Background: The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014. Methods: Asystematicreviewofmedicalliteraturefrom2014to2020wascarried out. Consensus on the content of the manuscript, including recommendations, was achievedbytheauthorsthroughelectronicandvirtualmeans.Theexpertopinionof the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature. Results: The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low-profile devices can be inserted initially using the single-stage procedure or after 2-3 months by replacing a standard PEG tube, in those requiring longer-term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain-typically 8-12 weeks-a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC) has recently been used with considerable success in this scenario. Conclusions: A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of the change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.

BackgroundCOVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic.MethodsFor the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD.ResultsAll centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres.ConclusionsDiagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.

Children with DM and CD have a higher frequency of gastrointestinal symptoms than their diabetic peers with negative celiac serology and are not truly asymptomatic. Institution of a GFD has a positive effect on nutritional status and symptom resolution in the short-term.

What Is KnownEndoscopy Training is becoming an integral part of Paediatric Gastroenterology Training within Europe. There is a great degree of variation between European endoscopy training in terms of duration, content, procedural volume, assessment during and at the end of training. What Is New?Achievement of milestones in training more accurately assesses competency compared with procedural number. 'Train the trainers' courses and educational material, such as e-learning and endoscopy simulator training improve a structured approach in endoscopy teaching. Cooperation with the National Paediatric Gastroenterology, Hepatology and Nutrition Societies in Europe will facilitate dissemination, discussion and implementation of results of this position paper. E ndoscopy Training is an integral part of paediatric gastroenterology training within Europe as mentioned in the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) training syllabus (1). National training programmes are often at least partly based on the ESPGHAN syllabus, however, there are a number of countries where endoscopy training is not included in Paediatric Gastroenterology, Hepatology and Nutrition (PGHN) training. There is increasing evidence that achievement of milestones in training more accurately assesses competency compared with procedural number (2,3). The updated ESPGHAN Syllabus has been approved by the European Union of Medical Specialists (UEMS), suggesting that countries with National PGHN society should comply with the syllabus. The ESPGHAN syllabus lists the endoscopic procedures to be fulfilled in order to certify for paediatric gastroenterologist and does not specify procedural volume anymore (4). A group of experts within the ESPGHAN was tasked to define milestones of competency in diagnostic and therapeutic endoscopy by the Endoscopy Special Interest Group (SIG). In addition, other areas of possible