What are the treatment options for constipation in infants?

From the Guidelines

Constipation in infants can be effectively managed with dietary interventions, particularly with the use of certain fruit juices, such as prune, pear, and apple juices, which contain sorbitol and other carbohydrates that can help increase the frequency and water content of stools. According to the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition constipation guideline, as mentioned in the study published in Pediatrics in 2017 1, these juices can be beneficial in treating constipation in infants. The study highlights that the malabsorption of carbohydrate from juice, especially when consumed in excessive amounts, can result in chronic diarrhea, flatulence, bloating, and abdominal pain, but when provided in appropriate amounts (10 mL/kg body weight), these different juices are absorbed equally as well.

Some key points to consider when treating constipation in infants include:

• Ensuring adequate feeding frequency and proper latch for breastfed babies
• Proper formula preparation and sometimes switching formulas for formula-fed infants
• Increasing dietary fiber through pureed fruits, vegetables, and whole grains once solid foods are introduced
• Adequate fluid intake, offering water between feedings for babies over 6 months
• Gentle belly massage in a clockwise direction and bicycle leg exercises to stimulate bowel movements
• Using glycerin suppositories (infant size) or 1-2 teaspoons of prune or pear juice diluted with water for temporary relief in babies over 4 months, as suggested by the study 1

It is essential to note that constipation often occurs during dietary transitions or formula changes, and most cases resolve with these conservative measures. However, persistent constipation warrants medical evaluation to rule out underlying conditions. The use of osmotic laxatives like Miralax (polyethylene glycol 3350) at a dose of 0.5-1.5 g/kg/day mixed in formula or juice may be recommended by a pediatrician if these measures fail. Stimulant laxatives should be avoided unless specifically prescribed.

The study published in Pediatrics in 2017 1 provides guidance on the use of fruit juice in infants, children, and adolescents, and its potential role in treating constipation. The American Academy of Pediatrics recommends focusing on nutrient-dense foods, including whole fruit, and limiting the intake of fruit juice to no more than 4-6 ounces per day for children over 6 months.

From the FDA Drug Label

Pediatric: Very little information on the use of lactulose in young children and adolescents has been recorded. As with adults, the subjective goal in proper treatment is to produce 2 or 3 soft stools daily. On the basis of information available, the recommended initial daily oral dose in infants is 2. 5 mL to 10 mL in divided doses. The recommended initial daily oral dose of lactulose for the treatment of constipation in infants is 2.5 mL to 10 mL in divided doses, with the goal of producing 2 or 3 soft stools daily 2.

• The dose may need to be adjusted based on the infant's response to the medication.
• If the initial dose causes diarrhea, the dose should be reduced immediately.
• If diarrhea persists, lactulose should be discontinued.

From the Research

Treatment Options for Constipation in Infants

• Lactulose/lactitol-based medications are authorized and effective for infants under 6 months, while polyethylene-glycol is recommended for infants over 6 months 3
• Mineral oil is less commonly prescribed for constipation in infants 3
• Hyperosmotic mineral water, diet, and endoanal medications are not recommended as treatments for established constipation in infants, regardless of age 3

Management of Constipation in Infants

• Fecal disimpaction using a high dose of polyethylene-glycol or repeated phosphate enemas is the first stage of treatment for fecal impaction with or without fecal incontinence 3
• Education on adapting toilets and promoting daily bowel movements can help restore colic motility and prevent relapses when treatment is discontinued 3
• Psychological concerns should be evaluated and treated as part of the management plan for constipation in infants 3

Evaluation and Treatment of Constipation in Children

• Constipation in children is usually functional and the result of stool retention, but organic causes such as Hirschsprung's disease or pseudo-obstruction should be ruled out 4
• Treatment of functional constipation involves disimpaction using oral or rectal medication, followed by a maintenance program to prevent relapse 4
• Maintenance medications for constipation in children include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol 4

Recommendations for Management of Constipation in Infants and Children

• The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has developed clinical practice guidelines for the management of pediatric constipation, including algorithms for medical management and recommendations for evaluation, initial treatment, and follow-up management 5
• Osmotic laxatives such as polyethylene glycol 3350 and lactulose are effective and safe for both long and short term treatment of pediatric functional constipation, while stimulant laxatives and probiotics may be used as adjunct therapies in specific clinical scenarios 6