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ObjectiveTo compare weight gain from birth to term equivalent age in very preterm infants in England born during two eras (2006–2011 and 2014–2018); to assess demographic and care factors influencing weight gain.MethodsData for infants born before 32 weeks of gestation during 2014–2018 in England were obtained (29 687 infants). Weight gain modelled using SuperImposition by Translation And Rotation (SITAR), with infants grouped by gestational week. A cohort from 2006 to 2011 was used for comparison (3288 infants). Multiple linear regression was used to assess factors influencing change in weight SD score from birth to 36 weeks postmenstrual age.ResultsWeight gain velocity (termed ‘intensity’ in SITAR models) was greater in the more recent cohort for all gestation groups born before 30 weeks of gestation. After adjustment for gestation, birth weight and other perinatal factors, care elements associated with faster weight gain included delivery in a level 3 unit (0.09 SD less weight gain deficit, 95% CI: 0.07 to 0.10) and parenteral nutrition initiation during the first day of life (0.08 SD, 95% CI: 0.06 to 0.10). Factors associated with slower weight gain included early ventilation (−0.07 SD, 95% CI: −0.08 to −0.05) and less deprived neighbourhood (−0.012 SD per Index of Multiple Deprivation decile, 95% CI: −0.015 to −0.009).ConclusionsWeight gain for extremely preterm infants was faster during 2014–2018 than during 2006–2011. Early initiation of parenteral nutrition and birth in a level 3 unit may contribute to faster weight gain.

Background Crohn’s disease (CD) is highly heterogenous and may be complicated by stricturing behavior. Personalized prediction of stricturing will inform management. We aimed to create a stricturing risk stratification model using genomic/clinical data. Methods Exome sequencing was performed on CD patients, and phenotype data retrieved. Biallelic variants in NOD2 were identified. NOD2 was converted into a per-patient deleteriousness metric (“GenePy”). Using training data, patients were stratified into risk groups for fibrotic stricturing using NOD2. Findings were validated in a testing data set. Models were modified to include disease location at diagnosis. Cox proportional hazards assessed performance. Results Six hundred forty-five patients were included (373 children and 272 adults); 48 patients fulfilled criteria for monogenic NOD2-related disease (7.4%), 24 of whom had strictures. NOD2 GenePy scores stratified patients in training data into 2 risk groups. Within testing data, 30 of 161 patients (18.6%) were classified as high-risk based on the NOD2 biomarker, with stricturing in 17 of 30 (56.7%). In the low-risk group, 28 of 131 (21.4%) had stricturing behavior. Cox proportional hazards using the NOD2 risk groups demonstrated a hazard ratio (HR) of 2.092 (P = 2.4 × 10-5), between risk groups. Limiting analysis to patients diagnosed aged Conclusions A NOD2 genomic biomarker predicts stricturing risk, with prognostic power improved in pediatric-onset CD. Implementation into a clinical setting can help personalize management.

Studies of Crohn’s disease have consistently implicated NOD2 as the most important gene in disease pathogenesis since first being identified in 2001. Thereafter, genome-wide association, next-generation sequencing and functional analyses have all confirmed a key role for NOD2, but despite this, NOD2 also has significant unresolved complexity. More recent studies have reinvigorated an early hypothesis that NOD2 may be a single-gene cause of disease, and the distinct ileal stricturing phenotype seen with NOD2-related disease presents an opportunity for personalized diagnosis, disease prediction and targeted therapy. The genomics of NOD2 has much that remains unknown, including the role of rare variation, phasing of variants across the haplotype block and the role of variation in the NOD2-regulatory regions. Here, we discuss the evidence and the unmet needs of NOD2 research, based on recently published evidence, and suggest methods that may meet these requirements.

To determine how the use of biological therapy is associated with surgical intervention for paediatric inflammatory bowel disease (PIBD) at a population level.Hospital Episode Statistics data were obtained for all admissions within England (1997-2015), in children aged 0-18 years, with an ICD-10 code for diagnosis of Crohn disease (CD), ulcerative colitis (UC), or inflammatory bowel disease-unclassified (IBD-U). Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures codes for major surgical resection associated with PIBD and for biological therapy were also obtained. Data are presented as median values (interquartile range).In total, 22,645 children had a diagnosis of PIBD of which 13,722 (61%) had CD, 7604 (34%) had UC, and 1319 (5.8%) cases had IBD-U. Biological therapy was used in 4054 (17.9%) cases. Surgical resection was undertaken in 3212 (14%) cases, more commonly for CD than UC (17.5 vs 10.3%, P0.0001). Time from diagnosis to major surgical resection was 8.3 (1.2-28.2) months in CD and 8.2 (0.8-21.3) months in UC. As the time-frame of the dataset progressed, there was a decreased rate of surgical intervention ( P = 0.04) and an increased use of biological therapy ( P0.0001). Additionally, the number of new diagnoses of PIBD increased.The introduction of biologic agents has been associated with a reduction in cases undergoing surgery in children with a known diagnosis of PIBD. As time progresses we will be able to determine whether biological therapies prevent the need for surgery altogether or just delay this until adulthood.

Abstract The rise of machine learning in healthcare has significant implications for paediatrics. Long-term conditions with significant disease heterogeneity comprise large portions of the routine work performed by paediatricians. Improving outcomes through discovery of disease and treatment prediction models, alongside novel subgroup clustering of patients, are some of the areas in which machine learning holds significant promise. While artificial intelligence has percolated into routine use in our day to day lives through advertising algorithms, song or movie selections and sifting of spam emails, the ability of machine learning to utilise highly complex and dimensional data has not yet reached its full potential in healthcare. In this review article, we discuss some of the foundations of machine learning, including some of the basic algorithms. We emphasise the importance of correct utilisation of machine learning, including adequate data preparation and external validation. Using nutrition in preterm infants and paediatric inflammatory bowel disease as examples, we discuss the evidence and potential utility of machine learning in paediatrics. Finally, we review some of the future applications, alongside challenges and ethical considerations related to application of artificial intelligence. Impact Machine learning is a widely used term; however, understanding of the process and application to healthcare is lacking. This article uses clinical examples to explore complex machine learning terms and algorithms. We discuss limitations and potential future applications within paediatrics and neonatal medicine.

Objective: The incidence of paediatric inflammatory bowel disease (IBD) has been increasing over 25 years; however, contemporary trends are not established and the impact of COVID-19 on case rates is unclear. Methods: Data from Southampton Children's hospital prospective IBD database were retrieved for 2002-2021. Incidence rates were calculated based on referral area populations and temporal trends analysed. Disease prevalence for those aged -6, driven by Crohn's disease, β = 0.732, P = 0.00024 and ulcerative colitis, β = 0.816, P = 0.000011. There was no change in IBDU incidence, β = 0.230, P = 0.33. From 2002-2021, 51 patients were diagnosed -7). There was no significant change in incidence of IBD in

Background Inflammatory bowel disease (IBD) is a chronic inflammatory disorder with two main subtypes: Crohn’s disease (CD) and Ulcerative Colitis (UC). Prompt subtype diagnosis enables the correct treatment to be administered. Using genomic data, we aimed to assess machine learning (ML) to classify patients according to IBD subtype. Methods Whole exome sequencing from paediatric/adult IBD patients was processed using an in-house bioinformatics pipeline. This data was condensed into the per-gene, per-individual genomic burden score, GenePy. Data was split into training and testing datasets (80/20). Feature selection with a linear support vector classifier, and hyperparameter tuning with Bayesian Optimisation was performed (training data). The supervised ML method random forest was utilised to classify patients as CD or UC using three panels: I) all available genes, 2) autoimmune genes, 3) ‘IBD’ genes. ML results were assessed using AUROC, sensitivity and specificity on the testing dataset. Results 906 patients were included in analysis (600 CD, 306 UC). Training data included 488 patients, balanced according to the minority class of UC. The autoimmune gene panel generated the best performing ML model (AUROC=0.68), outperforming an IBD gene panel (AUROC =0.61). NOD2 was the top gene for discriminating CD and UC, regardless of the gene panel used. Lack of variation in genes with high GenePy scores in CD patients was the best classifier of a diagnosis of UC. Discussion We demonstrate promising classification of patients by subtype utilising random forest and WES data. Focussing on specific subgroups of patients, with larger datasets may result in better classification.

Background/Objective– Heterogeneity and chronicity of Crohn’s disease (CD) make prediction of outcomes difficult. To date, no longitudinal measure can quantify burden over a patient’s disease course, preventing assessment and integration into predictive modelling. Here, we aimed to demonstrate the feasibility of constructing a data driven, longitudinal disease burden score.Methods– Literature was reviewed for tools used in assessment of CD activity. Themes were identified to construct a paediatric CD morbidity index (PCD-MI). Scores were assigned to variables. Data were extracted automatically from the electronic patient records at Southampton Children’s Hospital, diagnosed from 2012 to 2019 (inclusive). PCD-MI scores were calculated, adjusted for duration of follow up and assessed for variation (ANOVA) and distribution (Kolmogorov-Smirnov).Results– Nineteen clinical/biological features across five themes were included in the PCD-MI including blood/faecal/radiological/endoscopic results, medication usage, surgery, growth parameters and extraintestinal manifestations. Maximal score was 100 after accounting for follow-up duration.PCD-MI was assessed in 66 patients, mean age 12.5 years. Following quality filtering, 9528 blood/faecal test results and 1309 growth measures were included. Mean PCD-MI score was 14.95 (range 2.2-32.5), data were normally distributed (p=0.2) with 25% of patients having a PCD-MI Conclusions– PCD-MI is a calculatable measure for a cohort of patients diagnosed over an 8-year period, integrating a wide-range of data with potential to determine high or low disease burden. Future iterations of the PCD-MI require refinement of included features, optimised scores and validation on external cohorts.

Background: Growth failure in infants born with CHD is a persistent problem, even in those provided with adequate nutrition. Objective: To summarise the published data describing the change in urinary metabolites during metabolic maturation in infants with CHD and identify pathways amenable to therapeutic intervention Design: Scoping review. Eligibility criteria: Studies using qualitative or quantitative methods to describe urinary metabolites pre- and post-cardiac surgery and the relationship with growth in infants with CHD. Sources of evidence: NICE Healthcare Databases website was used as a tool for multiple searches. Results: 347 records were identified, of which 37 were duplicates. Following the removal of duplicate records, 310 record abstracts and titles were screened for inclusion. The full texts of eight articles were reviewed for eligibility, of which only two related to infants with CHD. The studies included in the scoping review described urinary metabolites in 42 infants. A content analysis identified two overarching themes of metabolic variation predictive of neurodevelopmental abnormalities associated with anaerobic metabolism and metabolic signature associated with the impact on gut microbiota, inflammation, energy, and lipid digestion. Conclusion: The results of this scoping review suggest that there are considerable gaps in our knowledge relating to metabolic maturation of infants with CHD, especially with respect to growth. Surgery is a key early life feature for CHD infants and has an impact on the developing biochemical phenotype with implications for metabolic pathways involved in immunomodulation, energy, gut microbial, and lipid metabolism. These early life fingerprints may predict those individuals at risk for neurodevelopmental abnormalities.

Background: Paediatric Crohn's disease (CD) has been associated with undernutrition. Accurate and accessible measures of body composition would provide data to personalise nutritional therapy. We assessed feasibility of MRI-derived measures of psoas cross-sectional area (PCSA) in paediatric CD and correlated with anthropometric and bioelectrical impedance spectroscopy (BIS) measures. Methods: MRI small bowel/pelvis images of patients with CD, aged

BackgroundTotal body water (TBW) is one component of fat-free mass and changes in TBW are influenced by fluid shifts (especially during transition to postnatal life), electrolyte balance and nutritional status. Normal values for term-born neonates and preterm infants at birth have not been defined in large cohorts, limiting investigation into its monitoring and use in clinical practice.ObjectiveTo systematically review the evidence base for percentage of TBW in term-born infants, quantify the effect of prematurity on TBW at birth, and describe normal progression of TBW over time in preterm infants.MethodsSystematic review of Medline, Web of Science Core Collection and EBSCO-CINAHL (January 1946 to January 2020). Included articles used dilutional methods to assess TBW.ResultsSearches identified 2349 articles of which 22 included data suitable for analysis. Mean TBW in term-born newborns was 73.8% (95% CI 72.47% to 75.06%, 15 studies, 433 infants). Meta-regression showed that TBW was higher in preterm infants (up to 90% at 26 weeks gestation, dropping to 75% at 36 weeks corrected gestation) and was negatively correlated with gestation at birth, falling 1.44% per week (95% CI 0.63% to 2.24%, 9 studies, 179 infants). Analysis of TBW over time during the ex utero growth of preterm infants was not possible due to paucity of data.ConclusionThis review defines the normal TBW percentage in term-born infants and confirms and quantifies previous findings that preterm infants have a higher TBW percentage.

Background and Aims Crohn’s disease [CD] arises through host-environment interaction. Abnormal gene expression results from disturbed pathway activation or response to bacteria. We aimed to determine activated pathways and driving cell types in paediatric CD. Methods We employed contemporary targeted autoimmune RNA sequencing, in parallel to single-cell sequencing, to ileal tissue derived from paediatric CD and controls. Weighted gene co-expression network analysis [WGCNA] was performed and differentially expressed genes [DEGs] were determined. We integrated clinical data to determine co-expression modules associated with outcomes. Results In all, 27 treatment-naive CD [TN-CD], 26 established CD patients and 17 controls were included. WGCNA revealed a 31-gene signature characterising TN-CD patients, but not established CD, nor controls. The CSF3R gene is a hub within this module and is key in neutrophil expansion and differentiation. Antimicrobial genes, including S100A12 and the calprotectin subunit S100A9, were significantly upregulated in TN CD compared with controls [p = 2.61 x 10-15 and p = 9.13 x 10-14, respectively] and established CD [both p = 0.0055]. Gene-enrichment analysis confirmed upregulation of the IL17-, NOD- and Oncostatin-M-signalling pathways in TN-CD patients, identified in both WGCNA and DEG analyses. An upregulated gene signature was enriched for transcripts promoting Th17-cell differentiation and correlated with prolonged time to relapse [correlation-coefficient-0.36, p = 0.07]. Single-cell sequencing of TN-CD patients identified specialised epithelial cells driving differential expression of S100A9. Cell groups, determined by single-cell gene expression, demonstrated enrichment of IL17-signalling in monocytes and epithelial cells. Conclusions Ileal tissue from treatment-naïve paediatric patients is significantly upregulated for genes driving IL17-, NOD- and Oncostatin-M-signalling. This signal is driven by a distinct subset of epithelial cells expressing antimicrobial gene transcripts.

The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government’s advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.

Abdominal pain in childhood is extremely common and presents frequently to both primary and secondary care, with many children having recurrent pain which impacts on daily functioning. Despite this most children have no discernible underlying pathology. We discuss the underlying mechanism for functional abdominal pain (visceral hypersensitivity), the evidence base linking parental anxiety and patient symptoms, and how parents can be supported in managing their children’s symptoms by addressing questions commonly asked by children and families. We look at the evidence for a one-stop rational approach to investigation including a coeliac screen, inflammatory markers and consideration of stool faecal calprotectin, in the absence of red flags. We evaluate commonly used treatments for functional abdominal pain, within a context of managing family expectations. Given the limitations in pharmacological treatment options, trials of probiotics, peppermint oil, mebeverine and (for short-term use only) hyoscine butylbromide may be appropriate. Psychological interventions including cognitive–behavioural therapy, distraction techniques and hypnotherapy have a better evidence base. There is also some evidence for other complementary therapies in children, including yoga and neurostimulation. Outcome is generally good providing there is child and family acceptance of the multiple factors implicated in the aetiology of the pain.

Nutritional management for children with neurodisability can be challenging and there are an increasing number of children at risk of malnutrition. Management involves healthcare professionals in community and hospital working together with the family with the aim of optimising nutrition and quality of life. Feeding difficulties can be the result of physical causes like lack of oromotor coordination, discomfort associated with reflux oesophagitis or gastrointestinal dysmotility. Non-physical causes include parental/professional views towards feeding, altered perception of pain and discomfort, extreme sensitivity to certain textures and rigidity of feeding schedule associated with artificial feeding. Estimating nutritional needs can be difficult and is affected by comorbidities including epilepsy and abnormal movements, severity of disability and mobility. Defining malnutrition is difficult as children with neurodisability reflect a wide spectrum with disparate growth patterns and body composition and auxology is less reliable and less reproducible. Management involves selecting the type and method of feeding best suited for the patient. As artificial feeding can place a significant burden of care any decision-making should be, as much as possible, in concurrence with the family. Symptom management sometimes requires pharmacological interventions, but polypharmacy is best avoided. The article aims to discuss the pathways of identifying children at risk of malnutrition and available management options with a strong emphasis on working as a clinical team with the child and family.

Background & aims: Nutritional assessment in paediatric inflammatory bowel disease (IBD) is key to supporting growth whilst minimising adiposity. Bedside assessment using bioelectrical impedance spectroscopy (BIS) has previous identified patients with declining cellular and nutritional health. We aimed to assess BIS measures in stable paediatric IBD patient. Methods: Stable IBD patients were recruited at routine hospital visits. All patients underwent BIS, anthropometry and disease activity assessment. Multivariable regression and receiver operator curve (ROC) analyses were undertaken to assess the utility of BIS phase angle 50 KHz (PA-50) and 200/5 KHz impedance ratio (IR) in nutritional assessment. Results: There were 140 study visits from 97 patients, mean age 14.49 years, 62.9% Crohn's disease. Mean BMI Z-score (BMIZ) was 0.31 (range −2.97 to 3.99), 33% of patients were overweight (BMIZ>1) and 13.8% of patients were underweight (BMIZ < −1). Crohn's disease patients had a lower mean BMIZ score 0.14, compared to ulcerative colitis, 0.68, p = 0.007. There was no relationship between PA-50 and BMIZ or disease activity. IR was not related to disease activity but was negatively related to BMIZ in a multivariable regression, accounting for age, sex and disease subtype (beta −0.331, p = 0.001). ROC analyses did not identify a clinically useful cut off for either PA-50 or IR to identify patients with active disease, biologic use or BMIZ>1 or < -1. Conclusion: BIS appears to have limited added value in nutritional assessment of stable paediatric IBD patients. Nearly 1/3 patients were overweight and personalised approach to supplementation is vital to avoid overnutrition.

Pain is a common complaint in children with gastrointestinal tract pathology. It has significant consequences for patients’ quality of life. A thorough evaluation should be performed to determine the cause and severity of pain. It is important to differentiate between organic and functional pain. Understanding the pathophysiology of pain in various conditions is useful in its management. This chapter outlines the causes and general principles in management of pain in gastrointestinal disorders. The specific management of common gastrointestinal conditions associated with pain, for example inflammatory bowel disease, gastroesophageal reflux disease, pancreatitis and gut dysmotility disorders, is discussed.

OBJECTIVES: Patients with paediatric inflammatory bowel disease (IBD) constitute one of the largest cohorts requiring transition from paediatric to adult services. Standardised transition care improves short and long-term patient outcomes. This study aimed to detail the current state of transition services for IBD in the United Kingdom (UK). METHODS: We performed a nationwide study to ascertain current practice, facilities and resources for children and young people with IBD. Specialist paediatric IBD centres were invited to contribute data on: timing of transition/transfer of care; transition resources available including clinics, staff and patient information; planning for future improvement. RESULTS: Twenty of 21 (95%) of invited centres responded. Over 90% of centres began the transition process below 16 years of age and all had completed transfer to adult care at 18 years of age. The proportion of patients in the transition process at individual centres varied from 10% to 50%.Joint clinics were held in every centre, with a mean of 12.9 clinics per year. Adult and paediatric gastroenterologists attended at all sites. Availability of additional team members was patchy across the UK, with dietetic, psychological and surgical attendance available in

Background Management of paediatric Crohn’s disease (CD) presents significant challenges. Escalation of therapy to biologics or a ‘top-down’ approach, with early introduction of biologics, is common. Anti-TNF agents are widely used, but the use of ustekinumab is still limited. Ustekinumab is a human monoclonal antibody targeting the p40 subunit of both IL-12/-23. Ustekinumab has recently emerged as an alternative treatment option in children with failure of response to anti-TNF alpha treatment and those developing intolerable side effects on anti-TNF treatment including psoriasis. Aims Data on ustekinumab efficacy in paediatric IBD are limited. We report our experience on the use of this monoclonal antibody in paediatric IBD at a tertiary GI service in Wessex. Methods Retrospective review of all paediatric patients (≤ 18 years) receiving ustekinumab for the management of their IBD. Data was collected by reviewing patients’ electronic medical records and available results. Only those who had the treatment for at least 26 weeks were included. Steroid free remission were the primary outcomes of this study and resolution of psoriasis (where applicable) as a secondary outcome measure. Results Between November 2017- November 2020, 12 patients (M:F=6:6) patients were identified who were commenced on ustekinumab for the treatment of their IBD; 9 patients with CD and 3 with IBDU- Crohn’s like. One patient was excluded as the duration of treatment was The median duration between diagnosis and initiation of treatment with ustekinumab was 104 weeks and median duration of treatment with ustekinumab at the time of the review was 60 weeks (26–160 weeks). All patients received standard anti-TNF alpha treatment prior to ustekinumab. (All 11 patients received infliximab, 7 patients received both infliximab and adalimumab, and 4 patients were escalated directly from infliximab to ustekinumab). The key indications for considering ustekinumab were primary non-response (N=5, 45%), secondary loss of response (N=3, 27%) and anti-TNF-alpha induced psoriasis. Six patients (54%) developed psoriasis while on treatment with anti-TNF alpha. Three patients (27%) were switched to ustekinumab primarily in view of anti-TNF-alpha induced psoriasis. Steroid-free remission rates were (81%) at 26 weeks (N=9), (90%) at 52 weeks and 100% thereafter in 5 individuals who remained on ustekinumab over 1 year at the last review. No significant side-effects were reported in any patient. 85% of patients (N=5:6) who were identified with psoriasis have shown good response to switching treatment from anti-TNF to ustekinumab. Conclusions This data suggests that ustekinumab is a useful and a safe treatment option in children with IBD refractory to standard monoclonal therapy and in those developing intolerable anti-TNF alpha induced side-effects, psoriasis in particular. Larger studies from multiple centres would be required to develop standardised pathways for the use of this promising monoclonal agent for the management of paediatric IBD.

There is a lack of robust data into whether aspirin increases the risk of gastrointestinal (GI) bleeding. Mahady et al ( GUT 2020, http://dx.doi.org/10.1136/gutjnl-2020-321585) extracted data from the ASPREE (ASPirin in Reducing Events in the Elderly) randomised controlled trial (n=19 114, age 70 years and over, median follow-up 4.7 years). The endpoint was major bleeding defined as that resulting in transfusion, hospitalisation, surgery or death. Over the study period there were 137 upper GI (89 in aspirin arm, 48 in placebo arm; HR 1.87, 95% CI 1.32 to 2.66, p

Activation of the nuclear factor (NF)-κB transcription factor is instrumental for the immune response and the survival of peripheral activated T cells. We demonstrate that ligation of CD95 (Fas/APO1), a potent apoptotic stimulus in lymphocytes, results in repression of NF-κB activity in Jurkat T cells by inducing the proteolytic cleavage of NF-κB p65 (Rel A) and p50. Inhibition of caspase-3-related proteases by a specific acetylated aldehyde (Ac-DEVD-CHO) prevented CD95-induced cleavage of p65 (RelA) or p50 and restored the inducibility of NF-κB in cells treated with an antibody against CD95. The addition of recombinant caspase-3 also resulted in proteolytic cleavage of RelA p65 and p50 in vitro. TNF-α treatment, unlike CD95 ligation, did not result in the death of Jurkat cells but did so in the presence of IκBαM, a transdominant inhibitor of NF-κB. These results suggest that intact, functional NF-κB maintains the survival of activated T cells, and that CD95-induced cleavage of NF-κB subunits sensitizes T cells to apoptosis and, hence, facilitates the decay of an immune response.

What you need to know A 29 year old white woman presents to her general practitioner with a 12 month history of borderline anaemia (diagnosed when she tried to donate blood) alongside increasing bloating at the end of every day. On direct questioning, she has slightly looser stools compared with 5-10 years ago, but this has been attributed to irritable bowel syndrome by both the patient and previous GPs. She has no other medical history, including normal menarche. The GP decides to order some blood tests including a tissue transglutaminase (TTG) IgA test, which gives a result of 78.4 U/mL (normal range 0.0-4.5 U/mL), with normal total IgA (normal range 0.80-2.8 g/L). Coeliac disease is a common autoimmune condition, often presenting with vague symptoms triggered by chronic gluten ingestion in genetically predisposed individuals. It is characterised by the presence of specific autoantibodies with a coexisting enteropathy.1 It is more common in females (1.5:1 predominance) and in populations with European ancestry, with an estimated prevalence of 1.4% globally.123 Despite growing recognition of coeliac disease, many cases remain undiagnosed: a North American study spanning 2006 to 2011 of over 30 000 individuals without a known coeliac disease diagnosis demonstrated coeliac-positive serology in 1.1%.4 The classic symptoms usually trigger testing, but patients with less common presentations are often not screened for coeliac disease.1 Timely diagnosis is important, …

ObjectiveManagement of acute severe UC (ASUC) during the novel COVID-19 pandemic presents significant dilemmas. We aimed to provide COVID-19-specific guidance using current British Society of Gastroenterology (BSG) guidelines as a reference point.DesignWe convened a RAND appropriateness panel comprising 14 gastroenterologists and an IBD nurse consultant supplemented by surgical and COVID-19 experts. Panellists rated the appropriateness of interventions for ASUC in the context of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Median scores and disagreement index (DI) were calculated. Results were discussed at a moderated meeting prior to a second survey.ResultsPanellists recommended that patients with ASUC should be isolated throughout their hospital stay and should have a SARS-CoV-2 swab performed on admission. Patients with a positive swab should be discussed with COVID-19 specialists. As per BSG guidance, intravenous hydrocortisone was considered appropriate as initial management; only in patients with COVID-19 pneumonia was its use deemed uncertain. In patients requiring rescue therapy, infliximab with continuing steroids was recommended. Delaying colectomy because of COVID-19 was deemed inappropriate. Steroid tapering as per BSG guidance was deemed appropriate for all patients apart from those with COVID-19 pneumonia in whom a 4–6 week taper was preferred. Post-ASUC maintenance therapy was dependent on SARS-CoV-2 status but, in general, biologics were more likely to be deemed appropriate than azathioprine or tofacitinib. Panellists deemed prophylactic anticoagulation postdischarge to be appropriate in patients with a positive SARS-CoV-2 swab.ConclusionWe have suggested COVID-19-specific adaptations to the BSG ASUC guideline using a RAND panel.

Many paediatric healthcare professionals are increasingly concerned about the long-term secondary impact of the COVID-19 pandemic on the care of children and young people (CYP) with chronic conditions. Those of us working in paediatric gastroenterology now lack the ability to provide the same level of diagnostic care and ongoing management to our patients, particularly the large number with inflammatory bowel disease (IBD). With all elective endoscopy cancelled, difficulty in obtaining day-case infusions and telemedicine becoming the norm, many professionals are justifiably uncomfortable. There is little known about the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on those CYP with IBD, or on patients with systemic immunosuppression, although the small amount of data derived thus far indicates mild disease in …

ObjectiveTo determine the challenges in diagnosis, monitoring, support provision in the management of inflammatory bowel disease (IBD) patients and explore the adaptations of IBD services.MethodsInternet-based survey by invitation of IBD services across the UK from 8 to 14 April 2020.ResultsRespondents from 125 IBD services completed the survey. The number of whole-time equivalent gastroenterologists and IBD nurses providing elective outpatient care decreased significantly between baseline (median 4, IQR 4–7.5 and median 3, IQR 2–4) to the point of survey (median 2, IQR 1–4.8 and median 2, IQR 1–3) in the 6-week period following the onset of the COVID-19 pandemic (pConclusionsIBD services in the UK have implemented several adaptive strategies in order to continue to provide safe and high-quality care for patients. National Health Service organisations will need to consider the impact of these changes in current service delivery models and staffing levels when planning exit strategies for post-pandemic IBD care. Careful planning to manage the increased workload and to maintain IBD services is essential to ensure patient safety.

Aim: We assessed growth in a paediatric inflammatory bowel disease (PIBD) cohort. Methods: Paediatric inflammatory bowel disease patients were eligible if they were diagnosed at Southampton Children's Hospital from 2011 to 2018. Weight and height standard deviation scores (SDS) were retrieved. Mean SDS values, SDS change and anti-TNF status were analysed at diagnosis and during follow-up. Results: Four hundred and ninety patients were included, 313 with Crohn's disease (CD). CD patients presented with mean height SDS −0.13, −0.1 at 1-year, −0.11 at 2-years and −0.03 at 5 years, reflecting preserved linear growth. There was no significant height-SDS change from diagnosis to 5-year follow-up, +0.12, 95%-CI: 0.48 to −0.24. Mean weight-SDS at diagnosis was −0.39, driven by CD patients (−0.65). Mean weight-SDS approached 0 after 1 year and remained at the 50th centile throughout follow-up. Growth in ulcerative colitis was maintained. In multivariable regression males had worse height growth from diagnosis to transition (P =.036). Anti-TNF treatment (P =.013) and surgical resection (P =.005) were also associated with poorer linear growth. Patients treated with anti-TNF therapy had lower height-SDS compared to those never treated with anti-TNF at 1 year (−0.2 vs −0.01, P =.22), 2-years (−0.27 vs −0.01, P =.07) and 5 years (−0.21 vs 0.25, P =.051). Conclusion: Height was generally maintained in Crohn's disease, and impaired linear growth was rare in this cohort.

Background: Pediatric ulcerative colitis (UC) presents at an earlier age and increasing prevalence. Our aim was to examine morbidity, steroid sparing strategies, and surgical outcome in children with active UC.Methods: A national prospective audit was conducted for the inpatient period of all children with UC for medical or surgical treatment in the United Kingdom (UK) over 1 year. Thirty-two participating centers recruited 224 children in 298 admissions, comparisons over 6 years were made with previous audits.Results: Over 6 years, recording of Paediatric Ulcerative Colitis Activity Index (PUCAI) score (median 65)(23% to 55%, P < 0.001), guidelines for acute severe colitis (43% to 77%, P < 0.04), and ileal pouch surgery registration (4% to 56%, P < 0.001) have increased. Corticosteroids were given in 183/298 episodes (61%) with 61/183 (33%) not responding and requiring second line therapy or surgery. Of those treated with anti-TNFalpha (16/61, 26%), 3/16 (18.8%) failed to respond and required colectomy. Prescription of rescue therapy (26% to 49%, P = 0.04) and proportion of anti-TNFalpha (20% to 53%, P = 0.03) had increased, colectomy rate (23.7% to 15%) was not significantly reduced (P = 0.5). Subtotal colectomy was the most common surgery performed (n = 40), and surgical complications from all procedures occurred in 33%. In 215/224 (96%) iron deficiency anemia was detected and in 51% treated, orally (50.2%) or intravenously (49.8%).Conclusions: A third of children were not responsive to steroids, and a quarter of these were treated with anti-TNFalpha. Colectomy was required in 41/298 (13.7%) of all admissions. Our national audit program indicates effectiveness of actions taken to reduce steroid dependency, surgery, and iron deficiency. 10.1093/ibd/izy042_video1izy042.video15769503407001.

Objective In newly diagnosed paediatric patients with moderate-to-severe Crohn’s disease (CD), infliximab (IFX) is initiated once exclusive enteral nutrition (EEN), corticosteroid and immunomodulator therapies have failed. We aimed to investigate whether starting first-line IFX (FL-IFX) is more effective to achieve and maintain remission than conventional treatment. Design In this multicentre open-label randomised controlled trial, untreated patients with a new diagnosis of CD (3–17 years old, weighted Paediatric CD Activity Index score (wPCDAI) >40) were assigned to groups that received five infusions of 5 mg/kg IFX at weeks 0, 2, 6, 14 and 22 (FL-IFX), or EEN or oral prednisolone (1 mg/kg, maximum 40 mg) (conventional). The primary outcome was clinical remission on azathioprine, defined as a wPCDAI

Key points Coeliac disease (CD) is a systemic, immune-mediated disorder precipitated by gluten and related prolamins. It is characterised by gut enteropathy. It can manifest at any age after weaning (6 months onwards). The estimated lifetime prevalence is around 1% when populations are screened, although significantly fewer are diagnosed. This partly reflects the wide range of presenting symptoms—gastrointestinal, non-gastrointestinal and occult—and many of the cases picked up on screening are asymptomatic at presentation. Other factors include gluten restriction before diagnosis, diagnostic overshadowing whereby the condition is not considered when other conditions are present and the fact that cases can test negative and then develop the condition later. This last issue makes the implementation of population screening complex …

The incidence of early-onset paediatric inflammatory bowel disease is increasing worldwide. Defined as a diagnosis of Crohn's disease, ulcerative colitis, or inflammatory bowel disease unclassified before the age of 10 years, the disease is complex, multifactorial, and lifelong, and affects nutrition and psychological wellbeing. Over 200 genes have been implicated and a further 52 genes are known to cause monogenic disease, often presenting in infancy. Heritability of early-onset inflammatory bowel disease is hypothesised to be between that of infantile-onset (ie

Summary Objective Infants with congenital heart disease (CHD) often experience growth failure prior to surgery, which is associated with increased paediatric-intensive-care unit length of stay (PICU-LOS) and post-operative complications. This study assessed the impact of a pre-operative, consensus-based nutritional pathway (including support from a multi-disciplinary team) on growth and clinical outcome. Design Single-centre prospective pilot study. Setting Tertiary paediatric cardiology surgical centre. Patients Infants with CHD. Intervention Infants with CHD were followed for up to 4-months-of-age before cardiac surgery and then to 12-months-of-age following the implementation of the consensus-based nutritional-pathway (Intervention group: November 2017–August 2018), with outcomes compared to a historic control group. The nutrition pathway involved a dietitian contacting parents of infants with the highest risk of growth failure weekly; reviewing weight gain and providing feeding support. Main outcome measure Growth (weight-for-age, WAZ, and height-for-age-z-score, HAZ) at 4 and 12 months-of-age. Results 44 infants in the intervention group were compared to 38 in the control group. Median (inter quartile range) change in WAZ from birth to 4 months-of-age (−0.9 (−1.5, 0.7)) and from birth to 12 months-of-age (−0.09 (−1.3, 1.1)) in the intervention group compared to the control group (−1.5 (−2.0, −0.4) (p = 0.04)) at 4 months-of age and at 12 months-of-age (−0.4 (1.9, 0.2) (p = 0.03)). HAZ at 4 months-of-age was −0.7 (−1.4, −0.1) vs. −1.0 (−1.9, −0.3) (p = 0.6) in the intervention and control groups respectively, and at 12 months-of-age HAZ was −0.7 (−1.9, −0.07) in the intervention group vs.-1.6 (−2.6, −0.4) in the control group (p = 0.04). Duration of PICU-LOS was 8.2 ± 11.6 days intervention vs. 18.3 ± 24.0 days control (p = 0.006). Conclusion Overall weight was well maintained and growth improved in infants who followed the pre-operative nutritional-pathway. The duration of PICU-LOS was significantly lower in the intervention group, which may be due to improved nutritional status, although this requires further investigation.

ObjectiveTo use repeated measurements of weight, length and head circumference to generate growth centile charts reflecting real-world growth of a population of very preterm infants with a well-described nutritional intake close to current recommendations.DesignInfants born before 30 weeks gestational age (GA) were recruited. Infants received nutrition according to an integrated care pathway, with nutrient intake recorded daily, weight recorded twice-weekly and length and head circumference weekly. The LMS method was used to construct growth centile charts between 24 and 36 weeks corrected GA for each parameter.SettingA single tertiary neonatal unit in England.Patients212 infants (124 male) (median GA at birth: 27.3 weeks, median birth weight: 900 g).ResultsMedian daily energy, protein, carbohydrate and fat intake were within 3% of published recommendations. The total number of measurements recorded was 5944 (3431 for weight, 1227 for length and 1286 for head circumference). Centile charts were formed for each parameter. Data for male and female infants demonstrated similar patterns of growth and were pooled for LMS analysis. A web application was created and published (bit.ly/sotongrowth) to allow infants to be plotted on these charts with changes in SD score of measurements reported and graphically illustrated.ConclusionsThese charts reflect growth in a real-world cohort of preterm infants whose nutrient intakes are close to current recommendations. This work demonstrates the feasibility of forming growth charts from serial measurements of growing preterm infants fed according to current recommendations which will aid clinicians in setting a benchmark for achievable early growth.