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COVID-19
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
  1. Richard Hansen1,
  2. Susanna Meade2,
  3. R Mark Beattie3,
  4. Marcus KH Auth4,
  5. Nick Croft5,6,
  6. Philip Davies7,
  7. David Devadason8,
  8. Conor Doherty9,
  9. Jenny Epstein10,
  10. Lucy Howarth11,
  11. Fevronia Kiparissi12,
  12. Rafeeq Muhammed13,
  13. Vinay Shivamurthy14,
  14. Christine Spray15,
  15. Michael P Stanton16,
  16. Franco Torrente17,
  17. Arun Urs18,
  18. David Wilson19,20,
  19. Peter M Irving2,
  20. Mark Samaan2,
  21. Jochen Kammermeier21
  1. 1 Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
  2. 2 Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
  3. 3 Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
  4. 4 Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
  5. 5 Blizard Institute, Queen Mary's University of London, Barts and the London School of Medicine, London, UK
  6. 6 Department of Paediatric Gastroenterology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK
  7. 7 Department of Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow, UK
  8. 8 Department of Paediatric Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
  9. 9 Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow, UK
  10. 10 Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  11. 11 Department of Paediatric Gastroenterology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
  12. 12 Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
  13. 13 Department of Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham, West Midlands, UK
  14. 14 Department of Paediatric Rheumatology, Evelina London Children's Hospital, London, UK
  15. 15 Department of Paediatric Gastroenterology, Hepatology & Nutrition, Bristol Royal Hospital for Children, Bristol, UK
  16. 16 Department of Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
  17. 17 Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
  18. 18 Department of Paediatric Gastroenterology, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield, UK
  19. 19 Child Life and Health, University of Edinburgh, Edinburgh, UK
  20. 20 Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
  21. 21 Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
  1. Correspondence to Dr Jochen Kammermeier, Paediatric Gastroenterology, Evelina London Children's Hospital, London, London, UK; jochen.kammermeier{at}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.

  • paediatric gastroenterology
  • inflammatory bowel disease
  • clinical decision making
  • ulcerative colitis

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. This is not a clinical trial, hence no patient identifiable data generated. Any other data generated in this study is included in the article.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

https://doi.org/10.1136/gutjnl-2020-322449

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. This is not a clinical trial, hence no patient identifiable data generated. Any other data generated in this study is included in the article.

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    Footnotes

    • RH and SM are joint first authors.

    • MS and JK are joint senior authors.

    • Twitter @SamaanMark

    • Correction notice This articel has been corrected since it published Online First. The author's name Conor Doherty has been corrected and ORCID IDs have been added for all authors.

    • Contributors All authors approved the final version. Study concept and design: RH, SM, RMB, MS, PMI and JK. Development of questionnaire: RH, RMB, SM, MS, PMI and JK. Data analysis: SM, MS and PMI. Interpretation of data and drafting of manuscript: RH, RMB, SM, MS, PMI and JK. Panellists, experts and moderators: all authors. Contributions to literature review and critical revision of the manuscript for important intellectual content: all authors.

    • Funding RH is supported by an NHS Research Scotland Career Researcher Fellowship.

    • Competing interests Competing interests listed in online supplementary table 1.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.