Swallowed topical steroid therapy for eosinophilic oesophagitis in children: practical, evidence-based guidance by the BSPGHAN Eosinophilic Oesophagitis Working Group.

OBJECTIVE: To develop evidence-based guidance for topical steroid use in paediatric eosinophilic oesophagitis (pEoE) in the UK for both induction and maintenance treatment. METHODS: A systematic literature review using Cochrane guidance was carried out by the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) Eosinophilic Oesophagitis (EoE) Working Group (WG) and research leads to determine the evidence base for preparation, dosing and duration of use of swallowed topical steroid (STS) formulations in EoE. Seven themes relating to pEoE were reviewed by the WG, alongside the Cochrane review this formed the evidence base for consensus recommendations for pEoE in the UK. We provide an overview of practical considerations including treatment regimen and dosing. Oral viscous budesonide (OVB) and, if agreed by local regulatory committees, orodispersible budesonide (budesonide 1 mg tablets) were selected for ease of use and with most improvement in histology. A practical 'how to prepare and use' OVB appendix is included. Side effects identified included candidiasis and adrenal gland suppression. The use of oral systemic steroids in strictures is discussed briefly. RESULTS: 2638 citations were identified and 18 randomised controlled trials were included. Evidence exists for the use of STS for induction and maintenance therapy in EoE, especially regarding histological improvement. Using the Appraisal of Guidelines, Research and Evaluation criteria, dosing of steroids by age (0.5 mg two times per day <10 years and 1 mg two times per day ≥10 years) for induction of at least 3 months was suggested based on evidence and practical consideration. Once histological remission is achieved, maintenance dosing of steroids appears to reduce the frequency and severity of relapse, as such a maintenance weaning regimen is proposed. CONCLUSION: A practical, evidence-based flow chart and guidance recommendations with consensus from the EoE WG and education and research representatives of BSPGHAN were developed with detailed practical considerations for use in the UK.

Optimizing nutrition IN pediatric intestinal pseudo-obstruction syndrome.

BACKGROUND: Pediatric intestinal pseudo-obstruction (PIPO) encompasses a variety of rare, heterogeneous, and disabling disorders that severely affect gastrointestinal motility and are associated with high morbidity and mortality. PIPO management is complex and focuses on maintaining an optimal nutritional status, improving gut function, relieving symptoms, and treating complications. Nutritional issues prevail, and PIPO patients often experience severe undernutrition and faltering growth. Thus, nutritional management plays a pivotal role for achieving the most favorable clinical outcomes. The calorie and nutrient intake of each patient needs to be tailored to age, extent and severity of gut involvement and nutritional needs to support an optimal nutritional status. After defining the extent and severity of gut dysmotility, an experienced team should perform a careful nutritional assessment. An oral diet should always be encouraged and might include bite and dissolve solids, liquid diet or simple oral stimulation. If oral caloric intake is inadequate, liquid gastric feeds should provide the subsequent step. In the presence of severe gastric dysmotility, continuous post-pyloric feeding represents a viable option. In the most severe cases, parenteral nutrition (PN) is required to meet appropriate nutritional requirements. PURPOSE: Pediatric data on this topic are scarce and mainly extrapolated from adult studies. In this review, we discuss current evidence and knowledge regarding nutritional options, implications of the use of different feed types, including a blended diet, and the use of PN. Moreover, based on our experience and the evidence from the literature, we propose a flow chart to guide the nutritional management of PIPO patients.

Exclusive enteral nutrition practices in the management of Crohn's disease: A cross sectional survey of specialist paediatric dietitians.

BACKGROUND AND AIM: Exclusive enteral nutrition (EEN) is the first line management to induce remission of active Crohn's disease (CD). EEN is well established but there continues to be significant variation in practice especially in relation to what first line formula is used, length of time on EEN, and food reintroduction. The survey aimed to establish dietetic practices in implementing EEN in the management of active CD across specialist paediatric inflammatory bowel disease (IBD) centres. METHODS: An online, cross-sectional survey was developed, piloted, and distributed to dietitians working at tertiary paediatric IBD centres. Centres were identified through a member of the British Society of Paediatric Gastroenterology, Hepatology, and Nutrition (BSPGHAN) working group. All 20 specialist IBD centres within the United Kingdom were approached and invited to complete the survey. RESULTS: Eighty-five percent (17/20) of the specialist IBD centres in the UK responded. 100% of centres used polymeric feeds as their first line and 70% (12/17) of centres recommended EEN for 6 weeks. Dietetic monitoring whilst on EEN over the 6-8 weeks varied significantly, ranging from 30% (5/17) of centres monitored weekly compared with 30% of centres (5/17) only if clinical need indicated. There was a wide range in practices regarding which foods and drinks were permitted whilst on EEN. Forty three percent (7/17) introduced solid foods over five to seven days, 19% (3/17) introduced food over seven to 14 days and 38% (6/17) introduced food over a minimum of 14 days. Eighteen percent (3/17) of centres were offering the Crohn's disease exclusion diet as a treatment for IBD. CONCLUSIONS: Despite available evidenced based guidelines there is still considerable variation in the management of EEN to induce remission in active CD especially in relation to frequency of dietetic review and foods permitted during and after EEN. Further research is required to understand the impact this may have on achieving and maintaining remission in CD.