Managing Small Intestinal Bacterial Overgrowth in Pediatric Short Bowel Syndrome

Importance Small intestinal bacterial overgrowth (SIBO) is a common and clinically important complication of short bowel syndrome (SBS) in children, contributing to feeding intolerance, malabsorption, bloodstream infections, and frequent antibiotic exposure. Diagnostic and management practices vary widely across centers, and no rigorously developed, evidence-informed pediatric-specific guidance currently exists. Objective To develop international, pediatric-specific, expert consensus recommendations for the diagnosis and management of SIBO in children with SBS, with emphasis on diagnostic approach, antibiotic therapy, treatment response, and prevention. Evidence Review A modified Delphi process was conducted between April 4, 2024, and February 18, 2025. A 7-member steering committee reviewed pediatric and adult SIBO literature using the terms small-intestinal bacterial overgrowth , short bowel syndrome , intestinal failure , and pediatric . Because pediatric-specific data were limited and study designs were heterogeneous, systematic reviews and meta-analyses were not feasible. Fifty-five international experts from multidisciplinary intestinal rehabilitation programs in North America and Europe were invited to participate in 3 rounds of anonymous online surveys and 2 in-person moderated consensus meetings. Draft statements were iteratively refined. Consensus was defined a priori as agreement of 75% or greater among respondents. Findings Completed surveys were received from 33 participants in round 1, 38 in round 2, and 28 in round 3. Consensus was achieved on 21 statements involving diagnostic approaches, therapeutic strategies, and monitoring practices. Recommendations addressed the use of breath testing and clinical criteria, indications for empiric antibiotic therapy and cycling, antibiotic selection and duration, and dietary considerations. Symptomatic improvement was considered an acceptable indicator of treatment response. Metronidazole was identified as the preferred first-line antibiotic, and long-term antibiotic cycling was supported for selected patients with recurrent, treatment-responsive SIBO. Collectively, the statements provide a practical framework to support consistent clinical decision-making in pediatric SBS-associated SIBO. Conclusions and Relevance This Delphi-based consensus provides the first international pediatric-specific guidance for diagnosing and managing SIBO in children with SBS. Implementation of these recommendations may reduce practice variability, support more judicious antibiotic use, and improve patient outcomes while establishing a foundation for future research in this high-risk population.