What is the appropriate stool softener and treatment for constipation in an otherwise healthy 11‑month‑old infant?

Stool Softener for 11-Month-Old Infant

For an 11-month-old with constipation, polyethylene glycol (PEG) is the first-line treatment, starting at 0.8-1 g/kg/day, with the goal of producing 2-3 soft, painless stools daily. 1

Initial Assessment

Before starting treatment, rule out organic causes and assess for fecal impaction 1:

• Check for red flags: Constipation since birth (Hirschsprung disease), failure to pass meconium within 48 hours, ribbon stools, blood in stools without anal fissures, or neurological abnormalities 2, 3
• Perform digital rectal examination to identify if the rectum is full or if fecal impaction is present 1
• If impaction is present, disimpaction must occur before maintenance therapy 1, 2

Disimpaction Phase (If Needed)

If fecal impaction is identified 1:

• Glycerin suppositories are the recommended first-line suppository option for this age group, acting as a rectal stimulant through mild irritant action 1
• Alternatively, manual disimpaction may be performed 1
• High-dose PEG can also be used for disimpaction over the first few days 4

Maintenance Pharmacological Treatment

Polyethylene glycol (PEG) 3350 is the laxative of first choice for infants 6 months and older 1:

• Dosing: 0.8-1 g/kg/day initially 1
• Goal: Produce 2-3 soft, painless stools daily 1
• Duration: Continue for many months before the child regains normal bowel motility and rectal perception 1

Alternative options if PEG is unavailable or not tolerated 1, 5, 4:

• Lactulose: For infants, the recommended initial daily oral dose is 2.5-10 mL in divided doses 5. Lactulose/lactitol-based medications are authorized and effective before 6 months of age 4
• Sorbitol-containing fruit juices (prune, pear, apple) can help increase stool frequency and water content 1

What NOT to Use

Avoid these medications in an 11-month-old 1:

• Docusate (stool softeners alone): Ineffective and not recommended for treatment of constipation in children 1
• Bisacodyl: No safety or efficacy data for use in infants under 6 months, and not recommended as first-line therapy in pediatric constipation 1
• Stimulant laxatives: Should not be used as first-line therapy 1

Non-Pharmacological Measures

While medications are the mainstay, these adjunctive measures can be helpful 1, 6:

• Continue breast-feeding on demand or use full-strength formula 1
• Sorbitol-containing fruit juices (prune, pear, apple) can help increase stool frequency 1
• Maintain regular diet with age-appropriate high-fiber foods including fruits, vegetables, and whole grains 1
• Note: Simply increasing fluid intake above normal recommendations provides no additional benefit 6

Monitoring and Follow-Up

Evaluate treatment efficacy by 1:

• Stool frequency and consistency
• Absence of pain with defecation
• Weight gain and growth parameters

Critical warning signs requiring immediate evaluation 1:

• Rectal bleeding
• Nausea, bloating, cramping, or abdominal pain
• Diarrhea (may indicate excessive dosing)

Common Pitfalls to Avoid

• Premature discontinuation: Parents often cease treatment too soon before the child regains bowel motility and rectal perception; maintenance therapy must continue for many months 1
• Relying solely on dietary changes: Without addressing impaction if present, this can worsen constipation 1
• Using suppositories alone: Without follow-up maintenance therapy, this leads to high relapse rates of 40-50% within 5 years 1
• Starting maintenance before disimpaction: If impaction is present, it must be treated first or maintenance therapy will fail 1, 2