Efficacy of a shorter bowel prep regime trialled during constraints from COVID19

BackgroundBowel preparation remains a significant barrier for patients who need to undergo colonoscopy and is recognised by children as the most difficult aspect of the colonoscopy process. Inadequate bowel preparation can lead to increased procedural times, lower caecal intubation rates, and the need for repeat colonoscopy. Practice across paediatric units providing colonoscopy is not uniform with regard to the total number of days of prep prior a colonoscopy and the agent(s) used. Data comparing a two-day regime vs a shorter one-day regime in children is limited. Restrictions during COVID19 including shielding, need for PCR testing, reduction in theatre capacity led to a re-appraisal of the need for a 2-day bowel prep, which was standard practice until 2020.AimTo evaluate the efficacy and safety profile of a shorter 1-day bowel prep regime in children undergoing colonoscopy and compare this to a standard 2-day regime.MethodsData was collected prospectively on patients who were prescribed a one-day regime prior to colonoscopy. The data was then compared with similar data on patients who were prescribed a two-day regime from an audit carried out 1 year prior to the COVID19 pandemic. The one-day regime involved taking a high dose of senna followed by two doses of picolax (dose dependent on age). The two-day regime involved a smaller dose of senna followed by three doses of picolax. Comparison was carried out between the two regimes. Boston Bowel Preparation Scale (BBPS) was used to assess the efficacy of bowel preparation. The maximum score possible for the BBPS is 9, and a score of ≥2 in all 3 segments is considered optimal for colonoscopy.1ResultsThere were 24 patients in the one-day bowel prep group and 19 patients in the two-day group. The mean age of children in the two groups were identical (11.4). The majority of patients in both groups received their bowel preparation at home. The indications for colonoscopy were very similar in both cohorts with IBD and PR bleeding being the most common indications. The median BBPS score in the 2-day regime was 6 and was 7 in the 1-day regime. 67% of patients in the one-day group had a BBPS score ≥2 in all 3 segments compared with only 47% of patients in the two-day group. In each group one procedure could not be completed due to inadequate bowel preparation.ConclusionsThe one-day bowel preparation was not inferior to the two-day regime. The higher dose of senna used in the shorter 1-day regime was well tolerated. There appears to be little to gain from a longer bowel prep regime. There are several benefits of the one-day regime such as acceptability by patients, fewer days off school/work, reduced numbers of medication doses, and fewer inpatient hospital days necessary to admit for supervised bowel prep.ReferenceLai EJ, Calderwood AH, Doros G, Fix OK, Jacobson BC. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointestinal Endoscopy 2009;69(3):620–625.

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.

OBJECTIVE: Paediatric 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. DESIGN: We 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. RESULTS: Panellists 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. CONCLUSION: Our 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.

Impact of COVID-19 on diagnosis and management of paediatric inflammatory bowel disease during lockdown: a UK nationwide study.

BACKGROUND: COVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic. METHODS: For the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD. RESULTS: All centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres. CONCLUSIONS: Diagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.