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Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Objective We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn’s disease [CD]. Methods We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained. Results We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone. Conclusions We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.

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Summaryobjectives This study was carried out to assess whether delaying umbilical cord clamping is effective in improving the haematological status of term infants living in a malaria-endemic area, and whether this is associated with complications in infants and mothers.methods We randomly assigned women delivering term babies in Mpongwe Mission Hospital, Zambia, to delayed cord clamping (DCC, n ¼ 46) or immediate cord clamping (controls, n ¼ 45) and followed their infants on a bi-monthly basis until the age of 6 months. We compared the haemoglobin (Hb) change from cord values and the proportion of anaemic infants. Secondary outcomes related to infant and maternal safety.results Throughout the observation period infant Hb levels in both groups declined, but more rapidly in controls than in the DCC group [difference in Hb change from baseline at 4 months 1.1 g/dl, 95% confidence interval (CI) 0.2; 2.1]. By 6 months, this difference had disappeared (0.0 g/dl, 95% CI )0.9; 0.8). The odds ratio for iron deficiency anaemia in the DCC group at 4 months was 0.3 (95% CI 0.1; 1.0), but no differences were found between the groups at 6 months. No adverse events were seen in infants and mothers.conclusion Our findings indicate that DCC could help improve the haematological status of term infants living in a malaria-endemic region at 4 months of age. However, the beneficial haematological effect disappeared by 6 months. This simple, free and safe delivery procedure might offer a strategy to reduce early infant anaemia risk, when other interventions are not yet feasible.keywords umbilical cord clamping, infant anaemia, term birth, appropriate technology

This study was conducted to evaluate the haematological effects of the timing of umbilical cord clamping in term infants 24 h after birth in Libya. Mother-infant pairs were randomly assigned to early cord clamping (within 10s after delivery) or delayed clamping (after the cord stopped pulsating). Maternal haematological status was assessed on admission in the delivery room. Infant haematological status was evaluated in cord blood and 24 h after birth. Bilirubin concentration was assessed at 24 h. 104 mother-infant pairs were randomized to delayed (n=58) or early cord clamping (n=46). At baseline the groups had similar demographic and biomedical characteristics, except for a difference in maternal haemoglobin, which was significantly higher in the early clamping group (11.7 g/dL, SD 1.3 g/dL versus 10.9 g/dL, SD 1.6 g/dL; P=0.0035). Twenty-four hours after delivery the mean infant haemoglobin level was significantly higher in the delayed clamping group (18.5 g/dL versus 17.1 g/dL; P=0.0005). No significant differences were found in clinical jaundice or plethora. Surprisingly, blood analysis showed that two babies in the early clamping group had total serum bilirubin levels (> 15 mg/dL) that necessitated phototherapy. There were no babies in the late clamping group who required phototherapy. Three infants in the delayed clamping group had polycythaemia without symptoms, for which no partial exchange transfusion was necessary. Delaying cord clamping until the pulsations stop increases the red cell mass in term infants. It is a safe, simple and low cost delivery procedure that should be incorporated in integrated programmes aimed at reducing iron deficiency anaemia in infants in developing countries.

This review evaluates the potential of delayed cord-clamping for improving iron status and reducing anaemia in term infants and for increasing the risk of polycythaemia and hyperbilirubinaemia. We applied a strict search protocol to identify controlled trials of early vs late cord-clamping. Four trials from developing and four from industrialised countries were finally assessed. Two of the four studies from developing countries found a significant difference in infant haemoglobin levels at 2-3 months of age in favour of delayed cord-clamping. This difference was more marked when mothers were anaemic. Three of four studies from industrialised countries showed a significant difference in haematocrit levels in favour of delayed clamping. Although meta-analysis showed an increased risk for hyperbilirubinaemia of 12%, no studies reported the need to apply phototherapy or perform exchange transfusion. We conclude that delayed cord-clamping in term infants, especially those with anaemic mothers, increases haemoglobin concentration in infants at 2-3 months of age and reduces the risk of anaemia, without an associated increased risk of perinatal complications. In developing countries where fetal anaemia is common, the advantages of delayed cord-clamping might be especially beneficial.

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