**Background:** Pediatric endoscopy has transformed the diagnosis and treatment of gastrointestinal (GI) disorders in children since its inception in the 1970s. However, many advanced diagnostic modalities routinely used by adult gastroenterologists—such as endomicroscopy, image-enhanced endoscopy, and impedance planimetry—are not yet standard in pediatric practice. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Endoscopy and Procedures Committee presents this first article in a series of state-of-the-art technology reviews, focusing on advances in diagnostic tools for pediatric GI disorders.
**Methods:** The NASPGHAN Endoscopy Committee identified a need to review new diagnostic modalities in pediatric endoscopy. Each section was written by pediatric endoscopists who conducted literature reviews using the PubMed database from 2016 to 2021. Some sections were based on expert opinion due to the paucity of pediatric data. Topics were proposed to and approved by the NASPGHAN Council.
**Key Results:** The review covers seven major technologies:
1. **Image-Enhanced Endoscopy (IEE):** Includes dye-based chromoendoscopy (using stains such as Lugol iodine, methylene blue, indigo carmine, acetic acid) and electronic chromoendoscopy (narrow-band imaging [NBI], FICE, i-SCAN). In adults, chromoendoscopy increases detection of dysplastic lesions by 2- to 3-fold compared with white light endoscopy. In children, Barrett's esophagus incidence is 1.43% in those without neurodevelopmental or tracheoesophageal conditions but rises to 15% (1.3–15%) in children with esophageal atresia. In pediatric PSC-UC/IBD-U patients (median age of IBD diagnosis 12.6 years), the 5-year probability of developing colorectal cancer after diagnosis was 0.8% and the 10-year probability was 4.8%. Spray catheters cost $60–100 and dyes range from $25–150.
2. **Confocal Laser Endomicroscopy (CLE):** Provides 1000-fold magnification and "optical biopsies" of GI mucosa at the cellular level, imaging from the epithelial surface to approximately 250 μm below the surface. In adults, CLE has 93% accuracy for diagnosing Helicobacter pylori infection. In pediatrics, a series of 44 patients (youngest 8 months old) underwent CLE without adverse events. Probe-based CLE costs include probes ($8,900–9,900) and the Cellvizio system ($175,000).
3. **Optical Coherence Tomography (OCT):** Uses low-coherence interferometry with 5–10 µm resolution for cross-sectional imaging. In adults, OCT showed adenomas had significantly less structure and scattered light to a lesser degree than hyperplastic polyps. A pediatric study showed 90.0% sensitivity and 83.3% specificity for detecting disrupted layered colon wall structure to distinguish Crohn's disease from ulcerative colitis. The NvisionVLE Imaging System costs approximately $200–235k USD.
4. **Endo Functional Luminal Imaging Probe (EndoFLIP):** Uses high-resolution impedance planimetry with 16 impedance sensors to assess GI lumen diameter, cross-sectional area, compliance, pressure, and distensibility index. FDA-approved for children 5 years and older in early 2019, with published off-label use in children as young as 10 months. The normal adult esophagogastric junction distensibility index is greater than 2.8 mm²/mmHg at 60 mL inflation. System costs range from $24,058 (1.0 system) to $69,500 (2.0 system).
5. **Wireless Motility/pH Capsule (WMC):** An orally ingested capsule (26.8 mm length, 12 mm diameter) measuring temperature, pH, and pressure to assess gastric emptying, small bowel transit, colonic transit, and whole gut transit time without radiation. FDA-approved for adult gastroparesis (2006) and chronic idiopathic constipation (2009). In pediatrics, one study found WMC highly sensitive compared with scintigraphic gastric emptying studies. Starter kit approximately $20,000 USD plus $3,000 for 5 capsules.
6. **Wireless Colon Capsule Endoscopy (CCE):** Second-generation capsule (CCE-2, 11.6 × 31.5 mm) with two cameras, adaptive frame rate (35 images/second when moving, 4 when stationary), and ~10-hour battery. In 40 pediatric Crohn's disease patients (mean age 13.1 ± 3.1 years), sensitivity and specificity for colon inflammation were 89% and 100%, respectively; for small bowel inflammation, 90% sensitivity and 94% specificity. In 29 pediatric ulcerative colitis patients (mean age 14.1 ± 3.2 years), sensitivity was 96% (95% CI, 79%–99%) and specificity was 100% (95% CI, 61%–100%).
7. **Endoscopic Ultrasound (EUS):** Expands examination beyond mucosa into deeper tissues. EUS has 91% sensitivity and 86% specificity for noncalcific pancreatitis, and 94% sensitivity and 95% specificity for choledocholithiasis. For common bile duct stones <4 mm, EUS sensitivity is 90% vs 23% for ERCP. EUS-guided liver biopsy obtained adequate tissue in 98% of 110 patients. EUS-celiac plexus neurolysis has >80% clinical success in pancreatic cancer and 60% in chronic pancreatitis. Overall mortality rate for EUS/EUS-FNA is 0.06% with complication rate under 3%. Start-up costs approach $400,000.
**Clinical Implications:** Although most advanced endoscopic technologies are primarily validated in adults, their pediatric applications are expanding. EUS is now integral to pediatric hepatobiliary disease management. Chromoendoscopy is recommended by consensus for screening metaplasia in children with longstanding IBD. The review emphasizes that pediatric gastroenterologists, uniquely trained to recognize and treat pediatric conditions, should apply these emerging technologies to benefit young patients. Key barriers include limited pediatric-specific data, equipment costs, and need for dedicated training opportunities. The NASPGHAN Endoscopy Committee hopes this document will stimulate further development and utilization of cutting-edge endoscopic technologies in pediatric gastroenterology.