This review highlights some of the recent advances in pediatric colon and anorectal motility testing including indications and preparation for the studies, and how to perform and interpret the tests. This update has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).

Pediatric gastroparesis is a complex condition with variable symptomatology and outcome depending on multiple parameters. Understanding the clinical features and response to therapy will improve our diagnosis and treatment of this disorder.

Background Antegrade continence enemas (ACE) have been used in the treatment of defecation disorders in children; little is known on their effect on colon motility and the utility of the colon manometry (CM) predicting long term ACE outcomes. Methods Retrospective review of children with constipation undergoing CM before and after ACE to evaluate CM changes and their utility on predicting ACE outcome. Results 40 patients (mean age 8.8 SD 3y and 53% female) were included; 39/40 responded to the ACE. Of these 39, 14 (36%) were dependent and 25 (64%) had decreased it (11 of those or 28% discontinued it). On repeat CM we found a significant increase in the fasting (p<0.01) and post-prandial (p=0.03) motility index, number of bisacodyl-induced high amplitude propagating contractions (HAPC’s) (p=0.03) and total HAPC’s (p=0.02). Gastrocolonic response to a meal, propagation and normalization of HAPC’s improved in 28%, 58% and 33%, respectively with CM normalizing in 33% of patients. The baseline CM did not predict ACE outcome. The presence of normal HAPC’s on the repeat CM was associated with ACE decrease. Progression and normalization of HAPC’s (p=0.01 and 0.02 respectively) and CM normalization (p=0.01) on repeat CM were individually associated with ACE decrease. No CM change was associated with ACE discontinuation. Multivariate analysis showed that older age and HAPC normalization on CM predict ACE decrease and older age is the only predictor for ACE discontinuation. Conclusions Colon motility improves after ACE and the changes on the repeat CM may assist in predicting ACE outcome.

Objective To present our experience using cyproheptadine, a potent serotonin antagonist used to stimulate appetite, in the therapy of dyspeptic symptoms in children. Study design Retrospective open label study evaluating the safety and efficacy of cyproheptadine in children with refractory upper gastrointestinal symptoms (nausea, early satiety, vomiting, retching post-fundoplication and abdominal pain). Response was graded as resolution if symptoms resolved and medication was discontinued, significant improvement if symptoms resolved with no further interventions, and anything else as failure. Results A total of 80 children were included (mean age 10 years and 65% were female). Response to therapy was reported in 55% of patients. Multivariate analysis showed children and female sex respond better (p=0.04 and 0.03, respectively). We found no association of therapy response and gastric emptying, antroduodenal manometry, functional dyspepsia, vomiting and use of cyproheptadine as first therapy. Vomiting within an hour after starting meals responded better than late vomiting (p=0.03) and patients with retching after a Nissen fundoplication had an 86% response rate. A total of 30% complained of side effects all mild, including somnolence (16%), irritability and behavioral changes (6%), increased appetite and weight gain (5%) and abdominal pain (2.5%) but only 2 discontinued therapy. Multivariate analysis demonstrated an association between presence of side effects and lack of response to therapy (p=0.04) and no association with age and sex. Conclusions Cyproheptadine is safe and effective in the treatment of dyspeptic symptoms in children, particularly in young children and those with early vomiting and retching post-fundoplication.