Abstract

Adaptations to the current ECCO/ESPGHAN guidelines on the management of paediatric acute severe colitis in the context of the COVID-19 pandemic: a RAND appropriateness panel

Gut. 2020 Sep 1;gutjnl-2020-322449. doi: 10.1136/gutjnl-2020-322449. Online ahead of print.

Richard Hansen 1, Susanna Meade 2, R Mark Beattie 3, Marcus Kh Auth 4, Nick Croft 5 6, Philip Davies 7, David Devadason 8, Conor Doherty 9, Jenny Epstein 10, Lucy Howarth 11, Fevronia Kiparissi 12, Rafeeq Muhammed 13, Vinay Shivamurthy 14, Christine Spray 15, Michael P Stanton 16, Franco Torrente 17, Arun Urs 18, David Wilson 19 20, Peter M Irving 2, Mark Samaan 2, Jochen Kammermeier 21

 
     

Author information

  • 1Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK.
  • 2Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK.
  • 3Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.
  • 4Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK.
  • 5Blizard Institute, Queen Mary's University of London, Barts and the London School of Medicine, London, UK.
  • 6Department of Paediatric Gastroenterology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK.
  • 7Department of Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow, UK.
  • 8Department of Paediatric Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.
  • 9Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow, UK.
  • 10Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
  • 11Department of Paediatric Gastroenterology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.
  • 12Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK.
  • 13Department of Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham, West Midlands, UK.
  • 14Department of Paediatric Rheumatology, Evelina London Children's Hospital, London, UK.
  • 15Department of Paediatric Gastroenterology, Hepatology & Nutrition, Bristol Royal Hospital for Children, Bristol, UK.
  • 16Department of Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK.
  • 17Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK.
  • 18Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK.
  • 19Child Life and Health, University of Edinburgh, Edinburgh, UK.
  • 20Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK.
  • 21Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK jochen.kammermeier@gstt.nhs.uk.

Abstract

Objective: Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison.

Design: We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey.

Results: Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8-10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19.

Conclusion: Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.

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