IMPROVED ADHERENCE TO THE ESPGHAN GUIDELINES IS NECESSARY FOR DIAGNOSING CELIAC DISEASE IN CHILDREN: A SINGLE-CENTER EXPERIENCE

ABSTRACT BACKGROUND: Celiac disease (CD) is an immune-mediated systemic disorder elicited by the ingestion of gluten. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines published in 2012 suggested a no-biopsy pathway (NBP) for symptomatic children with IgA tissue transglutaminase (TGA-IgA) ≥10x upper limit of normal (ULN). Biopsy confirmation remained mandatory for other cases. OBJECTIVE: This retrospective case note study was aimed at evaluating the adherence to the ESPGHAN 2012 guidelines for diagnosing CD in our unit. METHODS: Forty-three cases with positive TGA-IgA were identified by a laboratory database search from January 2013 to December 2019. 6 of 43 patients were not referred for a confirmation of CD diagnosis. Data was collected on the diagnostic pathways followed, and appropriateness of adherence was compared with the existing ESPGHAN guidelines. RESULTS: A total of 37 cases were included with 35 children diagnosed with CD. 29/35 (83%) were diagnosed via the NBP;15/29 (52%) children did not meet all the criteria required for NBP, but were diagnosed and managed as having CD. 20/35 (57%) children were diagnosed with CD in adherence to the 2012 guidelines. CONCLUSION: The recommended diagnostic guidelines were frequently not implemented; adherence to the guidelines may improve following regular educational sessions. The revised 2020 ESPGHAN guidelines which exclude HLA-DQ2/DQ8 testing would address the issue of diagnosis for the 10/15 NBP cases (with TGA-IgA >10xULN) in our study who did not have HLA testing and were therefore non-adherent to the 2012 diagnostic guidelines. NBP, with the reduced need for endoscopy may be beneficial in resource limited settings.

Efficient implementation of the ‘non-biopsy approach’ for the diagnosis of childhood celiac disease in the Netherlands: a national prospective evaluation 2010–2013

The aim of this study was (1) to prospectively evaluate the nationwide implementation of the ESPGHAN-guidelines for the diagnosis of celiac disease (CD), (2) to investigate the incidence and clinical presentation of diagnosed childhood CD (0–14 years) in the Netherlands, and (3) to compare the findings with national survey data from 1975 to 1990 and 1993 to 2000 using the same approach. From 2010 to 2013, all practicing paediatricians were invited to report new celiac diagnoses to the Dutch Pediatric Surveillance Unit. Data were collected via questionnaires. A total of 1107 children with newly diagnosed CD were reported (mean age, 5.8 years; range, 10 months–14.9 years; 60.5% female). After the introduction of the non-biopsy approach in 2012, 75% of the diagnoses were made according to the guideline with a significant decrease of 46.3% in biopsies. The use of EMA and HLA-typing significantly increased with 25.8% and 62.1%, respectively. The overall incidence rate of childhood CD was 8.8-fold higher than in 1975–1990 and 2.0-fold higher than in 1993–2000. During the study period, the prevalence of diagnosed CD was 0.14%, far below 0.7% of CD identified via screening in the general Dutch paediatric population. Clinical presentation has shifted towards less severe and extra-intestinal symptoms.Conclusion: ESPGHAN guidelines for CD diagnosis in children were effectively and rapidly implemented in the Netherlands. Incidence of diagnosed CD among children is still significantly rising with a continuous changing clinical presentation. Despite the increasing incidence of diagnoses, significant underdiagnosis still remains. What is Known:• Since 2000 the incidence of diagnosed childhood CD in the Netherlands has shown a steady rise.• The rise in incidence has been accompanied by a changing clinical presentation at diagnosis. What is New:• The ESPGHAN guidelines 2012 for CD diagnosis were effectively and rapidly implemented in the Netherlands.• The incidence of diagnosed childhood CD in the Netherlands has continued to rise significantly during the reported period.

Small patient – big problem. Diagnostics and treatment of gastroesophageal reflux in infants and young children

Gastroesophageal reflux is the movement of gastric contents into the esophagus. Is one of the most common motility disorders in children. In newborns and infants predominant is physiological reflux caused by immaturity of digestive tract. Gastroesophageal reflux disease is reflux that causes complications and/or esophagitis. Article presents actual gastroesophageal reflux disease diagnostic and treatment recommendations according to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines.

Does Having Rotavirus Infection in Early Childhood Increase the Risk of Celiac Disease?

Objective With the increasing prevalence of celiac disease (CD) in the population, possible risk factors are under investigation. Environmental and genetic factors that trigger the immune response have been analyzed for many years. This study investigates the presence of CD in children with rotavirus infection. Rotavirus infection is thought to be a risk factor for CD. Methods Included in the study were 105 of 160 pediatric patients hospitalized due to symptomatic rotavirus infection between 2012 and 2018. These children were screened for CD 45.6 ± 18.2 (14–90) months following the rotavirus infection diagnosed with CD as per ESPGHAN guidelines. Results A total of 105 pediatric patients who had rotavirus gastroenteritis were included in the study. The age of the children with rotavirus infection was 3.98 ± 1 (2–6) months. In terms of CD, it was 45.6 ± 18.2 months. Around 14 to 90 months later, patients were called for control. CD developed in four (3.8%) of the children with rotavirus, whereas none of the children in the control group developed CD. Conclusion Rotavirus infection may be a risk factor for CD through immune mechanisms. There are genetic and various environmental factors for the development of CD. Although the CD's occurrence on children who had rotavirus gastroenteritis in our study also supported this situation, there was no statistically significant difference.

A57 THE USE AND INTERPRETATION OF HLA-DQ2/DQ8 GENOTYPING BY PEDIATRIC GASTROENTEROLOGISTS

Background A recent classification of high and low risk alleles associated with celiac disease (CD) shows that the presence of a single allele (DQA1*05 or DQB1*02; coding together for HLA-DQ2), without a positive genotype (HLA-DQ2 and or HLA-DQ8), represents a risk of developing the disease. Aims The aim of this study is to evaluate the use and interpretation of the HLA-DQ2/DQ8 genotyping by pediatric gastroenterologists, as there is no study on the matter and the latest guidelines do not address this risk classification. Methods A web-based survey was sent by email to all NASPGHAN (North American society of pediatric gastroenterolgy, hepatology and nutrition) members. Results Results 294 pediatric gastroenterologists sent a complete survey. 86,1% use the HLA-DQ2/DQ8 genotyping according mainly to the NASPGHAN and ESPGHAN guidelines. The main indications considered were to exclude CD in a patient on a gluten-free diet with a resolution of his symptoms and in a seronegative patient with equivocal biopsies. A minority would consider the genotyping for screening high risk groups or for making a diagnosis in children with high specific CD antibodies and strong clinical suspicion without performing biopsies, as suggested by the ESPGHAN guidelines. The alleles associated with CD are not well known, but 76,7% the participants are aware of the risk classification. While only 62,8% have access to the complete genotype, 47,8% consider it useful. Nevertheless, 82,6% would still want to know the presence of a low risk allele. Conclusions The risk classification of alleles related to CD warrants a modification of the genotyping result with access to the alleles and an adaptation of the guidelines. Funding Agencies None

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

ObjectivePaediatric 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.DesignWe 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.ResultsPanellists 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.ConclusionOur 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.