The “rule of three” is a 40-year-old professional view that says dilating an esophageal stricture by more than 3 mm is dangerous. Few research have looked at this concept, and none have specified how much larger than 3 mm is acceptable. The goal of this study was to find the best point for maximal dilation diameter with tolerable risk in a paediatric population. A retrospective review was conducted in paediatric patients with esophageal strictures. The number of milliliters the structure was dilated was determined by subtracting the starting stricture diameter from the diameter of the biggest balloon utilised, which was denoted as delta dilation diameter (DD). The discriminatory capacity of DD was evaluated using receiver operating characteristic curve analysis. The Youden J index was used to determine the best cut-point for predicting perforation. 1384 balloon dilations were performed on 284 individuals. The overall rate of perforation was 1.66 percent. There were 8 perforations in 1075 DD 5 mm dilations and 15 perforations in 309 DD >5 mm dilations. The Youden J index determined that an appropriate cutoff was at a DD of 5 mm. The cumulative risk of perforation for all 5 mm dilations was 0.74 percent, while the cumulative risk of perforation for all 6 mm dilations was 4.85 percent.

In a juvenile population, balloon dilations that extend the initial esophageal anastomosis by 5 mm do not appear to enhance the risk of perforation. Prospective studies are needed to examine the possibility of a new rule of 5 for balloon dilation.