Can castor oil be used to treat constipation or promote meconium passage in term or preterm newborn infants?

Castor Oil Should Not Be Used in Newborns

Castor oil is contraindicated in newborns and should never be administered to term or preterm infants for constipation, meconium passage, or any other indication due to documented severe toxicity and lack of efficacy.

Evidence of Harm in Neonates

The most compelling evidence comes from direct clinical observations of castor oil toxicity in newborns:

• A case series from Haiti documented 8 neonates who developed severe illness after castor oil ingestion, with 5 deaths (62.5% mortality) and another likely death after leaving against medical advice 1
• These infants presented with sepsis-like shock, vomiting, hypotonia, lethargy, and abdominal distention—a distinct clinical syndrome associated with castor oil tea (known as "lok") 1
• Three infants received castor oil in the immediate neonatal period specifically to promote meconium passage, demonstrating that this traditional practice is both ineffective and potentially lethal 1
• The remaining five infants were 15-30 days old when given castor oil for undefined illness, all were previously healthy term infants with no identified risks at birth 1

Lack of Evidence for Efficacy

The available evidence demonstrates no benefit for castor oil in newborns:

• Castor oil has no role in promoting meconium passage—the American Heart Association and American Academy of Pediatrics recommend against routine tracheal suctioning even for meconium-stained amniotic fluid, emphasizing immediate positive pressure ventilation instead 2
• For delayed meconium passage or constipation concerns, safer alternatives exist that are appropriate for the neonatal population
• Adult guidelines note that castor oil is "rarely used" even in adults due to better alternatives 3

Mechanism of Toxicity

While castor oil is metabolized to ricinoleic acid in adults through pancreatic enzymes in the small intestine 4, neonates have:

• Immature pancreatic enzyme systems that may not adequately metabolize castor oil
• Increased susceptibility to the oil's effects on small bowel fluid secretion 3
• Higher risk of aspiration given the oily nature of the substance, as evidenced by the "dark, oily substance" found in nasal drainage and nasogastric tubes in affected infants 1

Clinical Algorithm for Meconium and Constipation Management

For meconium passage concerns:

• Normal term infants pass meconium within 24-48 hours without intervention
• If meconium aspiration syndrome occurs, management focuses on respiratory support with positive pressure ventilation, not laxatives 2
• Consider surfactant therapy for severe cases with hypoxic respiratory failure 2

For true neonatal constipation (rare):

• First evaluate for anatomic abnormalities (Hirschsprung disease, imperforate anus)
• Consider glycerin suppositories as the safest first-line intervention if needed
• Consult pediatric gastroenterology for persistent issues

Critical Safety Message

The practice of administering castor oil to newborns may be more widespread than documented, as parents often do not volunteer this information and it may not be discovered unless specifically sought 1. Healthcare providers must:

• Explicitly counsel families against traditional remedies containing castor oil for newborns
• Screen for castor oil use when evaluating sick neonates with unexplained sepsis-like presentations
• Consider nasogastric tube placement to identify oily residue if castor oil ingestion is suspected 1

The 62.5% mortality rate observed in the Haiti case series, combined with the complete lack of therapeutic benefit, makes castor oil use in newborns an unacceptable risk under any circumstance 1.