the PIBD-VTE group; C.H. (Heleen) van Ommen 4 ; Lissy de Ridder* 1 ; Nicholas M. Croft* 2 ; on behalf of the PIBD-SETQuality consortium, ‡ These authors share first authorship.

Background & Aims Guidelines regarding thromboprophylaxis for venous thromboembolisms (VTE) in children with inflammatory bowel disease (IBD) are based on limited paediatric evidence. We aimed to prospectively assess the incidence of VTE in paediatric-onset IBD (PIBD), characterize PIBD patients with VTE, and identify potential IBD-related risk factors. Methods From October 2016 till September 2020, paediatric gastroenterologists prospectively replied to the international Safety Registry, monthly indicating whether they had observed a VTE case in a patient <19 years with IBD. IBD details (type, Paris classification, clinical and biochemical disease activity, treatment) and VTE details (type, location, treatment, outcome) were collected. To estimate the VTE incidence, participants annually reported the number of PIBD patients, data source and catchment area of their center. A systematic literature review and meta-analysis was performed to calculate the VTE incidence in the general paediatric population. Results Participation of 129 PIBD centers resulted in coverage of 24,802 PIBD patients. Twenty cases of VTE were identified (30% Crohn’s disease). The VTE incidence was 3.72 [95%CI 2.27 – 5.74] per 10,000 person-years, 14-fold higher than in the general paediatric population (0.27 [95%CI 0.18-0.38], p<0.001). Cerebral sinus venous thrombosis was most frequently reported (50%). All but one patient had active IBD, 45% were using steroids and 45% hospitalized. No patient received thromboprophylaxis, whereas according to current PIBD guidelines, this was recommended in 4/20 patients. Conclusion There is an increased risk of VTE in the PIBD population compared to the general paediatric population. Awareness of VTE occurrence and prevention should be extended to all PIBD patients with active disease, especially those hospitalized.

Background and Aims Thromboprophylaxis use in paediatric inflammatory bowel disease [IBD] is inconsistent. Current guidelines only support treating children with acute severe colitis with risk factors. We convened an international RAND panel to explore thromboprophylaxis in paediatric IBD inpatients in the context of new evidence. Methods We convened a geographically diverse 14-person panel of paediatric gastroenterologists alongside supporting experts. An online survey was sent before an online meeting. Panellists were asked to rate the appropriateness of thromboprophylaxis in hospitalised paediatric IBD patients via 27 scenarios of varying ages, gender, and phenotype, with and without thrombotic risk factors. Anonymised results were presented at the meeting. A second modified survey was distributed to all panellists present at the meeting. Results from the second survey constitute the RAND panel results. The validated RAND disagreement index defined disagreement when ≥ 1. Results The combined outcome of thromboprophylaxis being considered appropriate until discharge and inappropriate to withhold was seen in 20 of 27 scenarios, including: all patients with new-onset acute severe colitis; all flares of known ulcerative colitis, irrespective of risk factors except in pre-pubescent patients with limited disease and no risk factors; and all Crohn’s patients with risk factors. Disagreement was seen in five scenarios regarding Crohn’s without risk factors, where outcomes were already uncertain. Conclusions RAND panels are an established method to assess expert opinion in areas of limited evidence. This work therefore constitutes neither a guideline nor a consensus; however, the findings suggest a need to re-evaluate the role of thromboprophylaxis in future guidelines.

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In children with gastrointestinal disorders such as inflammatory bowel disease (IBD) and intestinal failure (IF), the risk of venous thromboembolism (VTE) is increased. VTE may lead to pulmonary embolism, sepsis and central line infection, stroke and post-thrombotic syndrome. The purpose of this review is to summarize current knowledge and recent advances around VTE management in pediatric gastroenterology with a focus on IBD and IF. The VTE incidence in children with IBD is reported to be around 4–30 per 10,000 patient-years, with higher incidences for hospitalized children. While in general, IF is less common than IBD, the VTE incidence in children with IF is around 750 per 10,000 patient-years. The most common risk factors for development of VTE involve deviations leading to Virchow's triad (endothelial damage, stasis, and hypercoagulability) and include active inflammation, particularly with colonic involvement, presence of a central venous catheter, underlying thrombophilia, reduced mobility, surgery, and hospitalization. Classes of anticoagulants used for treatment of VTE are low molecular weight heparins and vitamin K antagonists. However, the use of direct oral anticoagulants for treatment or prevention of VTE has not been studied in this pediatric population yet. Pediatric gastroenterologists apply different VTE prevention and treatment strategies due to lack of literature and lack of consensus. We discuss the role of primary and secondary prophylactic use of anticoagulants, and provide tools and recommendations for screening, prevention and management for the specific pediatric populations.

Background Thromboprophylaxis is routinely used in adults with active inflammatory bowel disease (IBD), particularly inpatients, but not in children. Current ECCO/ESPGHAN guidelines support thromboprophylaxis only in children with acute severe colitis (ASC) with risk factors (RFs).1 We convened an international RAND panel to explore thromboprophylaxis in paediatric IBD (PIBD) inpatients. Methods We convened a 13-person voting panel of geographically diverse paediatric gastroenterologists alongside experts in RAND methodology, IBD surgery, haematology and nursing. Selective pertinent manuscripts were disseminated prior to the meeting. An online survey was sent to all panellists ahead of an online meeting. Panellists were asked to rate the appropriateness of thromboprophylaxis in hospitalised PIBD patients via clinical scenarios of varying ages, gender, and extent of ulcerative colitis (UC) and Crohn’s disease (CD) with and without RFs. Anonymised results were presented at the meeting. A second modified survey of 27 scenario-based statements was distributed to all panellists present at the meeting with three options each: offer no thromboprophylaxis; offer until discharge; offer until clinical remission. Results from the second survey constitute the RAND panel results. The validated RAND disagreement index (DI) defined disagreement when DI ≥1. Results The combined outcome of thromboprophylaxis being considered appropriate until discharge and inappropriate to withhold was seen in 20/27 scenarios, including all patients with new-onset ASC, irrespective of pubertal status or sex (Fig 1); all flares of known UC, irrespective of sex, or the presence/absence of RFs with the exception of pre-pubescent patients with limited disease and no risk factors (Fig 2); and CD patients with RFs, irrespective of pubertal status or sex (Fig 3). Thromboprophylaxis was always considered uncertain until clinical remission. Disagreement was only seen in 4/12 scenarios regarding CD without RFs where most options were also uncertain, particularly in those with limited ileal disease (Fig 3, * = DI ≥1). Conclusion RAND panels are an established method to assess expert opinion in areas of limited evidence. This work therefore constitutes neither a guideline nor a consensus; however, the findings suggest a need to re-evaluate the role of thromboprophylaxis in the next iteration of PIBD guidelines. Specifically, thromboprophylaxis was considered appropriate until discharge in all patients with active UC, irrespective of RFs except in pre-pubescent children with limited disease. Thromboprophylaxis was considered appropriate in CD with RFs but there was uncertainty in CD without RFs, particularly in limited ileal disease. Reference 1. Turner D, et al. JPGN 2018; 67: 293–310.

Diabetes mellitus (DM) in children is most often caused by impaired insulin secretion (type 1 DM). In some children, the underlying mechanism for DM is increased insulin resistance, which can have different underlying causes. While the majority of these children require insulin dosages less than 2.0 U/kg/day to achieve normoglycemia, higher insulin requirements indicate severe insulin resistance. Considering the therapeutic challenges in patients with severe insulin resistance, early diagnosis of the underlying cause is essential in order to consider targeted therapies and to prevent diabetic complications. Although rare, several disorders can attribute to severe insulin resistance in pediatric patients. Most of these disorders are diagnosed through advanced diagnostic tests, which are not commonly available in low- or middle-income countries. Based on a case of DM with severe insulin resistance in a Surinamese adolescent who was later confirmed to have autosomal recessive congenital generalized lipodystrophy, type 1 (Berardinelli-Seip syndrome), we provide a systematic approach to the differential diagnosis and work-up. We show that a thorough review of medical history and physical examination generally provide sufficient information to diagnose a child with insulin-resistant DM correctly, and therefore, our approach is especially applicable to low- or middle-income countries.

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