OBJECTIVES: Paucity of data and concerns about potential lower effectiveness and more adverse events limit the use of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic cystogastrostomy in younger children even in high-volume centers. We retrospectively analyzed indications, success rates, and adverse events of all the children (<
18 years) who underwent ERCP and endoscopic cystogastrostomy between January 2010 to May 2024 at our center. METHODS: Data, including patient demographics, indications for the procedure, technical details, and adverse events, were collected from our prospectively kept database and compared according to age groups (<
1 year, 1-5 years, 5-10 years, and 10-18 years). RESULTS: A total of 286 ERCP (273 therapeutic and 13 diagnostic) and 57 endoscopic cystogastrostomy were performed in 222 (138 boys) and 55 children (32 boys), respectively, during the study period with 20% ERCP procedures in under-five children. In children <
5 years, the majority of the ERCPs were for biliary diseases (87%), while pancreatic duct procedures (39.5%) were done in higher numbers in children >
5 years. For biliary ERCP, choledochal cyst (15, 33%) was the most common etiology in under-five children and choledocholithiasis (60, 34%) in children >
5 years. Cannulation and technical success rates were 95% and 92%, respectively with no significant difference across age groups. Adverse events were noted in 36 (16%) with post-ERCP pancreatitis (8%) being the most common. All adverse events were managed conservatively with no mortality. CONCLUSION: ERCP can safely be performed in all children, including those under five with various hepato-pancreato-biliary diseases with high technical success rates.