What is the best course of action for a 7-day-old male newborn with no bowel movement (bm) in 2 days?

Management of a 7-Day-Old Newborn with No Bowel Movement for 2 Days

For a 7-day-old male with no bowel movement in 2 days, first rule out serious pathology (Hirschsprung disease, meconium plug, intestinal obstruction) through careful history and physical examination, then if the infant is otherwise well-appearing and feeding normally, use glycerin suppositories as the safest first-line intervention while optimizing feeding practices. 1

Initial Assessment: Rule Out Red Flags

At 7 days of age, you must first exclude serious organic causes before treating as simple constipation:

• Ask specifically about meconium passage: Delayed passage of meconium beyond 48 hours of life is a critical red flag for Hirschsprung disease or other anatomic abnormalities 2
• Assess for bilious vomiting or abdominal distention: These suggest intestinal obstruction requiring urgent imaging and surgical consultation 3, 4
• Examine the abdomen carefully: A tense, distended abdomen with signs of peritoneal irritation demands immediate surgical evaluation 4
• Check for poor feeding or lethargy: These nonspecific signs can indicate serious pathology in neonates 5

If any red flags are present, obtain abdominal radiographs immediately and consult pediatric surgery 3, 2.

Management for Otherwise Well-Appearing Infant

If the infant is feeding well, gaining weight appropriately, and has no concerning signs:

Feeding Optimization (First-Line)

• If breastfed: Continue nursing on demand without interruption—breast milk has natural laxative properties and restricting feeds worsens constipation 1
• If formula-fed: Use full-strength formula immediately; do not dilute or switch formulas without clear indication 1
• Ensure adequate fluid intake: Feed every 2-3 hours to maintain hydration 1

Pharmacological Intervention

• Glycerin suppositories are the safest first-line pharmacological option for neonates, acting as a mild rectal stimulant 1
• Insert gently to avoid rectal trauma, and can be repeated once daily if needed 1
• Do NOT use polyethylene glycol (PEG) before 6 months of age—it is only authorized for infants 6 months and older 1, 6
• Avoid bisacodyl, mineral oil, stimulant laxatives, and enemas unless under specialist guidance, as these carry risks of aspiration, electrolyte disturbances, and rectal trauma 1

Common Pitfalls to Avoid

• Do not switch to lactose-free formula without clear evidence of lactose intolerance (worsening diarrhea upon lactose introduction, not just reducing substances in stool) 3, 1
• Do not perform digital rectal examination routinely in a well-appearing neonate without clear indication, as this can cause trauma 1
• Do not delay evaluation if the infant develops new symptoms: Vomiting, abdominal distention, or refusal to feed require immediate reassessment 2, 4

When to Escalate Care

Refer to pediatric gastroenterology or surgery if:

• No meconium passage by 48 hours of life (even if now 7 days old, this history matters) 2
• Persistent constipation despite glycerin suppositories and feeding optimization 6, 2
• Development of bilious vomiting, abdominal distention, or signs of intestinal obstruction 3, 4
• Associated developmental delays or failure to thrive 2