ABSTRACT
Introduction Children with idiopathic chronic constipation are extremely challenging to manage. Before review by tertiary specialist teams, Children have suffered for years with constipation, which leads to significant behaviour related issues around toileting, despite adequate medical treatment. The involvement of the health play specialist (HPS) in the nurseled constipation clinic is to address behaviours around toileting. Aims To demonstrate involvement of HPS in the clinic led to improved outcomes for children and families. This will be identified through the use of parental satisfaction questionnaires and four case studies. Case Studies We demonstrate four extremely complex constipation cases referred to clinic and successfully managed by HPS with unique individualised approach with support and plans for parents and school. 9-year-old boy with history of sexual abuse, with soiling and wetting accidents. 5 sessions with the HPS, focusing on toileting behaviours. Sessions involved desensitizing play around the body, use of toilet related games/activities, videos and mobile apps. All issues resolved. 5-year-old boy: Stool with-holding, will only pass stools in a nappy and soiling. 8 sessions with HPS - Intense toilet training for 2-4 days with hourly sits. Reward charts to compliment interests, targets adjusted when goal reached, prizes given. Desensitization play around toileting behaviours. Using analogies to improve behaviour, he loved dustbin lorries - body empties the waste (poo) just like the bin men collecting the rubbish to get rid of it from home. No more accidents, independent toileting achieved 5-year-old girl Issues with constipation, soiling and toilet refusal. All bowel movements in knickers. Complete HPS treatment virtually, secondary to COVID restrictions. 6 Video call sessions- individualised plan of regular sits to relax, with no pressure to perform. To do an activity whilst on the toilet. Visual pictures/videos explaining how the body works and the plan was adjusted on the video. Rewards when child reached the target, and prize sent in post. Outcome -no fear of the toilet, bowels open on the toilet, no accidents. 8 year old boy premature 33 + 5 weeks. Constipation with overflow since birth. Referred to surgeons for rectal biopsies and botox injections at the age of 3 but no improvement. Age 4 admitted to the ward for 1 week for observation, transit marker study and toilet training was unsuccessful. Referred to another unit for second opinion at parental request. Started to refuse medications. ACE surgery discussed. Diagnosed with Autism at 7 years. Invited for a week of intense toileting with HPS, hourly sits and desensitization activities on medication taking, toileting, with-holding, signs and signals of body. Reward system in place, when reached expectations, reward given by hospital. Outcome bowels open daily in the toilet, wears pants all the time. Satisfaction questionnaires were given to parents and feedback was extremely positive. Conclusion The health play specialist involvement in the nurse led constipation clinic allows for individualised intervention guided by the child's needs. Pharmacological interventions alone may be unsuccessful without addressing behavioural needs.
ABSTRACT
The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/6 food), steroids etc. It is recommended to perform endoscopies between each reintroduction to assess disease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagia was the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FED achieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following re-introduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding during endoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.
ABSTRACT
The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/ 6 food), steroids etc. It is recommendedto perform endoscopies between each reintroduction to assessdisease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives: We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods: Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagiawas the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FEDachieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following reintroduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding duringendoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.
ABSTRACT
Introduction: The health care system had to evolve rapidly to adapt to the multiple challenges posed by SARS-CoV-2 pandemic although significant progress has been made with vaccines and immunisation programmes, the challenge seems to be far from over. At Maidstone and Turnbridge Wells NHS trust we provide tertiary paediatric gastroenterology services to paediatric patients from Kent and East Sussex, including new patients with suspected Coeliac disease and long-term follow-up. Objective: We looked at the patient and their family's experience with regards to multiple aspects of management of Coeliac disease (CD) during the government-imposed lockdown and various restrictions from March 2020 to November 2021. Methods: We designed a questionnaire to assess patient's experience of management of their coeliac disease and included identifying symptoms during lockdown, access to gluten free (GF) products, and emotional wellbeing. Patient details were collected from our database. Phone calls were made and data was collected after obtaining verbal consent from patients and caregivers. Results: 50 telephone questionnaires were completed with patients (or parents of the patient) with diagnosed coeliac disease. The patients interviewed were between 3 years to 16 years. Our standard follow-up practice for patients with confirmed diagnosis with CD clinic is an annual review with specialist gastroenterology nurse and dietician and this target was met for 72% (36/50) of patients (both virtual and face to face clinic reviews). 98% (49/50) of patients denied development or worsening of any GI symptoms during the lockdown. 96% (48/50) of patients reported normal development in growth and height since the lockdown. 98% of patients (49/50) were able to procure GF product during the lockdown. During the initial 3-4 weeks of lockdown, some families reported of limited options of GF products but were still able to procure them. Patients and their families reported being emotionally well. All families were made aware to contact MTW nursing team for advice. The primary online resource used by families for guidance was Coeliac UK website with 50% (25/50) of families using the service. Conclusion: During SARS-CoV-2 pandemic, patients with coeliac disease managed CD well despite the lockdown. We managed to see majority of our patients (virtual/face to face clinics) There was no significant impact on procuring GF products and emotional well-being despite multiple challenges.