Comparative Cleansing Efficacy, Safety, and Tolerability of Bowel Preparation Agents in Pediatric Patients: A Network and Proportional Meta-Analyses of Randomized Controlled Trials.

BACKGROUND/AIMS: Efficient bowel preparation is essential for high-quality visualization and lesion detection during colonoscopy. In children, bowel cleansing is often challenging due to age-related physiology, poor palatability of agents, and low tolerability. The optimal regimen remains uncertain. We aimed to compare the efficacy, safety, and tolerability of bowel-cleansing agents in children.

METHODS

We conducted a network and proportional meta-analysis of randomized controlled trials (RCTs) retrieved through May 2025 from PubMed and Embase. The primary outcome was bowel cleansing efficacy, measured by validated preparation scales. Secondary outcomes included safety and tolerability. Polyethylene glycol electrolyte lavage solution (PEG-ELS) served as the reference comparator.

RESULTS

Twenty RCTs (2,468 subjects) were included. Polyethylene glycol 3350 (PEG-3350 or Miralax) demonstrated the highest cleansing efficacy (92.3%). Other regimens, including PEG-ELS + bisacodyl, sodium picosulfate with magnesium citrate, PEG-ELS + enema, PEG-ELS + ascorbic acid, and normal saline, also achieved adequate bowel preparation (> 80%) in the proportional meta-analysis; however, the latter two were evaluated in single studies. The network meta-analysis of safety outcomes revealed no significant differences in abdominal pain among agents. Furthermore, sodium picosulfate with magnesium citrate exhibited the lowest rates of nausea/vomiting and ranked highest in tolerability. Notably, the two small RCTs evaluating PEG-3350 (Miralax) reported safety outcomes but did not include tolerability data.

CONCLUSION

Sodium picosulfate with magnesium citrate offers the most favorable balance of efficacy, safety, and tolerability for pediatric colonoscopy preparation. PEG-3350 (Miralax) may be considered when maximized cleansing is the goal, but additional efficacy and tolerability data in children are needed. PROSPERO registration number: CRD42024508556.