P40 Are 2020 ECCO-ESPGHAN guidelines practiced in the care of children with crohn’s disease?
Authors: O’Toole Ciaran , Treadwell Maria , Thangarajah Anthi 
Published: April 2023

Aim

Crohn’s disease (CD) is characterised by severe inflammation in the gastrointestinal tract. At diagnosis, risk stratification is recommended for children to predict a more severe disease progression, influencing management. The 2020 European Crohn’s and Colitis Organisation and the Paediatric IBD Porto group of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ECCO-ESPGHAN) guidelines recommend that low-risk children should be managed using a stepwise approach (starting with exclusive enteral nutrition (EEN)/corticosteroids).1High-risk children should be managed using a top-down approach starting with tumour necrosis factor-alpha inhibitors (anti-TNF agents) e.g. infliximab. This contrasts with 2014 guidance, where a universal stepwise approach was recommended.2The aim was to evaluate the level of compliance between clinical practice at a tertiary gastroenterology centre with recommendations made within the 2020 ECCO-ESPGHAN guidelines, specifically with regards to treating and monitoring children newly diagnosed with CD.1

Methods

This was a single-centre retrospective audit of the management of children newly diagnosed with CD after the guideline publication.1We aimed to assess the adherence of management to the guidelines, and clinical implications of non-adherence. We used electronic hospital records to identify eligible patients, before conducting a case-note review of their clinical management in the year following their diagnosis.

Results

At diagnosis, we identified 17 low-risk, 2 medium-risk, and 16 high-risk children with CD. One high-risk child commenced anti-TNF therapy within two weeks of diagnosis. Eight (50%) high-risk children did not receive anti-TNF therapy whatsoever. Overall, we found that the vast majority (97%) of paediatric CD patients were initially managed using a step-up approach, irrespective of risk stratification. Using a non-validated composite score measuring disease activity at treatment initiation and follow-up, we found no difference between high-risk children treated with anti-TNF and those who were not. Of the low-risk children whose management was not escalated beyond EEN or corticosteroids, 5/11 could have been considered for escalation to anti-TNF therapy. All children were received standard regimens of infliximab. 7/12 (58%) children receiving infliximab had baseline serum infliximab concentrations below the recommended threshold (5 mg/L), however, 92% (n=11) of low concentrations were responded to appropriately.

Conclusion

The management of children with CD at this centre tended to be reactive, rather than proactive. This audit has identified key areas in which the clinical practice should be updated to reflect advances in management.1This includes facilitating standardisation of risk stratification at diagnosis (using the Paris Classification3), with children identified as being at high risk for a serious disease progression initially managed using anti-TNF agents. This study has been a retrospective case note review, as such, we relied upon the quality of documentation within the medical notes, limiting the level of detail that could be recorded for each patient. These findings are not indicative of an inherent mismanagement but instead reflective adherence to previous guidelines published in 2014.2Educational tools to improve recognition of high-risk features of children with CD, and updates to their recommended management, are recommended to improve future compliance with the current guidelines.

References

van Rheenen P, Aloi M, Assa A,et al. The medical management of paediatric crohn’s disease: an ECCO-ESPGHAN guideline update.Journal of Crohn’s and Colitis2020;15:171–194.

Ruemmele F, Veres G, Kolho K,et al. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric crohn’s disease.Journal of Crohn’s and Colitis2014;8:1179–207.

Levine A, Griffiths A, Markowitz J,et al. Pediatric modification of the Montreal classification for inflammatory bowel disease: the Paris classification.Inflammatory Bowel Diseases2011;17:1314–1321.