Pediatric Gastroenterology Research Articles

Child Health Needs and the Pediatric Gastroenterology Workforce: 2020-2040.

This article is part of an American Board of Pediatrics Foundation-sponsored effort to analyze and forecast the pediatric subspecialty workforce between 2020 and 2040. Herein, an overview of the current pediatric gastroenterology workforce is provided, including demographics, work characteristics, and geographic distribution of practitioners. Brief context is provided on the changing nature of current practice models and the increasing prevalence of some commonly seen disorders. On the basis of a rigorous microsimulation workforce projection model, projected changes from 2020 to 2040 in the number of pediatric gastroenterologists and clinical workforce equivalents in the United States are presented. The article closes with a brief discussion of training, clinical practice, policy, and future workforce research implications of the data presented. This data-driven analysis suggests that the field of pediatric gastroenterology will continue to grow in scope and complexity, propelled by scientific advances and the increasing prevalence of many disorders relevant to the discipline. The workforce is projected to double by 2040, a growth rate faster than most other pediatric subspecialties. Disparities in care related to geography, race, and ethnicity are among the most significant challenges for the years ahead. Changes to training and education, incentives to meet the needs of underserved populations, and new multidisciplinary models for health care delivery will be necessary to optimally meet the volume, diversity, and complexity of children with gastroenterological diseases in the years ahead.

Forecasting the Future Supply of Pediatric Subspecialists in the United States: 2020-2040.

Concerns persist about whether the United States has an adequate supply of pediatric subspecialists and whether they are appropriately distributed across the nation to meet children's health needs. This article describes the data and methods used to develop a workforce projection model that estimates the future supply of 14 pediatric subspecialities certified by the American Board of Pediatrics at the national and US census region and division levels from 2020 to 2040. The 14 subspecialties include adolescent medicine, pediatric cardiology, child abuse pediatrics, pediatric critical care medicine, developmental-behavioral pediatrics, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology-oncology, pediatric infectious diseases, neonatal-perinatal medicine, pediatric nephrology, pediatric pulmonology, and pediatric rheumatology. Hospital medicine was excluded because of the lack of historical data needed for the model. This study addresses the limitations of prior models that grouped adult and pediatric physician subspecialty workforces together and aggregated pediatric subspecialties. The model projects supply at national and subnational levels while accounting for geographic moves that pediatric subspecialists make after training and during their career. Ten "what if" scenarios included in the model simulate the effect of changes in the number of fellows entering training, the rate at which subspecialists leave the workforce, and changes in hours worked in direct and indirect clinical care. All model projections and scenarios are available on a public, interactive Web site. The model's projections can also be examined with other data to provide insight into the possible future of the pediatric subspecialty workforce and offer data to inform decision-making.

CURRENT VIEWS AND CLINICAL MANIFESTATIONS OF ACUTE APPENDICITIS AND APPENDICULAR PERITONITIS IN CHILDREN

Acute appendicitis is the most common urgent disease in pediatric surgery (75% of emergency operations). Not only pediatric surgeons, but also pediatricians, pediatric gastroenterologists, and pediatric gynecologists have to deal with appendicitis in children. In childhood, inflammation of the cecum develops rapidly, which causes an increase in destructive changes in the appendix in a relatively short time. With appendicitis in a child, the peritoneum is often involved in the inflammatory process, leading to the development of appendicular peritonitis. The peak incidence of appendicitis in children (more than 80% of cases) is at school age, in preschool children the disease occurs in 13%, in toddlers - in 5% of cases.

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy.

A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.

Understanding the living-related pediatric liver transplantation donor's decision process: A questionnaire-based retrospective study.

To analyse the donor characteristics and understand the sociocultural and familial aspects of the decision to donate for living donor liver transplant. This is a retrospective study done in the Department of Pediatric Gastroenterology and Hepatology of a liver transplant centre. We enrolled the consenting donors of pediatric liver transplantation between January 2020 and January 2022. The study was conducted through an anonymized questionnaire which was drafted in a multiple-choice format. The questionnaire had three domains having questions pertaining to demographic details, donor characteristicsand sociofamilial aspects of the decision-making process. The study cohort consisted of 50 donors, 23 males (46%) and 27 females (54%), with the mean age being 31.8 ± 5.6 years. Parent-to-child was the most frequent relationship (n = 39, 78%). More than half of our donors had annual income <2.5lakh/annum or <3500 USD(n = 27, 54%). Twenty-six (52%) responders had >4 members in their family; 62% were residing in urban areas and 52% of the donors were graduates. The main source of information regarding the feasibility of living donor liver transplantation wasprimary physicians in 46%. Financial management was the main hurdle in 72%. Majority (74%) denied any effect on their marital relationship and 6% of donors thought that the degree of information provided to them before the transplantation regarding donation was insufficient. Our study serves as an essential tool for health professionals to provide sufficient support to the donor. Clinical outcomes and cost must be part of the discussion between caregivers, health professionalsand fund contributors.

Endoscopist experience with pediatric recurrent and intentional foreign body ingestion (RIFBI): Management considerations and future directions.

Accidental foreign body ingestion (FBI) is a common pediatric referral concern. In contrast, recurrent and intentional FBI (RIFBI) is infrequent and associated with greater endoscopic and surgical intervention in adults. Although pediatric guidelines exist for FBI, the risk and therapeutic implications of RIFBI are not addressed. An anonymous international survey on pediatric gastroenterologist experience with RIFBI was distributed. A 33-item REDCap© survey was distributed via email to pediatric gastroenterologists identified through mailing and email lists obtained from pediatric gastroenterology professional organizations. During 9-12/2021 we accrued 202 completed surveys. Respondents were from 27 countries and across the career span. Eighty percent reported experience with RIFBI; 74% reported seeing ≤ 3 patients with RIFBI within the past 24 months and 4% reported seeing ≥ 6. Of those who treated RIFBI, 38% reported an average number of annual ingestions per patient was ≥5. Frequent morbidity but not mortality was reported. Half reported adherence to FBI guidelines. Later-career endoscopists treated RIFBI more aggressively than accidental ingestion. Ninety-six percent noted that patients with RIFBI had psychiatric comorbidities. Providers at academic medical centers reported referring to behavioral health more than those in other settings. Most gastroenterologists surveyed reported encountering RFBI several times a year and in patients with psychiatric comorbidities. Greater likelihood of adverse outcomes associated with endoscopy was reported. Most reported referral to behavioral health and few had RIFBI management protocols. A broader spectrum of psychologic comorbidities in the pediatric population with RIFBI, notably depression and autism spectrum disorder, were reported.

Anthropometric assessment: ESPGHAN quality of care survey from paediatric hospitals in 28 European countries.

Assessment of anthropometric data is essential for paediatric healthcare. We surveyed the implementation of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) evidence-based guidelines and practical recommendations on nutritional care, particularly regarding anthropometric measurements. Paediatric hospitals from 28 European countries provided pseudonymized data through online questionnaires on hospital characteristics and their standards of nutritional care. Practical tasks assessed an unbiased collection and reporting of anthropometric measurements in random patients'files and discharge letters. Of 114 hospitals (67% academic), 9% have no nutritionist/dietitian available, 18% do not provide standard policy to assess weight and height and 15% lack training for nursing staff for accurate performance. A wall-mounted stadiometer to measure standing height and equipment for sitting weight is unavailable in 9% and 32%, respectively. Infant length is measured by one instead of two healthcare professionals and with a tape instead of a rigid length measuring board in 58% and 15% of hospitals, respectively. The practical tasks reviewed 1414 random patients, thereof 446 younger than 2 years of age. Missing documentation occurred significantly more often for height versus weight and their percentiles in infants ≤2 years versus older children, and in general paediatric versus gastrointestinal patients, with no difference between academic and nonacademic hospitals. Review of documented anthropometric data in discharge letters disclosed that consultants significantly underestimated the deficits in their units compared to documented data. The survey revealed significant gaps in performance and documentation of anthropometry in the participating hospitals. A resurvey will assess changes in quality of care over time.

Diagnosis, Clinical Presentation and Management of Celiac Disease in Children and Adolescents in Poland

Celiac disease (CD) is a chronic immune-mediated disorder triggered by the ingestion of gluten in genetically predisposed individuals, affecting about 1% of the general population in the developed world. In 2012, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommendations for CD diagnoses in children and adolescents were introduced, allowing the “no-biopsy” approach if certain criteria were met. This approach was also confirmed in the revised guidelines published in 2020. Thus, the aim of this study was to assess—over a one-year period—the clinical presentations and current status of the management of children and adolescents diagnosed with CD in Poland. Medical records of children and adolescents, newly diagnosed with CD in 2022/2023 in three medical centers in Poland, were involved. Gastroenterologists completed the specific anonymous web-based forms developed in the CD SKILLS project, including data routinely assessed at individual visits about the diagnostic approach and clinical presentation of the disease. Our study assessed 100 patients (56% girls) with an age range 1.6–18.0 years. We found that 98% of patients were serologically tested prior to a CD diagnosis and 58% of patients were diagnosed using the “no-biopsy” approach. In the analyzed group, 40% belonged to a known risk group, only 22% had annual screening before the CD diagnosis (the longest for 9 years), and 19% showed no symptoms at the time of the CD diagnosis. Our research confirmed the applicability of the “no-biopsy” approach for the diagnosis of CD in children and adolescents in Poland, and also showed changes in the clinical picture of CD. Moreover, we highlight the need to introduce broad CD serological screening in risk groups of the Polish population.

Racial and ethnic differences in diagnosis age and blood biomarkers in a pediatric inflammatory bowel disease cohort.

Prompt diagnosis of pediatric-onset inflammatory bowel disease (IBD) is crucial for preventing a complicated disease course; however, it is not well understood how social determinants of health might affect pediatric IBD diagnosis. This study examined differences in diagnosis age, biomarkers of disease severity, and anthropometrics with sociodemographic factors in a pediatric IBD cohort. Pediatric IBD patients (n = 114) and their parents/caregivers were enrolled from the Children's of Alabama Pediatric IBD Clinic in Birmingham, Alabama. Primary analyses examined associations of child race and ethnicity, parental income, parental education, single-parent household status, insurance type, and distance to a tertiary pediatric gastroenterology referral center with diagnosis age. Secondary analyses examined differences in biomarker levels, height, and body mass index at the time of diagnosis. Racial and ethnic minority children were diagnosed at an older age compared to Non-Hispanic White children (14.4 ± 0.40 vs. 11.7 ± 0.38 years; p < 0.001), and this trend was robust to adjustment with other sociodemographic variables. Parental attainment of a college education attenuated the link between minority race and ethnicity and the likelihood of older age at diagnosis, while other sociodemographic variables had no moderating effect. Racial and ethnic minority children were 5.7 times more likely to have clinically elevated erythrocyte sedimentation rate at diagnosis compared to Non-Hispanic White children (p = .024). These results suggest that child race and ethnicity may exert a primary effect on the age at diagnosis with pediatric-onset IBD. This study highlights the need for further research on racial and ethnic disparities to promote health equity in pediatric-onset IBD.

VALIDATION OF AN INFLIXIMAB POPULATION PHARMACOKINETIC MODEL FOR MAINTENANCE DOSING IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract INTRODUCTION The use of infliximab has revolutionized the care of pediatric patients with inflammatory bowel disease (IBD); however, infliximab may lose efficacy over time during the maintenance phase and the use of therapeutic drug monitoring has been advocated to improve response rates. A population pharmacokinetic (popPK) model using infliximab concentrations, common clinical biomarkers, and demographic information to predict future infliximab concentrations would be clinically invaluable. Previous popPK models such as the Buurman [1] and Fasanmade [2] exist, but their utility, accuracy, and predictive values have not been clinically validated. This study aims to validate a reliable set of covariates for an infliximab popPK model that will predict maintenance drug concentrations and guide treatment decisions for children with IBD. METHODS This retrospective study included 134 pediatric patients with 503 infliximab trough concentrations between 5 and 21 years of age, seen at the Division of Pediatric Gastroenterology, Hepatology, and Nutrition at UH Rainbow Babies and Children’s Hospital between January 1, 2008 and December 31, 2018. We recorded the patients' therapeutic infliximab trough concentrations and other clinical and demographic factors. In previous work, we refit published popPK models using induction phase data. Here, we refit our originally constructed one-compartment model based on induction phase data, the Cleveland Model, with maintenance phase data to yield the Cleveland Refit model. We then tested six different models: Buurman (B), Buurman Refit (BR), Fasanmade (F), Fasanmade Refit (FR), Cleveland (C), and Cleveland Refit (CR). Each model was evaluated on root mean square error (RMSE), mean percent error (MPE), and accuracy of the predicted infliximab concentration. We defined accuracy as the percentage of samples each model correctly predicted to be on the same side of 5 ug/mL, which is our clinical trough target. RESULTS On the first infliximab concentration following the induction phase, published models refit on induction phase data (BR, FR) have higher accuracy but also higher RMSE than published models. In contrast, the CR model was refit on maintenance phase data and has higher accuracy (71.1% vs 66.7%) and lower RMSE (6.8 vs 7.8 ug/mL) and MPE (-5% vs 10%) than the previous induction-only model. CONCLUSIONS The CR model improved upon the performance of the induction-only models tested on this cohort. This study suggests refit popPK models on a specific patient population work well for predicting maintenance phase infliximab concentrations, and may be useful for personalization of dose of frequency for pediatric patients with IBD. Further validation with external data in a multicenter, prospective study is needed. References 1) https://doi.org/10.1111/apt.13299 2) https://doi.org/10.1016/j.clinthera.2011.06.002

Prebiotics in the management of pediatric gastrointestinal disorders: Position paper of the ESPGHAN special interest group on gut microbiota and modifications.

Prebiotics are substrates that are selectively utilized by host microorganisms conferring a health benefit. Compared to probiotics there are few studies with prebiotics in children. Most studies have been performed using infant formula supplemented with prebiotics, while add-on prebiotic supplementation as prevention or treatment of childhood gastrointestinal disorders has rarely been reported. The aim of this position paper was to summarize evidence and make recommendations for prebiotic supplementation in children with gastrointestinal diseases. Recommendations made are based on publications up to January 1, 2023. Within the scope of the European Society for Paediatric Gastroenterology Hepatology and Nutrition Special Interest Group on Gut Microbiota and Modifications, as in our previous biotic recommendations, at least two randomized controlled clinical trials were required for recommendation. There are some studies showing benefits of prebiotics on selected outcomes; however, we cannot give any positive recommendations for supplementing prebiotics in children with gastrointestinal disorders.

P130 High serum lipocalin-2 expression at the diagnosis in children with ulcerative colitis: a pilot study

Abstract Background The identification of new biomarker is a main challenge in inflammatory boweldisease. Lipocalin-2 (LCN-2) is a pleiotropic mediator of various inflammatory processes. We determined the serum levels of LCN-2 in a cohort of newly diagnosed UC children, and we compared them with healthy controls. Methods Prospective cross-sectional observational study conducted at the Pediatric Gastroenterology, hepatology, and nutrition Unit of the Umberto I Hospital in Rome and at the IBBC – Institute of Biochemistry and Cell Biology – CNR in Rome. All children aged 6-18 years of age, newly diagnosed with UC at the Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, were consecutively enrolled. Blood withdrawal was conducted upon diagnosis. Human serum LCN-2 (Cat. No. DY1757) was measured using a sandwich enzyme-linked-immunosorbent assay (ELISA) kits (R&amp;D Systems, Minneapolis, MN, USA), according to the protocols provided by the manufacturer. Clinical, demographic, biochemical and endoscopic data were recorded. Results Thirty-two children with a new diagnosis of UC [11 (34%) female, mean age 12,7 ± 4] and 38 age- and sex-matched healthy control [21 (55%) females, mean age 11.71 ± 4] were consecutively enrolled. Serum LCN-2 levels were significantly higher in cases compared to controls (280 ± 152 ng/mL vs 66 ± 55 ng/mL), p &amp;lt; 0,001]. Among UC children, significantly higher LCN2 levels were measured in pancolitis (363.7± 155.2 ng/mL) compared to proctitis, left-sided and extensive colitis (184.9 ± 74.65 ng/mL; p = 0.0003). A significant inverse correlation was observed between LCN-2 and albumin levels at the diagnosis by the Spearman coefficient correlation (r = −0.455; P = 0.03) and a significant direct correlation was observed between LCN-2 and CRP values at the diagnosis (r = 0.44; p &amp;lt;0.05). Conclusion Serum LCN-2 levels are significantly higher in children with UC compared to the healthy control group, with the highest levels observed in children with the most extensive disease. Such results as well as and its correlation with the actual disease monitoring tool, make this protein an interesting candidate biomarker.

P411 Is transmural healing better than mucosal healing in pediatric Crohn’s disease?

Abstract Background While the long-term benefit of achieving mucosal healing (MH) in Crohn’s disease (CD) has been demonstrated, data on transmural healing (TH), assessed by non-invasive imaging modalities (i.e. magnetic resonance enterography, MRE) are scarce, particularly in the pediatric setting. Nonetheless it has been deemed as an adjunctive target for CD by the STRIDEII consensus. We aimed to investigate the outcomes of pediatric CD patients with TH comparing them to those with MH and with “no healing”. Methods Prospective, single-center, observational study conducted at the Pediatric Gastroenterology and Liver Unit of the Umberto I Hospital, Sapienza University of Rome. Children with an established diagnosis of CD and under biological therapy undergoing an MRE and an ileocolonoscopy performed within a 3-month interval were consecutively enrolled. Transmural healing was defined as the complete healing of both the mucosa at endoscopy (absence of ulceration) and of the bowel layers at the MRE. In the presence of a normal colonoscopy but an active MRE children were deemed as MH. The group “no healing” (NH) included children with an active endoscopy, regardless of the MRE classification. At 6, 12, and 24 months, the following outcomes were evaluated and compared in the three groups: disease flares, CD-related hospitalization, CD-related surgery, need for step-up treatment, and occurrence of complications. Results 93 children were included (30% female, mean age 11,2±3,8). Twenty-three (25%) were classified as TH, 27 (29%) as MH and 43 (46%) as NH. Overall, at the Kaplan Meier analysis, the risk of any unfavorable outcome was significantly lower in both TH and MH patients compared to NH (Log Rank p&amp;lt;0.0001 and p=0.002, respectively). Specifically, children with TH were at lower risk of hospitalization (p=0.02), and complications (p=0.007) compared to those with NH. No difference was found between MH and NH children for the same outcomes. Both TH and MH children were at lower risk of step-up treatment (p&amp;lt;0.0001 and p=0.0.0002, respectively) compared to NH. No difference was found between TH and MH patients for all the outcomes evaluated. Conclusion Achieving transmural healing in pediatric CD is associated with better long-term outcomes, although the additional benefit compared to reaching MH alone does not appear significant. However, the persistence of inflammation is associated with worse outcomes in all patients.

N48 Exploring &amp; evaluating the benefits of initiating an IBD Transition clinic

Abstract Background Establishing an Inflammatory Bowel Disease (IBD) Transition Clinic can bring about several significant benefits. This includes providing continuity of care, specialised care, education in new treatment, emotional support, collaboration and coordination of care, empowering patients and assisting in adherence to medication and follow up appointments. In the author's history within the Trust there has never been an established IBD Transition clinic. This has led to young adults delayed in transitioning to adult services without any formal handover. Methods The IBD Consultant Nurse felt that the young adults were given a second class service and that they were not receiving the care and advice that they needed in the difficult time of being a young adult with a long term condition. They enlisted the help of a paediatric gastroenterologist and worked with the paediatric operations team and a cohort of patients were booked into a three monthly clinic held on a Saturday as this was felt the best day for engaging both patients and family. The paediatric gastroenterologist and IBD Consultant Nurse undertook the clinic jointly. Results A number of clinics were undertaken and the IBD Consultant Nurse asked for all patients to be assigned to an adult gastroenterologist after the first appointment. At the joint clinic all medication was discussed and a personalised plan of care was adopted for all patients to allow a smooth transition into adult services. The feedback from patients and family members was extremely favourable and all patients felt that they had been given all of the required information, a personalised care plan and were prepared to be transitioned to adult care. All patients were given a post clinic questionnaire on their satisfaction of the Transition clinic. The clinic was recently stopped as a adult gastroenterologist felt that this should not have been undertaken by a nurse and that they can only be undertaken by doctors. The current waiting time to be reviewed by a gastroenterologist is currently around 65weeks which could lead to a delay in treatment. Conclusion Ideally establishing a nurse-led transition clinic requires collaboration among healthcare providers, administrative support, and resources dedicated to its development. Additionally, an emphasis on patient and family involvement in the planning and execution stages can lead to a more patient-centric and successful transition program. This clinic was extremely successful but has had to stop as the gastroenterologists feel that only gastroenterologists can undertake transition clinics and should not be nurse led. Unfortunately this will lead to transition patients having an extended delay into adult services.

P763 Rare and severe adverse events in pediatric inflammatory bowel disease: identification of safety signals through the international prospective PIBD-SETQuality Safety Registry

Abstract Background Rare but severe adverse events (AEs) can occur in pediatric inflammatory bowel disease (PIBD) due to ongoing inflammation, secondary to immunosuppressive drugs or as coincidental finding. These events can lead to significant disability or even death. Limited prospective research hampers the understanding of the incidences, risk factors, and outcomes associated with these events. Methods As part of the ongoing international PIBD-SETQuality Safety Registry, participating pediatric gastroenterologists prospectively reported the occurrence of any of 10 listed rare and severe AEs in their PIBD patient population (&amp;lt;19 years) via monthly electronic surveys since October 2016. Additionally, physicians could report ‘other rare and severe AEs’. Participants received an annual denominator survey, to report the number of PIBD patients under their care. Incidence rates (IRs) were calculated for each AE using Poisson regression models and were compared between countries. Upon reporting AEs, participants received specific follow-up forms to collect patient and IBD characteristics, as well as complication details (diagnosis, risk factors, management, outcome). Results Over a 77-month study period (October 2016 to April 2023), 222 pediatric gastroenterologists from 167 centers across 36 countries actively contributed to the registry, completing 7,975 monthly surveys with a median response rate of 86% [IQR 82%-88%]. On average, participants contributed for 53 months [IQR 25-72]. They covered 30,192 PIBD patients, with 114,528 patient-years (PY) of follow-up. In total, 285 listed complications were reported, alongside 117 uncategorized ‘other rare and severe AEs’. The highest IRs (95%CI) per 10,000 PY were found for VTE (IR 5.50 [2.74-4.99]), renal failure (IR 3.67 [2.67-4.89]), opportunistic infections (IR 2.88 [2.01-3.98]), and cancer (IR 2.71 [1.86-3.77]) (Figure 1). The lowest IRs (95%CI) per 10,000 PY were found for liver failure (IR 0.35 [0.11-0.81]) and HLH (IR 0.52 [0.21-1.06]). Combined IRs of the listed AEs did not differ among the five countries with the highest contribution of PY (p=0.18). Conclusion Through international collaboration among a large network of PIBD specialists, the Safety Registry has confirmed the increased incidence of several AEs in PIBD, including VTE, cancer and renal failure. Clinical characterization of these events may lead to a better understanding of their underlying etiologies and outcomes. This improves patient care by providing guidance for management development, facilitating well informed clinical decision making and may lead to prevention of these rare and severe events.

P1181 Prevalence and trend of anemia in a large cohort of children with inflammatory bowel disease

Abstract Background Anemia is a common extraintestinal manifestation in inflammatory bowel disease (IBD) with an impact on patients’ quality of life. Our aim was to determine the prevalence of anemia and its characteristics at the diagnosis in children with inflammatory bowel disease (IBD) and to investigate its trend during follow-up. Methods We conducted an observational, multicenter cohort study including data of IBD children with anemia at the diagnosis enrolled in the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) IBD registry. Demographic, clinical, laboratory and endoscopic data were collected at the diagnosis and anemia trend was evaluated at 1-year follow-up. Anemia was diagnosed based on the WHO criteria and classified as mild, moderate, and severe accordingly. Results Five hundred eighty-nine [295 CD (50%) and 294 UC/IBDU (50%)] out of 1634 with IBD presented with anemia, resulting in a prevalence of 36%. Anemia rate was higher in CD than in UC (39% vs 33%, p = 0.009). Most patients presented at the diagnosis with moderate anemia (55%). The most common forms of anemia were iron deficiency anemia (IDA) and combined inflammatory and IDA anemia (InflIDA), both present in 42% of children. Only 15% of children had anemia of inflammation. Children with CD had higher rates of mild anemia than UC (38% vs 33%, p&amp;lt;0.0001), while severe anemia was more common in UC (13% vs 6%, p= 0.001) as well as IDA (53% vs 31%, p&amp;lt;0.0001). Younger age and lower albumin levels significantly correlated with the severity of the anemia in CD. In UC, females were more likely to experience severe anemia (69% vs 47%, p=0.02) and an extensive disease was more prevalent in children with moderate and severe anemia then in those with mild anemia (p=0.01 and p=0.03, respectively). At 1 year, 99 children (17%) were still anemic. At multivariable logistic regression analysis, baseline wPCDAI and SES-CD significantly correlated with the persistence of anemia at 1 year in CD. No variables correlated with the persistence of anemia in UC. Conclusion More than one-third of pediatric patients present with anemia at the diagnosis of IBD, most commonly moderate. A severe anemia is most common in UC compared to CD. Iron deficiency anemia (alone or in its form of InflIDA) is the most common cause of anemia in children with IBD. One out of five is still anemic after 1 year from the diagnosis.

N27 Group meetings for adolescents with IBD: results of a survey on patients’ interests

Abstract Background The increase in both the incidence and prevalence of IBD, especially in people under 21 years of age1,2,3 outlines new issues to be considered in caring for these patients, like the psychosocial effects on both adolescents and their families, school absences, and developmental delay2. The need for better support to improve their HRQoL4, the embarrassment related to the disease, the anxiety about a sudden appearance of gut symptoms, frequent hospital admissions, and diet restrictions, can lead to social isolation5,6. Group meetings designed to make adolescents and young adults with IBD meet each other and with healthcare professionals (HCP) who are experts in IBD can create a safe environment in which to discuss fears, everyday problems and possible solutions, and any doubt about their condition. This could also provide support, suggestions, and opportunities to peer-compare, further promoting social relationships. This study investigated their willingness to participate in this experience and what they consider important to discuss. Methods A focus group involving HCP from a paediatric gastroenterology clinic and interviews with a sample of patients provided the basis on which a clear and easy-to-understand survey was developed concerning interest in the project, willingness to participate, topics to be discussed, and needs of peer relationship. The survey was then performed collecting anonymous data to avoid any kind of potential bias. Results Twenty-two patients aged 14 to 19 years completed the survey, showing their poor occasions of discussion about the disease and its related issues with other patients (54.5% of them do not know people with IBD) even if they can talk with their family, HCP and peers outside the hospital or outpatient clinic settings (tab 1). The willingness to participate in a group meeting is higher in the oldest subjects, and they show the highest interest in a peer relationship with patients of the same age and expert HCP. The topics considered more significant are 'nutrition' and 'mood' (described by almost two-thirds of patients) followed by ‘symptoms’ and ‘social life’ (fig 1). The best meeting schedule from the patient's point of view is every 6-8 weeks, with both in-person and virtual participation. Conclusion This study provides useful information on the feasibility and willingness of young patients with IBD to participate in such interventions. After the experimental application of group meetings, it will be mandatory to let patients provide feedback on this activity and to assess their effects on patients’ psychosocial well-being. References (DOI) 1 10.1016/j.crohns.2013.01.010 2 10.1053/j.gastro.2021.12.282 3 10.1016/j.gtc.2023.05.001 4 10.1093/ibd/izy041 5 10.1007/s10880-021-09778-0 6 10.1111/hsc.13755

P993 IMPACT-III and IMPACT-III-P questionnaires: the transcultural adaptation and validation in Spanish families. A SEGHNP (Spanish Society of Pediatric Gastroenterology, Hepatology and Nutrition) multicenter study

Abstract Background IMPACT-III and IMPACT-III-P are Health-Related Quality of Life (HRQoL) questionnaires for pediatric Inflammatory Bowel Disease (p-IBD) patients and their parents/caregivers. They consist of 35 items answered with a 1-5 points Likert scale that evaluate six domains. Higher scores indicate better HRQoL. IMPACT-III has been translated into over 70 languages and validated in several countries. However, the existing IMPACT-III Spanish translation showed room for improvement and none of the tools had been validated in our population. We aimed to perform a transcultural adaptation and validation of the Spanish versions. Methods With permission from the questionnaires’ authors, we performed the translation and back-translation by professional translators, followed by evaluation by an expert committee and a small group of p-IBD families (n=12). Members of the SEGHNP (Spanish Society of Pediatric Gastroenterology, Hepatology and Nutrition) were invited to recruit p-IBD patients aged 10-18 and their families (February’21-November’22) to complete the questionnaires. Demographical and clinical data of the p-IBD participants were analyzed. Validation was performed with the Cronbach's alpha coefficient (considering 0.8-0.9 a good internal consistency) and a confirmatory factorial analysis with Varimax rotation (desirable values &amp;gt;0.5). The Kaiser Meyer Olkin (KMO) measure (&amp;gt;0.5 good correlation) and the Bartlett’s sphericity test (p&amp;lt;0.05) were calculated to confirm the adequacy of the factor analysis. The utility (method and completion time) was considered. The correlation coefficient between IMPACT-III and IMPACT-III-P was analyzed. Data were collected and analyzed with REDCap and Stata 16. Results We included 370 patients and 356 parents/guardians from 37 hospitals. Descriptive statistics of the participants are shown in table 1. The KMO measure (0.8998 and 0.9228, respectively) and the Bartlett's sphericity test (p-value &amp;lt;0.001 for both) confirmed the factor analysis’ adequacy. The factorial model with four factors, complying with Kaiser’s criterion, explained 89.19% and 88.87% of the variance in the model. Cronbach's alpha (0.9123 and 0.9383) indicated excellent internal consistency. The use of a Likert scoring system and the completion median time of 10 minutes for both tools was considered optimal. The correlation coefficient was 0.92, which was considered excellent. Conclusion The SEGHNP versions of the IMPACT-III and IMPACT-III-P are valid and reliable to use with Spanish p-IBD families. Our findings suggest a 4-factor scores in both questionnaires, although the optimal factor structure should be further examined. In our sample, parents/caregivers were good proxies for rating their p-IBD children overall HRQoL.

P274 Renal failure in children with inflammatory bowel disease

Abstract Background Renal manifestations may occur in children with inflammatory bowel disease (IBD). The cause of renal manifestations is often unclear, but may occur as an extra-intestinal manifestation or due to IBD treatment. Renal complications can lead to acute renal failure, a severe complication and associated with a risk of developing chronic kidney disease (CKD). Current paediatric ECCO/ESPGHAN guidelines recommended to regular monitor renal function with calcineurin inhibitors. However, these recommendations are based on limited knowledge of renal manifestations in paediatric IBD. The aim of this study was to investigate the diagnosis and underlying causes of renal failure in children with IBD. Methods Cases of renal failure in children &amp;lt;19 years with IBD were collected from the international, prospective PIBDSETQuality Safety Registry1. A monthly survey was sent to participating paediatric gastroenterologists throughout the world asking to report cases of renal failure within their clinical practice. Renal failure was defined as an estimated glomerular filtration rate (eGFR) &amp;lt;60 mL/min/1.73m2 based on the Schwartz formula. Upon reporting a case of renal failure, a follow-up form was automatically sent to obtain more information about renal failure, IBD characteristics and outcomes (including CKD, defined as an eGFR &amp;lt;60 for &amp;gt;3 months). Results From November 2016 until August 2023, 220 gastroenterologists from 36 countries participated in the Safety Registry and 38 cases of renal failure were included. Characteristics at time of renal failure are reported in Table 1. Reported causes and diagnoses of renal failure are represented in Figure 1. Most frequently reported causes were IBD medication (n=12) and IBD itself (n=10). IBD medication included 5-ASA (n=5), tacrolimus (n=2) and one case of azathioprine or ibuprofen, vedolizumab, adalimumab, cyclosporine A and ciprofloxacin. Of the cases most likely caused by IBD itself, disease activity was remission (n=4), mild (n=2), moderate (n=3) or severe (n=1). In the majority of cases (n=26, 68%) creatinine was measured during routine follow-up, and not due to kidney-related symptoms. In 13/37 patients creatinine remained elevated after a median follow-up of 82 weeks [41-136 weeks]. Nine patients developed CKD, two patients required renal replacement therapy. Conclusion This is the first prospective study to report cases of renal failure in children with IBD. Renal failure can occur without symptoms, and may lead to CKD. Timely identification of cases of renal failure is important to adequately treat and monitor patients. We recommend to monitor creatinine in all children with IBD, independent of drug use, every 6 months.

P1039 RECtal OUtcomes in Paediatric Ulcerative Colitis (RECOUP-UC): An International Clinical Practice Survey of Paediatric Gastroenterologists

Abstract Background Ulcerative Colitis (UC) in childhood is associated with a higher risk of developing acute severe colitis and colectomy compared to adult populations. Following subtotal colectomy, the rectal remnant is typically oversewn and remains in-situ until ileal continuity surgery is undertaken. Access to such surgical expertise determines the timing of restorative surgery, which may range from months to years. There is a paucity of data regarding residual rectal activity during this interval, its medical management and clinical outcomes. Methods An electronic survey (SurveyMonkey) of clinical practice was disseminated to the paediatric inflammatory bowel disease (PIBD) community internationally. Data collected included treating centre demographics, local colectomy practices, expert opinion on rectal cuff assessment and management. Clinicians were asked to rank order the symptoms and signs considered most relevant to determining disease activity. They also ranked the clinical features they believed most important to patients. Descriptive statistics were used to present findings. Results Responses were collated from over 10 countries, including Ireland, Sweden, UK, Australia, Israel, Canada, Iran, Finland, UAE and Austria. Centre sizes were categorised based on total PIBD population. There was heterogeneity across centres - 16% of respondents were from small volume centres in the range of 0-100 patients, 45% were from medium sized centres (101-300), 25% were from large volume centres (301-500) and 12% treat &amp;gt;500 patients which we categorised as very large volume. Despite variation in centre volume majority of respondents (75%) diagnose &amp;gt;20 new cases of UC annually. Over 90% of respondents reported having no formal guideline for managing rectal disease. Most centres’ patients (60%) waited at least 3 months post-colectomy for restoration surgery. Mild intermittent symptoms were expected to continue by 60% of respondents. Of these symptoms, 45% ranked haematochezia as the most important in determining severity. There was no consensus on the best assessment tool to use; 30% use the PUCAI. Most (80%) use blood markers and endoscopy routinely to assess rectal activity. Favoured treatments include rectal therapy (80%) followed by oral steroids and surgical referral. All respondents agreed that additional research was needed. Conclusion International management of the rectum following subtotal colectomy in children is characterised by variable clinical practises, and a lack of guidelines or validated assessment tools. Additional research in the field is needed to address current literature deficits and improve care for children.