Constipation in a 5-Month-Old Baby

First: Is It Really Constipation?

• No meconium passed within 48 hours of birth (history)
• Ribbon-like stools
• Abdominal distension
• Bloody stools
• Poor weight gain / failure to thrive
• Weak cry, floppiness (rule out Hirschsprung disease, hypothyroidism, infant botulism)

Identify the Feeding Type First

Breastfed Baby

• Breast milk is a natural laxative - true constipation is rare in exclusively breastfed infants.
• Check latch and feeding frequency - inadequate intake can cause hard stools.
• Do NOT add water, juice, or solid foods at this age; 5 months is before the WHO-recommended 6-month introduction of solids.
• Consult a lactation consultant if supply or latch is a concern.

Formula-Fed Baby

• Check mixing instructions - over-concentrated formula is a common cause.
• Switch to a properly mixed formula and reassess.
• Some babies may respond to a partially hydrolyzed or hypoallergenic formula if cow's milk protein intolerance is suspected (constipation resolves in ~78% of cases when cow milk protein is removed in susceptible infants, per Iacono et al.).
• Do NOT switch to a low-iron formula - iron in formula has not been shown to cause constipation.

Started Solids Early (before 6 months)

• Some parents introduce solids before 6 months, which can cause constipation.
• Per Alberta Health Services guidelines, consider stopping solid foods until closer to 6 months if early introduction has occurred.

Non-Pharmacological Measures (Try These First)

1. Tummy massage - Gently massage the baby's abdomen in a clockwise circular motion (following the direction of the colon).
2. Bicycle legs - Lay the baby on their back and gently move the legs in a cycling motion for a minute or two, a few times a day.
3. Knees-to-chest - Gently bring both knees up to the chest and hold briefly, then release. This mimics a squatting position and helps stimulate bowel movement.
4. Warm bath - Can help relax abdominal muscles and stimulate bowel activity.
5. Ensure adequate feeding - Make sure the baby is getting enough milk overall.

When to Use Medication

• Glycerin suppository (infant-size): May be used short-term for acute relief - it works by softening stool locally. Used carefully and not routinely.
• Lactulose (osmotic laxative): Safe for infants, often used as first-line if dietary measures fail. Dose is typically 1-3 mL/kg/day, adjusted by response.
• Polyethylene glycol (PEG/Movicol): The ESPGHAN/NASPGHAN guideline recommends PEG as first-line maintenance treatment in older children; its use in infants under 6 months requires specialist guidance.
• Do NOT use: mineral oil, stimulant laxatives (senna, bisacodyl), or enemas in a 5-month-old - these are not safe at this age.

When to See a Doctor

• Constipation has lasted more than 1-2 weeks without improvement
• The baby appears to be in significant pain, is crying persistently, or is not feeding well
• There is blood in the stool
• The abdomen looks bloated or hard
• There is poor weight gain
• Home measures have not worked after a few days

Key Takeaway

1. Confirm it's actually constipation (not just infrequency)
2. Check feeding - breastmilk, formula mixing, or early solids
3. Use physical maneuvers (massage, bicycle legs)
4. See a doctor before starting any laxative