Efficacy and safety of intrapyloric botulinum toxin injection in pediatrics: Current evidence and future directions

Pediatric gastroparesis is a debilitating disease requiring more diverse and effective treatment options. Intrapyloric botulinum toxin (IPBT) injection has emerged as a therapeutic option, although evidence supporting its use in children remains limited. The aim of this review is to summarize the current literature on IPBT injection for pediatric gastroparesis, focusing on symptomatic outcomes and potential predictors of response. Overall, most studies report some degree of symptomatic improvement following the injection; however, these findings are derived from small, retrospective cohorts without control groups. Objective predictors of response evaluated include gastric emptying scintigraphy, which did not show correlation with treatment response. Similarly, antroduodenal manometry general impressions and endoscopic functional luminal probe parameters did not reliably predict symptomatic response to the injection. Several studies describe repeated injections, although protocols for repeat are unclear, and the response is varied. Body surface gastric mapping represents a novel modality that may provide gastric physiological data allowing its use as a biomarker guiding IPBT injection, although pediatric data is still limited. Other emerging modalities, including gastric emptying breath test and gastric magnetic resonance imaging, may further enhance assessment of gastroparesis and treatment response. The current pediatric evidence on IPBT injection for gastroparesis is limited by suboptimal study designs and lack of objective assessments of treatment response. Future prospective, controlled studies are needed to strengthen conclusions on IPBT injection efficacy for pediatric gastroparesis and to clarify its role in clinical practice.