MIAMI – Pediatricians play an essential role in optimizing the diagnosis, care, and outcomes of children with inflammatory bowel disease, according to a pediatric gastroenterologist with expertise in this area.
"What would we like you to do as a pediatrician, perhaps, before they come to our office? There are definitely things you can start as far as the workup is concerned," Dr. Alisa J. Muñiz Crim said at a pediatric update sponsored by Miami Children’s Hospital. The pediatrician can rule out infectious diarrhea; evaluate the patient for rashes and other external manifestations; and order specific laboratory and biomarker tests, for example.
If further evaluation with endoscopy, colonoscopy, or imaging is warranted, consult a pediatric gastroenterology specialist, said Dr. Muñiz Crim, a pediatric gastroenterologist at Miami Children’s Hospital.
Suppression of inflammation, alteration of the disease course, and improvement in quality of life are among the shared goals of IBD treatment, Dr. Muñiz Crim said. Prevention of complications and disease relapse are additional aims.
Of the estimated 1 million to 2 million affected Americans, approximately 100,000 are younger than 18 years. These figures include about a 50% increase in children who have been diagnosed with IBD in the past decade. "We believe this is a true increase in the incidence of inflammatory bowel disease, not just an increase in the diagnostic capabilities," Dr. Muñiz Crim said.
Although IBD (which includes both ulcerative colitis and Crohn’s disease) affects both adults and children, there are special considerations for the pediatric population. Abdominal pain, diarrhea, rectal bleeding, anemia, and perianal disease are classic IBD symptoms. However, "presentations can be more severe in children," Dr. Muñiz Crim said.
As an example, children with ulcerative colitis experience a higher incidence (up to 80%) of a more severe form called pancolitis. Pancolitis is the single biggest risk factor for colorectal cancer in patients with ulcerative colitis.
The risk for colorectal cancer in the setting of ulcerative colitis is estimated at 2% at 10 years after diagnosis, 8% by 20 years, and 18% by 30 years. "Those numbers are very high and ... alarming to families," Dr. Muñiz Crim said. "We don’t deal with it very much as pediatric physicians, but it’s something [patients] need to know early on." Emphasize that adolescents who transition to adult provider still need to be closely monitored.
A greater risk of progression to surgery for some children with Crohn’s disease, as well as greater risk of psychosocial impact from their disease, also characterize pediatric IBD, Dr. Muñiz Crim said.
Pediatricians can help address another high risk concern in these patients: growth and pubertal delay. "Growth failure is very common, more in Crohn’s disease than in ulcerative colitis," Dr. Muñiz Crim said. Approximately 36%-39% of children with IBD will demonstrate decreased height percentiles.
Diagnosis and intervention typically lead to gradual improvements, "but their height and weight don’t make it back" to where those measures would be without the disease, Dr. Muñiz Crim said. "Adult height is often compromised. It is a big issue for our male adolescent patients in particular."
Multiple factors in IBD can impede growth, including inadequate dietary intake, malabsorption, and disease location. Children typically experience more growth failure when IBD affects the small intestine, Dr. Muñiz Crim said.
Early diagnosis and intervention improve the likelihood of minimizing adverse growth effects. Optimize nutrition through careful evaluation and calorie supplementation in concert with a nutritionist, Dr. Muñiz Crim suggested. Use routine laboratory testing to monitor disease progression.
Stay away from prolonged corticosteroid treatment, said Dr. Muñiz Crim. Although corticosteroids are appropriately prescribed to induce disease remission initially, "prolonged use can have debilitating effects" on growth, bone metabolism, and other effects. You might need to carefully counsel patients and families about the dangers of long-term steroid use, she added, because it seems counterintuitive to stop therapy when it makes patients feel better. Biologics and immunomodulators are the preferred maintenance medications to help patients achieve their growth potential, Dr. Muñiz Crim said.
The treatment of pediatric IBD patients relies on clinical judgment because most evidence is extrapolated from adult studies. Some pediatric studies with smaller numbers of participants show, for example, that therapy can induce disease remission to an extent similar to that in adults. A remaining issue, Dr. Muñiz Crim said, is that "we don’t know the lifetime toxicity of some of these medications because they haven’t been around long enough."
Continue routine immunizations in most children with IBD, Dr. Muñiz Crim said. Importantly, catch up with any vaccinations they might be missing upon diagnosis, she added, and avoid live vaccines, as always, in immunocompromised patients.