Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease

Abstract

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.

Inflammatory Bowel Disease in Childhood and Adolescence

“…Both German (1,2) and European (11)(12)(13) guidelines for both the above-mentioned diseases are available and were consulted. For the diagnosis of IBD, the available data is mostly limited to case series, but treatment recommendations are usually based on controlled trials or meta-analyses of controlled trials.…”

The Use of 5-Aminosalicylic Acid in Children and Adolescents With Inflammatory Bowel Disease

“…20 In concordance with this evidence the actual treatment guideline for pediatric CD recommends oral 5-ASA only for selected patients with a very mild colonic disease. 1 Only 13% of CD patients in our cohort had colonic-only disease at diagnosis, whereas nearly half of all CD patients received oral 5-ASA at some time point. The yearly prescription rate of 5-ASA in CD patients was stable between 2009 and 2015; however, the effect and the adjustment of treatment modalities from the 2014 published pediatric guideline may not yet be evident.…”

“…This explains overlapping treatment strategies yet differing efficacy of medications depending on the subtype. 1,2 For mild to moderate UC 5-aminosalicylic acid (5-ASA) is the primary treatment choice for induction and maintenance of remission in pediatric and adult patients. 2,3 Topical 5-ASA has been proven effective especially in distal disease in both children and adults.…”

Fecal calprotectin in the prediction of postoperative recurrence of Crohn's disease in children and adolescents

“…Crohn's disease (CD) is a chronic relapsing inflammatory disorder of the alimentary tract with a continuously increasing incidence in the pediatric population [1][2][3][4][5]. Compared to adults, childhood-onset CD typically shows a more active disease pattern and greater need for immunosuppressant therapy [4].…”

“…Recurrent mucosal inflammation is observed in endoscopy in 70-90% of adult CD patients within a year of surgery although only one third present with symptomatic relapse of the disease [1,[8][9][10]. Histological activity may develop at the site of the anastomosis as soon as after a week of bowel resection [11].…”