The benefits and risks of any treatment should be discussed openly with patients and their family, particularly in relation to steroids and immunomodulators. Factors such as the potential risk of immunosuppression, bone marrow suppression, and malignancy must be discussed and the discussion recorded in the case notes. Disease activity can be expressed using a disease activity index such as the Paediatric Crohn's Disease Activity Index (26).
The choice of treatment in most cases is between exclusive enteral nutrition and oral corticosteroids. This is concordant with the BSG guidelines, which also state that there is insufficient evidence to recommend the use of other agents outside trials/specialist centres. Recently, some centres have started using azathioprine at diagnosis for those with severe disease. Azathioprine prevents relapse, but it is not fully effective until at least 3 months after starting the drug.
Patients in whom standard induction therapy, including high-dose intravenous steroids, has failed to induce remission either at diagnosis or during subsequent relapse are defined as having nonresponsive CD. Steroid refractory CD may be defined as active disease despite an adequate dose (1–2 mg · kg−1 · day−1; minimum 20 mg/day) and duration (at least 2 weeks) of steroid therapy. Such patients should be considered for treatment with immunomodulators if surgery is not an immediate consideration.
Treatment of UC depends on disease activity and distribution. Disease activity can be expressed using a clinical activity index (98–100). If on evaluation the disease is severe, the patient needs to be admitted to a paediatric gastroenterology unit for intensive intravenous therapy. If the disease is fulminant, the patient needs urgent resuscitation, an abdominal x-ray to exclude perforation, and joint medicosurgical assessment and management. The majority (90%) of children with UC have pancolitis, fewer than 10% have left-sided colitis, 4% have disease confined to the rectum alone, and 4% have rectal sparing (7). Half of those without pancolitis at presentation will rapidly progress to pancolitis (25). Infective aetiology should be sought because this may coexist with active disease, but in severe disease, immediate treatment with corticosteroids should not be delayed (Fig. 3).
Children with severe colitis should be admitted to hospital for intravenous therapy and close monitoring of temperature, pulse rate, stool frequency, CRP, FBC, and a plain abdominal x-ray as a baseline to look for colonic dilatation. Regular reassessment is essential.
Manage patients with IC the same as patients with UC. Re-evaluate periodically because the histological picture and/or disease distribution may change to CD or UC.
The complexity of cases means that facilities and expertise are necessary beyond those normally provided in district hospitals. Shared care pathways are essential between specialist pediatric gastroenterology units and district general hospitals, particularly if the child is prepubertal. Service-specific and clinical standards are vital (eg, National Association of Colitis and Crohn's Disease (NACC)/BSG/BSPGHAN standards, government of Wales' standards for gastroenterology, hepatology, and nutrition).
Any specialty service must be arranged around the needs of the child and family with the child receiving the highest quality care but as close to home as possible (eg outreach clinics) as part of a managed clinical network. It is clear that the following are important elements in any clinical network:
Explanations or advice given by clinical staff can be complemented by other sources of information. Patients usually welcome additional information, but it needs to be appropriate and relevant to their condition. The following and many other sources provide access to information:
The authors acknowledge the assistance of all BSPGHAN members and thank the authors of the BSG adult IBD guidelines for their contributions. Drs A. Akobeng, D. Casson, N.M. Croft, M. Elawad, S.H. Murch, M.S. Murphy, J. Puntis, A.S. Sawczenko, and A.G. Thomas were contributing authors to this guideline.
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