Review of the shielding categories (Published 17 June 2020)

As part of the initial response to the coronavirus outbreak thousands of children and young people with pre-existing medical conditions were advised to shield. Covid-19 was a completely new virus and professionals erred on the side of caution because of the lack of clinical evidence.

Over time, we have learnt more about coronavirus and its impact on individuals. For this reason, specialists have now been able to adapt the shielding list as knowledge and experience has improved.

What are the changes and new categories?

Updated advice by British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) have identified three groups for children and young people (under 18) diagnosed with a liver condition. These guidelines are advisory and subject to review as we move further through this pandemic.

Group A: A child with a condition in this group should continue to shield.

• Decompensated liver disease (ascites, portal hypertension)
• Receiving post-transplant immunosuppression (less than 3 months from liver transplant) or on liver/small bowel/multivisceral transplant waiting list
• Liver disease AND other significant co morbidities (immunodeficiency, post other organ transplantation, respiratory conditions) or other organ involvement (renal, haematology, cardiac, GI, respiratory, diabetes mellitus etc)
• Active or frequently relapsing autoimmune liver disease where they are likely to need increase in treatment
• Intravenous or oral steroids equal to or greater than 20mg per day prednisolone (> than 0.5mg/kg) or equivalent per day. They only need to continue shielding while on this dose.
• Commencement of biologic therapy plus immunomodulatory or systemic steroids within previous six weeks
• Requirement for parenteral nutrition

Group B: A child with a condition in this group requires discussion between clinician and family and may possibly be taken off the list if both parties agree.

• 3-12 months post liver transplant
• Patients with autoimmune liver disease (less than 3 months from diagnosis) on maintenance immunosuppression (<20mg prednisolone or <0.5mg/kg)

Group C: A child with a condition in this group can unshield but must continue to maintain strict social distancing and hygiene guidelines.

• Chronic but stable liver disease (no ascites and/or no portal hypertension, no immunosuppression)
• Portal vein thrombosis/portal cavernoma
• More than 1 year post liver transplant with stable immunosuppression levels
• Autoimmune liver disease for more than 3 months on maintenance treatment

How is this going to work?

We have been informed that children, young people (under 18) and families under King’s College Hospital can use the advice to make their own decisions about shielding. If you are in any way unsure about which category you/your child falls into, or would like confirmation, it is important that you contact your clinical team for support in your decision. Birmingham Children’s Hospital and Leeds General Infirmary are currently following a similar process with letters being sent to families in light of the new guidance. It is our understanding that BSPGHAN guidelines also apply to those in Scotland and Northern Ireland. As we hear back from all centres and countries we will provide an update about their approaches here.

Extension of shielding dates

Those who need to continue shielding should continue doing so according to their country’s dates as expressed in individual briefings. Currently, Scotland has extended shielding to 31st July and Wales 16th August. Northern Ireland and England have yet to announce whether shielding will continue past the end of June but we believe further information is imminent. We will update you when we hear more. You can view our previous article about guidelines for easing of shielding in each country here.

What about those over 18?

We will continue to investigate potential shielding advice changes for those over 18 and those in adult services. This is made more complex as adult hepatologists may follow different guidance set by their own adult networks rather than BSPGHAN. It is important that if you are over 18 and have been advised to shield you should continue to do so until told otherwise by your clinical team. We will update you further once we know more.

PLEASE NOTE: If you/your child has been removed from the shielding list it is still important that you remain vigilant and adhere to social distancing and hygiene precautions.

We know you have been through an emotional rollercoaster with continually changing advice and information. We want to reiterate that you will never be forgotten and are central to all the work we are doing. We are often aware of work in the background but understand how quickly things can change. For this reason, we request further clarification on how this will affect children, young people and families before communicating to those we support. By doing this we hope to allow you to make educated decisions based on your individual circumstances.

These times require us all to all come together – we are listening to everything you are saying and feeling and ensuring that your voices are heard. You are the experts in how the pandemic is affecting you. For this reason, we want to thank you all for sharing your experiences and knowledge with us and request that you continue to do so. We all need to support each other through this and we will reach the other side!

You can view detailed information about these guidelines at the BSPGHAN site linked below. The document also explores some of the unfolding global evidence around how Covid-19 is affecting children with liver disease.
https://bspghan.org.uk/wp-content/uploads/2020/06/Updated-shielding-guidance-for-children-with-chronic-liver-disease-and-those-on-immunosuppression_TG-1.pdf