Bowel preparation for pediatric colonoscopy: Which regimen is the best?

Bowel preparation is a key aspect of colonoscopy, and inadequate bowel preparation is associated with an increased rate of missed adenomas, cecal intubation failure, and unsatisfactory patient experience.1 Various bowel preparation regimens have been developed to achieve adequate bowel preparation. The recent European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend the use of polyethylene glycol (PEG)-based regimens or non-PEG-based agents such as sodium picosulfate with magnesium citrate (PMC) and oral sulfate solution.2 Pediatric colonoscopy is most commonly performed when considering a diagnosis or during follow-up of inflammatory bowel disease, meaning that some patients require repeated colonoscopies. In pediatric colonoscopy, bowel preparation is both the most important and most challenging aspect of the procedure.3 In children, the large volume and poor taste of the preparatory solution is an obstacle to the completion of bowel preparation, and around 20% of colonoscopies are associated with suboptimal bowel preparation and substantial patient discomfort. Patient acceptability for the solution is crucial for pediatric colonoscopy, and poor patient acceptability means that some cases require a nasogastric tube to administer the solution.4 The clinical guidelines for pediatric gastrointestinal endoscopy, commissioned by the ESGE and the European Society for Pediatric Gastroenterology Hepatology and Nutrition, recommend low-volume preparation for bowel preparation in children, using either PEG with ascorbate or PMC.5 This recommendation was made based on a previous randomized controlled trial (RCT) which showed that the low-volume PEG and PMC regimens were noninferior to the high-volume PEG regimen in pediatric colonoscopy.6 Regarding acceptance, the PMC regimen might be the most suitable bowel preparation for pediatric colonoscopy. The split-dose of PEG is better tolerated and more effective as compared to the single-dose regimen.7 However, whether the day-before PMC regimen or the split-dose PMC regimen is superior remains unclear. In this issue of Digestive Endoscopy, Di Nardo et al.8 reported the efficacy of the PMC split-dose regimen for pediatric colonoscopy. In this study, the authors conducted a multicenter, randomized, observer-blind, parallel group study to assess the superiority of the split-dose PMC regimen compared with the day-before PMC regimen for pediatric colonoscopy. In the PMC split-dose group, patients received the first oral doses of PMC at 7:00 p.m. of the day before colonoscopy and the second one at 7:00 a.m. on the morning of the day of colonoscopy. In the PMC day-before dose group, patients received two oral doses of PMC at 5:00 p.m. and 4 h later in the evening prior to the colonoscopy. The primary end-point was the rate of successful cleansing level, defined as the Boston Bowel Preparation Scale (BBPS) ≥6. In total, 368 patients were allocated and 360 (180 per group) patients were analyzed. The rate of successful cleansing level was significantly higher in the split-dose group than in the day-before group (95.6% vs. 80.9%; P < 0.001). The total BBPS score was also higher in the split-dose group (7.58 vs. 6.75; P < 0.001). Notably, patient acceptability (ease of taking the solution and willingness to repeat) was significantly better and the percentage of children requiring nasogastric tube placement was significantly lower (0% vs. 3.8%; P = 0.007) in the split-dose group. This is the first study comparing the day-before and the split-dose PMC regimens, and has the largest sample size of all studies assessing PMC regimens in pediatric colonoscopy. The findings of this study should be taken into consideration when choosing a bowel preparation regimen for pediatric colonoscopy. In a previous RCT, Di Nardo et al.6 showed that the day-before PMC regimen was noninferior to the other three day-before PEG regimens, including high-volume PEG in the cleansing level. This study also demonstrated that the PMC regimen tended to show an improved tolerability (including the need for nasogastric tube), acceptability, and compliance compared with other day-before PEG regimens. According to their studies,6, 8 split-dose PMC appears to be the most suitable regimen because of its improved tolerability. However, no study has yet compared split-dose PMC and split-dose PEG regimens in pediatric colonoscopy. Future studies are warranted to assess these regimens. In addition, the efficacy of the new 1 L PEG plus ascorbate solution has recently been reported in adults, in a study which showed that the day-before 1 L PEG plus ascorbate regimen demonstrated a noninferior cleansing level compared with the day-before PMC regimen.9 The lower volume of this new solution may improve acceptability and tolerability, but this product is not recommended for use in children below 18 years of age due to the lack of safety and efficacy profiling. Thus, there seems to be room for the development of new pediatric-friendly preparations. In the recent endoscopy quality guidelines for pediatric endoscopy, a minimum target for the key quality indicator “rate of adequate bowel preparation” was set at ≥80%.10, 11 However, the current evidence supporting this indicator is limited, and there is uncertainty about the definition of “adequate”. A number of bowel preparation scales have been validated in adult colonoscopy, including BBPS, Ottawa Bowel Preparation Scale, and Aronchick Scale; however, their application to pediatrics has not yet been systematically evaluated. Prospective validation of this indicator is the next issue to be solved. In summary, the study by Di Nardo et al. clearly demonstrated that the split-dose PMC regimen is superior to the day-before PMC regimen for pediatric colonoscopy. Notably, no patient required nasogastric tube placement in the split-dose PMC group with higher acceptability. Combined with the study outcomes of other RCTs, the split-dose PMC regimen should be regarded as a standard regimen for pediatric colonoscopy. Author declares no conflict of interest for this article. None.

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