The diagnosis and treatment of gastrointestinal disease in children includes effective and safe bowel preparation before colonoscopy. Patients with inadequate preparation are at risk for increased duration of anesthesia exposure, poor mucosal visualization, and need to abort the procedure.1 Several laxatives are currently approved in pediatrics, and there is variability in using them due to tolerance, acceptability, availability, and efficacy. There is no single recommended protocol for bowel preparation before colonoscopy, with regimens including polyethylene glycol (PEG) 3350, magnesium citrate, senna, and bisacodyl.2 This lack of consensus demands that providers acknowledge factors impacting preparation quality, prescribe a patient-specific regimen, and assist with troubleshooting unsuccessful preparations. The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee has reviewed quality indicators for pediatric colonoscopy and recommends utilizing bowel preparation as a quality metric.3 The Boston bowel preparation scale (BBPS) and Ottawa bowel preparation scale assign cleanliness scores to each colonic segment whose sum reflects a global assessment of bowel preparation while acknowledging that the colon is not uniformly prepared.4 By contrast, the Aronchick scale assigns one score to represent preparation quality of the colon and has been utilized in studies comparing bowel preparations due to its perceived simplicity and intent to grade preparation prior to additional endoscopic cleansing.1 Optimal preparation renders efficient colonoscopies, as shown by ileal intubation rate and procedure time.3 While ileal intubation rate is a quality indicator for pediatric colonoscopy and bowel preparation, important limitations to success exist such as presence of ileocecal valve stricture.3 Procedure time may correlate with bowel preparation quality; however, it may be impacted by therapeutic maneuvers and endoscopist experience level.3 Bowel preparation prior to colonoscopy can be challenging as laxatives are not always palatable and require consumption of large volumes of liquid. Several studies observed that children experience nausea, vomiting, abdominal pain, and bloating while undergoing bowel preparation.1 Therefore, the gastroenterologist should anticipate challenges when patients have risk factors for inadequate bowel preparation. Prior to recommending a laxative regimen, one should consider tolerability factors that may impede adequate bowel preparation. Unfortunately, there is minimal data regarding the tolerability and efficacy of bowel preparation by age. A single-center review in South Korea observed that adequate preparation could be achieved in older children through PEG 3350 with electrolytes and infants through small-volume enemas with clear liquid diet for 12–24 h.5 However, other studies demonstrate pre-school-age children had poor bowel preparation quality,6 and children under 7 years old had a higher risk of hypoglycemia with a weight-based PEG 3350 and bisacodyl regimen.1 Studies investigating the use of split-dose preparation are promising. Two randomized control trials demonstrated that split-dose PEG with electrolytes was better tolerated and more effective than a single-dose regimen.1 Split-dose regimens of sodium picosulfate plus magnesium citrate (SPMC) were tolerated by children and provided superior overall and segmental bowel preparation quality compared to a single-dose regimen as studied in a group of 360 children.7 Furio et al. stressed the superior acceptability and effectiveness of split-dose regimens in children, while also recognizing a higher rate of tolerability to SPMC compared to PEG 4000 despite similar efficacy.8 Overall, these studies suggest that split-dose and lower-volume regimens can improve laxative acceptability in children at risk for poor tolerance to bowel preparation. Thus, providers should consider prescription of split-dose regimens if a child is expected to have poor tolerance to a preparation regimen. Furthermore, if a child has not tolerated a more typical regimen, such as PEG 3350, providers should consider bowel preparation with SPMC if appropriate. Knowledge of multiple preparation regimens, including some adult regimens approved by the United States Food and Drug Administration for use in some children depending on age (Table 1), should empower providers to tailor recommendations to each child.9 While sodium phosphate-based regimens are not recommended in children under age 18, sodium sulfate regimens such as SUPREP may be utilized in children over age 12 and sodium picosulfate-based regimens such as CLENPIQ may be administered to children over age 9.1 In pediatrics, a clear liquid diet is often recommended 1 day prior to a colonoscopy while taking the prescribed bowel preparation. Adult studies and one pediatric randomized controlled trial have shown no significant difference in preparation quality when comparing the use of a low-residue diet to a clear liquid diet.1 A recent randomized double-blind placebo-controlled trial in Iran evaluated the impact of administering Lactobacillus reuteri daily for 10 days prior to colonoscopy with a 2-day PEG 4000 (Pidrolax) and bisacodyl bowel preparation in a group of 84 children.4 BBPS scores were significantly higher in the probiotic group. Another study of 30 children in India noted that a high proportion of patients who took a combination of Bacillus coagulans and senna achieved adequate BBPS scores.1 These studies suggest that use of low-residue diet and probiotics or probiotic-rich foods during bowel preparation deserves further investigation in pediatrics. A single-center retrospective study noted that children with Medicaid insurance and for whom English was a second language had a higher risk of inadequate BBPS scores during colonoscopy.1 Similar findings are demonstrated in adult studies, and a cross-sectional observational study in adults noted low health literacy to be a significant predictor of decreased comprehension of written colonoscopy preparation instructions.10 Therefore, pediatric gastroenterologists should anticipate a need for additional communication and follow-up of bowel preparation progress with families who have Medicaid insurance, primary language other than English, and/or lower health literacy. Low health literacy may be accompanied by low socioeconomic status (SES), a widely reported risk factor for suboptimal bowel preparation. An Australian study examining risk factors for poor preparation quality in adults found that patients with low education, low SES, poor health literacy, and increased age were at higher risk for inadequate bowel preparation prior to colonoscopy.11 After implementation of targeted education (face-to-face or phone education) for at-risk patients, a significant improvement in bowel preparation was observed. While this was a time-intensive intervention requiring access to resources, the results demonstrate that at-risk populations benefit from supplemental bowel preparation education.11 Most preparation regimens are provided in written and/or verbal format in advance of a colonoscopy. Given the previously discussed risk factors for inadequate bowel preparation—Medicaid insurance, primary language other than English, low health literacy, and low SES—providers should consider the most effective means to communicate preparation instructions. This may include non-traditional modes of communication (Figure 1). The utility of an instructional cartoon has been evaluated and did not provide a significant difference in Ottawa scores.1 Some institutions provide an animated video to supplement verbal and written instructions.1 Interestingly, the use of a digital application in both adult and pediatric studies has had promising results. An automated digital navigation program (DNP), which is known to improve preparation quality in adults, was implemented in a recent pediatric study to evaluate its impact on bowel preparation quality.12 The DNP provided text reminders, access to bowel preparation instructions, and educational content. Significantly higher quality of bowel preparation was observed in the DNP group compared to the non-DNP group.12 Another study observed improvement in preparation quality with the use of a smartphone application to provide educational materials and reminders.1 Applications may provide reminder notifications to caregivers and access to a portal that houses bowel preparation instructions and troubleshooting resources during laxative administration. Successful bowel preparation prior to colonoscopy in children is challenging, often requiring the consumption of large volumes of laxatives and divergence from normal diet. Inadequate bowel preparation increases the risk of missed pathology and longer procedure time under anesthesia. Given this, the pediatric gastroenterologist should assess preparation quality via a validated scoring system and recognize potential barriers to adequate bowel preparation, such as patients with Medicaid insurance, non-English primary language, lower health literacy, and lower SES. Providers should employ evidence-based approaches that improve bowel preparation, such as split-dose and/or lower volume regimens and innovative forms of preparation education. While low-residue diet and probiotics require further study, they may provide a springboard for feasible quality improvement work at the institutional level. Bruno P. Chumpitazi may receive royalties from the Rome Foundation and is a consultant for Ironwood Pharmaceuticals. The remaining authors declare no conflicts of interest.
Patel et al. (Fri,) studied this question.