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The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update
Patrick F van Rheenen1, Marina Aloi2, Amit Assa3
1Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Beatrix Children's Hospital, Groningen, The Netherlands.
Insights
Updated guidelines recommend early identification of high-risk pediatric Crohn's disease (CD) patients for intensified treatment. Key strategies include anti-tumour necrosis factor [TNF] agents for high-risk cases and exclusive enteral nutrition [EEN] for low-risk patients.
Area of Science:
- Pediatric Gastroenterology
- Inflammatory Bowel Disease Research
- Clinical Guideline Development
Background:
- Paediatric Crohn's disease (CD) management requires updated, evidence-based recommendations.
- Existing guidelines may not fully address the complexities of managing CD in children and adolescents.
Purpose of the Study:
- To provide an updated, evidence-supported guideline for the medical management of paediatric Crohn's disease.
- To consolidate current best practices for treating children and adolescents with CD.
Main Methods:
- Formed 10 working groups to address 17 PICO-structured clinical questions.
- Conducted a systematic literature search from 1991 to 2019 across major medical databases.
- Refined 30 provisional statements through a consensus meeting and voting process, achieving ≥80% agreement for 22 statements.
Main Results:
- Identified early identification of high-risk patients crucial to minimize bowel damage.
- Recommended upfront anti-tumour necrosis factor [TNF] agents with immunomodulators for high-risk patients (perianal disease, stricturing/penetrating behavior, severe growth retardation).
- Advocated for exclusive enteral nutrition [EEN] or corticosteroids for low-risk luminal CD, followed by immunomodulator maintenance.
- Emphasized therapeutic drug monitoring over empirical dose escalation or switching anti-TNF therapies.
- Highlighted serial faecal calprotectin or small bowel imaging as superior markers of treatment response compared to clinical scores.
Conclusions:
- Established state-of-the-art guidance for the medical treatment of paediatric Crohn's disease.
- Provided recommendations for the long-term management of children and adolescents with CD.
- Aimed to improve outcomes through evidence-based strategies and close patient monitoring.
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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