Procedural Sedation in Pediatric Gastroenterology: A Narrative Review from the Shared Perspective of Pediatric Gastroenterology and Anesthesiology

Background/Objectives: Endoscopic and interventional procedures in pediatric gastroenterology are increasing in number and complexity, and most require sedation or, in selected cases, general anesthesia (GA); children face a higher risk of serious sedation-related adverse events than adults. Written jointly by pediatric gastroenterologists and anesthesiologists, this review provides a practical, evidence-referenced framework for procedural sedation across pediatric gastrointestinal procedures. Methods: We performed a narrative review of PubMed/MEDLINE (inception to 20 June 2026, the date of the final search), prioritizing society guidelines, systematic reviews, randomized controlled trials, and large registries on pediatric procedural sedation, sedative agents, capnography, and high-flow nasal oxygen (HFNO). Results: Sedation should be matched to the procedure and to a structured risk tier, targeting the lightest depth that allows safe completion. Propofol-, ketamine-, and dexmedetomidine-based regimens dominate; remimazolam and esketamine are emerging, but pediatric data are limited. Capnography detects hypoventilation before desaturation, and HFNO reduces hypoxemia in adults, whereas pediatric-specific evidence remains limited and the pediatric subgroup analysis did not reach statistical significance. Higher-risk groups require tailored planning, monitoring, and rescue readiness; most evidence is observational or extrapolated from adults. Conclusions: Safe pediatric gastrointestinal sedation combines structured risk assessment, rational drug combinations, capnography-supported monitoring, and consistent complication reporting. Who administers deep sedation, and whether general anesthesia is preferred, should depend on patient and procedural risk together with local regulations, institutional policy, training and credentialing, and rescue capability, within a shared gastroenterology-anesthesiology framework. Adequately powered pediatric trials of HFNO and of remimazolam/esketamine, and long-term neurodevelopmental follow-up, are priorities.