BNF for Children 2011-2012

48 1.5 Chronic bowel disorders BNFC 2011–20121 Gastro-intestinal systemSide-effects abdominal cramps, dizziness, drowsiness,and skin reactions including urticaria; paralyticileus and abdominal bloating also reportedLicensed use capsules not licensed for use in childrenunder 8 years; syrup not licensed for use inchildren under 4 years; not licensed for use inchildren for chronic diarrhoeaIndication and doseChronic diarrhoea. By mouthChild 1 month–1 year 100–200 micrograms/kgtwice daily, 30 minutes before feeds; up to 2 mg/kgdaily in divided doses occasionally requiredChild 1–12 years 100–200 micrograms/kg (max.2 mg) 3–4 times daily; up to 1.25 mg/kg daily individed doses may be required (max. 16 mg daily)Child 12–18 years 2–4 mg 2–4 times daily (max.16 mg daily)Acute diarrhoea (but see notes above). By mouthChild 4–8 years 1 mg 3–4 times daily for up to 3days onlyChild 8–12 years 2 mg 4 times daily for up to 5daysChild 12–18 years initially 4 mg, then 2 mg aftereach loose stool for up to 5 days (usual dose 6–8 mg daily; max. 16 mg daily)Loperamide (Non-proprietary) ACapsules, loperamide hydrochloride 2 mg, net price30-cap pack = £1.07Tablets, loperamide hydrochloride 2 mg, net price 30-tab pack = £2.15Brands include Norimode cNote Loperamide can be sold to the public, for use in childrenover 12 years, provided it is licensed and labelled for thetreatment of acute diarrhoeaImodium c (Janssen) ACapsules, green/grey, loperamide hydrochloride2 mg. Net price 30-cap pack = £1.09Syrup, sugar-free, red, loperamide hydrochloride1 mg/5 mL. Net price 100 mL = £1.17Compound preparationsImodium c Plus (McNeil)Caplets (= tablets), loperamide hydrochloride 2 mg,simeticone 125 mg, net price 6-tab pack = £2.27, 12-tab pack = £3.58DoseAcute diarrhoea with abdominal colicChild 12–18 years initially 1 caplet, then 1 caplet aftereach loose stool; max. 4 caplets daily for up to 2 days1.5 Chronic bowel disordersIndividual symptoms of chronic bowel disorders needspecific treatment including dietary manipulation aswell as drug treatment and the maintenance of a liberalfluid intake.Inflammatory bowel diseaseChronic inflammatory bowel diseases include ulcerativecolitis and Crohn’s disease. The treatment of inflammatorybowel disease in children should be initiated andsupervised by a paediatric gastroenterologist. Effectivemanagement requires drug therapy, attention to nutrition,and in severe or chronic active disease, surgery.Aminosalicylates (balsalazide, mesalazine, olsalazine,and sulfasalazine), corticosteroids (hydrocortisone,budesonide, and prednisolone), and drugs that affectthe immune response are used in the treatment ofinflammatory bowel disease.Treatment of acute ulcerative colitis and Crohn’sdisease Acute mild to moderate disease affecting therectum (proctitis) or the recto-sigmoid (distal colitis) istreated initially with local application of an aminosalicylate(section 1.5.1); alternatively a local corticosteroid(section 1.5.2) can be used but it is less effective. Foampreparations and suppositories are useful for childrenwho have difficulty retaining liquid enemas.Diffuse inflammatory bowel disease or disease that doesnot respond to local therapy requires oral treatment.Mild disease affecting the proximal colon can be treatedwith an oral aminosalicylate alone; a combination of alocal and an oral aminosalicylate can be used in proctitisor distal colitis. Refractory or moderate inflammatorybowel disease usually requires adjunctive use of an oralcorticosteroid such as prednisolone (section 1.5.2) for4–8 weeks. Modified-release budesonide is used forchildren with Crohn’s disease affecting the ileum andthe ascending colon; it causes fewer systemic sideeffectsthan oral prednisolone, but may be less effective.As an alternative to an oral corticosteroid, enteralnutrition (Appendix 2) may be used for 6–8 weeks inchildren with active Crohn’s disease.Severe inflammatory bowel disease or disease that isnot responding to an oral corticosteroid requires hospitaladmission and treatment with an intravenouscorticosteroid such as hydrocortisone (p. 375) ormethylprednisolone (p. 376); other therapy mayinclude intravenous fluid and electrolyte replacement,and possibly parenteral nutrition. Children with ulcerativecolitis that fails to respond adequately to thesemeasures may benefit from a short course of ciclosporin.Children with unresponsive or chronically activeCrohn’s disease may benefit from azathioprine,mercaptopurine, or once-weekly methotrexate; thesedrugs have a slow onset of action.Infliximab (section 1.5.3) is used in specialist centresfor children with severe active Crohn’s disease whosecondition has not responded adequately to treatmentwith a corticosteroid and a conventional drug thataffects the immune response, or who are intolerant ofthem. Infliximab has also been used for the treatment ofsevere, refractory ulcerative colitis. There are concernsabout the long-term safety of infliximab in children;hepatosplenic T-cell lymphoma has been reported.Crohn’s disease of the mouth or of the perineum is morecommon in children than in adults and it is difficult totreat; elimination diets and the use of a topical corticosteroid(section 13.4) may be beneficial, but a systemiccorticosteroid (section 6.3.2) and occasionally azathioprinemay be required in severe cases.