Eosinophilic Esophagitis (EoE) Working Group

British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)

Position Statement: Management of paediatric EoE during the Coronavirus outbreak

28th April 2020


 

Background

This statement is intended as guidance for professionals managing patients with paediatric EoE; please refer to the additional document if you are a parent of a child with EoE (1) Click Here . This guidance is subject to review and will be amended where necessary as more data becomes available. 

 


  1. Assessment of COVID-19 related risk for paediatric EoE patients

There are two scenarios detailing how the general public should interact. They are referred to as; ‘social distancing’ and ‘shielding’ (2).

     a. Do EoE patients need shielding? 

  • No.
  • The majority of EoE patients are classed in the same group as the general public and should follow ‘social distancing’ as per government advice (2).
  • Note:  If the patient is on significant systemic immune suppressive medication (eg 0.5mg/kg prednisolone or >20mg prednisolone for an adult-sized patient, shielding guidelines apply.

     b.How should EoE patients socially isolate?

  • Avoid contact with someone who is displaying symptoms of COVID-19. These symptoms include high temperature and/or new and continuous cough.
  • If you go out, stay 2 metres (6ft) away from other people at all times.
  • Wash your hands as soon as you get home.
  • Do not meet others, even friends or family.


  1. EoE specific medications and management advice during the outbreak

  1. Recent diagnosis of EoE or recently started treatment or on maintenance therapy
  • Medications - Continue to take medications as prescribed. If the treatment course coming to an end, complete the course as initially planned. Treatments include proton pump inhibitors (Omeprazole, Lansoprazole) and Oral Viscous Budesonide (OVB).
  • Elimination diets – Continue with elimination diet as normal. Additional support from a dietitian may be needed if the patient has limited access to suitable alternatives during the current situation with food supplies.
  • Combination topical corticosteroids - Patients on combination topical corticosteroids (for example OVB and high dose inhaled steroids) may have a very small risk of adrenal suppression. They should be maintained on the minimum steroid dose to control their disease as directed by their specialist.

    b. Worsening symptoms of EoE

  • Mild / moderate – Discuss with Gastroenterology service +/- dietician
    • For patients who have successfully responded to elimination diets before, consider restarting the elimination diet.
    • In the absence of COVID-19 contact or COVID-19 symptoms consider treating with OVB at the dosage required to control symptoms.
    • Topical corticosteroids may have an effect on the immune system, this effect is considered to be very low risk.
    • Endoscopic reassessment should happen once elective programmes resume.
  • Severe (food bolus impaction) – Present urgently to A&E and contact local Paediatric Gastroenterology team. Upper GI foreign body removal is an emergency/essential procedure that should continue during the coronavirus outbreak (3). Upper GI Endoscopy is an ‘aerosol generating procedure’ and staff need to ensure adequate personal protective equipment as per Public Health England (4) and local trust policy.

    c. EoE patients with signs of or proven COVID-19

Follow government advice (2).

    • Ensure that patients on systemic steroids inform NHS 111 or their treating doctor.
    • For patients on an elimination diet, PPI or OVB, treat the same as any other patient.
    • Patients with EoE and adrenal gland suppression (as confirmed by paediatric endocrinology) should follow endocrinology advice. 

  • Currently there is no conclusive evidence that patients with EoE on combination topical steroids (eg for asthma), or prolonged full dose OVB are at significant risk of adrenal gland suppression. 


 

  1. Special considerations


  1. Generating evidence based data for children and adolescents with EoE and COVID 19

Please report all cases of patients with EoE and COVID-19 (9). We are collaborating with international colleagues to gather more specific data to help guide professionals and patients with EoE through the outbreak. Data is being collated on behalf of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) in collaboration with; the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR), The European Consortium for Eosinophilic Diseases of the GI Tract (EUREOS), the North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and United European Gastroenterology (UEG).

 Click here to report a case 


  1. Information for parents

To provide information for parents worried about their child and for their GP, please refer to the additional guidance on frequently asked questions answered (1). 

Click here for Patient /Carer EoE and Covid-19 FAQ's 

This EoE Working Group statement is based on data available up to the 28th April 2020. This document is not an evidence-based clinical guidance. The approach to EoE patients in the coronavirus outbreak might vary due to different individual trust policies.

 

EoE Working Group, BSPGHAN 28th of April 2020

Marcus Auth, Nadeem Afzal, Joe Chan, Amanda Cordell, Jenny Epstein, Diana Flynn, Mark Furman, Julie Harrington, Lucy Jackman, Vinod Kolimarala, Kerryn Moolenschoot, Christine Spray.

 

References and Web-Links

  1. https://www.eosnetwork.org/eoe-and-covid-19-uk-faqs
  2. https://www.gov.uk/coronavirus
  3. https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/
  4. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879107/T1_poster_Recommended_PPE_for_healthcare_workers_by_secondary_care_clinical_context.pdf
  5. http://www.espghan.org/societal-papers/covid-19-informational-statements/
  6. https://www.esge.com/esge-and-esgena-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic/
  7. https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/
  8. https://www.bsg.org.uk/covid-19-advice/bsg-jag-summary-recommendations-for-ppe-in-endoscopy-protecting-staff-patients-and-the-ppe-supply-chain/
  9. To report a case of COVID-19 in an EoE patient please follow this link: https://www.eosnetwork.org/covid-19-eoe-egid-research

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