Recommendations for management strategies for children with in ﬂ ammatory bowel disease during the epidemic of new coronavirus (COVID-19) infection

The novel Coronavirus, COVID-19, is highly infectious is mainly transmitted from an infected person through liquid droplets. Most patients have a good prognosis, a few patients are in critical condition. Children’s infections are relatively mild, without fever and pneumonia and since they have the characteristics of clustering onset, they are easy to miss diagnosis and are thus more likely to cause disease transmission. Children with in ﬂ ammatory bowel disease need to travel to and from the hospital multiple times to receive treatments due to this disease’s own characteristics, which in turn increases their risk of infection. Therefore, management recommendations for children with in ﬂ ammatory bowel disease through a network platform during the pandemic of COVID-19 infection are proposed.


Introduction
symptoms may also appear. In some cases, gastrointestinal symptoms are the fi rst manifestation [2]. Infl ammatory Bowel Disease (IBD) is a group of non-specifi c chronic gastrointestinal infl ammatory diseases of unknown cause, including Crohn's Disease (CD), Ulcerative Colitis (UC) and unshaped IBD. IBD is often associated with fever, stunted growth, malnutrition, delayed puberty, anemia, arthritis, primary sclerosing cholangitis, nodular erythema, bowel stricture, anal fi stula, perianal abscess, etc., and requires long-term treatment and follow-up. During the pandemic, children with IBD may be using drugs that affect immune function, such as hormones, immunosuppressive agents, or biological agents, and require multiple outpatient follow-up or hospital treatments. Children Citation: Ao  with IBD are at high risk during the major pandemic of new coronavirus infection. Management, family care, and outpatient follow-up of children with IBD also face challenges. With the popularity of the Internet, our communication methods have undergone tremendous changes. The Internet has largely replaced traditional media such as newspapers and televisions as the primary channel for obtaining information. With the popularity of 5G networks and the development of the communications industry, mobile phones and the Internet have become necessities of our lives. In order to minimize the exposure of children with IBD to COVID-19, we have adopted WeChat and mobile apps combined with video follow-up Methods to help solve their follow-up and treatment problems; these specifi c strategies are summarized below.

Risk classifi cation
Children with IBD who are at High Risk for New Coronavirus Pneumonia: Based on the clinical evaluation and stage of the disease, we have positioned the following children at high risk: (1) in the induction remission phase, (2) Children with genetic defects as confi rmed by genetic testing: such as patients with genetic defects in the IL-10 receptor, (3) children with comorbidities requiring follow-up: such as combined with moderate or higher malnutrition, intestinal stenosis, perianal disease, etc. and(4) children in major pandemic areas.
Children with IBD who are at moderate or lower risk of new coronavirus pneumonia: (1) children in maintenance therapy, (2) no history of disease in the pandemic area, (no use of immunosuppressants and biological agents to treat children).

Strictly abide by the residents' life recommendations
for pandemic prevention and control. At the same time, it is emphasized that children with IBD self isolate.
2. Strengthen the health education and preventive measures of the accompanying family members: The risk of infection of IBD children by COVID-19 increases with parents going out to the clinic. Therefore, it is very important to protect the home and reduce the risk of infection caused by parents going out. This requires parents to strictly abide by the relevant levels of management's requirements for epidemic prevention and control, with a focus on home ventilation and disinfection; families with conditions recommend that low-risk personnel take care of children with IBD.
Timely counseling for children: Due to the characteristics of the disease, long-term follow-up and treatment of children with IBD often affects the child's psychology. In addition to the cause of the COVID-19 pandemic, the child may not fully understand the pandemic situation, which is likely to cause negative reverie being unable to go out from the home for a long time, which can also cause unpleasant emotions. Parents should change their minds at this time, and should inform the children of the current epidemic situation scientifi cally, and create a good family atmosphere, actively communicate and enlighten, and can relieve children's tension and anxiety by appreciating soothing music and breathing training, and ensure the greatest degree daily activities [3,4].

Effective use of online platforms
During the epidemic, we should effectively use online platforms such as WeChat groups and public accounts to track and manage children. The specifi c methods are as follows: 1. Establish a WeChat group for children with IBD, and release relevant information accurately and timely.

About the outpatient consultation process for children with IBD
Appointment scheduling: In order to avoid the risk of infection that may be caused by frequent medical appointments, patients should try to make appointments for specialist outpatient visits, avoid visiting high-risk clinics such as popular clinics, infection departments, and respiratory departments, or consider blood routine and liver and kidney in the nearest community hospital Work detection [5]. Parents of children with IBD can keep in touch with the attending doctor through the IBD WeChat group, or through various forms of online consultation. If the child is generally in good condition or stable, you can continue to observe at home and provide timely feedback. (1)recent travel history of the child to exclude travel to territories with the outbreak of COVID-19within the past 14 days; (2)have not come in contact with patients either presenting with fever and respiratory symptoms orpersons that have travelled to pandemic-stricken areas within 14 days; (3). No cluster incidence. b) An appointment with a digestive specialist should be arranged in a timely manner when the child has the following symptoms: (1) the abdominal pain becomes worse and cannot be tolerated; (2) a large amount of blood in the stool; (3) Intolerable or febrile perianal swelling and pain; (4) more bleeding or fever in the fi stula; (5) Persistent fever.

Hospitalization
For admitted patients, medical staffs need to inquire about related medical history (especially related epidemiological history of family members) at the time of admission, and screen for suspicious cases again. All hospitalized specialists must sign a hospital commitment to prevent and control the new coronavirus-infected pneumonia when they are admitted. The ward is strictly protected and disinfected. A low-risk person will accompany the patients. Other relatives should be prohibited from visiting the infected patient to ensure the safety of patients and wards and restrict further transmission of the virus.

Drug treatment during the epidemic for children with IBD
Induced remission children: With strict protective measures in place, it is not recommended to postpone the use of biological agents or immunomodulators. If the condition is stable, continue the original treatment. Additionally, it is not recommended to add immunosuppressive agents or increase the dose of immunosuppressive drugs during the SARS-CoV-2 outbreak. For patients treated with Infl ixicil monoclonal antibody or adalimumab, it is recommended that SARS-CoV-2 virus screening and lung CT examination be performed before medication, except for the possible case of SARS-CoV-2 infection; Mesalazine and thalidomide treatment can continue to be applied. For those who cannot go to the hospital to maintain medications due to epidemic related factors, it is recommended to use enteral nutrition to survive the epidemic period [5].
Maintenance treatment of children with IBD:Children in the remission phase of the disease should receive continuous drug treatment while in a stable condition. In children who are treated with biologics for maintenance treatment, the regular maintenance medication cycle is intravenous drip infusion once every 8 weeks. During the non-peak period of the COVID-19 pandemic, children can be treated in the hospital normally according to the prescribed time; during peak pandemic situations or in regions severely affl icted with COVID-19, medication can be postponed for 1 to 2 weeks as appropriate [5]. For children who can't go to the hospital for various reasons, especially those with mucosal healing time less than 1 year, it is recommended to use enteral nutrition. of Children's Digestive Endoscopy Center for New Coronavirus Infection" [12].

Result and prospect
During the epidemic, our hospital adopted WeChat and mobile App video follow-up methods for 35 IBD patients, and adopted the above relevant recommendations. Among them, 32 were in stable condition and successfully passed the severe epidemic period, and 3 of them experienced relapse. Two of them were due to prolonged use of infl iximab; the other was due to hormone reduction. Failure to add immunosuppressants in time caused a relapse.
According to the establishment of the online platform and the results obtained, in today's society, the rational use of the online platform to achieve the management of children, follow-up, diagnosis and treatment of special periods and timely feedback of parents' opinions is a new development direction. Reasonably use network technology to establish an infl ammatory bowel disease management platform, even a chronic disease management platform. IBD patients in various regions can use this platform to track their condition and conduct joint consultations, which is also more conducive to hospital management of patients.
In short, the global pandemic is still severe, and children with IBD are more susceptible and should pay close attention to it. It is recommended adhere to personal protective protocols during the pandemic and utilize WeChat and online consultation platforms to keep in touch with pediatric digestive experts or physicians in charge. Standardized treatment and effective management can reduce the risk of SARS-CoV-2 infection.