Is maltitol appropriate for treating constipation in otherwise healthy children?

Is Maltitol Appropriate for Pediatric Constipation Management?

No, maltitol is not appropriate for treating constipation in otherwise healthy children—it is a sugar alcohol that can cause diarrhea and flatulence, not relieve constipation, and established first-line therapies include polyethylene glycol, lactulose/lactitol, and sorbitol-containing fruit juices. 1, 2

Why Maltitol Is Not a Constipation Treatment

Maltitol is classified as a sugar alcohol (polyol) used as a sweetening agent in foods, not as a laxative. 1 While sugar alcohols can have laxative effects at high doses, this is an adverse effect rather than a therapeutic benefit:

• Sugar alcohols may cause diarrhea, especially in children, when consumed in significant amounts 1
• The FDA requires warning labels stating "excess consumption may have a laxative effect" for foods containing ≥20 g mannitol or ≥50 g sorbitol per day, indicating this is an unwanted side effect 1
• A study in children found that maltitol at 15 g per intake caused increased flatulence scores compared to placebo, though these effects were considered minor 3

The mechanism of maltitol is fundamentally different from therapeutic laxatives—it acts through incomplete absorption and fermentation in the colon, producing unpredictable osmotic effects and gas, rather than the controlled osmotic action of proven laxatives. 1

Evidence-Based First-Line Treatments for Pediatric Constipation

Initial Non-Pharmacological Approach

• Increase fluid intake to maintain proper hydration 2, 4
• Increase dietary fiber through age-appropriate fruits, vegetables, whole grains, and legumes (only if fluid intake is adequate) 2, 4
• Fruit juices containing sorbitol—specifically prune, pear, and apple juices—can increase stool frequency and water content in infants and children 2, 5, 4
• Establish a regular toileting schedule with proper posture (buttock support, foot support, comfortable hip abduction) 2, 5

Pharmacological Management by Age

For infants under 6 months:

• Lactulose or lactitol are authorized and effective 6
• Dosing for lactulose: approximately 5,670–11,340 mg per day (8–17 mL of 10 g/15 mL solution) for an 8.5 kg infant, titrated to produce soft stools 2
• Avoid lactulose preparations containing sorbitol as a preservative in very young infants due to hyperosmolar complications 2

For infants 6 months and older:

• Polyethylene glycol (PEG) 3350 is the first-line laxative of choice 2, 6, 7, 8
• Initial dosing: 0.8–1 g/kg/day, with goal of 2–3 soft, painless stools daily 2
• PEG achieved significantly more treatment success compared to all other laxatives (pooled RR: 1.47; 95% CI 1.23–1.76) 7
• PEG works as an osmotic laxative by sequestering fluid in the intestinal lumen, increasing stool water content 2

For acute relief:

• Glycerin suppositories are the recommended first-line suppository option for young children, acting as a rectal stimulant through mild irritant action 2, 4

Treatment Algorithm

1. Rule out impaction via digital rectal examination—if present, use glycerin suppositories or manual disimpaction first 2, 4
2. Initiate dietary modifications (fluids, fiber, sorbitol-containing juices) 2, 5
3. Start osmotic laxative therapy (PEG for ≥6 months, lactulose/lactitol for <6 months) 2, 6
4. Maintenance phase must continue for many months before normal bowel motility returns—premature discontinuation is a common pitfall 2
5. Monitor for treatment success: 2–3 soft, painless stools daily, absence of pain with defecation, normal growth parameters 2

Critical Warnings

• Do not use stool softeners alone (like docusate)—they are ineffective for pediatric constipation 2
• Do not use stimulant laxatives as first-line therapy—osmotic agents are preferred 2
• Avoid suppositories/enemas in children with neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis 2
• Relapse rates are 40–50% within 5 years if maintenance therapy is not continued long enough 2

Why This Matters for Morbidity and Quality of Life

Proper constipation management in children prevents serious complications including rectal prolapse, hemorrhoids, intestinal perforation, and urinary tract infections. 2 In children with concurrent bladder dysfunction, treating constipation resolves daytime wetting in 89% and nighttime wetting in 63% of cases. 2, 5 Chronic untreated constipation significantly impairs quality of life and can interfere with emotional growth and development. 9, 8