Outcomes of Premature Infants With Type C Esophageal Atresia

BACKGROUND

To review the outcomes of premature patients with type C esophageal atresia (EA).

METHODS

In this retrospective cohort study, charts of patients of type C EA patients were reviewed from 1992 to 2022. Outcomes of premature patients were compared to term patients. Preterm patients were analyzed to compare outcomes of infants with very low birth weights (VLBW) to patients >1,500 g as well as primary versus delayed anastomosis.

RESULTS

Among 192 type C EA, 67 were premature. Median and interquartile range (IQR) gestational age and birth weight of preterm patients were 34 [33-36] weeks and 1965 [1740-2290] g. Delayed anastomosis was performed in 12 (18%) preterm vs. 3 (2%) term patients (p = 0.0003). Short-term postoperative outcomes were similar between preterm and term patients, except for recurrent fistula (16% vs. 6%, p = 0.01). Prematurity was associated with an increased need for long-term enteral tube feeding (56% vs. 10%, p = 0.0001) and parenteral nutrition (10 days vs. 0 days, p = 0.0004). The length of stay was 3 times longer when patients were premature (50 days vs. 17 days, p = 0.002). Delayed surgery in preterm patients was associated with post-operative leaks, strictures, recurrent fistula, prolonged enteral tube feeding, and gastrostomy insertion. Patients with very low birth weight (VLBW) were compared to other preterm patients and showed no difference in terms of rate of delayed surgery, and post-operative outcomes.

CONCLUSION

Despite increased prematurity-related comorbidities and low birth weight, premature infants with type C EA/TEF have similar post-operative outcomes to term patients though recurrent fistula was more frequent with prematurity.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Inflammatory Bowel Disease Among Canadian Children: Comparison Between Children of Non-European Descent and Children of European Descent

BACKGROUND

Inflammatory bowel disease (IBD) phenotypes may differ between countries and ancestral groups. The study aim was to examine ancestry and subtype variations of children newly diagnosed with IBD.

METHODS

Children newly diagnosed with IBD enrolled into the Canadian Children Inflammatory Bowel Disease Network inception cohort study were categorized into 8 ancestral groups. Prospectively collected data at diagnosis and follow-up were compared between ancestral groups.

RESULTS

Among 1447 children (63.2% Crohn's disease, 30.7% ulcerative colitis), 67.8% were European, 9.4% were South Asian, 3.8% were West Central Asian and Middle Eastern, 2.3% were African, 2.2% were East/South East Asian, 2.0% were Caribbean/Latin/Central/South American, 9.9% were mixed, and 2.6% were other. Children of African descent with ulcerative colitis had an older age of diagnosis compared with children of European descent (median 15.6 years vs 13.3 years; P = .02). Children of European descent had a higher proportion of positive family history with IBD (19.3% vs 12.1%; P = .001) compared with children of non-European descent. Children of European descent also had a lower proportion of immigrants and children of immigrants compared with children of non-European descent (9.8% vs 35.9%; P < .0001; and 3.6% vs 27.2%; P < .0001, respectively) .

CONCLUSIONS

Important differences exist between different ancestral groups in pediatric patients with IBD with regard to age of diagnosis, family history, and immigrant status. Our study adds to the knowledge of the impact of ancestry on IBD pathogenesis.

ADALIMUMAB VERSUS INFLIXIMAB IN LUMINAL PEDIATRIC CROHN'S DISEASE: COMPARABLE OUTCOMES IN A PROSPECTIVE MULTICENTER COHORT STUDY

BACKGROUND

This study compared real-world effectiveness between adalimumab (ADA) and infliximab (IFX) in children with Crohn's disease (CD).

METHODS

Children enrolled into the prospective Canadian Children Inflammatory Bowel Disease Network (CIDsCaNN) National Inception Cohort between 2014 and 2020 who commenced ADA or IFX as first anti-tumor necrosis factor (antiTNF) agent for luminal CD were included. Multivariate logistic regression modelled the propensity of commencing ADA; propensity score matching was used to match IFX-treated children to ADA-treated children. The primary outcome at one year was steroid-free clinical remission (SFCR). Secondary outcomes at one year were I) combined SFCR and c-reactive protein (CRP) remission; II) treatment intensification; and III) antiTNF durability. Odds ratios (aOR) and hazard ratio (aHR) adjusted for concomitant immunomodulator use with 95% confidence interval (CI) are reported.

RESULTS

In the propensity score matched cohort of 147 ADA-treated and 147 IFX-treated children, 92 (63%) ADA- and 87 (59%) IFX-treated children achieved SFCR at one year (aOR: 1.4, 95% CI 0.9-2.4); 75 of 140 (54%) ADA- and 85 of 144 (59%) IFX-treated children achieved combined SFCR and CRP remission (aOR: 1.0, 95% CI 0.6-1.6). ADA-treated children less frequently underwent treatment intensification (21 [14%]) compared to IFX-treated children (69 [47%]) (P<0.0001). Discontinuation of antiTNF occurred in 18 (12%) ADA-treated and 15 (10%) IFX-treated children (aHR: 1.2, 95% CI 0.6-2.2).

CONCLUSION

Children with Crohn's disease achieved favourable outcomes at one year with either ADA or IFX as first antiTNF agents. Those receiving IFX did not have significantly superior outcomes compared to clinically similar children receiving ADA.

A290 PHENOTYPE AND OUTCOME OF PATIENTS HOSPITALIZED FOR ACUTE PANCREATITIS IN A TERTIARY PEDIATRIC CENTER

Background

A recent meta-analysis of 48 studies, showed an equal prevalence of AP (16%) among the following etiologies; systemic disease, alcohol, medication, genetics, gallstones and infection in North American hospitalized and ambulatory pediatric patients. However, data on the epidemiology of severe pediatric acute pancreatitis (AP) in Canada are lacking.

Purpose

We aim to evaluate the clinical presentation, etiologies, comorbidities and outcome of pediatric patients with AP admitted to a tertiary hospital in Quebec, Canada.

Method

A retrospective observational cohort study (January 2014-December 2021) was performed at the CHU Sainte-Justine. Descriptive analyses were performed with SAS statistical softwar

Result(s)

Among the 214 patients included (110 (51%) males), 58 (27.1%) were already hospitalized at time of AP diagnosis (AP as secondary diagnosis) while 156 (72.9%) were admitted from the emergency room mainly with a presentation of abdominal pain (AP as primary diagnosis). Thirty-two patients (15.0%) were transferred to the ICU due to hemodynamic instability or respiratory failure. Comorbidities included cancer (38 patients (17.7%)), obesity (17 (7.9%)) and inflammatory bowel disease (15 (7.0%)). The three most commonly identified etiologies were medication (19.6%), biliary disease (16.3%) and infection (14,9%). Despite extensive investigations, 26.2% of cases were idiopathic. The main complications were, ascites (48 patients (22.4%)), necrotic pancreatitis (10 (4.6%)) and pancreatic pseudocyst (10 (4.6%)). The median duration of hospitalization for AP as a primary diagnosis was 4 days (interquartile range (IQR) 2-7) as compared to 22 (11-37) for AP as a secondary diagnosis.

Conclusion(s)

Approximately one third of hospitalized patients had an underlying condition requiring treatments that could cause AP, which explains the high prevalence of drug-induced AP in this report. The longest hospitalizations were associated with AP as secondary diagnosis. Ongoing work will identify factors associated with disease severity and outcome in particular in primary AP.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

A203 EARLY PROACTIVE DRUG MONITORING STRATEGY OF INFLIXIMAB AS MONOTHERAPY FOR INFLAMMATORY BOWEL DISEASE IN PAEDIATRIC PATIENTS IS ASSOCIATED WITH GOOD SUSTAINED CLINICAL REMISSION

Background

Monotherapy with Infliximab (IFX) can be as efficient as combotherapy with immunomodulators in the treatment and maintenance of remission for children with inflammatory bowel disease (IBD) if an early proactive therapeutic drug monitoring strategy is adequately performed. This strategy may allow optimization of blood levels of IFX in order to obtain a sustained clinical response.

Purpose

This study demonstrated that with appropriate early trough levels of IFX before dose #3 and dose #4 , monotherapy was very efficient in inducing remssion at week 52 .

Method

A retrospective study was conducted at CHU Sainte-Justine, Montréal,Canada .Children with IBD 2 to 18 years old diagnosed between 01/2018 and 06/2020 and treated with IFX less than 30 days after diagnosis were included .IFX blood levels were collected before the 3rd and/or 4th dose of IFX and regularly thereafter. Adjustments were done in IFX dose per infusion according to blood levels and clinical response. The primary outcome was clinical remission at one year after diagnosis.The secondary outcomes included: (1) At 52 weeks, the median (IQR) dose of IFX (mg/kg) and the intervals between IFX infusions ; (2) the median (IQR) number of IFX dose changes and the median (IQR) number of blood trough levels of IFX done.

Result(s)

101 patients were included : 56.4% males; 81CD; 18 UC; 2 IBDU. Mean age at diagnosis was 13.2 years (IQR = 11.20 to 15. 20).

Median time to IFX initiation after diagnosis was 5 days (IQR :3-14).Median IFX dose #1: was 8.4 mg/kg (IQR = 5. 8 to 10).

90% of patient had an IFX optimisation (increasing dose and/or shortening intervals) after dose 3 or dose 4. At week 52, 36,5% of patients were receiving IFX infusion every 4 weeks and 30,6% every 6 weeks. The median IFX dose per infusion was 8,9mg/kg (IQR = 7.4- 9,8 ). The IFX doses at week 52 varied greatly according to age at diagnosis The median number of IFX blood level dosage was 4 per patient over a year (IQR=3-5).At week 52, 83 patients (84.6%) achieved clinical remission with a median IFX level of 10.96 (7.05-15.59). 74 /83 (89%) were on monotherapy and 9/83(10.8%) on combotherapy

Image

Conclusion(s)

Early treatment for IBD with IFX as monotherapy and an early proactive optimization strategy is associated with a good sustained steroid free clinical remissionAt week 52, 83 patients (84.6%) achieved clinical remission with a median IFX level of 10.96 (7.05-15.59). 74 /83 (89%) were on monotherapy and 9/83(10.8%) on combotherapy.The majority of the patients required IFX optimization during their first year of treatment. We therefore recommend to proactively monitor blood levels of IFX before the third and fourth dose of IFX and thereafter, in order to lower the risk of treatment failure and anti-infliximab antibodies occurrence.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

C. Girard: None Declared, S. Ackhar: None Declared, S. Sassine: None Declared, L. Chapuy: None Declared, P. Jantchou: None Declared, C. Deslandres Speakers bureau of: moderator and speaker Abbvie and Janssen

158 - Impact de la pandémie COVID19 sur l'ingestion de corps étrangers par les enfants au Québec

Contexte

Plus de 90 % des cas d'ingestions de corps étrangers en pédiatrie se produisent à domicile. Notre hypothèse était que le temps supplémentaire passé par les enfants à domicile durant la pandémie COVID-19 serait associé à une augmentation du nombre de cas d'ingestions de corps étrangers et leur sévérité. Nos objectifs étaient de comparer l'incidence d'ingestions pédiatriques de corps étrangers et le taux de cas sévères (hospitalisation, complications ou interventions par endoscopie) avant et pendant la pandémie.

Méthodes

Toutes les consultations pédiatriques au CHU Sainte-Justine de Montréal pour ingestion de corps étrangers entre mars 2018 et février 2020 (pré-pandémie) ainsi qu'entre mars 2020 et février 2021 (pandémie) ont été incluses (n=614). L'incidence d'ingestions de corps étrangers a été calculée en rapportant le nombre de cas au nombre de visites aux urgences selon les périodes. Les différences entre les deux groupes ont été analysées par un test T de Student ou Chi-carré.

Résultats

L’âge médian des patients était de 3,5 ans [(interquartile: 1,6-5,9); 54 % garçons]. Le nombre mensuel moyen de cas (min-max) durant la pandémie [20,0 (12-28)] était significativement plus élevé qu'avant la pandémie [15,5 (8-24)] (p=0,02). Le taux d'incidence a doublé, passant de 23,2 pour 10 000 visites aux urgences en pré-pandémie à 51,6 pour 10 000 visites pendant la pandémie (p=0,0002). Près d'un quart de la cohorte a dû être hospitalisé. Le taux d'hospitalisations (>1 jour) est resté stable entre les deux périodes: 6,95 % pré-pandémie et 7,08 % pendant la pandémie. Les taux d'endoscopies (21,3 %) et de complications (4,6 %) étaient similaires entre les deux périodes.

Discussion/Conclusion

L'incidence d'ingestions de corps étrangers au CHU Sainte-Justine a augmenté significativement durant la pandémie comparativement aux deux années précédentes. Les taux élevés de cas sévères, bien que stables durant la pandémie, témoignent de l'impact considérable des ingestions de corps étrangers en pédiatrie.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Appendectomy and risk for inflammatory bowel disease: effect of age and time post appendectomy - a cohort study

Background and objective

Appendectomy may modulate the risk of inflammatory bowel disease through an effect on the gut microbiota. This study investigated the associations between appendectomy and incidence of Crohn’s disease (CD) or ulcerative colitis (UC), with an emphasis on the influence of age and time post appendectomy.

Methods

This cohort study included 400 520 subjects born in Québec in 1970–1974 and followed until 2014. Administrative health data were used to ascertain appendectomy and cases of CD and UC. Cox proportional hazards models with time-dependent variables (appendectomy and time elapsed post appendectomy) allowed for the estimation of HRs and 95% CIs.

Results

A total of 2545 (0.6%) CD cases and 1134 (0.3%) UC cases were identified during follow-up. Appendectomy increased the risk of CD (HR=2.02; 95% CI: 1.66 to 2.44), especially when performed at 18–29 years of age. The risk of CD was increased in the first 2 years, and decreased significantly after ≥15 years post appendectomy. Appendectomy appeared to protect against UC (HR=0.39; 95% CI: 0.22 to 0.71). The risk of UC was not associated with age at appendectomy, but decreased with time elapsed post appendectomy (HR=0.21; 95% CI: 0.06 to 0.72, comparing ≥5 with 0–4 years after appendectomy).

Conclusions

The increased risk of CD related to appendectomy in young adults may result from detection bias, but physicians should have a low threshold for suspicion of CD in young symptomatic adults with a history of appendectomy. A strong protective effect of appendectomy against UC was observed after 5 years.

Canadian Consensus Statements on the Transition of Adolescents and Young Adults with Inflammatory Bowel Disease from Pediatric to Adult Care: A Collaborative Initiative Between the Canadian IBD Transition Network and Crohn’s and Colitis Canada

Objectives

With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn’s and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care.

Methods

Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice.

Results

The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research.

Conclusions

These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.

Changes in the clinical phenotype and behavior of pediatric luminal Crohn's disease at diagnosis in the last decade

BACKGROUND AND AIMS

The aims of this study were to describe the trends in the behavior of pediatric CD during the last decade and to describe the seasonal variation of disease presentation.

METHODS

Patients under 18 years old and diagnosed between 2009 and 2019 were included. The clinical, endoscopic, histological, and laboratory data were collected from the medical records. We analyzed the trends of these parameters according to the year and season of diagnosis.

RESULTS

654 patients were included in the study. The number of incident CD cases increased yearly. Patients diagnosed between 2015 and 2019 were younger at diagnosis (OR 2.53, p = 0.02), had more perianal diseases (OR: 2.30, p < 0.0001) and more granulomas (OR: 1.61, p = 0.003), but fewer eosinophils (OR: 0.35, p < 0.0001) and less chronic lymphoplasmacytic infiltrate (OR: 0.56, p = 0.008) as compared to the 2009-2014 cohort. There was fewer CD diagnosis during winter. Patients diagnosed in the fall had lower PCDAIs, less failure to thrive and less extensive digestive involvement. Colonic disease was significantly more frequent during summer and fall.

CONCLUSION

The clinical and histological phenotype of CD has changed over time and there are important seasonal trends in the frequency and severity on disease behavior suggesting possible disease triggers.

A186 CHANGES IN THE CLINICAL PHENOTYPE AND BEHAVIOR OF PEDIATRIC LUMINAL CROHN’S DISEASE AT DIAGNOSIS IN THE LAST DECADE

Background

Crohn’s disease (CD) triggers are incompletely understood and the incidence of the disease has been increasing.

Aims

The aims of this study were to describe the trends in the clinical, endoscopic, histological, and laboratory characteristics of pediatric CD during the last decade and to describe the seasonal variation of disease presentation at diagnosis.

Methods

Patients under 18 years old and diagnosed between 2009 and 2019 were included. Patients clinical, endoscopic, histological, and laboratory data were collected from the medical records. Data were analyzed for the cohort as a whole and according to diagnostic periods (2009–2014 and 2015–2019) and seasons.

Results

654 patients were included in the study. The total number of incident CD cases significantly increased yearly. Patients diagnosed between 2015 and 2019 were younger at diagnosis (OR: 2.30, p<0.0001), had more perianal diseases (OR= 2.30, p<0.001) and more intestinal biopsy granulomas (OR= 1.61, p=0.003) as compared to the 2009–2014 cohort. Also, there was a strong association between intestinal biopsy granulomas, young age at diagnosis and perianal fistulas or abscesses; the presence of granulomas was associated with greater perianal involvements (OR= 2.25, p<0.001) and younger age at diagnosis (OR = 0.90, p=0.0002). PCDAI and SES-CD scores at diagnosis, disease location and behavior and laboratory markers did not change over time.

There were fewer CD diagnosis during winter. The highest vitamin D levels in patients occurred in summer and fall, but the majority of patients had, regardless of the season of diagnosis, severe vitamin D deficiency (the median vitamin D level was 60.0 nmol/L in summer and fall compared to 47.0 nmol/L in winter-spring, p=0.003). Vitamin D levels at diagnosis are inversely correlated with PCDAI (Pearson correlation coefficient = -0.19, p=0.03) and SES-CD (-0.20, p=0.04). Patients diagnosed in fall had lower PCDAI and SES-CD scores, less failure to thrive, less digestive symptoms and less extensive digestive involvement. Colonic disease was significantly more frequent during summer and fall (27.3% of patients diagnosed in summer and fall versus 18.2% of cases in winter and spring, p=0.01).

Conclusions

The disease phenotype has changed over the years and there are important seasonal trends in the frequency and severety of the disease suggesting possible disease triggers. Our findings provide interesting avenues for future research, such as identifying the clinical significance of granulomas, vitamin D deficiency and microbiota on pediatric CD activity.

PCDAI at diagnosis according to the season.

Funding Agencies

NoneFonds Recherche Santé Québec / Fondation du CHU Sainte-Justine

A253 IMPACT OF THE COVID-19 PANDEMIC LOCKDOWN ON PHYSICAL ACTIVITY LEVELS IN CHILDREN AND ADOLESCENTS WITH INFLAMMATORY BOWEL DISEASE IN QUEBEC

Background

An average daily moderate-to-vigorous physical activity (MVPA) of at least 60 minutes was recommended by the Canadian Guidelines for children. Because of lockdown restrictions during the COVID-19 pandemic, maintaining physical activity levels (PAL) has been a challenge for youth.

Aims

The primary aim of this study was to compare MVPA levels in children with inflammatory bowel diseases (IBD) before and after this period. The secondary aims were to assess clinical factors that might influence any changes in MVPA patterns.

Methods

Patients with IBD, age ≥5 years, were enrolled in a prospective study on PAL starting June 2018 (self-reported questionnaires during outpatient visits). They were then surveyed online at the end of the second lockdown in July-August 2021. PAL were assessed with the Canadian Health Measure Survey Children-Physical Activity Questionnaire. The responses were converted into metabolic equivalents of tasks by using validated tables. Influence of clinical factors of IBD on changes in MVPA was assessed. A multivariate logistic regression was performed to investigate the association between several risk factors and PAL.

Results

We included 72 patients (38 males; mean (SD) age 17.0 (2.89) years, 48 (66.7%) diagnosed with Crohn’s disease, 19 (26.4%) with ulcerative colitis, and 5 (6.9%) with indeterminate colitis). At last follow-up, 90.3% were in clinical remission according to validated disease activity score. During summer 2021, 16.7% of patients reached the Canadian PAL target, compared to 38.9% before the pandemic. The median daily duration of MVPA in summer 2021 decreased from 37 (Interquartile range (IQR) = 3–82) to 21 (IQR=3–40) minutes. The proportion of sedentary patients increased by 1.4% (37.5% to 38.9%). The proportion of extremely active patients decreased by 16.7% (27.8% to 11.1%), while moderately active patients increased by 20.9% (8.3% to 29.2%). Age, gender, disease type and activity were not significantly associated with the PAL at baseline or at follow-up.

Conclusions

This study found a significant decrease in PAL and time spent doing MVPA in children with IBD in Quebec following the COVID-19 pandemic lockdown. While the recommended target was far from being met before the pandemic, the gap has widened further during the pandemic. We found no clinical factors associated with the PAL. The impact of low PAL on well-being, weight, disease activity and quality of life will be assessed during the follow-up of this cohort.

Funding Agencies

None

A187 RISK FACTORS OF CLINICAL RELAPSES IN PEDIATRIC LUMINAL CROHN’S DISEASE, A RETROSPECTIVE COHORT STUDY

Background

Few risk factors are associated with the risk of relapses of Crohn’s disease in children.

Aims

The aims of this retrospective cohort study were to describe the rate of relapses in children with Crohn’s disease, its evolution over the past decade and to determine risk factors associated with relapse.

Methods

Patients under 18 years old and diagnosed between 2009 and 2019 were included. Patients clinical, endoscopic, histological, and laboratory characteristics, as well as their treatments, where collected from their medical records and the prospective CHU Sainte-Justine inflammatory bowel disease registry. Survival analyses and Cox regression models were used to assess the impact of those risk factors on relapse.

Results

639 patients were included. There was a decrease in the clinical relapse rate over the past decade: 70.9% of patients diagnosed between 2009 and 2014 experienced a relapse compared to 49.1% of patients diagnosed between 2015 and 2019 (p&lt;0.0001). The following variables were associated with clinical relapse: female sex (adjusted hazard ratio (aHR)= 1.51, p=0.0009), high PCDAI (aHR= 1.02, p=0.04) and SES-CD (aHR= 1.03, p=0.03) scores at diagnosis, upper digestive tract involvement (aHR= 1.59, p=0.0003), exposure to oral 5-ASA (aHR= 1.91, p=0.0003), use of immunomodulatory agents compared to TNF-alpha inhibitors (methotrexate aHR= 1.91, p=0.0006; thiopurines aHR= 2.06, p&lt;0.0001), presence of granulomas (aHR= 1.27, p=0.04) and increased eosinophils on intestinal biopsies (aHR= 1.34, p=0.02), high levels of C-reactive protein (aHR= 1.01, p&lt;0.0001) and fecal calprotectin (aHR=1.09, p&lt;0.0001) during clinical remission and low serum infliximab levels during maintenance (aHR for mean serum infliximab level under 7ug/mL = 2.48, p=0.005).

Conclusions

Relapse risk was significantly associated with baseline clinical, endoscopic, histological and laboratory data and treatment strategies. These results could help better select treatment options for pediatric Crohn’s disease at induction and maintenance.

Funding Agencies

NoneFonds Recherche Santé Québec / Fondation du CHU Sainte-Justine

A188 FACTORS ASSOCIATED WITH CLINICAL REMISSION IN PEDIATRIC LUMINAL CROHN’S DISEASE: A RETROSPECTIVE COHORT STUDY

Background

The natural evolution of Crohn’s disease is incompletely understood in the pediatric population. Data on factors influencing time-to-remission are very limited in the literature.

Aims

The aim of this retrospective cohort study was to describe the time to clinical remission in children with Crohn’s disease as well as changes over the past decade and to identify factors associated with time to clinical remission.

Methods

Patients under 18 years old diagnosed between 2009 and 2019 were included. All data were collected from the patients’ medical records and the CHU Sainte-Justine inflammatory bowel disease registry. Survival analyses and linear regression models were used to assess the impact of clinical, laboratory, endoscopic, histological and therapeutic factors on time to clinical remission.

Results

654 patients were included in the study. There was no change in the time to clinical remission over the past decade. Female sex in adolescents (ajusted bêta regression coefficient (aβ)= 31.8 days, p= 0.02), upper digestive tract involvement (aβ= 46.4 days, p= 0.04), perianal disease (aβ= 32.2 days, p= 0.04), presence of active inflammation on biopsies (aβ= 46.7 days, p= 0.01) and oral 5-ASA exposure (aβ=56.6 days, p= 0.002) were all associated with longer time to clinical remission. However, antibiotic exposure (aβ= -29.3 days, p=0.04), increased eosinophils on biopsies (aβ= -29.6 days, p=0.008) and combination of exclusive enteral nutrition and TNF- alpha inhibitors as induction therapy (aβ= -36.8, p=0.04) were associated with shorter time to clinical remission.

Conclusions

Time to clinical remission did not improve during the decade and was associated with baseline clinical and histological data and treatment strategies. Combination of enteral nutrition and TNF-alpha inhibitors was associated with faster clinical remission.

Funding Agencies

NoneFonds Recherche Santé Québec / Fondation du CHU Sainte-Justine

A81 TRANSITION PRACTICES FROM PEDIATRIC TO ADULT CARE OF CHILDREN LIVING WITH CROHN’S DISEASE IN QUEBEC

Background

Nearly 25% of Crohn’s disease cases are diagnosed during childhood. Among them, several adolescents may have extensive or complex disease implying specific needs during transition to adult care.

Aims

The primary aim was to describe current transition practices from pediatric to adult care in patients diagnosed with Crohn’s disease at CHU Sainte-Justine. The secondary aim was to determine factors that influenced the type of adult health centers (academic vs non-academic) to which patients were referred.

Methods

This single center study included patients diagnosed with Crohn’s disease at CHU Sainte-Justine between 2009 and 2019. Adult centers were separated into five categories: academic centers in Montreal (CHU-Mtl) and outside of Montreal (CHU), non-academic centers in Montreal (CHG-Mtl) and outside of Montreal (CHG), and other centers. The following factors influencing the transfer to an academic center were analyzed in a multivariate logistic regression model: age at diagnosis, gender, disease location, disease activity: relapses, hospitalizations, emergency room (ER) visits, and place of residence.

Results

A total of 366 patients were included: 44% female, median (IQR) age at transfer 18.0 (17.9–18.4). Among them, 169 (48%) were transferred to CHU-Mtl, 144 (39%) to CHG, 22(6%) to CHU, 4 (1%) to CHG-Mtl, 27 (7%) to other centers. There was a significant increase in the annual number of patients referred to CHG and CHU-Mtl across the decade, compared to other centers. Patients transferred to CHU-Mtl had more relapses per year (mean (SD) 0.8 (0.5) versus patients transferred to CHU, CHG and CHG-Mtl, p=0.0348), and 57% (N=97) of patients sent to CHU-Mtl had already visited the ER, as compared to 54%, 40% and 25% for CHU, CHG and CHG-Mtl respectively (p=0.0258). However, gender, age at diagnosis, maintenance treatment, number and duration of hospitalisations, extraintestinal manifestations, perianal inflammation or extensive disease location did not correlate with the type of adult center. Place of residence played a role in the choice of adult center: 56% (N= 95) of patients transferred to CHU-Mtl lived in Montreal (p<0.0001).

Conclusions

Clinical evolution and disease burden have an impact on the type of adult center. Efforts should be put to understand patient factors associated with the transfer to an academic vs non-academic center, for a better utilization of healthcare resources and adequate patient quality of life during transition.

Funding Agencies

NonePrincipal researcher funds

A22 IMPACT OF COVID-19 PANDEMIC ON FOREIGN BODY INGESTION IN CHILDREN AND ADOLESCENTS: A CROSS-SECTIONAL STUDY

Background

Foreign Body Ingestions (FBI), sometimes associated with severe complications, are a common reason for emergency unit visits in children. In Quebec, since March 2020, the restrictions in response to the COVID-19 pandemic have increased the time children spend at home. We hypothesized that this could contribute to a rise in FBI incidence and severity.

Aims

The primary objective of our study was to evaluate the incidence as well as the clinical presentation of FBI cases seen at CHU Sainte-Justine Children’s Hospital in Montreal (CHUSJ) during the COVID-19 pandemic as compared to the two previous years. Our secondary objectives were to estimate the rate of severe FBI (involving hospitalisations and/or complications) and to evaluate the nature of the foreign bodies that were ingested.

Methods

All children referred to or who presented at CHUSJ for FBI between March 2018 and February 2020 (pre-pandemic) as well as between March 2020 and February 2021 (pandemic) were included (n=690). Cases of food impaction were excluded (n=78). Incidence of FBI was calculated by dividing the number of FBI cases by the total number of emergency department visits per period. Differences between the two groups were analyzed by Student T test or Chi-square test.

Results

Between March 2018 and February 2021, 612 patients (median age 3.5 years (1.6–5.9); 54% male) were eligible. The mean monthly number of FBI cases (min-max) in 2020–2021 was 18.6 (9–28), significantly higher than the year 2018 [16.6 (8–22)] and the year 2019 [15.5 (9–24)]; p=0.04. The incidence rate of FBI doubled during the pandemic as compared to the prepandemic group: respectively 57.5/10,000 emergency department visits and 23.2/10,000 visits (p=0.002). Almost one fourth of the cohort was hospitalized. The hospitalization rate (&gt;1 day) was similar between the 2 periods: 8.8% before the pandemic and 7.1% during the pandemic. Digestive endoscopy was performed in 21.5% of cases, a rate similar before and during the pandemic. A total of 3.3% of the children developed complications related to FBI. This rate remained stable between the two periods. The most frequently ingested objects were coins (25.0%), toys (10.8%), button batteries (10.6%), magnets (6.2%), and jewellery (6.2%). There was no significant difference in the nature of FB ingested between the 2 periods although the number of magnet ingestions increased during the pandemic (18 per year vs 10 per year).

Conclusions

The incidence of FBI increased significantly during the pandemic in comparison with the two previous years. The high hospitalization and complications rates, although stable during the pandemic, underline the significant impact of pediatric FBI.

Funding Agencies

None

Benchmark of Data Processing Methods and Machine Learning Models for Gut Microbiome-Based Diagnosis of Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) wait months and undergo numerous invasive procedures between the initial appearance of symptoms and receiving a diagnosis. In order to reduce time until diagnosis and improve patient wellbeing, machine learning algorithms capable of diagnosing IBD from the gut microbiome's composition are currently being explored. To date, these models have had limited clinical application due to decreased performance when applied to a new cohort of patient samples. Various methods have been developed to analyze microbiome data which may improve the generalizability of machine learning IBD diagnostic tests. With an abundance of methods, there is a need to benchmark the performance and generalizability of various machine learning pipelines (from data processing to training a machine learning model) for microbiome-based IBD diagnostic tools. We collected fifteen 16S rRNA microbiome datasets (7,707 samples) from North America to benchmark combinations of gut microbiome features, data normalization and transformation methods, batch effect correction methods, and machine learning models. Pipeline generalizability to new cohorts of patients was evaluated with two binary classification metrics following leave-one-dataset-out cross (LODO) validation, where all samples from one study were left out of the training set and tested upon. We demonstrate that taxonomic features processed with a compositional transformation method and batch effect correction with the naive zero-centering method attain the best classification performance. In addition, machine learning models that identify non-linear decision boundaries between labels are more generalizable than those that are linearly constrained. Lastly, we illustrate the importance of generating a curated training dataset to ensure similar performance across patient demographics. These findings will help improve the generalizability of machine learning models as we move towards non-invasive diagnostic and disease management tools for patients with IBD.

Factors associated with time to clinical remission in pediatric luminal Crohn's disease: A retrospective cohort study

Background and Aim

Data on factors influencing time to remission in pediatric Crohn's disease (CD) are very limited in the literature. The aim of this retrospective cohort study was to describe the trends of time to clinical remission over the past decade and to identify factors associated with time to clinical remission in children with luminal CD.

Methods

Patients under 18 years old diagnosed between 2009 and 2019 were included. All data were collected from the patients' medical records. Survival analyses and linear regression models were used to assess the impact of clinical, laboratory, endoscopic, histological, and therapeutic factors on time to clinical remission.

Results

A total of 654 patients were included in the study. There was no change in the time to clinical remission over the decade. Female sex in adolescents (adjusted bêta regression coefficient [aβ] = 31.8 days, P = 0.02), upper digestive tract involvement (aβ = 46.4 days, P = 0.04) perianal disease (aβ = 32.2 days, P = 0.04), presence of active inflammation on biopsies at diagnosis (aβ = 46.7 days, P = 0.01) and oral 5‐aminosalicylates (5‐ASA) exposure (aβ = 56.6 days, P = 0.002) were associated with longer time to clinical remission. Antibiotic exposure (aβ = −29.3 days, P = 0.04), increased eosinophils (aβ = −29.6 days, P = 0.008) and combination of exclusive enteral nutrition with tumor‐necrosis‐factor‐alpha (TNF‐alpha) inhibitors as induction therapy (aβ = −36.8 days, P = 0.04) were associated with shorter time to clinical remission.

Conclusion

In children with newly diagnosed Crohn's disease, time to clinical remission did not shorten during the decade. It was associated with baseline clinical and histological data and treatment strategies. Combination of enteral nutrition and TNF‐alpha inhibitors was associated with faster clinical remission.

Risk Perception of COVID-19 Infection and Adherence to Preventive Measures among Adolescents and Young Adults

To explore factors influencing adolescents and young adults' (AYAs) risk perception of COVID-19 and adherence to public health measures, we conducted a cross-sectional online survey of AYAs (14-22 years old) from Quebec (Canada) recruited through school and community partners in April 2020 during the first wave of the COVID-19 pandemic. The study included 3037 participants (mean age = 17.7 years, 74.6% female). AYAs had higher mean (standard deviation (SD)) risk perception of COVID-19 for their relatives (8.2 (1.9)) than for themselves (5.6 (2.6)) (p < 0.001). Factors associated with higher risk perception included higher disease knowledge (adjusted odds ratio (aOR) 1.06, 95% CI 1.01-1.11), presence of chronic disease (aOR 2.31, 95%CI 1.82-2.93) and use of immunosuppressants (aOR 2.53, 95%CI 1.67-3.87). AYAs with a higher risk perception (aOR 1.06, 95%CI 1.02-1.10) those wishing to help flatten the disease curve (aOR 1.18, 95%CI 1.12-1.25) or to protect their family/friends (aOR 1.14, 95%CI 1.05-1.24) were more likely to engage in preventive behaviors. Self-perceived risk and desire to protect others were significantly associated with adherence to preventive measures among youth. These findings may help inform public health messaging to AYAs in the current and future pandemics.

Pernio as the clinical presentation of celiac disease: A case report

We present the case of a 12-year-old girl with severe pernio as the sole clinical presentation of celiac disease (CD), without associated gastrointestinal symptoms. Lesions greatly improved once a gluten free diet was initiated. At 5-year follow-up, she remains in clinical remission throughout the year with no pharmacological treatment, without skin lesions flare-up in the winter months.

Skin Manifestations in Pediatric Patients Treated With a TNF-Alpha Inhibitor for Inflammatory Bowel Disease: A Retrospective Study [Formula: see text]

BACKGROUND

Tumor necrosis factor (TNF) alpha inhibitors (anti-TNF) are effective in the treatment of inflammatory bowel disease (IBD) as well as psoriasis. Their increasing use has raised the identification of cutaneous side effects (CSEs). Evidence in children is limited.

OBJECTIVES

The objective of this study is to describe CSEs of anti-TNF treatment in a pediatric population with IBD.

METHODS

This is a retrospective single-center study of children with IBD under anti-TNF treatment between 2013 and 2016. A total of 40 patients with CSEs related to anti-TNF were referred to our pediatric dermatology clinic. A control group was randomly selected from patients receiving anti-TNF for IBD, who were referred to the dermatology clinic for other conditions unrelated to anti-TNF.

RESULTS

Of 343 patients with IBD, 40 (11.3%) presented CSEs potentially related to the treatment. No differences in sex, age, and underlying disease were found between those with and without CSEs. The most frequent CSEs were psoriasiform eruptions (41%) which were more exudative than usual, located especially in skin folds and on the scalp; skin infections (20%); and eczematous eruptions (10%). Only 5% of patients changed or discontinued the current anti-TNF because of CSEs.

CONCLUSION

This is one of the largest pediatric cohorts of IBD patients with CSEs. Psoriasiform eruptions were the most common CSEs, with predilection for skin folds and scalp, and frequent superimposed bacterial infection. Topical and/or systemic antibiotics were required in addition to topical corticosteroids in 25% of patients. The rate of discontinuation of anti-TNF therapy due to CSEs was low.

Phenotypic Variation in Paediatric Inflammatory Bowel Disease by Age: A Multicentre Prospective Inception Cohort Study of the Canadian Children IBD Network

BACKGROUND AND AIMS

Incidence of paediatric inflammatory bowel disease [IBD] in Canada is among the highest worldwide, and age of onset may be decreasing. In a multicentre nationwide inception cohort study, we examined variation in phenotype of IBD throughout the paediatric age spectrum.

METHODS

Children aged ≥2 years [y] and <17y [A1 age at diagnosis], with new onset IBD, were systematically evaluated at sites of the Canadian Children IBD Network. Prospectively recorded phenotypic data were compared between age groups.

RESULTS

Among 1092 children (70% Caucasian; 64% Crohn's disease [CD], 36% ulcerative colitis/inflammatory bowel disease unclassified [UC/IBD-U]; median age 13 y, interquartile range [IQR] 11-15 y), 210 [19%] were diagnosed before the age of age 10 y [Paris A1a] and 43 [4%] before age 6 y (very-early-onset [VEO-IBD]). CD was less common in younger children [42%, 56%, 66%, respectively, of VEO-IBD, A1a; A1b]. Colon-only IBD [UC/IBDU or CD-colon] was present in 81% of VEO-IBD and 65% of A1a; ileal disease increased progressively, reaching plateau at age 10 y. CD location was ileocolonic [L3] in 53% overall. Ileitis [L1] increased with age [6% of VEO-IBD; 13% of A1a; 21% of A1b], as did stricturing/penetrating CD [4% of A1a; 11% of A1b]. At all ages UC was extensive [E3/E4] in >85%, and disease activity moderate to severe according to Physician's Global Assessment [PGA] and weighted Paediatric Crohn's Disease Activity Index/Paediatric Ulcerative Colitis Activity Index [wPCDAI/PUCAI] in >70%. Heights were modestly reduced in CD [mean height z score -0.30 ± 1.23], but normal in UC/IBD-U.

CONCLUSIONS

Paris classification of age at diagnosis is supported by age-related increases in ileal disease until age 10 years. Other phenotypic features, including severity, are similar across all ages. Linear growth is less impaired in CD than in historical cohorts, reflecting earlier diagnosis.

Natural history of gastroesophageal reflux in infancy: new data from a prospective cohort

Background

Gastroesophageal reflux (GER) is common in infants. Gastroesophageal reflux disease (GERD) is defined as GER leading to troublesome symptoms that affect daily functioning and/or complications. This study is aimed at determining the prevalence and progression of GER and GERD in a cohort of healthy term infants from birth to 12 months old.

Methods

We conducted a prospective cohort study including all full-term living neonates born at Besançon Teaching Hospital, France. Parents completed a clinical report form and the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) at 1, 3, 6, 10, and 12 months of age. GER was defined as score ≥ 1 to the first question with I-GERQ-R score < 16, and GERD as score ≥ 1 to the first question with I-GERQ-R score ≥ 16. Regurgitation was based on the answer to the first question of the I-GERQ-R as anything coming out of the mouth daily.

Results

157/347 births were included (83 boys). The prevalence of regurgitation at least once a day was 45.7% overall. In total: 72, 69, 56, 18, and 13% of infants regurgitated at least once a day at 1, 3, 6, 10, and 12 months of age, respectively. Physiological GER affected 53, 59, 51, 16, and 12% of infants; GERD, 19, 9, 5, 2, and 2%, respectively. Two risk factors were identified: family history of GER and exposure to passive smoking. Treatment included dietary modification (14%) and pharmacotherapy (5%).

Conclusion

Physiological GER peaked at 3 months, GERD at 1 month. Most cases resolved on their own. GER and GERD are very common in the infant’s population and parents should be reassured/educated regarding symptoms, warning signs, and generally favorable prognosis. I-GERQ-R is useful to the clinical screening and follow up for GER and GERD.

A240 ASSESSING THE IMPACT OF AGE AT DIAGNOSIS ON TRANSITION PROCESS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES FROM PEDIATRIC TO ADULT CARE

Background

Twenty-five percent of pediatric patients with inflammatory bowel disease (IBD) are diagnosed between the age of 16 and 18 years. They represent a unique challenge associated with the short follow-up time between diagnosis and transition to adult care.

Aims

The primary aim was to compare the current practices related to the transitional process in adolescents diagnosed before 16 years (early-adolescence (EA)) or after 16 years (late-adolescence (LA)). The secondary aim was to investigate clinical factors associated with age at transfer.

Methods

Patients diagnosed between 2013 and 2015, at the IBD clinic of CHU Sainte-Justine were included in the study. The date of transfer to adult care was defined as the date of the last visit in the pediatric unit. The factors associated with transition process and transfer included: disease type, disease severity at diagnosis and last pediatric visit, age at diagnosis, treatment group, disease burden (hospitalizations/relapses) and disease education.

Results

We included 144 patients (77 males; median (interquartile range (IQR) age at diagnosis 15.2(14.3–16.2) years; Crohn’s disease (N=98), ulcerative colitis (N=31) and IBD-unclassified (N=15). The median (IQR) duration of pediatric follow-up was 3.6 (2.7–4.1) years in the EA group as compared to 1.4 (1.0–1.8) yrs in the LA group; P&lt; 0.01. While most of the patients completed the transition at a median (IQR) age of 18.0 (17.9–18.3) years, 15 % of patients were transferred at an older age (18.5 to 20 years). Overall, 75.7% were in remission, 13.9% with mild disease activity and 10.4% with moderate activity at the last pediatric visit. Patients with moderate activity at last pediatric visit tend to be transferred at an older age as compared to patients in remission or mild activity. The median (IQR) age were respectively 18.4 (18.2–19.1), 18.0 (17.9–18.1), 18.0 (17.9–18.3) years; P=0.024. There was a modest correlation between age at diagnosis and age at transfer (R = 0.22; P = 0.0068). Patients were transferred to adult gastroenterologists in academic hospitals (50.8%) or non-academic hospitals (43.1%). However, the disease activity at transfer was not associated with the adult care setting (academic vs non-academic). The number of relapses and hospitalizations during pediatric care were associated with older age at transfer: (&gt; 18.5 yrs vs &lt; 18.5 years): median(IQR) of 0.8(0.4–1.4) vs 0.3 (0.-0.6) for relapses; P=0.009 and 0.4 (0.0–1.1) vs 0.3 (0.0–0.7) for hospitalizations; P=0.009.

Conclusions

Pediatric IBD diagnosed at late adolescence tend to have more active disease and older age at transfer. Therefore, efforts to design a structured transitional care program are needed in order to improve transition outcomes for IBD patients with a special focus for subjects diagnosed in late adolescence.

Funding Agencies

CAG

A247 VIRAL LOAD OF EPSTEIN-BARR VIRUS IN PEDIATRIC PATIENTS WITH NEW ONSET IBD AT DIAGNOSIS AND ON FOLLOW UP: AN OBSERVATIONAL STUDY

Background

Patients with Inflammatory Bowel Disease are at increased risk for complications associated with Epstein-Barr Virus, such as uncontrolled infection, colitis mimicking IBD, and lymphoproliferative disease. These complications may be due to inherent immune dysfunction or effects of immunomodulating therapies used. We have previously identified that the seroprevalence of EBV in our cohort of IBD patients at time of diagnosis was 44.2%, with prevalence stratified by age as follows: 0 to &lt;10 years 36%, 10 to &lt;17 years 46%, and 17 + years 50%.

Aims

Our objective is to assess the risk of EBV reactivation in this population, to determine whether patients treated with immunomodulators should be more closely monitored for EBV viral load.

Methods

Retrospective chart review was done for all patients with new-onset IBD diagnosed at CHU Sainte-Justine over a two-year period, from Jan. 2016 to Dec. 2017. Serum from time of diagnosis was retrieved from the microbiology laboratory for patients with positive EBV serology, and quantitative PCR was performed to assess viral load at diagnosis. 47 of 53 seropositive patients had available serum at time of retrieval. EBV PCR was subsequently performed on serum drawn one to two years after start of immunosuppressants.

Results

53 patients were EBV positive at time of diagnosis (EBNA/VCA IgG). Two patients were IgM positive, suggesting recent or active infection. The viral load as measured by quantitative PCR on serum drawn at diagnosis was negative in all retroactively tested patients. Of the two IgM-positive patients, one had known positive quantitative PCR at time of diagnosis. PCR previously tested in clinical follow-up of two seropositive, PCR-negative patients became positive at 7 and 17 months from diagnosis, suggesting viral reactivation. Both patients had received anti-TNF’s and systemic corticosteroids. Viral loads on follow-up are to be assessed for the rest of the cohort. Overall, therapies started within 6 months of diagnosis were similar in the seropositive and seronegative groups, the majority receiving some form of immunosuppression. Within the seropositive group: 66% received corticosteroids, 32.1% Infliximab, 5.7% Adalimumab, and 5.7% Azathioprine.

Conclusions

Only one patient had active EBV infection with positive PCR at time of diagnosis. All other patients had no sign of active infection based on retroactive PCR’s. While a majority of patients, regardless of EBV serology, receive immunomodulating agents, we currently do not routinely screen for seroconversion in seronegative patients, or for viral load in seropositive patients. We will be assessing viral loads after start of immunomodulation to better understand the potential impact of these agents on disease progression.

Funding Agencies

None

A161 MACROSCOPIC AND HISTOLOGY FINDINGS DURING UPPER DIGESTIVE ENDOSCOPY IN CHILDREN WITH SUSPICION OF CELIAC DISEASE AND HIGH LEVELS OF TRANSGLUTAMINASE IGA-ANTIBODY

Background

The European Society of Pediatric Gastroenterology Hepatology and Nutrition suggests that the diagnosis of Celiac disease (CD) can be confirmed solely on the basis of clinical symptoms and bloodwork including a level of transglutaminase IgA-antibodies (TGA) ≥ 10 times the upper limit of normal (10XN). In Canada and the United States, this recommendation has not been endorsed. We recently demonstrated that TGA ≥ 10XN performed at our institution (INOVA Diagnostics’ Quanta Lite) was a reliable predictive test of villous atrophy in patients with suspicion of CD.

Aims

The aim of the present study was to investigate the rate of supplemental endoscopic or histological findings in a cohort of children with TGA ≥ 10XN and the association of these findings with clinical symptoms.

Methods

Consecutive children with suspected CD who had an endoscopy between 2011 and 2018 were included in this analysis. Data was extracted from our CD database. The macroscopic and histological findings were reported. We compared these diagnoses to the clinical symptoms.

Results

From 2011 to 2018, 405 new cases of CD were identified in our pediatric center. In total, 238 (58.7%) patients had baseline TGA levels ≥ 10XN (67.2% females, median (IQR) age 8.4 (4.8–12.2)). The median interval between the first visit to the gastroenterology unit and the endoscopy was 43.0 (21.0–78.0) days. In total, 58% of the endoscopies had macroscopic findings in the bulb (37.8 %) or the duodenum (41.5%) including a mosaic pattern, mucosal fissuring, or erythema. Seven cases (2.8%) of esophagitis were identified during endoscopy; histological analysis confirmed eosinophilic esophagitis in 3 cases (1.2%) and peptic esophagitis in 4 cases. Non-specific gastritis was present in 58 patients (24.4%) and 2 cases of Helicobacter pylori infection were identified. The biopsies showed subtotal/total villous atrophy of duodenum in 171 (71.8%) or partial villous atrophy in 51 patients (29.8 %). Ten patients (4,3%) had villous atrophy in the duodenal bulb alone, with normal biopsies of the second part of the duodenum. Abdominal pain did not correlate with gastritis or duodenitis. However, children with diarrhea had a greater prevalence of visible endoscopic inflammation in the duodenum than those without diarrhea: 53.5% vs 38.9% respectively; P= 0,037.

Conclusions

Apart from the classical features associated with CD, the supplementary diagnostic yield of endoscopy was low. There were only a few cases of additional diseases identified by the endoscopic procedure in a large cohort of children and adolescents with suspicion of CD. Therefore, these results support the no-biopsy approach in the settings of TGA ≥ 10XN using a reliable diagnostic kit.

Funding Agencies

None

A236 REAL LIFE HEALTH CARE UTILIZATION IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN THE ERA OF BIOLOGICS

Background

The burden associated with the management of pediatric patients with inflammatory bowel disease (IBD) has been rising over the past years as the incidence of IBD is increasing in children. In addition, the widespread use of biologics and a treat-to-target approach also contributes to the increase of healthcare utilization.

Aims

The purpose of this study was to assess the health care services utilization and the associated factors in a prospective cohort of children diagnosed with IBD in Quebec.

Methods

Patients diagnosed from 2013 to 2015 and followed up until the transfer to adult care were identified in our IBD database. Data on IBD related services and treatments: imaging procedures, hospitalizations and outpatient visits, medications from diagnosis to transition was extracted. We analyzed the healthcare utilization according to the baseline disease severity (pediatric Crohn’s disease activity index (PCDAI) or pediatric ulcerative colitis activity index (PUCAI)) at diagnosis, and according to exposition to intravenous biologics.

Results

A total of 144 patients were included in the study [(77 males), Crohn’s disease (98), Ulcerative Colitis (31) and IBD-unclassified (15); median (interquartile(IQR)) age at diagnosis 15.2(14.3–16.3)]. The median(IQR) duration of follow up at the IBD clinic was 2.9 (1.8–3.9) years. The median (min-max) number of imaging procedures varied largely: esophagogastroduodenoscopy 1(0–2), Colonoscopy 1(1–6), abdominal ultrasound 1(0–13), abdominal MRI 1(0–4), tomodensitometry 0(0–2), Bone densitometry 1(0–5). Patients had various follow-up encounters (median (min-max)): outpatient visits 9 (1–28), IBD nurses phone follow-up 4(0–33). A total of 64.6% of patients had at least one hospitalization [median(min-max) number 1(0–10); median duration 4(0–150 days)] and 35.41% had at least one emergency room visit. Baseline disease severity did not predict the disease burden: the mean number of encounters was 3.0 /year in the moderate/severe group as compared to 2.5/year in the mild group; P= 0.61. Among the, 63.5% of patients exposed to an intravenous biologic (Infliximab or Vedolizumab), those exposed earlier (&lt;3 months after diagnosis) used more health care services (mean = 3.3/year) than those exposed later (mean =2.23/year); P &lt;0.0001. In addition, the median (interquartile (IQR)) cumulative days of healthcare utilization (missing school days) for patients treated with intravenous biologics was 48.5 (32.4–67.9) days during pediatric care.

Conclusions

Adolescents with IBD have several encounters between the diagnosis and transition to adult care. Disease severity at diagnosis was not related to a higher level of health services utilization during follow-up. However, treatment with intravenous biologics was associated with a high health service utilization and school missing during follow-up.

Funding Agencies

None

A256 TRENDS IN THE PREVALENCE AND SEVERITY OF ANEMIA IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN THE LAST DECADE

Background

Anemia is one of the most common extraintestinal manifestations in patients with inflammatory bowel disease (IBD) at diagnosis. Studies have shown that anemia was associated with low levels of quality of life, which improves with the correction of anemia in adults. Recent data have shown an increase in the incidence and severity of pediatric IBD.

Aims

To investigate the prevalence of anemia in children at diagnosis of IBD and the trends in the past decade. The secondary aim was to investigate the associations between hemoglobin (Hb) levels and disease characteristics.

Methods

Eligible patients (age ≤18 years, diagnosed with IBD from 2009 to 2018) were retrospectively identified through our IBD database. Disease localization and phenotype were defined according to the Paris Classification of IBD. Anemia was defined by Hb levels according to WHO targets. The annual prevalence of anemia was calculated according to subtype (inflammatory vs iron deficiency). The Pediatric Crohn’s Disease Activity Index (PCDAI) and the Pediatric Ulcerative Colitis Activity Index (PUCAI) were used to assess the disease severity at diagnosis.

Results

We included 887 patients (439 females), mean (SD) age of 13.1 (3.4) years. Of these, 519 (58.5%) were identified with anemia within 30 days of diagnosis. The median (IQR) Hb level was 108 (98 -114) g/dL. Severe anemia (&lt; 70 g/dL) was present in 1.8 % of patients. The prevalence of anemia at diagnosis remained relatively stable ranging from 60.2% in 2009 to 60.4% in 2018. The annual proportion of inflammatory vs iron-deficiency anemia is displayed in figure 1. Anemia was more prevalent in Crohn’s disease (CD) (62.2%) than Ulcerative colitis (UC) (57.9%) or IBD-unclassified (39.6%). The disease severity scores were higher in those with anemia. The median (IQR) PCDAI and PUCAI were respectively 37.5 (27.5–47.5) and 55.0 (40.0–65.0) in the anemic group as compared to 27.5 (20.0–37.50) and 35.0 (25.0–55.0) in the non-anemic group; P&lt;0.0001. Patients with anemia had a lower BMI z-score [median (IQR) -0.84 (-1.84 - 0.08)] than the non-anemic patients [median (IQR) -0.38 (-1.21 - 0.43)]; P&lt;0.001. The prevalence of anemia correlated significantly with disease location: upper intestinal involvement [L4a(67.7%) L4b(63.6%) L4aL4b(60.7%) none (52.8%)] P = 0.024 for CD; for UC [E1(21.1%) E2(44.4%) E3(75.0%) E4 (71.1%)] P&lt;0.0001. A moderate correlation was found between Hb levels and C-reactive protein (r= -0.312, 95% CI: -0.378 to -0.243, P&lt;0.0001).

Conclusions

Anemia remains a prevalent symptom in pediatric patients with IBD, and it is correlated with the extent of intestinal involvement and disease severity. The impact of anemia at Diagnosis and during follow-up on the levels of quality of life and physical activity is currently under investigation.

Funding Agencies

None

Oral Lorazepam is not Superior to Placebo for Lowering Stress in Children Before Digestive Endoscopy: A Double-Blind, Randomized, Controlled Trial

BACKGROUND

Digestive endoscopies must be performed within a safe and comfortable environment. We have previously shown that the quality of intravenous sedation is influenced by preoperative stress.

AIM

Our primary objective was to compare the effects of oral lorazepam and placebo on the salivary cortisol response of children undergoing a digestive endoscopy. Secondary objectives were the assessment of procedural pain and comfort as well as the occurrence of adverse events.

METHODS

Participants were randomized and received either lorazepam, placebo, or no premedication. Saliva was collected upon arrival at the hospital and 1 h following randomization. The sedation protocol included midazolam and fentanyl ± ketamine. Procedural pain was evaluated with the Nurse Assessed Patient Comfort Score (NAPCOMS). Patients completed a postoperative questionnaire. The primary outcome was defined as the proportion of children having a cortisol decrease ≥ 15 nmol/L.

RESULTS

101 participants (54 females) were included. The rate of children having a cortisol decrease ≥ 15 nmol/L was 27.3%, 35.3%, and 19.4% for lorazepam, placebo, and no premedication, respectively (p = 0.356). The median (IQR) NAPCOMS pain score was 3.0 (0-6) for lorazepam, 4.4 (0-6) for placebo, and 3.4 (3-4) for no premedication (p = 0.428). With lorazepam, 75.9% of children reported experiencing a comfortable procedure, compared with 41.9% taking placebo and 34.5% with no premedication (p = 0.013). Transient tachycardia was the most frequent intraoperative adverse event, particularly with lorazepam (62.5%, p = 0.029).

CONCLUSIONS

Oral lorazepam had no effect on patients' preoperative stress, as measured by salivary cortisol, but was associated with a higher rate of comfortable procedures.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, Identifier NCT03180632.

Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease

BACKGROUND & AIMS

We aim to provide guidance for medical treatment of luminal Crohn's disease in children.

METHODS

We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them.

RESULTS

The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation.

CONCLUSIONS

Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.

Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease

BACKGROUND & AIMS

We aim to provide guidance for medical treatment of luminal Crohn's disease in children.

METHODS

We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them.

RESULTS

The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation.

CONCLUSIONS

Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.

Two Cases of Mistaken Polyuria and Nephrocalcinosis in Infants with Glucose-Galactose Malabsorption: A Possible Role of 1,25(OH)2D3

BACKGROUND/AIMS

Glucose-galactose malabsorption (GGM) is a rare and potentially fatal disorder. The autosomal recessive mutation of the SGLT1 gene interferes with the active glucose transport in the gut resulting in osmotic diarrhea and failure to thrive (FTT). Two nonrelated infants with GGM are presented as well as a novel mutation in SGLT1.

CASE PRESENTATION

The first case consulted for FTT and presented with hypercalcemia and hypercalciuria. His mother had self-medicated with high doses of vitamin D. The second case consulted for macroscopic hematuria, and presented with dehydration and secondary acute kidney injury. In both cases, the profuse diarrhea, initially mistaken for polyuria, promptly resolved after the introduction of glucose-galactose-free milk. Investigations showed bilateral nephrocalcinosis and high levels of 1,25(OH)2D3 in both patients. We hypothesize that the upregulation of epithelial calcium channels (TRPV6) and 1,25(OH)2D3 are possible factors involved in the pathophysiology of nephrocalcinosis sometimes seen in GGM. Furthermore, a novel intronic SGLT1 mutation (c.207+2dup) is described.

CONCLUSION

These 2 cases demonstrate that a malabsorption disorder such as GGM can present with nephrocalcinosis and/or hypercalcemia, with increased 1,25(OH)2D3 levels in infants. Prompt recognition of GGM is sometimes difficult but crucial.
.

Quality assessment of economic evaluation studies in pediatric surgery: a systematic review

PURPOSE

To assess economic evaluation studies (EES) in pediatric surgery and to identify potential factors associated with high-quality studies.

METHODS

A systematic review of the literature using PubMed and Cochrane databases was conducted to identify EES in pediatric surgery published between 1 June 1993 and 30 June 2013. Assessment criteria are derived from the Drummond checklist. A high quality study was defined as a Drummond score ≥7. Logistic regression analysis was used to determine factors associated with high quality studies.

RESULTS

119 studies were included. 43.7% (n=52) of studies were full EES. Cost-effectiveness analysis was the most frequent (61.5%) type of full EES. Only 31.6% of studies had a Drummond score ≥7 and 73% of these were full EES. The factors associated with high quality were identification of costs (OR: 14.08; 95% CI: 3.38-100; p<0.001), estimation of utility value (OR: 8.13; 95% CI: 2.02-43.47; p=0.005) and study funding (OR: 3.50; 95% CI: 1.27-10.10; p=0.02).

CONCLUSION

This review shows that the number and the quality of EES are low despite the increasing number of studies published in recent years. In the current context of budget constraints, our results should encourage pediatric surgeons to focus more on EES.