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Pediatric Crohn's disease (CD) is increasing in incidence globally. Trends in specific types of inpatient pediatric CD-related surgical procedures have not been widely reported.Patients ≤20 years of age with CD were identified in the Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes, and trends were identified. Logistic regression was used to identify factors associated with surgical intervention and trends.Rates of overall bowel resection (including ileocolic resection, other small bowel resection, or other colon resection) did not change significantly over time. However, the odds of having a laparoscopic colon resection increased by 41% annually (p0.001). Rates of subsequent ileostomy formation increased (odds ratio 1.09, p0.001). Older age, male sex, fewer comorbidities, and treatment in large urban teaching hospitals were also associated with higher odds of undergoing bowel resection.This study noted a stable rate of all types of bowel resections and increase in post resection ileostomy formation in US pediatric inpatients with CD from 2003-2012. Other rates of many CD-related procedures have remained stable. Further studies correlating the effects of biologic agents on surgical rates are warranted.Treatment Study LEVEL OF EVIDENCE: Level III.

BACKGROUND Pediatric inflammatory bowel disease (IBD) care is complex and rapidly evolving. The Crohn's and Colitis Foundation of America and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition cosponsored a needs assessment survey of pediatric gastroenterology trainees and program directors (PDs) to inform on educational programming. METHODS A Web-based, self-completed survey was provided to North American trainees and PDs during the 2013-2014 academic year. Standard descriptive statistics summarized demographics and responses. RESULTS One hundred sixty-six of 326 (51%) trainees (62% female) and 37 of 74 (50%) PDs responded. Median trainees per program = 5 and median total faculty = 10 (3 IBD experts); 15% of programs did not have a self-identified "IBD expert" faculty member. Sixty-nine percent of trainees were confident/somewhat confident in their IBD inpatient training, whereas 54% were confident/somewhat confident in their outpatient training. Trainees identified activities that would most improve their education, including didactics (55%), interaction with national experts (50%), trainee-centered IBD Web resources (42%), and increased patient exposure (42%). Trainees were most confident in managing inpatient active Crohn's disease/ulcerative colitis, phenotype classification, managing biological therapies, and using clinical disease activity indices. They were least confident in managing J-pouch complications, performing pouchoscopy, managing extraintestinal manifestations, and ostomy-related complications. Eighty-five percent would like an IBD-focused training elective. Most directors (86%) would allow trainees to do electives at other institutions. CONCLUSIONS This IBD needs assessment survey of pediatric gastroenterology trainees and PDs demonstrated a strong resource commitment to IBD training and clinical care. Areas for educational enrichment emerged, including pouch and ostomy complications.

Although randomized trials demonstrated the efficacy of infliximab for both pediatric Crohn disease and ulcerative colitis (UC), few patients in these studies exhibited colitis requiring hospitalization. The aims of this study were to determine the rate of subsequent infliximab failure and dose escalation in pediatric patients who started taking infliximab during hospitalization for colitis-predominant IBD, and to identify potential predictors of these endpoints.This is a single-center retrospective cohort study of patients admitted from 2005 to 2010 with Crohn colitis, UC, or IBD-unspecified (IBD-U) and initiated on infliximab.We identified 29 patients (12 Crohn colitis, 15 UC, and 2 IBD-U; median age 14 years) with a median follow-up of 923 days. Eighteen patients (62%) required infliximab dose escalation (increased dose or decreased infusion interval). Infliximab failure occurred in 18 patients (62%) because of ineffectiveness in 12 (67%) and adverse reactions in 6 (33%). Twelve patients (41%) underwent colectomy. Subsequent need for infliximab dose escalation was associated with lower body mass index z score (P = 0.01), lower serum albumin (P = 0.03), and higher erythrocyte sedimentation rate (ESR) (P = 0.002) at baseline. ESR predicted subsequent infliximab dose escalation with an area under the curve of 0.89 (95% confidence interval [CI] 0.72-1.00) and a sensitivity and specificity at a cutoff of 38 mm/hour of 0.79 (95% CI 0.49-0.95) and 0.88 (95% CI 0.47-0.99), respectively.Most hospitalized pediatric patients with colitis treated with infliximab require early-dose escalation and fail the drug long term. Low body mass index and albumin and high ESR, may identify patients who would benefit from a higher infliximab starting dose.

program directors during the 2013-2014 academic year. Standard descriptive statistics summarized demographics and responses. Results: 164 of 326 (50%) eligible trainees (62% female) and 36 of 74 (50%) eligible program directors responded. Median number of trainees per program=5 and median number of total faculty was 10 with 3 IBD experts and 15% of programs without faculty self-identified as an "IBD expert". 64% had dedicated IBD nurse(s), 69% research coordinator(s), 53% a dietitian and 28% had other IBD staff (social worker, psychologist). Most programs participate in IBD clinical trials (86%), IBD-based consortia (78%), and have dedicated IBD clinics (67%). 69% of trainees were confident/somewhat confident in their IBD inpatient training, while 54% were confident/somewhat confident in outpatient training. 13% had no formal IBD-centered didactics and 31% had monthly teaching. Activities identified by trainees that would most improve their education included: didactics (55%), interaction with national experts (50%), trainee-centered IBD web resources (42%), increased patient exposure (42%). Trainees were most confident in managing active Crohn's disease, phenotype classification, using clinical disease activity indices, and managing immunomodulator and biologic therapies. They were least confident in managing J-pouch complications and performing pouchoscopy, managing extra-intestinal manifestations and managing ostomy related complications. 85% would like an IBD-focused training elective. 4 knowledge competencies were rated as "somewhat important" by 50% to 64% of directors: medical management of J-pouch complications; perform, identify landmarks, findings on pouchoscopy; manage ostomy, related complications; and classify endoscopic disease severity using endoscopic indices. The majority of directors (89%) would allow trainees to do 1month training electives at other institutions. Conclusions: This IBD needs assessment survey of pediatric gastroenterology trainees and program directors demonstrated a strong resource commitment to IBD training and clinical care. Areas for educational enrichment emerged including pouch and ostomy complications. Possible educational enhancements include case-based didactics and interaction with experts perhaps through hands-on sessions at national conferences, elective rotations or web based sessions.