Therapeutic Role of Neostigmine and Pyridostigmine in Pediatric Chronic Intestinal Pseudo-Obstruction: A Systematic Review

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.