What are the best management options for a breastfeeding mother and her infant, both experiencing constipation?

Management of Constipation in a Breastfeeding Mother and Her Infant

For the breastfeeding mother, start with polyethylene glycol (PEG) 17g once or twice daily as first-line therapy, and for the constipated infant, continue breastfeeding while ensuring adequate maternal hydration, as breast milk itself is protective against infant constipation. 1, 2, 3

Management for the Breastfeeding Mother

First-Line Interventions

• Increase fluid intake to at least 2 liters daily as the primary non-pharmacological intervention, particularly important during lactation 1, 2

• Increase dietary fiber to approximately 30g/day (fruits, vegetables, whole grains, legumes) only if adequate fluid intake is maintained, as fiber without sufficient hydration can worsen constipation 1, 2

• Encourage physical activity and exercise within limitations, as mobility promotes intestinal motility 1, 2

Pharmacological Management (Safe During Breastfeeding)

• Polyethylene glycol (PEG) is the preferred first-line laxative during lactation due to its superior safety profile, minimal systemic absorption, and lack of transfer into breast milk 1, 2, 4

  • Dosing: 17g (1 capful) in 8 oz water once or twice daily 2

• Lactulose 30-60 mL twice daily is an alternative osmotic laxative that is safe during breastfeeding, though it may cause more maternal bloating and flatulence compared to PEG 1, 4

• Bulk-forming agents (psyllium husk, methylcellulose) are safe during breastfeeding due to lack of systemic absorption, but require adequate fluid intake 1, 5

Second-Line Options (If First-Line Fails)

• Bisacodyl 10-15 mg daily can be used during lactation if osmotic laxatives are ineffective, with the goal of 1 non-forced bowel movement every 1-2 days 1, 2, 4

  • The 2024 AGA guidelines note that bisacodyl should be reserved for second-line use in pregnancy, and this caution extends to lactation 1

• Sodium picosulfate is another diphenolic laxative option during lactation 4

Critical Pitfalls to Avoid

• Avoid stimulant laxatives (senna, bisacodyl) for long-term use due to risk of colonic dependency, though short-term use is acceptable 6

• Avoid excessive fiber without adequate hydration, as this can worsen constipation 1, 2

• Rule out fecal impaction if diarrhea accompanies constipation (overflow diarrhea around impaction) 1, 2

Management for the Constipated Infant

Breastfeeding as Primary Intervention

• Continue breastfeeding, as it is protective against infant constipation - infants under artificial feeding are 4.53 times more likely to develop constipation than predominantly breastfed infants 3

• Breastfeeding reduces the risk of constipation with a duration-response effect; longer breastfeeding provides greater protection 1

Maternal Dietary Modifications

• Ensure the mother maintains adequate hydration (at least 2 liters daily), as maternal fluid status can affect breast milk composition 1, 2

• Consider a 2-4 week trial of maternal dietary exclusion (restricting milk and eggs) if the infant has persistent symptoms, though this is more commonly recommended for reflux than constipation 1

When to Consider Formula Changes (If Partially Formula-Fed)

• If the infant receives any cow's milk-based formula, consider withholding it as a trial, since cow's milk may promote constipation in some children 7

• An extensively hydrolyzed protein or amino acid-based formula may be appropriate if cow's milk intolerance is suspected 1

Pharmacological Options for Infants

• Polyethylene glycol (PEG) is effective and well-tolerated for infant constipation after disimpaction, though dosing must be weight-appropriate 7

• Alternative maintenance medications include mineral oil, lactulose, milk of magnesia, and sorbitol, though PEG is generally preferred 7

• Glycerine suppositories can be used for acute relief in infants 1

Red Flags Requiring Further Evaluation

• Rule out serious organic causes including Hirschsprung's disease, hypothyroidism, cystic fibrosis, or congenital anorectal malformation if constipation is severe or associated with failure to thrive 7

• Warning signs include bilious vomiting, gastrointestinal bleeding, fever, lethargy, abdominal distension, or failure to pass meconium in the first 48 hours of life 1, 7

Monitoring and Follow-Up

• The goal is 1 non-forced bowel movement every 1-2 days for both mother and infant 1, 2, 6

• Reassess regularly as functional constipation in infants may require maintenance therapy for months to years, with only 50-70% showing long-term improvement 7

• Maternal laxatives (PEG, lactulose, bisacodyl) do not adversely affect breastfed infants - very low-certainty evidence suggests no increase in loose stools or diarrhea in babies 8