A new study published in the Journal of Pediatric Surgery investigated the safety and efficacy of Botulinum Toxin (BT) administration in pediatric patients, including response duration, symptom association and effectiveness in relation to sphincter dynamics. This was a retrospective study of 164 children receiving sphincter BT for severe constipation unresponsive to medication management. Patients were grouped as – normal sphincter pressure (≤50 mmHg), elevated (>50 mmHg) or normal and abnormal recto-anal inhibitory reflex (RAIR). Overall, 142 children were analyzed. Among these, 124 had completed anorectal manometry (ARM); 98 had positive response with 57% lasting greater than 6 months; 36 had normal sphincter pressure with 24 being responsive; 88 had elevated pressure with 60 being responsive; 90 with normal RAIRs with 64 being responsive; 34 with abnormal RAIRs with 22 being responsive. Furthermore, fecal incontinence prior to BT was a predictor of poor response. The most common side effect was fecal incontinence typically resolving within a week, regardless of sphincter dynamics. Thus, it was concluded that BT is effective in children with chronic constipation. However, patients with fecal incontinence are less likely to respond to this intervention. Therefore, injection may be considered in patients with intractable constipation unresponsive to medication, regardless of anal sphincter dynamics.