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British Society of Paediatric Gastroenterology, Hepatology and Nutrition

Dear members

I hope that BSPGHAN can help you feel as safe as possible, find guidance you need, allow remote peer support and provide clarification if existing advice is not clear. 

People are  pulling together and supporting each other locally and nationally and please keep on doing this to help us share the current burden of uncertainty. 

Buddy up. 

Ask each other “ Are you OK?”

These principles in these exceptional times may be useful to prioritise –

·         To keep our teams and patients safe

·         To support each other 

·         To be up to date and to work by the best evidence that is available

·         To manage our patients with highest standards possible, making decisions case by case

·         To work within our existing resources and use resources fairly taking account of all patients including those outside our care

·         To ensure we are not putting others at a disadvantage or at risk by what we do. 

We may reach out to ethical principles, including justice, to guide decision making under these difficult times. 

We have been lucky while working in the NHS that we haven’t had to make such tough decisions and we are seeing truly exceptional circumstances.

Also 

·         Be aware of delayed presentation to hospital of children due to family’s reluctance to come to hospital

·         Keep families well informed and signposting to regularly updated resources (eg CLDF, CCUK https://www.crohnsandcolitis.org.uk/news/coronavirus-covid-19-advicehttps://childliverdisease.org/coronavirus-updates/)

·         Reinforce the vital work of all the wider team to your Trust so that they can continue support of children to help them stay well and avoid hospital admission

·         Please see guidance from BIFA / BAPEN for HPN patients during COVID19 pandemic   https://www.bapen.org.uk/about-bapen/bapen-special-interest-groups/bifa

Paediatric endoscopy

·         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    

·         We will not put members in a position where BSPGHAN guidance is impossible to implement.

·         The decision to go ahead with an endoscopy has to be a case by case decision.

·         There is no place for routine work

·         Endoscopy should be done only if it’s an emergency requirement to manage that patient.

·         Lifesaving management of GI bleeding is the priority

·         Local implementation of national guidance is needed since  resources ( PPE, paediatric staff, lists) are not the same in each centre.

·         Decisions to proceed to theatre will involve wider discussion and each Trust has a SOP

·         PPE is needed for all close work that may involve production of an aerosol even with asymptomatic patients who aren’t febrile, coughing or ill. 

·         If a trust has lists and PPE and operators, then diagnostic work that is deemed to be an emergency may carry on. 

·         In reality, there may be less availability of resources, PPE may be scarce, and no diagnostic work may be possible

·         BSPGHAN endorses that it is acceptable to have a  “treat first and investigate later” policy if resources are not available to proceed to endoscopy and to minimise risk to yourself, anaesthetic and theatre colleagues 

·         Case by case anonomised, remote discussion with peers can be useful to inform treatment decisions.

In summary, please  implement at national guidance at a local level to offer the best practice for patients that is safest for your team and can be provided within existing resources

Modified BSG risk criteria for paediatric IBD patients  – March 2020(adapted by Richard Russell from BSG guidance)

Highest Risk ‘Shielding’ $Moderate risk ‘Stringent social distancing’Lowest risk ‘Social distancing’
 1. PIBD patients who have a co-morbidity (respiratory, cardiac, hypertension or diabetes mellitus) and are on any therapy for IBD (per middle column) except 5ASA, budesonide, EEN/MEN or rectal therapies  
2. PIBD patients regardless of co-morbidity and who meet one or more of the following criteria: 
·         on oral or intravenous steroids equivalent to prednisolone ≥20 mg per day * 
·          new induction therapy with combo therapy (starting biologic within previous 6 weeks) 
·         moderate-to-severely active disease despite immunosuppression/ biologics 
·          short gut syndrome requiring nutritional support 
·          requirement for parenteral nutrition
Patients on the following medications: 
· Ustekinumab 
· Vedolizumab 
· Methotrexate 
· Anti-TNF alpha monotherapy (infliximab, adalimumab, golimumab) 
· Thiopurines (azathioprine, mercaptopurine) 
· Calcineurin inhibitors (tacrolimus or ciclosporin) 
·Janus kinase (JAK) inhibition (tofacitinib)
· Combination therapy in stable patients** 
· Immunosuppressive/biologic trial medication 
Patients on the following medications: 
· 5ASA
· Rectal therapies 
· Orally administered topically acting steroids (budesonide or beclometasone) 
· Exclusive enteral nutrition/minimal enteral nutrition
· Antibiotics for bacterial overgrowth or perianal disease 

$ UK government COVID 19 terminology

* For patients <40kg this means >0.5mg/kg per day of oral steroids, for patients >40kg then its 20mg per day or higher 

** Established on this for more than 6 weeks

Stay safe and I hope you all get some rest this weekend. 

Thanks for reaching out to colleagues, particularly who may be isolated,  and please ask if they are ok. 

All the best. 

Sue 

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