5-day-old newborn with constipation, the primary approach is to optimize feeding—continue breastfeeding on demand or use full-strength formula, and consider glycerin suppositories if simple measures fail. 1, 2

Initial Assessment and Red Flags

Before treating, verify this is true constipation rather than normal newborn stool patterns:

• Rule out delayed meconium passage beyond 48 hours of life, which signals potential Hirschsprung disease or other anatomic abnormalities requiring urgent evaluation 3
• Assess for signs of intestinal obstruction including bilious vomiting, abdominal distension, or failure to pass any stool 3
• At 5 days old, breastfed infants may normally stool infrequently (even once per week) if stools are soft when passed 2

First-Line Management: Feeding Optimization

Breast-fed infants should continue nursing on demand without interruption, as breast milk has natural laxative properties and restricting feeds worsens constipation 4, 1

For formula-fed infants, use full-strength formula immediately—do not dilute or switch formulas without clear indication 4

• Ensure adequate fluid intake through frequent feeds (every 2-3 hours) 1
• Fruit juices containing sorbitol (prune, pear, apple) can increase stool frequency in infants, though use cautiously at this young age 1

Pharmacological Options for Neonates

If feeding optimization fails after 24-48 hours:

Glycerin suppositories are the safest first-line pharmacological option for neonates, acting as a mild rectal stimulant 1, 2

• Insert gently to avoid rectal trauma 1
• Can be repeated once daily if needed 1

For infants under 6 months, lactulose or lactitol-based medications are authorized and effective if suppositories are insufficient 5

• Dosing should be adjusted based on response, aiming for soft stools 5

Polyethylene glycol (PEG) is NOT recommended before 6 months of age—it is only authorized for infants 6 months and older 1, 5

Bisacodyl has no safety or efficacy data in infants under 6 months and should be avoided 1

Critical Management Principles

Never stop feeding for more than 4 hours in an attempt to manage constipation—this worsens the problem 6

Avoid mineral oil, stimulant laxatives, and enemas in neonates unless under specialist guidance, as these carry risks of aspiration, electrolyte disturbances, and rectal trauma 1, 2

If fecal impaction is present on digital rectal exam, manual disimpaction or suppositories are preferred first-line therapy before oral laxatives 1

When to Escalate Care

Refer immediately to pediatric gastroenterology if:

• Delayed meconium passage beyond 48 hours 3
• Associated vomiting, abdominal distension, or failure to thrive 3
• No response to glycerin suppositories and feeding optimization within 48-72 hours 2
• Any concern for anatomic abnormality (anal stenosis, imperforate anus) 2

Common Pitfalls

Do not switch to lactose-free formula without clear evidence of lactose intolerance (worsening diarrhea upon lactose introduction, not just reducing substances in stool) 4

Do not use homemade remedies, plain water, or diluted feeds—these provide inadequate nutrition and can worsen constipation 6

Do not rely solely on dietary changes if impaction is present—this requires active disimpaction first 1