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Therapeutic Role of Neostigmine and Pyridostigmine in Pediatric Chronic Intestinal Pseudo-Obstruction: A Systematic
Caterina Cocchi1, Vanessa Rossetti2, Luisa Zupin3
1University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy. cate160cocchi@gmail.com.
Insights
Cholinesterase inhibitors like pyridostigmine and neostigmine show promise for pediatric chronic intestinal pseudo-obstruction (PIPO). These treatments offer symptom improvement in many children, with generally good safety profiles.
Area of Science:
- Gastroenterology
- Pediatric Medicine
- Pharmacology
Background:
- Chronic intestinal pseudo-obstruction (CIPO) presents as intestinal obstruction without a mechanical cause.
- Pediatric intestinal pseudo-obstruction (PIPO) is the manifestation of CIPO in children.
- Diagnosis is challenging, often relying on exclusion, and management focuses on symptom relief.
Purpose of the Study:
- To review the evidence for pyridostigmine and neostigmine in treating pediatric CIPO.
- To assess the efficacy and safety of these cholinesterase inhibitors in children.
Main Methods:
- A systematic review of studies published up to July 2025.
- Searches were conducted across PubMed, Embase, Web of Science, and Scopus.
- Inclusion criteria focused on pyridostigmine and neostigmine use in pediatric CIPO patients.
Main Results:
- 22 publications involving 54 pediatric patients were analyzed.
- Approximately two-thirds of patients experienced favorable clinical responses.
- Adverse events were infrequent, with rare treatment discontinuations.
Conclusions:
- Pyridostigmine and neostigmine show potential as therapeutic options for pediatric CIPO.
- Neostigmine may be more effective in acute situations, while pyridostigmine suits chronic management.
- Further robust clinical trials are needed to confirm efficacy and guide standard care integration.
Background:
Chronic intestinal pseudo-obstruction (CIPO) is a rare and severe disorder presenting with the clinical and radiological features of intestinal obstruction in the absence of a mechanical cause. When it manifests in children, it is referred to as pediatric intestinal pseudo-obstruction (PIPO). Diagnosis remains challenging and is largely based on exclusion. Management is primarily symptomatic, and among the available therapeutic approaches, cholinesterase inhibitors have emerged as potential options for severe gastrointestinal dysmotility, particularly when conventional treatments are insufficient. This review summarizes the current evidence on the use of pyridostigmine and neostigmine in CIPO, with a focus on pediatric patients.
Methods:
A systematic review was performed using PubMed, Embase, Web of Science, and Scopus, including all studies published up to July 2025 that evaluated the use of pyridostigmine and neostigmine in pediatric patients with CIPO.
Results:
Our review identified 22 publications reporting a total of 54 patients. Overall, treatment with neostigmine or pyridostigmine was associated with a favorable clinical response in approximately two-thirds of cases, ranging from partial improvement to complete symptoms resolution. Safety outcomes were generally reassuring, with few adverse events and only rare cases requiring treatment discontinuation.
Discussion:
Pyridostigmine and neostigmine may represent therapeutic options for pediatric CIPO, with neostigmine appearing particularly effective in acute settings and pyridostigmine more suited to chronic management. Although current evidence supports both safety and potential efficacy, robust clinical trials are essential before these agents can be integrated into standard care protocols.
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