What are the treatment options for an 8-month-old patient with constipation?

Treatment of Constipation in an 8-Month-Old Infant

For an 8-month-old with constipation, start with fruit juices containing sorbitol (prune, pear, or apple juice) and if this fails, use polyethylene glycol (PEG) as first-line pharmacological therapy. 1

Initial Non-Pharmacological Approaches

Dietary Modifications

• Continue breast-feeding on demand or use full-strength formula - do not dilute or change formula unless true lactose intolerance is documented 2
• Introduce sorbitol-containing fruit juices (prune, pear, apple) which increase stool frequency and water content in infants 1
• Ensure adequate fluid intake to maintain proper hydration 1
• For infants already on solid foods, emphasize age-appropriate high-fiber foods including fruits, vegetables, and whole grains 1

What NOT to Do

• Avoid hyperosmolar mineral water, which is not an effective treatment for established constipation at any age 3
• Do not restrict fruits and vegetables 1
• Do not use the "BRAT" diet (bananas, rice, applesauce, toast) as this is more appropriate for diarrhea management, not constipation 2, 1

Pharmacological Management

First-Line Treatment

• Polyethylene glycol (PEG) is the laxative of first choice for infants 6 months and older 1
• Initial dosing: 0.8-1 g/kg/day 1
• Goal: achieve 2-3 soft, painless stools daily 1
• PEG is effective and well tolerated compared to alternatives 4

Alternative First-Line Options

• Lactulose or lactitol-based medications are authorized and effective for infants under 6 months of age 3
• Sorbitol-containing preparations can also be used 1

Second-Line Options (if PEG insufficient)

• Mineral oil (though less commonly prescribed) 3
• Magnesium hydroxide 5

Assessment for Fecal Impaction

Before starting maintenance therapy, rule out impaction:

• If impaction is present, glycerin suppositories are the preferred first-line suppository option for this age group as they act as a rectal stimulant through mild irritant action and are safe 1
• Manual disimpaction may be performed as an alternative 1
• High-dose PEG for the first few days can also be used for disimpaction 3

Treatment Goals and Monitoring

• Target: one non-forced bowel movement every 1-2 days without abdominal pain or straining 5, 1
• Monitor stool frequency and consistency, absence of pain with defecation, and weight gain/growth parameters 1

Critical Warning Signs Requiring Immediate Evaluation

• Rectal bleeding 1
• Nausea, bloating, cramping, or abdominal pain 1
• Diarrhea (may indicate medication overdose) 1

Duration of Treatment

• Maintenance therapy may need to continue for many months before the infant regains normal bowel motility and rectal perception 1
• Common pitfall: parents often cease treatment too soon, leading to relapse 1
• Despite treatment, only 50-70% of children demonstrate long-term improvement 4

When to Reassess

If constipation persists after 4 weeks of appropriate therapy:

• Reassess for underlying organic causes including hypothyroidism, hypercalcemia, hypokalemia, and diabetes mellitus 1
• Rule out Hirschsprung's disease, pseudo-obstruction, spinal cord abnormality, or other serious organic causes 4

Medications to AVOID in This Age Group

• Bisacodyl is NOT recommended for infants under 6 months - no safety or efficacy data exists for this age group 1
• Stimulant laxatives should not be used as first-line therapy 1
• Stool softeners alone (like docusate) are ineffective and not recommended 1
• Do not use suppositories or enemas if the infant has thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis 1