818 YJ Kim • General considerations and updates in pediatric gastrointestinal diagnostic endoscopy of each medicine, monitoring during and after the procedure, and complications. Patient and parent preparations Understanding of the methods and preparations for gastro- intestinal endoscopy (GIE) on the part of pediatric patients and their families allows the procedure to be performed without difficulties and with good outcome. It is recommended that the preparation should start early, and sufficient information should be provided to the patients and their families. The endoscopist should decide on the sedation methods to be used on the basis of the patient’s past experiences with the procedure. Parents and children often express anxiety about separation during the procedure; thus, parental presence is warranted during the preprocedure educational period. Parental presence during the induction of anesthesia has been approved to alleviate stress in both children and parents2). Loss of inhibition and agitation in patients are common during the induction phase. Informed parents may help reduce fears and worries in their child. Child life specialists may also participate, and they can assist the child and the family to cope with the psychological aspects of the procedures3). Psychological preparations significantly reduce anxieties in the patient and the family4). Such specialist care are available in developed countries. Preprocedure assessments To determine the patients’ physical and emotional readiness for the procedure, developmental, physical, cognitive, and laboratory assessments are done. The assessment includes systemic review and physical examination. Body weight and baseline vital signs, including blood pressure, pulse, temperature, respiratory and heart rates, oxygen saturation, level of consciousness, and pain scale score, are obtained in this phase. Recent and current medications are checked by the admitting nurse or doctors. Use of homeopathic, herbal, and dietary supplements is also determined because these substances may interact with sedation medications. The respiratory system should be examined thorough airway assessment. Examination of loose teeth, oral piercings, and enlarged tonsils is important. Loose teeth may be accidentally dislodged and enter the patient’s airway as a foreign body. Oral and tongue piercings must be removed for the same reason. Patients with enlarged tonsils may experience obstructive apnea and should be evaluated by the physician before sedation or anesthetization. Laboratory examinations, including coagulation and liver function tests, are also important. The endoscopic procedure is contraindicated in most cases of coagulopathy. The doses of sedative medications should be lowered and the patient should be carefully monitored in the event of poor liver function. Informed consent Obtaining informed consent is an important initial step, as well as providing the patient and family with sufficient information about the potential risks and benefits of the procedure. Doctors explain the risks of sedation and the steps in the procedure. The important elements of this discussion should then be acknowledged in writing. Writing and signing of the informed consent form enforces a sense of trust between the patient and the physician, and provides legal documentation. Informed consent forms for pediatric patients can be obtained from the Internet home page of the Korean Society of Gastrointestinal Endoscopy (www.gie.or.kr). Contraindications Absolute contraindications for upper endoscopy include cardiovascular collapse, unstable airway, deteriorating pulmonary or neurologic status, intestinal perforation, peritonitis, and cervical traumas. The procedure should be delayed or cancelled in the absence of signed consent or competent medical personnel. Relative contraindications are recent digestive surgery, bowel obstruction, coagulopathy, severe thrombocytopenia, prematurity, and recent food intake. Hypoglycemic episodes should be a concern for patients with insulin-dependent diabetes. These patients should be prioritized in the endoscopy list and advised to reduce the amount of morning insulin therapy. In a child with hematemesis, an abdominal radiograph must be obtained to determine the presence of any intestinal obstruction or perforation5). Dietary restrictions To reduce the potential for aspiration of gastric contents during sedation, preendoscopy dietary restrictions are required. Patients with large residual gastric f luid volumes with a low pH are at increased risk for aspiration injury6). Traditionally, fasting for solids for 6 hours and liquids for 2-4 hours is recommended. A longer fasting time may be required for conditions such as achalasia and gastric outlet obstruction because retained food in the esophagus or stomach can increase the risk of aspiration7). Dietary restrictions are designed to minimize the volume of gastric acid at the time of sedation. Conventional recommendations for a prolonged fast before sedation have been challenged by 2