Background: Intestinal transplant (ITx) represents a life-saving treatment for children with intractable intestinal failure (IF). Surgeries and prolonged hospitalization may impact their motor development and physical activity, which is an important health behaviour for overall physical, social, and mental health. The aim of this position paper is to provide recommendations for optimizing physical function through supporting physical activity (PA), and exercise in children pre-and post-ITx.
Methods: A working group of the International Intestinal Rehabilitation and Transplantation Association Allied Health Committee conducted a literature review to identify relevant articles published between 2000-2023 that reported on physical function, body composition, muscle strength, and PA in a pediatric population (0-18 years) with IF or ITx. Key recommendations are based on scientific evidence and expert-informed opinion.
Results: Research indicates children with IF have altered body composition and lower levels of physical function, PA, and muscle strength compared to healthy peers. They also have a higher prevalence of motor delays, which persist even after ITx. There is a significant association between PA (steps per day) and increased % fat free mass and decreased % fat mass in children with IF and there is an increased risk of sarcopenia both pre-and post ITX. While studies in healthy children suggest that exercise could potentially improve all of these physical outcomes, parents of children with IF report unique barriers to PA including central lines and medical appliances. 
Key practice recommendations are summarized in the infographic and include: 
1) Early intervention with rehabilitation specialists in hospital and on discharge to the community.
2) Education related to PA guidelines including aerobic intensity and strengthening activities.
3) Provision of individualized exercise plans with communication and support in school/community settings. 
4) Ongoing screening at out-patient visits to monitor body composition, strength, and PA. 
5) Address potential barriers and safety issues. Each centre should establish its own guidelines around safe sport participation, ensuring families have the information they need to make informed decisions about their child’s potential PA and sport participation. 
6) Pre-and post-transplant rehabilitation to ensure optimal functional recovery. 
7) Prioritizing multi-centre research on PA benefits and effective interventions.
Conclusion: This position paper offers actionable steps for ITx teams to optimize physical function, PA, and exercise outcomes and highlights the need for research on exercise efficacy, safety, and intervention in this population.