British Society Of Paediatric Gastroenterology , Hepatology And Nutrition Research Articles

Swallowed topical steroid therapy for eosinophilic oesophagitis in children: practical, evidence-based guidance by the BSPGHAN Eosinophilic Oesophagitis Working Group

ObjectiveTo develop evidence-based guidance for topical steroid use in paediatric eosinophilic oesophagitis (pEoE) in the UK for both induction and maintenance treatment.MethodsA systematic literature review using Cochrane guidance was carried...

Radiopaque marker colonic transit study in the pediatric population BSPGHAN Motility Working Group consensus statement.

Functional constipation (FC) is a common condition in childhood in the United Kingdom and worldwide. Various radiological approaches have been established for diagnostic purposes. The radiopaque marker study (ROMS) is universally accepted and used to assess colonic transit time (CTT) in children with FC. Despite being widely used, there is a lack of standardization with various technical protocols, reproducibility of different populations, the purpose for using investigation, variance in the number of markers used, the amount of study days and calculations, the need to empty the colon before performing the test, and whether to perform on medication or off, or the use of specific diets. As part of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) motility working group (MWG), we decided to explore further into the evidence, in order to provide guidance regarding the use of ROMS in dealing with FC in the pediatric population.

Exclusive enteral nutrition practices in the management of Crohn's disease: A cross sectional survey of specialist paediatric dietitians.

Exclusive enteral nutrition (EEN) is the first line management to induce remission of active Crohn's disease (CD). EEN is well established but there continues to be significant variation in practice especially in relation to what first line formula is used, length of time on EEN, and food reintroduction. The survey aimed to establish dietetic practices in implementing EEN in the management of active CD across specialist paediatric inflammatory bowel disease (IBD) centres. An online, cross-sectional survey was developed, piloted, and distributed to dietitians working at tertiary paediatric IBD centres. Centres were identified through a member of the British Society of Paediatric Gastroenterology, Hepatology, and Nutrition (BSPGHAN) working group. All 20 specialist IBD centres within the United Kingdom were approached and invited to complete the survey. Eighty-five percent (17/20) of the specialist IBD centres in the UK responded. 100% of centres used polymeric feeds as their first line and 70% (12/17) of centres recommended EEN for 6 weeks. Dietetic monitoring whilst on EEN over the 6-8 weeks varied significantly, ranging from 30% (5/17) of centres monitored weekly compared with 30% of centres (5/17) only if clinical need indicated. There was a wide range in practices regarding which foods and drinks were permitted whilst on EEN. Forty three percent (7/17) introduced solid foods over five to seven days, 19% (3/17) introduced food over seven to 14 days and 38% (6/17) introduced food over a minimum of 14 days. Eighteen percent (3/17) of centres were offering the Crohn's disease exclusion diet as a treatment for IBD. Despite available evidenced based guidelines there is still considerable variation in the management of EEN to induce remission in active CD especially in relation to frequency of dietetic review and foods permitted during and after EEN. Further research is required to understand the impact this may have on achieving and maintaining remission in CD.

Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement.

Defecatory disorders in children, including chronic constipation (CC) and fecal incontinence (FI), are common conditions worldwide and have a significant impact on children, their families, and the healthcare system. Anorectal manometry (ARM) and high-resolution anorectal manometry (HRAM) are relatively novel tools for the assessment of anal sphincter function and rectal sensation and have contributed significantly to improving the understanding of the anorectum as a functional unit. ARM has been recognized as the investigation of choice for adults with symptoms of defecation disorders, including fecal incontinence (FI), evacuation difficulties, and constipation. Although it is the gold standard tool in adults, it has yet to be formally accepted as a standardized diagnostic tool in the pediatric age, with limited knowledge regarding indications, protocol, and normal values. ARM/HRAM is slowly becoming recognized among pediatricians, but given that there are currently no agreed guidelines there is a risk that will lead to diversity in practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)-Motility Working Group (MWG) therefore has taken the opportunity to provide guidance on the use of ARM/HRAM in children with CC and/or FI.

Paediatric Endoscopy Global Rating Scale: Development of a Quality Improvement Tool and Results of a National Pilot.

The endoscopy Global Rating Scale (GRS) is a web-based self-assessment quality improvement (QI) tool that provides a framework for service improvement. Widespread use of the GRS in adult endoscopy services in the United Kingdom (UK) has led to a demonstrable improvement in quality. The adult GRS is not directly applicable to paediatric endoscopy services. The objective of this study is to develop and pilot a paediatric endoscopy Global Rating Scale (P-GRS) as a QI tool. Members of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) Endoscopy Working Group collaborated with the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) to develop the P-GRS. After a period of consultation, this was piloted nationally at 9 centres and data were collected prospectively at 2 census points, May and December 2016. The P-GRS mirrors the adult GRS by dividing care into 4 domains and includes 19 standards with several measures that underpin the standards. Eight services completed the online P-GRS return in May 2016 and 6 in December 2016. All pilot sites identified areas that needed improvement and post-pilot reflected on the key challenges and developments. Several positive developments were reported by the pilot sites. The national pilot helped ensure that the P-GRS developed was relevant to the paediatric endoscopy services. The pilot demonstrated that even in the first year of engaging with this QI tool, services were starting to identify areas that needed improvement, share best practice documents, put in place QI plans, and support greater patient involvement in services.

Guidelines on the management of abnormal liver blood tests

These updated guidelines on the management of abnormal liver blood tests have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under...

Reliability of diagnosing coeliac disease without duodenal biopsy

A recent Italian prospective cohort study1 of 468 children evaluated the reliability of diagnosing coeliac disease without a duodenal biopsy and the consequences of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)2 and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)3 guidelines on outcomes. The diagnosis was reliably made without a duodenal biopsy in about 11% of all cases (n = 51). A similar approach would result in up to 37% of cases being diagnosed without biopsy at under 2 years of age. The reassuring news is that despite only 11% of all cases being reliably diagnosed without biopsy, if less restricted clinical diagnostic criteria had been used (i.e. including less typical symptoms) that percentage would be 35.2% (165 biopsies would be avoided). Over a median 2 year follow up, there was no difference in nutritional and clinical status, follow up antibody titres, adherence to coeliac diets, the quality of life and the number of clinic presentations compared to cases diagnosed by biopsy. This study shows that duodenal biopsies can indeed be avoided without adverse clinical consequences using current ESPGHAN and BPSGHAN guidelines. More biopsies can be avoided if they are also applied to less typical cases.

Coeliac disease in the ERA of the new ESPGHAN and BSPGHAN guidelines: a prospective cohort study

ObjectiveTo evaluate the consequences of the last European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) guidelines for the diagnosis...

G62 A questionnaire survey of adherence to European guidelines for the diagnosis of coeliac disease in asymptomatic children with type 1 diabetes mellitus

AimsUpdated guidelines were released by ESPGHAN in January 2012, outlining separate diagnostic algorithms for asymptomatic diabetic patients to those presenting symptomatically. Recent epidemiological analysis at our tertiary centre revealed an...

Rationalized assessment of prolonged jaundice is safe and cost-effective

Prolonged jaundice (PJ) in healthy term neonates is common and frequently benign. It can, however, be the earliest manifestation of underlying liver disease. Its management requires a balanced approach, avoiding over-investigation of well babies while ensuring the early identification of those with pathology. Currently marked heterogeneity exists in the assessment of PJ. Over a two-year period we prospectively audited the management of PJ in two Level 3 neonatal units prior to and after the introduction of a rationalized investigation algorithm in keeping with the recently published British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) guidelines (i.e. clinical examination and stool inspection combined with measurement of split bilirubin). In this study we reviewed initial practice and then evaluated the impact of our change in practice. A total of 197 babies, 1.5% of live births, were referred with PJ. Of these, 105 babies were included in the first part of the study and 92 babies were included in the second part. No pathology relating to PJ, such as infection, hepatitis or liver disease, was identified. Following the introduction of our rationalized algorithm, we demonstrated a statistically significant reduction in the number of return appointments (28 versus 7; P < 0.0009) and repeat investigations (37 versus 7; P < 0.0001). This represented a saving of £1575-2625 per year in laboratory costs alone. Contemporaneously, three infants presented with biliary atresia, none of whom were identified by PJ screening and all of whom were over seven weeks old at diagnosis. A rationalized approach to the assessment of PJ reduces workload and is cost-effective; however, the limitations of selective screening, irrespective of how streamlined it is, remain--if babies are not identified and referred, they cannot be screened. Population-based methodologies offer an alternative approach to the identification of cholestatic liver disease and are worthy of further consideration.

The provision of paediatric gastrointestinal endoscopy services in the United Kingdom

ObjectiveThere are no specific data available regarding paediatric endoscopy provision in the UK and anecdotal experiences suggest that such provision varies widely between the units. The aim of our study...

EWTD: incompatible with subspecialty training?

IntroductionHistorically, the RCPCH College Specialty Advisory Committee (CSAC) recommends that trainees in Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) spend at least 70% of working hours in that subspecialty. Since changes...

A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease

Adalimumab is efficacious therapy for adults with Crohn's disease (CD). To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience. British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA). Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate). Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate.

768 Exclusive Enteral Nutrition in Paediatric Crohn's Disease

Background: The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) guidance (October 2008) advocates the use of Exclusive Enteral Nutrition (EEN) as an alternative first line treatment to oral corticosteroids for induction of remission in paediatric Crohn's disease. Compared to steroids, EEN is not known to produce any harmful consequences. Aims: To assess whether EEN was being offered at two neighbouring district general hospitals (DGHs) in accordance with BSPGHAN standards and whether EEN courses were producing a remission rate similar to that in the literature. Methods: All patients on the Crohn's Disease Register were included. Data was collected from medical and dietician records and analysed using Microsoft Excel. Results: 95% children were offered and tolerated a full course of EEN. 83% EEN courses lasted 6-8 weeks. Remission was acheived in 78% overall (consistent with the literature). The length of period for food reintroduction was much more variable. Average number of dietician consultations for induction of remission and food reintroduction were also variable. 71% of those patients who achieved complete remission with EEN had a relapse ( 3 years). Conclusions: EEN was widely used in both the DGH settings. It was tolerated well and proved to be an effective treatment acheiving complete remission in 78% of patients. Our findings support the use of EEN as a first line treatment for paediatric crohn's disease. There is a need for more collabortive research and regular audits into the care of paediatric Crohn's disease patients.

New paediatric IBD guidelines: the way forward in managing children with IBD

The first UK guidelines on the care of children and adolescents with inflammatory bowel disease (IBD) − ulcerative colitis (UC) and Crohn′s disease (CD) − were published by the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) in October 2008. They specifically address the issues of growth failure, delayed sexual development and loss of education caused by IBD in childhood. Although symptoms of the conditions and the principles of treatment may be the same, the epidemiology, treatment considerations and indeed consequences of treatment can be vastly different for those under the age of 18−years. The environment in which they are treated and seen is also very different. Epidemiology, growth, psychology and transition are key concepts in paediatric management, as supported by the new guidelines. In this article, the authors highlight those differences from the ′adult′ perspective and provide an understanding of IBD in children.