BACKGROUND & AIMS:Functional constipation (FC) is a prevalent condition in pediatrics that significantly impacts quality of life and health care utilization. The American Gastroenterological Association (AGA) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) collaborated to develop a clinical care pathway for pediatric primary care providers and pediatric gastroenterologists, based on consensus among content experts, for the diagnosis and management of FC in children. This pathway aims to provide a structured, practical approach to streamline clinical decision-making and improve patient outcomes. METHODS:A multi-disciplinary panel of experts selected based on their clinical experience and leadership and/or scientific contribution to the field conducted a roundtable discussion of the state of the art, identifying key diagnostic and management principles. A consensus-driven approach with agreement between panel members was used to establish standardized recommendations for diagnosis, treatment, and transition to adult care. RESULTS:The pathway integrates Rome IV pediatric FC criteria with a symptom-based approach to enhance clinical utility. Diagnostic recommendations prioritize history and physical examination, with limited use of diagnostic studies. Treatment strategies include dietary modifications, behavioral interventions, pharmacologic therapies, and escalation to subspecialty referrals, and advanced interventions when necessary. The pathway also provides guidance for special populations, including neurodivergent children, and outlines a structured transition process to adult care. CONCLUSIONS:The AGA-NASPGHAN Pediatric Functional Constipation Clinical Care Pathway standardizes evaluation and management, ensuring a practical approach for clinicians. Future research should focus on optimizing real-world implementation and evaluating long-term patient outcomes.

BACKGROUND:Antegrade continence enema (ACE) is an effective therapy for many children with medically refractory constipation. However, some patients lose response over time. This study aims to describe and explore physiological and anatomic correlates of ACE failure in children. METHODS:Electronic medical records of children who were no longer responding to ACE and were seen in our collaborative neurogastroenterology and colorectal surgery clinic over 7 years were reviewed. Demographic and clinical data, as well as contrast enema (CE) and colonic manometry (CM) findings, were examined in all subjects. Data was compared among the cohort who had a normal versus abnormal CM study, and between those who had a duration of ACE use<36 months versus ≥36 months. RESULTS:Over a 7-year period, 22 children (median age 11 years, IQR 8.1-14.4; 54.5% male) with ineffective ACE therapy were included, of whom 41% had abnormal colonic manometry. Patients with normal CM demonstrated significantly greater total and bisacodyl-induced high-amplitude propagated contractions and higher right colonic contractile amplitude compared with those with abnormal manometry (all p ≤ 0.01), but colonic caliber did not differ and did not correlate with manometry findings (right: r = 0.04, p = 0.87; left: r = -0.12, p = 0.57). Patients with ACE duration ≥36 months had a higher prevalence of right colonic dilation (83.3% vs 30%, p = 0.027) and larger maximal right colonic diameter (p = 0.02). Within this group, right colonic contractile amplitude was lower than left colonic contractile amplitude (p = 0.02). CONCLUSION:Prolonged ACE use (≥36 months) demonstrated a higher prevalence of right colonic dilation and differences in selected colonic manometry parameters compared with those with shorter ACE duration.

Rubinstein-Taybi syndrome is a rare genetic condition associated with a wide range of physical, cognitive, and developmental impairments, yet its gastrointestinal manifestations remain poorly characterized. Case reports and small series suggest a high prevalence of gastroesophageal reflux, constipation, dysphagia, and nutritional compromise, but no large cohort has examined these symptoms in detail. This study aimed to characterize gastrointestinal and nutritional comorbidities in children with Rubinstein-Taybi syndrome seen at a tertiary pediatric center between 2013 and 2023. Among 85 affected patients, 46 (54%) reported gastrointestinal symptoms, and 31 (66%) were evaluated in the Gastroenterology clinic. Symptoms frequently predated the genetic diagnosis. Constipation was most common, followed by reflux symptoms, dysphagia, vomiting, and feeding intolerance or poor weight gain. Most patients underwent at least one diagnostic evaluation, including upper gastrointestinal imaging, video swallow studies, or esophagogastroduodenoscopy. Nearly half required gastrostomy tube support, typically in later childhood, with subsequent improvements in weight and body mass index z-scores and successful transitions to partial or full oral intake in some cases. Oral-fed patients demonstrated modest growth improvement over shorter follow-up intervals. These findings highlight a substantial gastrointestinal disease burden in Rubinstein-Taybi syndrome and underscore the importance of early recognition and multidisciplinary management.

BACKGROUND:Antroduodenal (ADM) and colonic (CM) manometries are performed in pediatric patients to evaluate gastrointestinal motility disorders. While minimal standards for performing ADM and CM have been published, there are no standardized protocols for performance of these studies. We aimed to evaluate the diversity in ADM and CM protocols in pediatric centers worldwide. METHODS:A cross-sectional study using an anonymous survey was conducted among pediatric centers worldwide comparing US and non-US centers. RESULTS:Responses were received from 37 pediatric centers. ADM: 17 (45.9%) centers perform next-day and 14 (37.8%) centers perform same-day studies. Study length ranges from 4 to 24 hours. Erythromycin stimulation is implemented by 29/33 (87.9%), azithromycin by 15/33 (45.5%) and octreotide by 7/33 (21.2%) centers. US centers perform more pharmacological stimulations (30/31 (96.8%) vs. 3/6 (50%), p = 0.0018), while non-US centers conduct longer studies (15.3 hours vs. 7.4 hours, p = 0.0291). CM: 17 (45.9%) centers perform same-day studies with length from 4 to 24 hours, and 89.2% perform pharmacological stimulation, all using bisacodyl. CONCLUSIONS:Significant variability exists in ADM and CM protocols among pediatric centers, affecting study length and pharmacological stimulation. Universal standardized guidelines are needed to ensure uniformity in the performance and interpretation of these studies. IMPACT:Pediatric gastroenterological societies set minimal standards for antroduodenal (ADM) and colonic (CM) manometry studies, allowing variability in timing, fasting, postprandial phases, and provocation tests. Protocol variability among pediatric centers worldwide has not been previously assessed. This study offers a real-life overview of ADM and CM practices in pediatric centers worldwide, highlighting the need for standardized guidelines due to observed variability in timing, duration, and pharmacologic stimulation. The lack of standardization affects study interpretation and underscores the importance of developing universal guidelines.

INTRODUCTION:The optimal first-line treatment of pediatric achalasia remains debated. Pneumatic balloon dilation (PD) shows variable success and low complication rates in small cohorts. To evaluate the efficacy and safety of PD as first-line therapy for pediatric achalasia. METHODS:A retrospective review (2011-2022) of patients aged younger than 21 years treated at a single center was conducted. Success was defined as no additional intervention within 12 months. RESULTS:Of 23 patients (median age 13 years), 78% had success at 12 months; 74% maintained success at 30 months. No major complications occurred. DISCUSSION:PD is a safe, effective first-line treatment of pediatric achalasia.

OBJECTIVES:Percutaneous electrical nerve field stimulation (PENFS) is an FDA-approved nonpharmacological modality for treating disorders of gut-brain interaction (DGBI) in pediatric patients. PENFS presumably functions through stimulation of cranial nerves. There is limited data on patients that require more than a 4-week cycle of treatment with PENFS. We examined the effect of repeated rounds of PENFS on recurrent symptoms and predictors for multiple treatments. METHODS:We evaluated charts of patients who underwent PENFS placement for DGBI. Data included demographics, medical history, and validated questionnaire responses. Changes over time after each round of placement were assessed. Baseline measures were compared between patients with single versus two rounds. RESULTS:A total of 22 patients (median age 17.5 years, 18 (82%) females) with repeated PENFS met the inclusion criteria. A propensity-matched control group (n = 22) showed no significant differences in demographics or diagnoses. Patients requiring repeated PENFS placements had higher PCS-C scores (median 24.5 (IQR 18-28) vs. 16.5 (IQR 9.5-22.5); p = 0.0135), and higher PHQ-9 scores (median 10 (IQR 8-14) vs. 7 (IQR 7.5-9.5); p = 0.0272). The second round of PENFS placements significantly reduced API, PCS-C, FDI, PHQ-9, and CSI scores (p < 0.05). No statistically significant differences between scores after the first and second rounds were noted. CONCLUSION:Repeating PENFS treatments are becoming common in clinical practice. Our study shows that repeat rounds are as effective as the initial ones, with pain catastrophizing and depression predicting worse outcomes and the need for repeat and/or longer round of treatment.

ABSTRACTIntroductionColonic manometry (CM) is a diagnostic procedure used to evaluate pediatric patients with refractory constipation, fecal incontinence, Hirschsprung disease, and pediatric intestinal pseudo‐obstruction. Pan‐colonic high‐amplitude propagated contractions (HAPCs), measured by CM, reflect an intact neuromuscular function of the colon. Current guidelines recommend starting CM with fasting recording for 1–2 h, but no prior evaluation has determined the diagnostic yield of the fasting phase.We aimed to determine the utility of the fasting phase during CM studies.MethodsWe evaluated CM studies conducted at a tertiary pediatric center (2018–2022). Fasting phases of normal CM studies were evaluated.Key ResultsIn 433 included studies 241 (55.7%) females, median age (9.7 years), the average fasting recording lasted 126 min. A total of 193 (44.6%) studies exhibited fasting HAPCs, with 123 (28.4%) being pan‐colonic. The presence of pan‐colonic HAPCs was based solely on the fasting phase in 11 (2.5%) studies.Patients with fasting pan‐colonic HAPCs were younger (median age of 6.9 vs. 9.8 years, p = 0.0001) and had a higher rate of postprandial HAPCs (69.1% vs. 25.2%, p < 0.0001).Most fasting pan‐colonic HAPCs presented during the first 60 min (94/123, 76.4%). All studies demonstrated HAPCs after stimulation with bisacodyl.In analyzing just the initial 30 min of fasting on CM, only 2 (0.5%) studies would have been misclassified as abnormal, with no bisacodyl administration in these studies.Conclusions & InferencesShortening the fasting phase minimally affects next‐day CM results and could reduce patient inconvenience, hospital‐related costs, and potential side effects.

Objectives:Dysphagia is a frequent symptom of active eosinophilic esophagitis (EoE), but at times it persists despite attaining histologic healing and lack of fibro-stenotic changes. We aimed to describe the manometric findings in this subset of patients. Methods:A retrospective review of charts between 2013 and 2023 at a tertiary pediatric gastroenterology center, treating roughly 1500 EoE patients per year. We included children with EoE referred to high-resolution impedance manometry (HRIM) for persistent dysphagia despite histologic healing (i.e., <15 eosinophils/high-power field [Eos/hpf]). Data including initial EoE diagnosis, endoscopy reports, esophageal biopsies, treatment regimens, and HRIM were retrospectively collected. Results:The estimated prevalence of post-remission dysphagia in our cohort was exceedingly rare (<0.05%). Four patients met the eligibility criteria of histologic remission and absence of fibro-stenotic features on endoscopic evaluation and thus, were included in this case series. Patients achieved remission with steroids, proton-pump inhibitor, or both within a median time of 5 months from diagnosis. Peak Eosinophil count at remission was ≤5 Eos/hpf in three patients and ≤10 Eos/hpf in one. On HRIM, all four patients had a hypomotile esophagus and abnormal bolus clearance. Lower esophageal sphincter integrated relaxation pressure values were normal in three patients and elevated in one. Two patients were diagnosed with ineffective esophageal motility, one with aperistalsis and one with achalasia type 1. Conclusions:Post-remission dysphagia is rare in EoE. Esophageal dysmotility with a hypomotile pattern may contribute to the persistent dysphagia in children with EoE. HRIM should be considered in patients with EoE in whom symptoms persist despite histologic remission.

The gastrointestinal (GI) manifestations in children with hypermobile Ehlers-Danlos syndrome/joint hypermobility syndrome (hEDS/JHS) are not well described. We investigated the prevalence of GI disorders in children and young adults with hEDS/JHS through a single-center retrospective review. Demographic data, clinical history, symptoms, and diagnostic studies were reviewed. Of 435 patients with hEDS/JHS, 66% were females (age 5-28 years). We noted a high prevalence of constipation (61%), dysphagia (32%), dyspepsia and/or gastroparesis (25%), eosinophilic esophagitis (EoE) (21%), and celiac disease (4%) in our cohort. Upper endoscopy and gastric emptying scans had the highest yield to detect abnormalities. Motility studies were abnormal in 31% of the 80 patients who underwent them. Dysphagia symptoms are significantly associated with EoE. Thirty-three percent of dysphagia patients had EoE, versus 16% of non-dysphagia patients (p < 0.001). Screening hEDS/JHS patients for GI issues should be routine, with further investigations and referrals guided by identified symptoms.

BACKGROUND:Sacral nerve stimulation (SNS) is a minimally invasive surgical procedure used to treat refractory constipation in children. While its efficacy in improving symptoms has been studied, its effect on colonic motor function remains unclear. This case series explores SNS's impact on colonic motor function in pediatric patients with idiopathic constipation, using high-resolution colonic manometry (HRCM). METHODS:Four pediatric patients with chronic idiopathic constipation underwent SNS placement for intractable symptoms and were subsequently evaluated via HRCM. Clinical characteristics, comorbidities, treatment regimens, and outcomes were reviewed. HRCM was conducted during the SNS-off and SNS-on phases. The motility index (MI) was measured during the SNS-off (fasting and postprandial) and SNS-on phases. RESULTS:Four pediatric patients aged 8 to 21 years met the inclusion criteria. In three patients, SNS-induced high-amplitude propagating contractions (HAPCs) were noted, and in one patient, low-amplitude propagating contractions (LAPCs) were noted. In one patient, propagating contractions were induced only when SNS was turned on. MI changes with SNS-on were variable among different patients with an increase in MI in two patients after turning SNS on and a decrease in the other two compared with baseline. Adverse effects following SNS placement remained minimal across all cases. CONCLUSION:This case series is the first to report SNS effects on colonic motility evaluated by HRCM in pediatrics. We demonstrate that propagating colonic contractions are promptly induced when SNS is turned on. Although the initial effects of SNS on colonic motility were observable, additional investigation is necessary to comprehend the fundamental mechanisms and long-term effectiveness of SNS in pediatric patients.

The authors declare no conflict of interest.

BackgroundFeeding difficulty is widely recognized in patients with Down syndrome, and many patients require gastrostomy tube (G-tube) placement for nutrition. No reliable factors have been identified to predict the expected duration of G-tube feeds in patients with Down syndrome. This descriptive cohort study aimed to determine the factors affecting the duration of G-tube feeds. We also investigated change in body mass index (BMI) from G-tube placement to discontinuation.MethodsMedical records of patients with Down syndrome seen by a pediatric gastroenterologist at a tertiary care center between September 1986 and December 2021 were reviewed. Data collection included demographics, anthropometrics, comorbidities, and feeding route. Comparison was performed between patients who discontinued G-tube feeds and those who did not.ResultsTwo hundred twenty patients (45% female) were included. The median age at G-tube placement was 5 months (interquartile range [IQR]: 0.2-1.3 years). There were 113 (51%) patients who discontinued G-tube feeds, after a median duration of 31.6 months (IQR: 15.6-55.7 months). Tracheostomy was the only covariant associated with a longer duration of G-tube feeds (158 months vs 53 months; P = 0.002). Neither age at G-tube placement nor any comorbidities were associated with BMI status at discontinuation of G-tube.ConclusionIn our cohort of patients with Down syndrome, age at placement of G-tube did not impact the duration of G-tube feeds. Most patients who had a G-tube placed were likely to require enteral feeds for at least 1 year. Those who had a tracheostomy needed their G-tube for a longer time.

INTRODUCTION:Pediatric prucalopride studies for treatment of gastrointestinal (GI) disorders have reported mixed results. We aimed to assess the safety and effectiveness of prucalopride in functional constipation (FC) with and without upper GI symptoms.METHODS:Retrospective data on patients with FC receiving combined prucalopride and conventional therapy was compared with those receiving conventional therapy alone within 12 months. Thirty patients on combined therapy and those on conventional therapy were each matched on the basis of age, gender, race, and presence of fecal soiling. Response (complete, partial, or no resolution) was compared. Similarly, response to concurrent functional upper GI symptoms (postprandial pain, bloating, weight loss, vomiting, early satiety, or nausea) and dysphagia, as well as adverse effects, were evaluated in the combined group.RESULTS:Mean age of 57 cases was 14.7 ± 4.9 years and 68% were female. Comorbidities included functional upper GI (UGI) symptoms (84%), dysphagia (12%), mood disorders (49%), and hypermobility spectrum disorder (37%). Unmatched cases reported 63% improvement to FC; response did not differ between the matched cohorts (70% versus 76.6%, p = 0.84). Cases showed a 56% improvement in functional UGI symptoms and 100% in dysphagia. Adverse effects were reported in 30%, abdominal cramps being most common. Four (7%) patients with a known mood disorder reported worsened mood, of which two endorsed suicidal ideation.CONCLUSION:Prucalopride efficaciously treated concurrent UGI symptoms and dysphagia in constipated pediatric patients and was overall well tolerated. Preexisting mood disorders seemed to worsen in a small subset of cases.

Road Traffic Injuries are one of the world’s leading cause of death, with greatest burden falling on nations with lower and moderate incomes. They are consistently ranked in top 10 leading causes of mortality worldwide for persons of all ages. The biggest advantage of classifying victim degree of injuries in road accidents can pave a way for safer roads and reduced accident rates. This article employs California based SWITRS dataset to propose a novel approach namely Stacked DCL-X model for classifying “victim_degree_of_injury” . It classifies injuries that might take place due to collisions occurring between vehicles and near by pedestrians, obstacles etc. on roads. To verify the superiority of our proposed model, several Machine Learning algorithm-based classification models are stacked together to classify “victim_degree_of_injury” . A total of 1 27 000 accidents are considered from SWITRS dataset when determining the “victim_degree_of_injury” . Machine Learning classifiers implemented in this article includes XGBoost, CatBoost, LightGBM, Decision Tree, Random Forest, Gradient Boosting and Stacked DCL-X. In addition, the algorithm used at feature selection step is Harris Hawk Optimization algorithm, a Nature Inspired Algorithm to select the best features. Prediction results shows that the proposed Stacked DCL-X model provides good stability, fewer hyper-parameters, and highest accuracy under different levels of training data volume. The values of Accuracy, Mean Square Error, and ROC-Auc in Stacked DCL-X model are 87.52, 0.5677 and 97.43, respectively. Moreover, confusion matrix and evaluation metrics of the proposed model provides better results than state-of-the-art classifiers. Statistical analysis has also been performed using Friedman’s rank test on different datasets to ensure the superiority of our proposed Stacked DCL-X model. The findings of this study would be helpful in classifying the “victim_degree_of_injury” . These findings are highly significant in smart city projects to effectively establish timely proactive strategies and improve road traffic safety.

BACKGROUND:Colonic manometry (CM) is a diagnostic procedure utilized in the evaluation of intractable constipation and involves endoscopic insertion of a manometry catheter with the tip placed in the cecum. Difficulty in advancing the colonic manometry catheter to the right colon and/or distal displacement of the catheter after appropriate placement can result in partial evaluation of the colon. Our study aimed to assess the value of limited left CM in identifying motility disorders.METHODS:We evaluated CM studies conducted at a tertiary pediatric center (2019-2022). Abnormal CM studies with catheter tips located in the cecum or ascending colon were included.KEY RESULTS:Of 161 CM studied, 68 with abnormal CM studies met inclusion criteria (29 [42.7%] females, median age 10.3 years). Pan-colonic dysmotility was noted in 29 (42.7%) studies and segmental dysmotility in 39 (57.4%) studies. Dysmotility of the descending and/or sigmoid colon was the most common segmental dysmotility (30, 76.9%). Isolated dysmotility of the ascending colon was noted only in patients with a cecostomy (6/13, 46.2%). The diagnostic sensitivity for dysmotility by left CM was 91.2%, which increased to 100% when excluding patients with cecostomy.CONCLUSIONS AND INFERENCES:Left CM is a valuable and sensitive diagnostic tool for identifying abnormal colonic motility in most pediatric patients with constipation without cecostomy. Our study results provide reassurance when the manometry catheter becomes dislodged from the cecum and moves distally. Those with cecostomy have a high prevalence of dysmotility in the ascending colon and need a complete CM to identify it.