Paediatric Digestive Health Across Europe: Early Nutrition, Liver Disease and Inflammatory Bowel Disease

Download as pdf or txt
Download as pdf or txt
You are on page 1of 20

Paediatric Digestive

Health Across Europe


Early Nutrition, Liver Disease and
Inflammatory Bowel Disease
2 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

Contents

Introduction 3

Six point action plan to deliver


change in paediatric gastroenterology 4

Early nutrition & obesity 6

Paediatric inflammatory
bowel disease 10

Paediatric liver disease 14

Summary 18

References 19

This review has been produced by UEG with kind support from ESPGHAN and representatives of other UEG member societies
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 3

Introduction

United European Gastroenterology (UEG)


is committed to raising political and public
awareness of digestive health conditions,

Across Europe we have leading paediatric
experts and many centres of excellence but
informing policy makers and encouraging these are not widespread and currently
research. cannot meet the needs of children
This review highlights the poor quality of throughout the continent. This has an impact
paediatric digestive health across Europe, not just on individuals and their families but
the current state of service provision and on society and wider health service provision.
the potential impact on longer-term health UEG hope this report will encourage policy
outcomes and economies. makers, stakeholders and health service
providers to adopt the recommendations
The opinions of leading gastroenterologists and and prioritise the development of specific
patient organisations have been canvassed to paediatric focused strategies for improving
help identify priority areas for improvement the digestive health of children today and
both now and in the future. What is clear, is for future generations.


the urgent need for investment in paediatric
digestive health treatments and services,
Professor Michael Manns, UEG President
including harmonised training to improve
health outcomes.
4 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

Six Actions To Deliver Change In


Paediatric digestive health across Europe

Further development Improve and Improve


and political harmonise training subspeciality
support for national and standards paediatric GI training
strategies and public through the and ensure a greater
health campaigns development of a understanding of the
to reduce obesity European paediatric complex physical,
through education, gastroenterology, psychological and
prevention and early hepatology and social needs of
intervention nutrition syllabus children

1 2 3
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 5

4 5 6

Develop managed Generate and encourage Further development of


transition and support further research into specialised centres for the
services as patients move paediatric digestive optimal management of
from teenage to adult care diseases and early life children with digestive
programming to fully diseases with long-term
understand the causes of follow up, regular reviews
GI conditions, enabling and frequent medical
the development of new interventions by multi-
diagnostic and genetic disciplinary teams
technology and effective
treatment and prevention
strategies
6 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

Early Nutrition & Obesity

Incidence
The burden of disease
associated with poor
nutrition continues to grow
throughout Europe.
one in every three being overweight can
In 46 European countries one in
every three children aged 6-9 years children aged 6-9 years cause extreme anxiety
is overweight or obese1. Childhood is overweight or obese and depression
obesity is particularly prevalent in
Italy and Spain with 35% of 11 year
old boys and 22% of 11 year old
girls affected2. It is increasing at an
alarming rate and it is predicted
that the global number of children
under five who are overweight will
rise from the current 41 million to
70 million by 2025 if current trends
continue3.

Childhood obesity is overweight under fives


particularly prevalent will rise from 41 million
in Italy and Spain to 70 million by 2025
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 7


Early nutrition and
metabolism can
Impact
Childhood obesity is linked to many chronic and life threatening
diseases including:
programme the course
• a wide range of functional gastrointestinal diseases4
of the individual’s
health throughout life. • liver diseases ranging from simple steatosis to cirrhosis, and cancer5

Balanced nutrition in • organic GI diseases such as coeliac disease and inflammatory bowel disease6

pregnancy, breast feeding • hypertension and cardiovascular disease


and appropriate food • respiratory and musculoskeletal problems
choices in early childhood • type 2 diabetes
reduce the risk of both
rapid weight gain in The emotional and psychological effects Recent research9 has established that
infancy and of obesity of being overweight include extreme prenatal nutrition and diet in early
anxiety and depression with severely childhood not only has a significant
in later life. However, obese children rating their quality of life effect on growth rates in early life, but
we need to improve our as low as that of children with cancer on exerts a lifelong influence on metabolic
understanding of the chemotherapy7. and endocrine regulation and associated
health outcomes.
detailed mechanisms Studies have shown that rapid weight
that mediate these gain during the first two years of life is The increase in obese children has
linked to a markedly increased risk of now reached epidemic proportions
protective effects.


obesity and related illnesses in later life and the high cost of treating obesity
and obese children are more likely to and related disorders—currently up to
become obese adults with an associated 10% of total healthcare costs—threatens
Professor Berthold Koletzko higher risk of morbidity, disability and the sustainability of public health care
ESPGHAN President and coordinator premature mortality8. systems across Europe9.
of the EarlyNutrition collaborative
research programme
8 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

Current initiatives to tackle childhood obesity


A number of positive strategies aimed at improving diet, service
provision, diagnosis and awareness of obesity are in place
in a bid to reduce the alarming rise.

These include: pregnancy and early childhood is the This research programme also
global EarlyNutrition collaborative highlights that early environment and
• The European Union (EU), WHO and
research programme. The five year nutrition during sensitive phases of
several European medical scientific
project anticipated for completion development plasticity in pregnancy
associations such as UEG and the
in 2017, with a budget of nearly and early childhood can affect the
European Society of Paediatric
€11 million, aims to analyse a wide process of epigenetic modification.
Gastroenterology, Hepatology &
variety of metabolic factors and genetic These modifications can in turn
Nutrition (ESPGHAN) are actively
modifications that may be involved alter organ function and influence
involved in a range of programmes to
in the process of early metabolic one’s lifetime risk of various disease
raise awareness of obesity as a disease
programming of lifelong health, conditions. These results throw new
and its prevention. These programmes
helping to identify the key molecules light on key questions concerning
offer greater understanding about
that mediate links between nutrition the regulation of growth during early
metabolic programming, essential
and growth rate. childhood, and help to frame well-
for aiming to meet the World Health
founded recommendations for early
Assembly’s target of halting the As part of this research programme,
nutrition practice.
increase of childhood obesity by 2025. simple low-cost early interventions
have shown marked benefits of • The EU Childhood Obesity Project
• The new EarlyNutrition Academy
preventing children’s risk of obesity. (CHOP) identified that infants fed
and e-learning facility established
Structured counselling of pregnant formula milk with a low protein
in collaboration with ESPGHAN and
women with advice about diet and content—closer to that of breast
their harmonised training syllabus
physical activity reduced birth weight milk—weighed significantly less than
for paediatric gastroenterology,
of more than 4kg by approximately one those on higher protein formula.
hepatology and nutrition have helped
fifth. Birth weight above 4kg has been These differences persisted over time.
to significantly improve training and
shown to double the risk of obesity10, By this simple improvement of infant
harmonise standards across Europe for
therefore these simple interventions, feeding, the risk of obesity at school
subspecialty training.
including three counselling sessions age was 2.5 fold reduced12.
• The largest research-related EU and three telephone calls, have
initiative currently investigating resulted in significant preventative
the prevention of obesity through benefits11.
nutritional programming effects in
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 9


We are born with practically
sterile guts, which are then
Recommendations for improving nutrition and tackling
childhood obesity
Early nutrition and obesity needs serious attention and urgent
colonised for life with the
action to ensure that the EU Commission’s goal to halt the
bacteria from our mothers,
increase in childhood obesity by 2020 is met.
that stay with us for life. The
first two years of childhood
are critical for establishing


bacterial colonisation and The following measures are
recommended to help achieve
future gastrointestinal health. this goal: The economic burden of
These early events may be • Further development of national treating adult obesity is just
vital in preventing IBD, IBS strategies for healthy nutrition too great for the European
and other inflammatory education, prevention and early
region and priorities need to
intervention
conditions, as well as obesity. change quickly. With growing


• Political support to improve
and harmonise training and evidence of the link between
standards and the development early nutrition and lifestyle
Professor Berthold Koletzko
of a European paediatric and obesity, and digestive
ESPGHAN President and coordinator
gastroenterology, hepatology and
of the EarlyNutrition collaborative
nutrition syllabus to ensure high health in general, we must
research programme
quality provision across Europe prioritise research into the
• Subspeciality paediatric underlying mechanisms
GI training and a greater and focus our resources
understanding of the complex
physical, psychological and social
and training on prevention
needs of children strategies.

10% more likely to ”


Professor Herbert Tilg
UEG Scientific Committee and Professor
overcome life threatening and Director of the Division of Endocrinology,
childhood diseases with Gastroenterology and Metabolism, Innsbruck
Medical University
the right nutrition
10 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

PAEDIATRIC INFLAMMATORY BOWEL DISEASE (PIBD)

Incidence
Crohn’s disease (CD) and ulcerative colitis (UC) are chronic
inflammatory disorders of the gastrointestinal tract, collectively
“Paediatric IBD is increasing
in incidence and severity
known as inflammatory bowel disease (IBD). and provision needs to
be improved with more
According to the United European There is no solitary cause of IBD but it consistent treatment practices
Gastroenterology (UEG) Survey of is thought to be due to a combination to improve the outlook for
Digestive Health across Europe13: of genetic and environmental factors. young people with IBD across
A study based on data in the Danish
• up to one in four cases of IBD are
National Patient Register found that Europe, many of whom suffer
diagnosed during childhood
the children, siblings or parents of well into adulthood.


• childhood onset IBD accounts for individuals with IBD had an eightfold
20-30% of all IBD cases increased risk of developing the
disease14.
• incidence has been steadily increasing Professor Gigi Veereman
over the last few decades Extensive research highlights the UEG Public Affairs Committee and
role intestinal microbiota play in the Consultant in Paediatric Gastroenterology
• highest reported incidence of Crohn’s and Nutrition at the Free University, Brussels
development of IBD. The well-known
disease reported in Sweden, Norway
‘hygiene hypothesis’ suggests that a
and Hungary and ulcerative colitis in
cleaner environment, smaller families
France, Finland and Hungary
and lower exposure to farm animals
• childhood onset IBD presents different increase the risk of IBD and other
challenges for the patient and the immune-mediated and inflammatory
gastroenterologist diseases in westernised nations15,16.
The period immediately pre and post
birth as well as early life events,
including antibiotic use, may also play
a significant role in the development Up to 1 in 4 cases of IBD
of IBD17.
diagnosed during
childhood
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 11


It is vital that the transition
from paediatric to adult
Impact
Paediatric gastroenterologists treating PIBD face many challenges,
with the majority being linked to the differences in diagnosing and
care is handled properly as treating IBD in children compared with adults.
this is such a challenging
time for a young adult and IBD can be extremely debilitating and The recent European IMPACT survey,
their family. It is well- patients with IBD may also have a carried out by the European Federation of
documented that children higher risk of developing small bowel Crohn’s and Ulcerative Colitis Associations
cancer and colorectal cancer (CRC), with (EFCCA), assessing the burden of IBD in
with GI conditions who research indicating that IBD patients are Europe, revealed that 52% felt that IBD
are not managed properly six times more likely than the general had negatively affected their education21.
have a high incidence of population to develop CRC18. In fact,
The same survey also highlights alarming
CRC accounts for approximately 10-
psychosocial morbidity in 15% of all deaths among IBD patients19.
delays in diagnosis of up to 5 years for
18% of under 18’s22. These delays as well
adulthood. Complications in adult life may also


as the debilitating symptoms can have a
include osteoporosis and infertility. In
significant impact on a child’s emotional
addition, traditional adult based therapies
and mental health, with many found to
can have a potentially negative effect on
Dr. Nikhil Thapar have behaviour problems, psychiatric
the developing body, for example the
Consultant Paediatric Gastroenterologist disorders and severe psychosocial issues23.
and chair of the European Society of impact of corticosteroid therapy on bone
Paediatric Gastroenterology, Hepatology density20. Not only does this present huge emotional
& Nutrition costs to the patient and their family but
Children with IBD often present with a
CD and UC also create a considerable
more severe form of the disease than
economic burden to health care systems
adults and a more aggressive disease
and society.
course which can have a devastating
effect on their quality of life, as well as
their education and career prospects.

52% felt that IBD had


negatively affected their
education
12 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

Current initiatives to tackle PIBD


Initiatives aimed at improving patient outcomes and service delivery in PIBD include:

• The recently created global paediatric Research Network (PEDDCReN), with • The first set of paediatric specific
IBD network (PIBDnet) allows the support from UEG and in collaboration guidelines26 — the Paris Classification
initiation of academic multicenter with national gastroenterology — developed by ECCO, in partnership
studies over Europe and beyond. societies as well as PIBDnet. with ESPGHAN, is a welcome step
PIBDnet aims to advance the care forward in the process of assessing the
of children with IBD globally through • A consensus statement from the specific needs of paediatric IBD service
investigator and industry initiated European Crohn’s and Colitis delivery through providing a clearer
research, the development of optimal Organisation (ECCO) of critical factors definition about characteristics unique
treatment plans, and by monitoring for the optimal conduct of paediatric to paediatric-onset IBD enabling a
safety and effectiveness of current IBD trials, highlighting the importance more tailored treatment approach.
and emerging treatments24. of steroid-free mucosal healing as
the primary outcome measure for • New research highlighting the link
The recent PIBDnet initiated and
all new drugs and that paediatric between early life and immunity, the
Horizon 2020 funded project
trials must be performed early in the role of vaccinations in preventing IBD,
PIBD-SETQuality provides a unique
development of new drugs in order the benefits of early treatment with
chance to advance the care of patients
to reduce current off-label use of IBD immunomodulators and the benefits
with PIBD all over Europe and it is
medication in children25. of exclusive enteral nutrition (EEN).
an exciting opportunity to see the
EEN has recently been recommended
benefits of collaborative work in the • New management guidelines and in the new ECCO and ESPGHAN
area of IBD. It will help to measure consensus statements by the Paediatric guidelines for the management of
the impact and severity of the disease IBD Porto Group, a group of 30 PIBD as a first-choice agent to induce
on the individual but will also look paediatric IBD experts from ESPGHAN, remission and is considered by many
at social outcomes and cost-effective
covering the use of biosimilars and gastroenterologists as an exciting
ways of treating patients in the
endoscopy in paediatric IBD as well advance in the treatment of PIBD.
community, thus improving the care
as surgery and post-operative care This has an excellent safety profile
of PIBD for future generations.
in Crohn’s disease. The Group is also which can alter the evolution of the
• A clinical trials network to study conducting collaborative research, disease, with changes seen in anti-
effective medicines for paediatric including ongoing registries and inflammatory markers within just a
patients in the speciality of establishing more precise predictive couple of days.
Gastroenterology, Hepatology and tools, leading the way in improving
Nutrition, set up by the Paediatric current diagnosis and treatment
European Digestive Diseases Clinical of children with IBD.
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 13


There is an urgent need for further
investment in clinical research
Future recommendations for PIBD
Advances have been made in the treatment of PIBD
across Europe with new guidelines, training syllabi,
dedicated to PIBD, and the research and the PIBDnet registry. However, to halt the
development of a specific research increase in the incidence and the impact and severity
programme, if the increase in incidence of the disease, further action needs to be taken
continues at the current pace. including:


Professor Frank Ruemmele, MD, PhD
President of PIBDnet and GETAID pédiatrique
Professor of Pediatrics Université Sorbonne Paris Cité, Paris-
• Greater understanding of the complex physical, psychological and
social needs of children with PIBD
• Tailored care and services, including the transitional period into adult
Descartes, Paris Hôpital Necker Enfants Malades, Service de services, which are key to improving the patient’s experience and
Gastroenterologie pédiatrique Institut
ensuring successful disease management.
• Funding to provide more extensive subspecialty paediatric GI training
to meet the requirements of new guidelines


• Further research into all types of IBD, not just UC and CD, to fully
understand the causes enabling the development of effective
In our practice we aim to start a treatments and prevention strategies
gradual transition of every child from • Further research into early life programming to understand the causes
the age of 13 years into ‘handover and enable the development of immune-mediated GI conditions and
facilitate the development of advanced treatment and prevention
clinics’ run jointly by paediatric and strategies
adolescent IBD doctors and it is my
• Long-term follow up, regular reviews and frequent medical
hope that this model can be rolled out interventions by multi-disciplinary teams
across Europe to improve the provision
• Significant reductions in the delay between adult trials of new
at this transitional stage, and prevent treatment and those in children to ensure that new appropriately
children getting ‘lost’ in the system. formulated licensed treatments with proven safety profiles are


available for children as soon as possible

Dr Nikhil Thapar
Consultant Paediatric Gastroenterologist and chair of the
Gastroenterology Committee of the European society of
Paediatric Gastroenterology, Hepatology & Nutrition
14 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

PAEDIATRIC LIVER DISEASE

Incidence
Liver disease is becoming increasingly common in young In the EU, the hepatitis C virus (HCV)
is unfortunately showing a significant
children, with chronic liver diseases in children representing a increasing trend with the number
rising problem with significant impact on public health. Several of newly reported cases per 100,000
paediatric liver diseases, including viral hepatitis B and C and population increasing from 4.3 cases
in 1995 to 6.9 cases in 2007. A higher
metabolic syndromes related to obesity and being overweight, are prevalence is recorded in southern
the leading causes of cirrhosis and primary liver cancer in Europe. Europe, including Italy, Romania and
Spain, medium prevalence in Bulgaria,
France, Greece and Poland and the
Non-alcoholic fatty liver disease (NAFLD) the obesity epidemic are expected lowest prevalence reported in Belgium,
is the term used to describe fat build-up to result in substantial increases Germany, the Netherlands, Sweden and
in liver cells in people who do not drink in NAFLD prevalence in the future30. the UK32.
alcohol excessively. NAFLD is rapidly
Hepatitis B virus (HBV) is transmitted Insufficient screening of transfusions,
becoming the most common liver disease
from mother to baby through contact unsterilised medical equipment and re-
worldwide and is the most common
with infected blood or other body used needles and syringes continue to
persistent liver disorder in Western
fluids. Although the incidence of HBV be the major routes of HCV transmission
countries. Over the past few decades
infection has dramatically declined in developing countries, whereas
(NAFLD) has become the most common
since the implementation of universal vertical transmission, from an infected
cause of chronic liver disease among
immunisation programmes in several mother to her unborn or newborn baby
children and adolescents in Western
countries and blood-donor screening, and drug abuse in young adults, are the
countries, with cases documented in
a significant number of children are still major routes in developed countries.
children as young as 3 years old27.
infected each year, often developing Vertical transmission is now the main
NAFLD prevalence continues to rise chronic infection which can lead to source of infection in children and is
among paediatric patients affecting up cirrhosis and liver cancer. Mother to child less than 10%33. Hepatitis C is often
to 10% of Europe’s paediatric population, transmission accounts for more than 50% asymptomatic, and symptoms may
with a higher incidence in boys28. of chronic infections in highly endemic not appear until the liver is severely
Obesity presents a major risk factor for areas, with the risk of chronic infection damaged34.
NAFLD, with German and Italian studies higher in newborns (90%), infants and
showing a high prevalence (up to 44%) children under 5 years (25-30%) than for
of NAFLD in obese children29. Increases in adolescents or adults (<5%)31.
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 15


Most paediatric liver diseases
need a lifetime of care which
Impact
The main future morbidity
and mortality of children
carries a significant cost with NAFLD is from type 2
burden for our healthcare
more than 50% of diabetes, atherosclerosis
systems. As a result, it is not
Chronic HBV transmissions always possible to provide
or end stage liver failure.
from Mother to child Currently there is no method
the ideal care for children of accurately assessing the
transmission and many children get lost stage of the disease apart
from the system and suffer as from taking a biopsy and
a result. management of the disease


Professor Michael Manns
UEG President and Director of the
focuses largely on weight-
loss programmes through
a combination of diet and
Department of Gastroenterology, Hepatology
and Endocrinology at the Medical School of
exercise35.
High prevalence Hannover
The risk of developing chronic hepatitis
(up to 44%) of NAFLD B infection depends on the age at which
in obese children infection is acquired. Chronic infection
occurs in up to 90% of children who
acquire the infection at birth but occurs
in less than 10% of people infected as
adults36.
If left untreated, hepatitis C carries
a significant risk of cirrhosis and
liver cancer. Impaired quality of life,
potentially severe enough to have a
negative effect on learning, has also
been reported in children with chronic
Chronic infection of HBV HCV infection, including developmental
delay and learning disorders37.
occurs in up to 90% of
children infectED at birth
16 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

New initiatives and developments in the management


of paediatric liver disease
Initiatives aimed at improving patient outcomes and service
delivery in paediatric liver disease include:

• An exciting new initiative to improve whether a child with NAFLD has the • New clinical practice guidelines for the
the management of paediatric GI more serious condition non-alcoholic management of hepatitis B in children
across Europe—European Reference steatohepatitis (NASH)38. by ESPGHAN highlight the importance
Network Paediatric Liver Centres—is of regular follow-up visits to evaluate
• Development of a new paediatric
being developed with the European the need for various treatments. They
specific grading score for NAFLD has
Association for the Study of the Liver recommend full blood counts and liver
significantly improved a paediatric
(EASL). If successful, this initiative function tests to be performed yearly
gastroenterologist’s and hepatologist’s
will ensure that accredited centres and liver cancer surveillance with
are available across Europe for method of interpreting liver histology
ultrasound to be carried out every 6-12
hepatic disease, to facilitate research in paediatric cases of NAFLD and NASH.
months, depending on the stage of
from ‘the cradle to the grave’ and a • Most EU and EEA countries now have fibrosis. It is also noted in the guidelines
comprehensive body of research to a surveillance system for HBV and HCV that a liver biopsy remains the most
ensure a life-time of optimal care for infections. However, due to differences effective method to evaluate the relevant
patients with liver disease. Currently, in system structures, reporting practices, treatment strategy but new non-invasive
many European countries have excellent data collection methods and case methods, such as FibroScan, could prove
specialist centres but transition to adult definitions used, the surveillance data useful in future to avoid liver biopsy,
services, essential for paediatric liver is difficult to compare across countries. particularly during follow-up visits40.
diseases, is poor. For example, in 14 countries there was • Universal HBV immunisation
• It is now widely recommended that one specific surveillance system whilst programmes. These are adopted in 47
every obese child or adolescent should 15 countries indicated that they use out of 53 countries in the WHO European
have their liver enzymes checked to multiple surveillance systems to monitor region, creating a generation of children
ensure the earliest possible diagnosis of hepatitis C. Eleven countries indicated and young adults with virtually no
NAFLD. The child may then be referred that they have implemented the EU- markers of HBV infection. Six countries
for confirmation of diagnosis, most 2008 case definition yet four countries (Iceland, United Kingdom, Denmark,
commonly via liver ultrasound, to verify apply the EU-2002 case definition. Norway, Sweden and Finland) have not
accumulation of fat in the liver. Liver There is also screening for hepatitis B employed universal immunisation and
biopsy is the current gold standard for in pregnancy in 24 countries but only only target people who are at risk, which
the diagnosis of NAFLD and the only 2 antenatal screening programmes for is more challenging to implement than
procedure currently available to assess hepatitis C in the EU/EEA39. the universal approach41.
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 17


The fundamental issues for
the future to prevent certain
Future recommendations for the management
of paediatric liver disease
Liver disease is increasingly common in young children and
paediatric liver diseases and
involves a lifetime of care. Further investment is required
improve treatment outcomes
to reduce incidence, improve diagnosis and to establish an
include, firstly, developing
infrastructure that offers seamless support and management
genetic technology to speed
from paediatric to adult service provision.
up diagnosis and facilitate the
development of more targeted
treatments. Secondly, we need
to improve the long-term Key recommendations include: • Specialised centres for the optimal
management of children with
management of children with • Primary non-invasive evaluation
chronic liver disease
using biochemical parameters,
liver disease and, lastly, we imaging tests and serum • Appropriate public health and
must harness the enthusiasm biomarkers as initial tools to education campaigns, implemented
for collaboration across Europe confirm the diagnosis of fatty through schools, to halt the rise of
liver disease HCV infection in Europe
to facilitate optimal treatment
management and outcomes. • Development of genetic technology • Harmonised screening programmes
to speed up diagnosis and facilitate for at risk groups, hard-to-reach
Funding is therefore vital to the development of more targeted populations, and the general
enable progress and essential treatments population
advancement of the management • Further research to evaluate the use • A multidisciplinary approach to
of paediatric liver disease across of oral direct acting antivirals for Europe-wide research, specialist
children training and paediatric patient
Europe, to ensure that these management
children lead full and active lives • Further development of vaccines
for HCV infection and a universal
well into their eighties.


vaccination for HBV infection

Professor Deirdre Kelly


Professor of Paediatric Hepatology
at Birmingham’s Children Hospital
18 Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease

SUMMARY

This comprehensive review of paediatric gastroenterology


outlines many exciting initiatives and strategies that are
in place across Europe but it also highlights many areas
“We hope that the issues UEG
has highlighted in this review
of concern that require urgent action and change for the will initiate an increased
benefit of paediatric patients. focus on improving paediatric
It is vital that work continues in order to halt the alarming gastroenterology services
rise in obesity and reduce the long-term impact on throughout Europe to ensure
health and society through improved nutrition and raised all children have access to
awareness of the impact of childhood obesity. a healthy diet, specialist
services and follow-up care
New networks, registries, guidelines and research, designed helping to minimise the risk
to reduce the impact of paediatric IBD need to be supported and burden of long-term GI
by investment to ensure more extensive sub-speciality problems.


training and on-going physical and psychological support
for paediatric patients.
Professor Paul Fockens
UEG Vice President
Non-alcoholic fatty liver disease now affects 10%
of Europe’s paediatric population and urgent action
is needed to improve screening and vaccination
programmes to halt the alarming increase in incidence.
Paediatric Digestive Health Across Europe
Early Nutrition, Liver Disease and Inflammatory Bowel Disease 19

References

1. www.euro.who.int/en/health-topics/disease- 16. Velasquez-Manoff M. An Epidemic of Absence: A New 28. http://www.childliverdisease.org/News/Research-


prevention/nutrition/policy Way of Understanding Allergies and Autoimmune funded-by-Birmingham-charity-identifies-genetic-
2. www.euro.who.int/en/health-topics/disease- Diseases. New York: Scribner 2013 variant-in-childhood-liver-disease
prevention/nutrition/publications/2015/european- 17. Shaw SY, Blanchard JF, Bernstein CN. Association 29. http://www.easl.eu/medias/EASLimg/Discover/
food-and-nutrition-action-plan-20152020 between the use of antibiotics in the first year of life EU/54ae845caec619f_file.pdf
3. 1,000days.org and pediatric inflammatory bowel disease. American 30. Roberts SE, Samuel DG, Williams JG, et al. Survey of
4. http://www.jnmjournal.org/journal/view. Journal of Gastroenterology. 2010. Vol 105 (12) 2687- Digestive Health Across Europe. Part one: The burden
html?doi=10.5056/jnm14067 2692 of gastrointestinal disease and the organisation and
5. Kanasaki K, Kova D. Biology of obesity: lessons from 18. Mattar MC, Lough D, Pishvaian MJ, Charabaty A. delivery of gastroenterology services across Europe.
Animal models of obesity. J Biomed Biotechnol Current Management of Inflammatory Bowel Disease Report for United European Gastroenterology. October
2011;2011:197636. and Colorectal Cancer. Gastrointestinal Cancer Res. 2014.p.94
6. Phatak UP, Pashankar DS. J Pediatr Gastroenterol Nutr. 2011 Mar-Apr; 4(2): 53-61 31. Sokal EM, Paganelli M, Wirth S et al. Management of
2015 Apr;60(4):441-5 Obesity and gastrointestinal 19. Mattar MC, Lough D, Pishvaian MJ, Charabaty A. chronic hepatitis B in childhood: ESPGHAN clinical
disorders in children. Current Management of Inflammatory Bowel Disease practice guidelines. Journal of Hepatology Oct 2013.
7. https://www.noo.org.uk/NOO_about_obesity/child_ and Colorectal Cancer. Gastrointestinal Cancer Res. Vol 59 (4) p814-829
obesity/Health_risks 2011 Mar-Apr; 4(2): 53-61 32. ECDC – Hepatitis B and C. Current situation in the EU/
8. https://www.noo.org.uk/NOO_about_obesity/child_ 20. Roberts SE, Samuel DG, Williams JG, et al. Survey of EEA
obesity/Health_risks (Public Health England) Digestive Health Across Europe. Part one: The burden 33. El-Shabrawi MH, Kamal NM Burden of Pediatric
9. EarlyNutritionproject. see http://www.kcl.ac.uk/lsm/ of gastrointestinal disease and the organisation and hepatitis C. World J Gastroenterol. 2013 Nov 28; 19
research/divisions/wh/newsevents/newsarchive/ delivery of gastroenterology services across Europe. (44): 7880-7888
earlynutritionfactsheet.pdf Report for United European Gastroenterology. October 34. http://fingertips.phe.org.uk/profile/liver-disease.
10. Yu et al. Obes Rev. 2011; 12: 525-42. project- 2014.p.196/7 Public Health England
earlynutrition.eu 21. B. Wilson, S. Lönnfors, S. Vermeire. The true impact 35. Mann JP, Goonetilleke R, McKiernan P. Paediatric
11. Dodd JM et al. BMJ. 201410;348. project-earlynutrition. of IBD: a European Crohn’s and Ulcerative Colitis non-alcoholic fatty liver disease: a practical overview
eu patient life. IMPACT Survey 2010-2011 http://efcca.org/ for non-specialists. Arch Dis Child doi:10.1136/
12. Weber M, Grote V, Closa-Monasterolo R, Escribano media/files/press-Join-Fight/3PRESS_KIT_IBD_IMPACT_ archdischild-2014-307985
J, Langhendries JP, Dain E, Giovannini M, Verduci E, REPORT_BCN.pdf 36. http://fingertips.phe.org.uk/profile/liver-disease.
Gruszfeld D, Socha P, Koletzko B; European Childhood 22. B. Wilson, S. Lönnfors, S. Vermeire. The true impact Public Health England
Obesity Trial Study Group. Lower protein content in of IBD: a European Crohn’s and Ulcerative Colitis 37. El-Shabrawi MH, Kamal NM Burden of Pediatric
infant formula reduces BMI and obesity risk at school patient life. IMPACT Survey 2010-2011 http://efcca.org/ hepatitis C. World J Gastroenterol. 2013 Nov 28; 19
age: follow-up of a randomized trial. Am J Clin Nutr. media/files/press-Join-Fight/3PRESS_KIT_IBD_IMPACT_ (44): 7880-7888
2014 May;99(5):1041-51. doi: 10.3945/ajcn.113.064071 REPORT_BCN.pdf 38. Vajro P, Lenta S, Socha P, Dhawan A, McKiernan P,
13. Roberts SE, Samuel DG, Williams JG, et al. Survey of 23. Macker LM, Greenley R, Szigethy E et al. Psychosocial Baumann U: Diagnosis of non-alcoholic fatty liver
Digestive Health Across Europe. Part one: The burden Issues in Pediatric Inflammatory Bowel Disease: A disease in children and adolescents: position paper
of gastrointestinal disease and the organisation and Clinical Report of the North American Society for of the ESPGHAN Hepatology Committee. J Pediatr
delivery of gastroenterology services across Europe. Pediatric Gastroenterology, Hepatology and Nutrition Gastroenterol Nutr. 2013, 54: 700- 713.
Report for United European Gastroenterology. October 24. http://pibd-net.org/ 39. ECDC – Hepatitis B and C. Current situation in the EU/
2014. 25. Ruemmele FM, Hyams JS, Otley A et al. Outcome EEA
14. Moller FT, et al. Familial risk of inflammatory bowel measures for clinical trials in paediatric IBD: an 40. Sokal EM, Paganelli M, Wirth S et al. Management of
disease: a population-based cohort study 1977-2011. evidence-based, expert-driven practical statement chronic hepatitis B in childhood: ESPGHAN clinical
Am J Gastroenterol 2015; 110: 564-571 paper of the paediatric ECCO committee. practice guidelines. Journal of Hepatology Oct 2013.
15. Bernstein CN, Rawsthorne P, Cheang M and 26. http://ecco-jcc.oxfordjournals.org/content/8/10/1179 Vol 59 (4) p814-829
Blanchard JF. A population-based case control study 27. Day CP. Non-alcoholic fatty liver disease: a massive 41. Van Damme et al. Should Europe have a universal
of potential risk factors for IBD. American Journal of problem. Clin Med. 2011; 11:176-178 hepatitis B vaccination programme? The BMJ, 2013,
Gastroenterology. 2006 Vol 101 (5) 993-1002 34.

You might also like