Inflammatory Bowel Disease
This statement is intended to summarise the national guidelines for returning to school including both, patients with IBD and their siblings.
The BSPGHAN IBD Working Group and the Birmingham Children’s Hospital Nutrition Team have prepared the following guidance for Health Care Professionals (posted 7th April 2020):
Our advice today when we called families of children and young people with IBD in the high risk category, (see guidance – while on steroids prednisolone equivalent to or greater than 20mg, or within 6 weeks of starting a biological therapy, or with severe active disease), was to reassure that Covid19 appears not to cause such severe disease in children and young people.
We reinforced that patients should continue their usual treatment, including infusion therapy, and to continue to contact their IBD team by phone if they have symptoms eg fever, typical features of a relapse. The team will assess each patient case by case and advise accordingly.
BSG Guidance for the Management of IBD during the Covid-19 pandemic (Posted 19th April 2020)
The British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has published service provision, medical and surgical therapy, endoscopy, imaging and clinical trials. The best available data and expert opinion has generated a risk grid for adults that groups patients into highest, moderate and lowest risk categories
The tool aims to help identify and reach moderate and high-risk IBD patients. The IBD registry tool is currently restricted to those are are aged 18 years or older but they are working on extending its use to under 18s.
Patients on immunosuppression therapies sufficient to significantly increase risk of infection have been outlined in the BSG Guidance:
- BSG COVID-19 Guidance on IBD patient risk groups
- BSG/BASL COVID-19 Advice on Hepatology patient risk groups
- BSG Guidance for health professionals with IBD or liver disease
Covid-19 in Paediatric IBD- Related Publications:
Preliminary data for PIBD patients during COVID-19 outbreak are reassuring. IBD per-se does not currently seem to be a risk factor for acquiring SARS-CoV-2, nor for a more severe infection. Standard IBD treatments including biologics should continue at present
Outcomes of COVID-19 in 79 patients with IBD in Italy: an IG-IBD study (Posted 3rd May 2020)
- Active IBD, old age and comorbidities were associated with a negative COVID-19 outcome, whereas IBD treatments were not.
- Preventing acute IBD flares in patients with IBD is important.
a) 10.1% of a cohort with coronavirus–infected pneumonia presented with diarrhoea and nausea, preceding fever and respiratory symptoms by 1–2 days
b) Endoscopy – SARS-CoV-2 was detected in the oesophagus, stomach, duodenum and rectum of the two most severe patients and also in the duodenum. The implication is uncertain but raise the issue of gastrointestinal involvement and potential faeco-oral transmission,
c) Uneventful course in patients with IBD during SARS-CoV 2020 in Northern Italy – awaiting data from Espghan Porto and SECURE-IBD database.
d)The clinical importance of continued presence of RNA in the stool is uncertain and further work is required to determine risk
e) Risk of surgery during incubation period in some does start to ask the question as to whether testing prior to surgery should become routine
BSPGHAN consensus statement on Paediatric endoscopy recovery and restoration during the Covid-19 pandemic (May 10th 2020)
BSPGHAN endorses the British Society of Gastroenterology (BSG) position paper on Recommencing GI Endoscopy with some paediatric-specific amendments:
1. The risks of transmission of SARS-CoV-2 to staff (especially those handling and cleaning the scopes) as a consequence of undertaking endoscopy are still unknown. Paediatric endoscopy takes place in a high-risk area; an anaesthetic is given by general anaesthetic (GA) or by total intravenous anaesthetic (TIVA) with laryngeal mask (LMA) which are both aerosol-generating procedures. We advise that upper and lower GI endoscopy under GA or TIVA be undertaken with level 2 PPE (FFP3 masks or respirators) until risk of transmission from faeces becomes clear. The BSG guidance acknowledges that there are other circumstances to be considered when deciding on PPE and states “It is important that consideration is given to other elements of endoscopy as well as the procedure itself. These might include but not be restricted to: use of nitrous oxide, oxygen gas (Entonox), use of nasal oxygen, administration of throat spray or enemas”
2. Careful consideration needs to be given to the risk of exposing children and their families to a high-risk environment vs. the benefit of performing diagnostic endoscopy. The risk for staff also needs to be evaluated particularly in light of the evidence of increased risk amongst BAME colleagues. Chief Executive of NHSE, Sir Simon Stevens suggests that: “regarding people from BAME backgrounds … we recommend employers should risk assess staff at potentially greater risk and make more appropriate arrangements accordingly. Organisations should continue to assess staff who may be at increased risk including older colleagues, pregnant women, and those with underlying health conditions and make adjustments including working remotely or in a lower risk area”.
3. BSPGHAN supports units trying to re-establish diagnostic endoscopy for suspected new IBD presentations where possible and to continue emergency endoscopy provision.
4. Centres should adhere to the same COVID-19 screening protocols developed by their co-located adult colleagues in gastroenterology and/or the pathways developed for paediatric surgical patients undergoing urgent and elective procedures.
5. Where possible paediatric endoscopy pathway should be in COVID-19-free areas of the hospital
6. Please refer to Gov.uk guidance on PPE (Appendix 1)
JAG accreditation: Supplementary environment guidance following the COVID-19 pandemic (Posted 17th May 2020)
This guidance provides a framework to assist endoscopy services to adapt their environment following the COVID-19 pandemic. It can be used by all endoscopy services in the UK and will be referred to during accreditation assessments. Restoration of services will vary significantly and so this guidance provides practical points for consideration locally and BSPGHAN Endoscopy Working Group is working on paediatric specific support for recovery of endoscopy services
The best available information for professionals in making decisions remains with the BSPGHAN- endorsed BSG / JAG guidance:
- Endoscopy activity and COVID-19: BSG and JAG guidance
- BSG rationale around current advice to all Endoscopy Units
Statement “Gastrointestinal endoscopy in children and COVID 19 pandemic” – ESPGHAN Endoscopy Special Interest Group Posted 30th March 2020: http://www.espghan.org/societal-papers/covid-19-informational-statements/
“..elective procedures – especially those such as upper gastrointestinal (GI) endoscopy which is an ‘aerosol-generating procedure’ (AGP) – should be put on hold at present. Equally ileocolonoscopy, given that we know now that COVID-19 can be excreted in stools. Local and physician judgment should occur when determining which patients require urgent endoscopic diagnostic testing, but these should be kept to a minimum. Obviously, life-saving endoscopy such as GI bleeding and button battery ingestion are mandatory and should not be deferred. In the event of endoscopy being required a full personal exposure protection package should be worn by those in the immediate vicinity of the endoscopy including an FPP3 mask or equivalent”
Covid-19 and Endoscopy- Related Publications:
Gastrointestinal endoscopy during COVID-19: when less is more (posted 11th May 2020)
The BSPGHAN Eosinophilic Oesophagitis Workin Group has prepared the COVID-19 consensus document for professionals:
This is based on published evidence and expert advice, government policies, and guidance from RCPCH, BSG and other BSPGHAN WGs.
We have also assisted the PPI (Eosnetwork) with an EoE and Covid-19: Patient and Carer FAQ.
BSG and BASL
Shielding and Resources:
This advice is intended to summarise the guidelines for shielding and returning to school including both patients and their siblings.
BSPGHAN has also contributed towards the RCPCH guidance for Paediatric Services. (Posted 19th April 2020).
It is also important to recognise that during this current pandemic, children who are unwell remain more likely to be unwell due to a non-COVID-19 condition than to COVID-19 itself; this includes those with the conditions described in this guidance. However, some children may remain more at risk of COVID-19 related disease, and these children should be protected as far as is possible from infection by ‘shielding’
Update posted 3rd May2020: We are taking stock while coming through a “peak ” of hospitalisations and set to enter the second phase in the NHS’s response to Covid-19.
On April 29th we heard from the NHS CE and CEO about:-
- Increased Covid-19 testing capacity – a pilot followed by roll out of regular testing to asymptomatic staff, guided by PHE and clinical advice.
- NHS to step up non-Covid19 urgent services as soon as possible with attention to infection prevention and control and start of some routine non-urgent elective care.
- Provisional plans to factor-in the availability of associated medicines, PPE, blood, consumables, equipment and other needed supplies.
- Expanded winter flu vaccination campaign alongside a school immunisation ‘catch up programme’.
Now more than ever a safety and learning culture is vital. BSPGHAN has been working with the RCPCH, PHE and NHS England this week to:-
- identify which patients should be recommended to still “shield” (or stay at home with stringent social distancing) once lockdown restrictions are lifted and
- understand more about the impact of delayed presentations to healthcare or delayed delivery of care within our speciality
- consider recovery and restoration plans of our routine activity for children and young people.
Public Health England: Advice Posted 19th April 2020: You will have seen in reports there is now a real concern at national level regarding the shortage of PPE gowns. On 17 April, Public Health England issued emergency advice on the use of gowns in clinical areas should shortages arise. It is important to emphasise that everyone should organise care to make best use of stock. The safety of teams is our priority and access to the appropriate PPE.
Public Health England Personal Protective Equipment Hub
RCPCH Shielding Advice
Home Parenteral Nutrition
Birmingham Children’s Hospital Nutritional Care Team Nurses have produced the following information letter which can be used as a reference:
Parent/ Carer Information Letter for families of children on home parenteral nutrition (Posted 7th April 2020):
Please also share this updated letter with families of children on home parenteral nutrition, which outlines plans that home care providers are putting in place and changes that families may expect:
Please be aware of the latest advice. (Posted 31st March 2020)
“Keeping yourself safe” “The government is regularly updating its guidance on at-risk groups. In light of the latest information your hospital teams now consider that patients on HPN are a high risk group, as you/your child have significant organ impairment (GI) and a central venous access device in place. This advice is endorsed by the British Society of Gastroenterology. It advises you to follow the guidance on ‘shielding’ stringently, as outlined by the government, and you are strongly advised to stay at home and avoid any face-to-face contact for at least 12 weeks in the first instance.
This can be challenging but the consensus is it is the best way to keep yourself/your child safe”.
Please see guidance from BIFA / BAPEN for HPN patients during COVID19 pandemic https://www.bapen.org.uk/about-bapen/bapen-special-interest-groups/bifa
HOMECARE (Home Parenteral nutrition) advice from 23/3/20 issued by Susan Gibert, who is leading on COVID-19 for Homecare: This has been sent to all regional homecare leads who will disseminate to the trusts.
NHSE contract – CCGs (12 week rule) (Posted 23rd March 2020): In TVW I have gained agreement that NHSE and CCGs will not be expecting the homecare activity to have been recorded within the usual time frames. It might be a good idea to do the same in your regions.
Delivery windows – relaxation of expectation (Posted 23rd March 2020)
I have agreed with NCHA members that the NHS will not be expecting homecare providers to ‘hit’ their 2 hour delivery windows. Deliveries may need to move to all day windows in the near future, and if this is necessary can we agree to be supportive please? Homecare providers and hospitals are asked to be extra vigilant with the delivery address details as patients may no longer be at their usual work or residential addresses.
Emergency deliveries (Posted 23rd March 2020)
We may reach a time where same day, next day and emergency deliveries are no longer possible. We may need to consider adjusting buffer stock in patients’ homes. At the moment, we do not have the reassurance that there is stock to do this, but it is something that we need to bear in mind for the coming weeks.
Phone Lines (Posted 23rd March 2020)
Homecare providers are experiencing high volumes of calls, this has led to longer wait times. Patients are also reporting that their hospital clinical teams are no longer manning some NHS helplines (as specialist nurses are being called to ward and other duties). Please can you ensure that you use the correct line of communication as per local agreements. If the route of contact is via your BDM, RBM etc, please can you refrain from ringing the homecare providers?
Equally if your CNS staff are being called to the front line, please can you ensure that the homecare providers have a contact number or email for an alternative contact? If in doubt, the pharmacy homecare team will be contacted for all enquiries that have not been dealt with in a timely manner. In TVW we will be ensuring that the pharmacy contacts are up to date, if you could do the same, that would be great.
Advice for Families
BSPGHAN has been working in partnership with the RCPCH on Speciality specific advice to help describe those patients who may be extremely vulnerable. This advice is being coordinated with all stakeholders including NHS, Gov.uk and charitable partners.RCPCH
Keep families well informed and signposting to regularly updated resources (eg CLDF, CCUK):
- Crohn’s and Colitis UK – FAQs for Patients with Crohn’s and Colitis
- Child’s Liver Disease Foundation – Coronavirus Updates
- EOS Network – EOE and Covid-19: Parent and Carer FAQs
CCUK Decision tree for children – isolation/social distancing and shielding: (Posted 23rd April 2020): Applicability of “shielding” is complex for children as the evidence for risk of serious illness / mortality from Covid-19 amongst children who are immune suppressed is very limited. This Decision Tree for families is welcome. crohnsandcolitis.org.uk/news/advice-for-people-with-crohns-and-colitis-self-isolation-social-distancing#child-risk If you would like to share via social media there is also a short link.
Public Health England: Post 23rd April 2020: Vulnerable children guidance: There are unintended consequence of lockdown on some vulnerable families (i.e. those known to CAMHS, social services and those with education, health and care plans.) see PHE Vulnerable children guidance. BSPGHAN is linking up with the RCPCH and the children’s team at NHS England to consider which groups should continue shielding once the lockdown restrictions are lifted.
ESPGHAN COVID-19 parental advice guide.
This short guide provides information and guidance for parents on gut, liver and nutritional conditions in children during the COVID-19 pandemic. Please find the parental advice by clicking here.
Guidance for Trainees
Exciting plans to support national teaching by Zoom for BSPGHAN trainee members from trainers, starting on 22nd April 2020 live from Birmingham. A national virtual meeting of interest to members may follow.
Please visit the Zoom Education Series page for details of upcoming sessions.
Treatments and Immunosuppression
Covid-19 Rapid Guideline: Children and Young People who are Immunocompromised– published May 1st 2020
This guideline is designed to be used alongside our professional guidance. It aims to maximise the safety of children, protect staff from infection and enable services to make best use of resources during the pandemic. It can be updated as necessary.
European Medicines Agency
Press releases related to COVID-19: (posted 2nd April 2020) which includes information to patients and healthcare professionals.
- Treatments and vaccines against COVID-19 under development
- Chloroquine and hydroxychloroquine only to be used in clinical trials or emergency use programmes
Please check EMA’s dedicated webpage on COVID-19 for the latest updates.
Letter from Lorenzo d’Antiga, Italy “Coronaviruses and immunosuppressed patients” (Posted 30th March 2020): https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/lt.25756
Preliminary experience so far show that children under 12 years of age do not develop coronavirus pneumonia regardless of their immune status although they get infected and can spread the infection. Immune suppressed patients are not at risk for severe pulmonary disease compared with the general population.
Paediatric Multisystem Inflammatory Syndrome Temporally Associated with Covid-19
Please see the RCPCH Guidance on this emerging phenomenon.
Most children are asymptomatic or exhibit mild symptoms from COVID-19 infection. However in the last two months a small number of children have been identified who develop a significant systemic inflammatory response which may be associated with COVID-19.
Children’s Liver Disease Foundation:
Crohn’s and Colitis UK:
BSPGHAN Survey Feedback
Survey Feedback: Thank you very much for your responses; the majority within the first few hours. It’s a helpful snapshot of views while planning recovery, restoration of paused services and supporting families as the lock down eases.
Please report cases of Covid-19 in children with paediatric IBD to the ESPGHAN Porto group using the link below:
2) Covid-19 and Eosinophilic Oesophagitis/ Eosinophilic GI Disease
Please report cases of Covid-19 in children with Eosinophilic Oesophagitis/ Eosinophilic GI Disease to this study run by Schneider’s Children Medical Center using the link below: