Objectives: To critically appraise ileocolonoscopy practice in a large tertiary center, where ileocolonoscopy is exclusively performed by experienced pediatric colonoscopists, particularly focusing on: indications for the procedure; bowel preparation efficacy; IC completion rates and timings; diagnostic yield; and complications. Patients and methods:We prospectively evaluated all patients referred to our clinic between July 2015 and June 2016. Data on age, height and weight, gender, surgical history, indications for colonoscopy, bowel preparation given, bowel cleansing efficacy were collected. The following were calculated: percentage of terminal ileal intubation; time to terminal ileum; total duration of each procedure. Additionally, we evaluated the number and the type of complications encountered and the number of patients readmitted within 30 days from the elective procedure. Endoscopic diagnostic yield, stratified for indication, was calculated.Results: A total of 1392 patients were referred; 181 required an endoscopic evaluation of the lower GI tract (Outpatient Department conversion rate: 13%). Main indications for IC were: recurrent abdominal pain 38.1%; unexplained chronic diarrhea 16%; suspected IBD 24.9%; isolated rectal bleeding 13.2%; occult GI bleeding 1.6%; unexplained faltering growth 1.6%; IBD restaging 2.6%; miscellaneous 1.6%. Terminal ileum was reached in all the patients (TI intubation rate = 100%). Median time to TI was 9.8 minutes (1 to 50 minutes). Time to TI was lower in younger patients compared to older ones (p = 0.005). Bowel-cleansing was judged as: Grade 1 in 49.2%; Grade 2 in 33.7%; Grade 3 in 13.3%; and Grade 4 in 3.9%. A significant statistical correlation was recorded between bowel-cleansing and time to TI. The positive diagnostic yield was: 11.6% in patients with abdominal pain; 37.9% in patients with chronic diarrhea; 51.1% in patients with suspected IBD; 29.2% in patients with isolated rectal bleeding; 33.3% in patients with occult GI bleeding; 0% in patients with faltering growth; and 33% in the miscellaneous group. Conclusions:In conclusion, appropriately targeted IC in the management of children with GI symptoms, is a safe, fast and useful investigation. TI intubation rates of 100% are achievable and desirable and can be conducted quickly. Poor bowel preparation impacts negatively on this and IC duration may be faster in younger children. High diagnostic yields have been recorded in patients with a clinical suspicion of IBD. Diagnostic yield in isolated recurrent abdominal pain is low. Training to excellence in pediatric IC should be a persistent goal.