Health supervision in the management of children and adolescents with IBD: NASPGHAN recommendations

Pediatric Crohn's Disease in Bahrain

OBJECTIVES

Our study aimed to report the epidemiology, clinical presentations, diagnostic and therapeutic approaches, and outcomes of Crohn's disease (CD) in pediatric patients in Bahrain.

METHODS

We conducted a retrospective review of the medical records of patients with CD diagnosed in the pediatric department, Salmaniya Medical Complex, Bahrain, between 1984 and 2017. We used the data to calculate the annual incidence and cumulative prevalence. Data about gender, nationality, clinical presentation, age at presentation and diagnosis, duration of illness, consanguinity, family history, contact with smokers, and comorbidities were gathered. Results of hematological, biochemical, and serological tests were also collected. All radiological, endoscopic, and histopathological findings were reviewed. Data about medical therapy, relapse episodes, hospital admissions, complications, and outcomes were collected.

RESULTS

Of 108 pediatric patients diagnosed with inflammatory bowel disease (IBD), 51 (47.2%) patients had CD. The annual incidence was 1 in 100 000 per year (range = 0-5 patients/year) with significant rise on comparing the three decades (p = 0.0001). Prevalence was 9.32 patients per 100 000 pediatric populations. Thirty-four patients (66.7%) were males, and the median age was 18.5 years (range = 6.4-35.0). Common clinical presentations were recurrent abdominal pain and weight loss. Family history of IBD was found in 10 patients. One patient had positive antineutrophil cytoplasmic antibody. The terminal ileum was involved in 68.1%, colon in 63.8%, and perianal area in 17.0% patients. Biological therapy was used in five patients. Surgical intervention was required in six patients. The mean follow-up period was 9.2±5.6 years.

CONCLUSIONS

The clinical characteristics of our population are comparable to that reported in neighboring countries and worldwide.

Chromoendoscopy for Dysplasia Surveillance in Inflammatory Bowel Disease

Long-standing ulcerative colitis (UC) and extensive Crohn's colitis confer increased risk for development of colorectal cancer. Screening and surveillance colonoscopy programs aim to identify, resect, or detect dysplasia or colorectal cancer. Dysplastic lesions can be removed by endoscopic resection and patients with unresectable lesions can be referred for colectomy at an earlier stage, with the goal of reducing overall morbidity and mortality from colorectal cancer. Surveillance colonoscopy for patients with inflammatory bowel disease (IBD) is endorsed by multiple specialty societies. High-definition endoscopy systems provide improved image resolution, and application of dilute indigo carmine or methylene blue for chromoendoscopy can provide increased contrast. International specialty society guidelines differ in their recommendations regarding use of chromoendoscopy for dysplasia surveillance, with some guidelines advocating a risk-stratified surveillance strategy. In this review, we discuss chromoendoscopy technique, training, implementation, yield as compared with standard-definition and high-definition white light colonoscopy, and positioning of this technique in clinical practice.

Vitamin D in pediatric age: consensus of the Italian Pediatric Society and the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Federation of Pediatricians

Vitamin D plays a pivotal role in the regulation of calcium-phosphorus metabolism, particularly during pediatric age when nutritional rickets and impaired bone mass acquisition may occur.Besides its historical skeletal functions, in the last years it has been demonstrated that vitamin D directly or indirectly regulates up to 1250 genes, playing so-called extraskeletal actions. Indeed, recent data suggest a possible role of vitamin D in the pathogenesis of several pathological conditions, including infectious, allergic and autoimmune diseases. Thus, vitamin D deficiency may affect not only musculoskeletal health but also a potentially wide range of acute and chronic conditions. At present, the prevalence of vitamin D deficiency is high in Italian children and adolescents, and national recommendations on vitamin D supplementation during pediatric age are lacking. An expert panel of the Italian Society of Preventive and Social Pediatrics reviewed available literature focusing on randomized controlled trials of vitamin D supplementation to provide a practical approach to vitamin D supplementation for infants, children and adolescents.

Assuring Quality for Non-hospital-based Biologic Infusions in Pediatric Inflammatory Bowel Disease: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

The primary aim of this Clinical Report by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition is to provide formal guidance to pediatric gastroenterologists and clinicians, health systems, and insurance payers regarding home- and office-based infusions for biologic therapies in pediatric inflammatory bowel disease. Patients in North America are increasingly denied coverage by payers based on "place of service" codes at hospital-based infusion units where the treating clinicians primarily provide care. A task force with topic expertise generated 8 best practice recommendations to ensure quality of care for pediatric patients with inflammatory bowel disease receiving non-hospital-based biologic infusions. Pragmatic considerations discussed in this report include patient safety, pediatric-trained nurse availability, care coordination, patient-centeredness, shared liability, administrative support, clinical governance, and costs of care.

Risk of tuberculosis among Alabama children and adolescents treated with tumor necrosis factor inhibitors: a retrospective study

BACKGROUND

Tumor Necrosis Factor inhibitors (TNFi) have dramatically improved the outlook for patients with inflammatory arthritides and bowel disease (IBD), but are associated with increased infection risks, including tuberculosis (TB). Pediatric inflammatory diseases are uncommon, and the risk of TB in children taking TNFi remains unclear. The objective of this study was to report the incidence of TB disease among TNFi recipients at a single pediatric medical center serving most of Alabama compared to that of the general population of Alabama children.

METHODS

Instances of TNFi usage among patients under age 20 years from July 1, 2007 through April 17, 2015 were captured from electronic health records at Children's of Alabama (CoA), which has the only pediatric rheumatology clinic in Alabama, and where a substantial number of children in Alabama with inflammatory bowel disease receive care., and reports of TB cases were obtained from the Alabama Department of Public Health (ADPH). Incidence was expressed as TB cases/10,000 person-years, using population estimates from the Alabama Center for Health Statistics.

RESULTS

1033 Alabama patients at CoA who were residents of Alabama were identified who received TNFi for a total of 1564 person-years. One adolescent on TNFi developed severe extrapulmonary TB (incidence density = 6.4 per 10,000; 95% CI 0.9-45.4 per 10,000). Sixty-three cases occurred in persons not on TNFi (incidence density = 0.064 per 10,000; 95% CI 0.050-0.082 per 10,000).

CONCLUSIONS

One case of TB disease among TNFi-exposed children was identified for 1564 person-years in Alabama residents. Although rare, this is higher than expected relative to the general rate of TB in Alabama. Thus, continued diagnostic vigilance for TB in children taking TNFi is required.

TRIAL REGISTRATION NUMBER

Not applicable.

Improving a process to obtain hepatitis B serology among patients treated with infliximab at a large urban children's hospital

BACKGROUND

Hepatitis B infection is a significant public health challenge despite improvements in vaccination efforts. Patients such as those on chronic immunosuppressive therapy for inflammatory bowel disease (IBD) or rheumatic disease may incur greater risk. The risk of reactivation of hepatitis B while on immunosuppressive therapy may have mortality rates up to 25%. These patients should be screened for acute or chronic infection and vaccinated if necessary. Our aim was to reliably complete hepatitis B screenings in patients receiving infliximab at Cincinnati Children's Hospital Medical Center (CCHMC).

METHODS

Eligible patients included all patients with gastroenterology (GI) IBD and rheumatology receiving infliximab between October 2015 and March 2016. Using quality improvement methodology and the 'plan-do-study-act' (PDSA) approach, interventions centred around education of clinical providers, previsit planning and the development of 'talking points' for patients.

RESULTS

An initial screen of the IBD population revealed that 48% of the IBD patient population had been screened for anti-HBs alone, but no patients from GI or rheumatology divisions had a complete set of hepatitis B serology prior to the intervention including anti-Hep B Core and Hep B Surface Antigen. Seven PDSA cycles were performed during the 32-week intervention period, resulting in an increase in patients screened from 0% to ~85%. By March 2016, a total of 251 patients (201 GI, 50 rheumatology) had up-to-date hepatitis B serology screening. Automated ordering of the hepatitis B serology and 'talking points' for the provider had the greatest impact on successful screening.

CONCLUSIONS

We developed a method to obtain hepatitis B serology on at-risk patients on infliximab within two subspecialty divisions within a large children's hospital. Next steps will be to develop a process to reliably provide vaccines for patients who are seronegative, expand this process to all patients who are identified as immunocompromised within GI and rheumatology and then expand this process to other divisions at the CCHMC.

Improving health maintenance supervision in a paediatric IBD clinic

Background

Previsit planning (PVP) has been an integral part of clinical care for paediatric patients with inflammatory bowel disease (IBD) at Cincinnati Children’s Hospital Medical Center since 2007. Over the past years, we have adopted several programmes to improve health maintenance supervision for our paediatric patients with IBD but did not have a sustainable way to provide health maintenance updates for every patient at every encounter that was concise and complete in the setting of an increasing patient population and fewer support staff to complete the work.

Methods

Using quality improvement methods, we completed several Plan-Do-Study-Act (PDSA) cycles aimed at improving our centre’s ability to provide complete health maintenance ‘bundle’ recommendations from 0% to 90% of patients over a period of 11 months.

Results

First steps included consensus gathering and summarising evidence into guidelines suitable for the group. PDSAs centred on consensus building from standardised guidelines, using empty checklists for simulated and real patients, and use of autofilled checklists. After several PDSA cycles, we have improved our ability to provide complete health maintenance PVP from 0% to nearly 100% with very little variation.

Conclusion

Using the health maintenance PVP process, we can now sustainably provide health maintenance guidance for all outpatient clinic visits. We have begun to scale up this work and anticipate over the coming months that we will be able to expand the health maintenance PVP to provide complete PVP for over 90% of patients for any scheduled encounter including biologic infusion visits. We anticipate that using this reliable process we can improve remission rates and reduce preventable infections for these at-risk patients.

Endoscopic recommendations for colorectal cancer screening and surveillance in patients with inflammatory bowel disease: Review of general recommendations

Screening for colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) is recommended by all scientific societies. However, there are differences in the recommendations they make regarding screening and surveillance. We address a series of questions that come up in the daily clinical practice of a physician. The first two questions that are raised are: (1) Who should be offered screening for CRC? and (2) When should the first colonoscopy be performed? The next step is to decide who should undergo endoscopic surveillance and at what intervals they should be performed. Chromoendoscopy is emerging as the recommended endoscopic technique for screening and surveillance. The terminology for describing lesions detected with endoscopy is also changing. The management of visible lesions or non-visible dysplasia is also a motive for the review. We end the review by addressing the follow-up for endoscopically resected lesions. These questions often cannot be answered easily due to the varying degrees of evidence available; therefore, we have made some general recommendations based on those made by the various guidelines and consensuses. The first screening colonoscopy should be offered 8 years after a IBD diagnosis and we recommend that patients be stratified according to the individual risk for each for endoscopic surveillance intervals.

Pediatric Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), including Crohn disease, ulcerative colitis, and IBD-unspecified, is a chronic immune-mediated condition of the gastrointestinal tract in which the goal of treatment is to induce and maintain durable remission. In pediatrics, there is a wide spectrum of presenting symptoms, but esophagogastroduodenoscopy and colonoscopy are imperative to confirming the diagnosis. Treatment goals include achieving mucosal healing of the gastrointestinal tract, reaching growth potential, limiting medication toxicities, and optimizing quality of life for all patients.

Diagnosis and management of inflammatory bowel disease in children

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are lifelong conditions that often begin in childhood. The implications of IBD are of particular importance in children because of the potential negative effects on growth, development, psychosocial function, and overall wellbeing. The key management strategy is to achieve sustained control of intestinal inflammation and monitor for potential complications of the disease and side effects of therapies. Overall, the evidence on the management of IBD in children is less extensive than in adults, but good quality multicenter studies and various guidelines and society consensus statements are available. This review summarizes the evidence on the pathophysiology, diagnosis, and approaches to management of children and adolescents with IBD.

Inflammatory Bowel Disease in Childhood and Adolescence

BACKGROUND

The incidence of inflammatory bowel disease (IBD) in childhood and adolescence is 5-11 cases per 100 000 persons per year, corresponding to a new diagnosis of IBD in 800-1470 patients in Germany each year.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, including guidelines from Germany and abroad.

RESULTS

Children and adolescents with IBD often have extensive involvement and an aggressive course of disease. Nonetheless, infliximab and adalimumab are the only biological agents that have been approved for this group of patients. In Crohn's disease, exclusive enteral nutrition is the treatment of first choice for inducing a remission. Patients with (peri-)anal fistulae are treated primarily with infliximab. Corticosteroids and aminosalicylates should be used with caution. In contrast, children and adolescents with ulcerative colitis are treated with either aminosalicylates or prednisolone to induce a remission. As a rule, maintenance pharmacotherapy with thiopurines in Crohn's disease and severe ulcerative colitis, or with aminosalicylates in mild to moderate ulcerative colitis, is indicated for several years, at least until the end of puberty. Patients with refractory disease courses are treated with methylprednisolone, anti-TNF-α-antibodies, and/or calcineurin inhibitors. The spectrum of surgical interventions is the same as for adults. Specific aspects of the treatment of children and adolescents with IBD include adverse drug effects, the areas of nutrition, growth, and development, and the structured transition to adult medicine.

CONCLUSION

Children and adolescents with IBD or suspected IBD should be cared for by pediatric gastroenterologists in a center where such care is provided. Individualized treatment with multidisciplinary, family-oriented longterm care is particularly important. Drug trials in children and adolescents are needed so that the off-label use of drugs to patients in this age group can be reduced.

Does clinical indication play a role in CT radiation dose in pediatric patients?

PURPOSE

The purpose of this study was to identify the main pathologies for which CT is applied on pediatric patients and the related radiation doses as reported in the literature in order to facilitate justification and CT optimization.

METHODS

A critical analysis of a literature review was performed. Different search engines were used such as PubMed, Google Scholar and Science Direct. Various terms and keywords were used to locate pertinent articles such as Pediatric, Computed tomography, Radiation Dose, Organ dose, Effective dose.

RESULTS

The results showed that the main pathologies for which CT is applied are: Crohn's disease, hydrocephalus, cystic fibrosis and pediatric malignancies-mainly lymphoma. The related radiation dose data are extremely scarce and are in the range of 3.48-17.56, 0.2-15.3mSv, 0.14-6.20mSv, and 2.8-518.0mSv, respectively. The radiation doses reported are high especially in pediatric oncology.

CONCLUSIONS

Pediatric patients with malignancies are those exposed to the higher levels of radiation during CT imaging. Literature is lacking reporting of dose in Pediatric CT imaging. More studies need to be realized for the determination of radiation dose in those patients. Special protocols need to be recommended in order to reduce the exposure of children in radiation.

Vitamin D in pediatric gastrointestinal disease

PURPOSE OF REVIEW

The purpose of this review is to examine the prevalence of vitamin D deficiency in pediatric gastrointestinal disease, specifically celiac disease and inflammatory bowel disease (IBD); to discuss the role of vitamin D and its deficiency in gastrointestinal disease pathophysiology; and to present current literature regarding diagnosis and treatment of vitamin D deficiency in these pediatric gastrointestinal diseases.

RECENT FINDINGS

Vitamin D deficiency is common in children with gastrointestinal symptoms and disease processes. In celiac disease, vitamin D status should be routinely assessed at the time of diagnosis and during subsequent follow up if deficient. There is growing evidence to suggest an inverse association between vitamin D and IBD activity; however, the therapeutic role of vitamin D in IBD patients requires further investigation.

SUMMARY

Suboptimal vitamin D status commonly occurs in children with gastrointestinal disease. It is advisable to check serum 25-hydroxy vitamin D levels in children with newly diagnosed celiac disease and IBD. In celiac disease, vitamin D status should be assessed during subsequent follow up if deficient. In IBD, 25-hydroxy vitamin D levels should be checked at least yearly. Therapy should be provided to maintain a level of greater than 30 ng/ml but less than 100 ng/ml; however, the ideal vitamin D dosing regimen to treat vitamin D deficiency and to maintain this optimum level remains unknown. The role of vitamin D as a therapeutic agent in IBD is still under investigation.

ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease

Recent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services at the same rate as general medical patients. Patients with IBD often consider their gastroenterologist to be the primary provider of care. To improve the care delivered to IBD patients, health maintenance issues need to be co-managed by both the gastroenterologist and primary care team. Gastroenterologists need to explicitly inform the primary care provider of the unique needs of the IBD patient, especially those on immunomodulators and biologics or being considered for such therapy. In particular, documentation of up to date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations. Health maintenance issues addressed in this guideline include identification, safety and appropriate timing of vaccinations, screening for osteoporosis, cervical cancer, melanoma and non-melanoma skin cancer as well as identification of depression and anxiety and smoking cessation. To accomplish these health maintenance goals, coordination between the primary care provider, gastroenterology team and other specialists is necessary.

Variation in inflammatory bowel disease care among saudi pediatric gastroenterologists

BACKGROUND/AIM

Although international guidelines in inflammatory bowel disease (IBD) management are currently available, variations in IBD care still exist. The aim of this study was to determine the extent of the variation in IBD care among Saudi pediatric gastroenterologists.

MATERIALS AND METHODS

A cross-sectional survey was conducted among all pediatric gastroenterologists who were members of the Saudi Society of Pediatric Gastroenterology, Hepatology, and Nutrition (SASPGHAN) from August 2015 to December 2015. The questionnaire included items on demographic characteristics and utilization of different diagnostic and therapeutic interventions in IBD care.

RESULTS

Of the 45 registered pediatric gastroenterologists surveyed, 37 (82%) returned the survey from 20 centers across the country; 75.7% were practicing in tertiary care centers. There was a considerable variation in the use of different diagnostic tests during the initial evaluation of the disease. Utilization of calprotectin assays, magnetic resonance imaging enterography, and bone densitometry seemed to vary the most between physicians practicing at tertiary and secondary care centers. There were statistically significant differences in the prescription of biological therapy between the two groups.

CONCLUSIONS

We found a considerable variation in the use of different diagnostic and therapeutic interventions in the management of pediatric IBD patients. Such variations could lead to unintended differences in patient outcomes. Implementation of the available evidence-based guidelines may limit such variations and ultimately could improve the quality of IBD care provided.

Crohn's Disease and Gynecologic Manifestations in Young Women

STUDY OBJECTIVE

The purpose of this study was to describe the reproductive and gynecological concerns of young women with Crohn's disease.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective chart review of young women with Crohn's disease and gynecologic concerns at a large, urban tertiary children's hospital.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Documentation of abnormal bleeding, pelvic pain, genital fistula, ulcer, or abscess.

RESULTS

Most of the patients (85.7%) had menstrual concerns reported as abnormal bleeding patterns or chronic pelvic pain. Genital complaints (fistula, ulcer, or abscess) were present in 75% of patients who ultimately required immune modulators or antibiotics to control their Crohn's disease. Genital complaints were present in only 1 of 3 patients who did not have a history of immune modulator use for Crohn's disease related flare.

CONCLUSION

There is a paucity of information available on gynecological concerns occurring in patients with Crohn's disease. Providers should be aware of gynecological manifestations that might appear concurrently with Crohn's colitis, including vulvovaginal pain, vulvar infections, rectovaginal or rectovestibular fistulas, pelvic pain, and menstrual irregularities.

Top-down Versus Step-up Prescribing Strategies for Tumor Necrosis Factor Alpha Inhibitors in Children and Young Adults with Inflammatory Bowel Disease

BACKGROUND

Early initiation of tumor necrosis factor-alpha inhibitor (TNFI) therapy for children and young adults with inflammatory bowel disease (IBD) is not well described.

METHODS

We conducted a retrospective cohort study of children and young adults (≤24 yr) newly diagnosed with IBD using health insurance claims from 2009 to 2013. The conventional "step-up" approach was defined as TNFI initiation >30 days after first IBD medication prescription, whereas the "top-down" approach was defined as new TNFI prescription within 30 days of first IBD medication prescription. Switching rates, time to initiation, discontinuation, and adherence to TNFIs were compared between the 2 strategies.

RESULTS

A total of 11,962 IBD patients were identified. Among 3300 TNFI users, 1298 (39.3%) were treated with the top-down approach, whereas 2002 (60.7%) were treated with the step-up approach. Top-down approach use increased from 31.4% to 49.8% during the 5-year period, and under this approach, most patients were treated with TNFIs alone. Time to TNFI initiation was shorter for patients diagnosed in more recent years. Patients treated with the top-down strategy had lower rates of corticosteroid use (32.5% versus 94.2%) compared with step-up treatment but presented a higher rate of TNFI discontinuation. The 2 strategies both exhibited high adherence (mean proportion of days covered: 83.7%-95.4%).

CONCLUSIONS

Early TNFI initiation increased over time for children and young adults with IBD and was related to lower rates of corticosteroid use compared with the conventional approach. However, the higher rate of TNFI discontinuation under the top-down approach requires further examination.

Patient-reported Anxiety: A Possible Predictor of Pediatric Inflammatory Bowel Disease Health Care Use

BACKGROUND

Anxiety is linked with adverse health-related outcomes and increased health-seeking behaviors among patients with chronic illness. Yet, this relationship has received little attention in pediatric inflammatory bowel disease. The aim of this study was to examine whether anxiety symptoms predicted youth at increased risk for repeated disease relapse and greater gastrointestinal health care use over the subsequent 12 months.

METHODS

Eighty-six pediatric patients aged 11 to 18 years (M = 14.7, SD = 2.0), and their caregivers completed a validated anxiety questionnaire during a gastrointestinal specialty appointment (baseline). Medical records were reviewed for the subsequent year to record the number of disease relapses and gastrointestinal health care services and generate disease activity scores at baseline and 12 months. Analysis of variance was used to examine anxiety levels between those who experienced ≤1 versus ≥2 disease relapses. Poisson regressions were used to model the relationship between child- and caregiver-reported anxiety and health care use, controlling for disease activity.

RESULTS

The sample was predominantly white (81%) and male (56%). Patients with higher anxiety at baseline (M = 19.6; SD = 13.7) had more frequent (≥2) disease relapses compared with those with lower anxiety at baseline (M = 12.6; SD = 10.3). Higher anxiety, irrespective of reporter, also predicted greater total gastrointestinal health care use (P < 0.01). This included hospital-based interventions (P < 0.01), but not office encounters or outpatient endoscopic procedures. Findings remained significant after controlling for disease severity (P < 0.05).

CONCLUSIONS

Assessment of anxiety may be one mechanism by which to identify those youth who are most vulnerable for disease exacerbation and costly interventions in the near future.

Health Care Maintenance for the Pediatric Patient With Inflammatory Bowel Disease

Nearly one-quarter of patients with inflammatory bowel disease (IBD) are younger than 20 years of age at diagnosis. Furthermore, the incidence of IBD in children continues to increase. Nevertheless, variation in management exists within the care of patients with IBD with regards to disease screening and preventive care. A multidisciplinary approach that involves the general practitioner and pediatric gastroenterologist is needed to routinely monitor growth, bone health, vitamin and mineral deficiencies, vaccination status, and endoscopic surveillance. It is also important to monitor for extraintestinal manifestations of IBD that may affect the liver, joints, skin, and eyes. The purpose of this article is to provide an updated overview of comprehensive care for pediatric patients with IBD.

Surgery in Pediatric Crohn Disease: Case Series from a Single Tertiary Referral Center

Introduction

There is a recognized increase of lifelong surgery risk in Crohn disease (CD). Outcome data concerning surgery in children, particularly in the biological era, are limited.

Aim

To characterize the clinical profile and the clinical outcome in children and adolescents with CD who underwent surgical intervention, in a single tertiary referral center.

Methods

Retrospective, cross-sectional study, including pediatric patients with CD undergoing intra-abdominal surgery in the last 11 years.

Results

Included eight of 50 CD total patients (16%); six female; median age at CD diagnosis of 12.0 years; Paris classification: (a) location: ileocolonic (5), colonic (1), upper disease (1), ileocolonic/upper disease (1); (b) behavior: stricturing (4), nonstricturing nonpenetrating (2), penetrating (1), both penetrating and stricturing disease (1); growth delay (2). Six children received thiopurines, five mesalazine, three corticosteroids and four anti-TNF therapy, preoperatively. Surgery followed diagnosis by a median of 2.9 years. Median PCDAI at the time of surgery was 35.0. Elective surgery was performed in six patients and emergency surgery in two, without major complications. Five children received anti-TNF and three thiopurines post-operatively. Within the follow-up period (median 1.7 years), relapse occurred in one child (3.2 years after intervention); the remaining seven patients persist in clinical remission. Median PCDAI in the last evaluation was 6.3. Weight and height recovery was observed in seven patients, at last follow-up.

Conclusion

Surgical treatment of CD is a valid alternative in selected cases, contributing to the resolution of acute complications and maintenance of remission, allowing disease-free interval and nutritional recovery.

Measuring Quality in Pediatric Endoscopy

Measuring quality in endoscopy includes the assessment of appropriateness of a procedure and the skill with which it is performed. High-quality pediatric endoscopy is safe and efficient, used effectively to make proper diagnoses, is useful for excluding other diagnoses, minimizes adverse events, and is accompanied by appropriate documentation from beginning through end of the procedure. There are no standard quality metrics for pediatric endoscopy, but proposed candidates are both process and outcomes oriented. Both are likely to be used in the near future to increase transparency about patient outcomes, as well as to influence payments for the procedure.

Challenges in the Medical and Surgical Management of Chronic Inflammatory Bowel Disease

Inflammatory bowel disease patients will likely come to the surgeon's attention at some point in their course of disease, and they present several unique anatomic, metabolic, and physiologic challenges. Specific and well-recognized complications of chronic Crohn disease and ulcerative colitis are presented as well as an organized and evidence-based approach to the medical and surgical management of such disease sequelae. Topics addressed in this article include intestinal fistula and short bowel syndrome, pouch complications, and deep venous thrombosis with emphasis placed on optimization of the patient's physiologic state for best outcomes.

Nutritional aspect of pediatric inflammatory bowel disease: its clinical importance

Inflammatory bowel disease (IBD) is a chronic inflammatory disease mainly affecting the gastrointestinal tract. The incidence of the disease is rapidly increasing worldwide, and a number of patients are diagnosed during their childhood or adolescence. Aside from controlling the gastrointestinal symptoms, nutritional aspects such as growth, bone mineral density, anemia, micronutrient deficiency, hair loss, and diet should also be closely monitored and managed by the pediatric IBD team especially since the patients are in the development phase.

Single High-Dose Oral Vitamin D3 Therapy (Stoss): A Solution to Vitamin D Deficiency in Children With Inflammatory Bowel Disease?

OBJECTIVES

Vitamin D deficiency is common in children with inflammatory bowel disease (IBD). The aim of this study was to determine the safety and efficacy of stoss therapy on vitamin D levels during a period of 6 months in children with IBD and vitamin D deficiency (<50 nmol/L).

METHODS

A retrospective chart review was undertaken, focusing upon children managed in the IBD clinic at Sydney Children's Hospital between 2006 and 2010. Those with a 25-hydroxyvitamin D (25-OHD) level <50 nmol/L and those who received stoss therapy were included in this study.

RESULTS

A total of 76 children received stoss therapy. There was a significant and sustained increase in 25-OHD levels at all of the time points compared with baseline (40.8 ± 7.5 nmol/L), 1 month (145.6 ± 51.8 nmol/L), 3 months (87.1 ± 28.4 nmol/L), and 6 months 69.2 ± 31.3 nmol/L). There were no significant changes in serum calcium, phosphate, or parathyroid hormone at any time points.

CONCLUSIONS

Stoss therapy safely and effectively achieved and maintained a level of 25-OHD >50 nmol/L during 6 months in these children with IBD. Further prospective studies are now required to confirm this finding and establish whether this intervention has other benefits.

Immunizations in Pediatric and Adult Patients with Inflammatory Bowel Disease: A Practical Case-based Approach

As the treatment of inflammatory bowel disease (IBD) becomes more complex and increasingly relies on combinations of immunosuppression in patients with moderate to severe ulcerative colitis or Crohn's disease, the provider must be aware of recommendations for the appropriate use of vaccines-both inactivated and live. The timing and type of vaccination required may be altered based on the underlying medical treatment for the IBD. In some instances, titers may be required to assess for vaccine response. Vaccination recommendations have changed dramatically over the past 5 years with direct implications for the protection of the patients with IBD. There are several newly licensed vaccines and new recommendations by the U.S. Advisory Committee on Immunization Practices and Infectious Diseases Society of America defining degrees of immunosuppression and the use of certain live vaccines based on these levels. This review provides a case-based approach to vaccinating the pediatric and adult patients with IBD, with an emphasis on practicality. Case scenarios include children and adults with newly diagnosed and chronic IBD. Recommendations for vaccine management in these scenarios are provided, including special circumstances such as pregnancy and infant vaccinations when the mother is receiving immunosuppressive medication.

Vaccination coverage of children with inflammatory bowel disease after an awareness campaign on the risk of infection

BACKGROUND

Children with inflammatory bowel disease are at risk of vaccine-preventable diseases mostly due to immunosuppressive drugs.

AIM

To evaluate coverage after an awareness campaign informing patients, their parents and general practitioner about the vaccination schedule.

METHODS

Vaccination coverage was firstly evaluated and followed by an awareness campaign on the risk of infection via postal mail. The trial is a case-control study on the same patients before and after the awareness campaign. Overall, 92 children were included. A questionnaire was then completed during a routine appointment to collect data including age at diagnosis, age at data collection, treatment history, and vaccination status.

RESULTS

Vaccination rates significantly increased for vaccines against diphtheria-tetanus-poliomyelitis (92% vs. 100%), Haemophilus influenzae (88% vs. 98%), hepatitis B (52% vs. 71%), pneumococcus (36% vs. 57%), and meningococcus C (17% vs. 41%) (p<0.05). Children who were older at diagnosis were 1.26 times more likely to be up-to-date with a minimum vaccination schedule (diphtheria-tetanus-poliomyelitis, pertussis, H. influenzae, measles-mumps-rubella, tuberculosis) (p=0.002).

CONCLUSION

Informing inflammatory bowel disease patients, their parents and general practitioner about the vaccination schedule via postal mail is easy, inexpensive, reproducible, and increases vaccination coverage. This method reinforces information on the risk of infection during routine visits.

Effectiveness and safety of ferric carboxymaltose treatment in children and adolescents with inflammatory bowel disease and other gastrointestinal diseases

Background

The treatment of iron deficiency anemia in children with inflammatory bowel disease is a particular challenge and often insufficient. Absorption of orally given iron may be impaired by intestinal inflammation and treatment with oral iron may aggravate intestinal inflammation. This retrospective study is the first to describe the use of intravenous ferric carboxymaltose (FCM) in the pediatric setting.

Methods

All subjects who had received at least one dose of FCM intravenously in the observation period were included in this analysis with data collected for up to 3 months post last FCM dose.

Results

In total, 72 children between 0 and 18 years with underlying gastrointestinal disorders had been treated for concomitant iron deficiency anemia. The majority of patients had Crohn’s disease (40.3%) or ulcerative colitis (30.5%). The total number of FCM administrations was 147, the mean number per patient was 2.0 and the mean cumulative dose 821 mg iron (median single dose: 500 mg; max. 1000 mg). Post administration of FCM, correction of iron deficiency anemia was observed with improved mean hemoglobin levels from 9.5 g/dL at baseline to 11.9 g/dL within 5–12 weeks. Decreases in white cell count, platelets and C-reactive protein were observed post FCM, potentially suggesting reduced inflammation with iron repletion. Three subjects reported mild adverse drug reactions related to FCM; two of these were considered to be potentially related to long duration of administration and to high volume of saline solution for dilution. As such, the method of administration was amended to have a maximum infusion time of 60 minutes and dilution with less than or equal to 100 mL saline solution.

Conclusions

Overall FCM was well tolerated in this pediatric population and appeared to be effective in correcting iron deficiency anemia. We cannot exclude that the correction of iron deficiency anaemia is in some part due to the treatment of the underlying disease and not related to the iron supplementation only.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-230X-14-184) contains supplementary material, which is available to authorized users.

Toward a consensus on endoscopic surveillance of patients with colonic inflammatory bowel disease

Surveillance colonoscopy in patients with inflammatory bowel disease (IBD) with colonic involvement is recommended by multiple national and international gastrointestinal societies. Recommendations differ on the timing of initial screening colonoscopy, recommended surveillance intervals, optimal technique for dysplasia detection, and management of endoscopically visible and nonvisible dysplasia. This article reviews current society guidelines, highlighting similarities and differences, in an attempt to summarize areas of consensus on surveillance protocols in IBD, while drawing attention to controversial areas in need of further research.

The effect of immunomodulators and biologics on indication for surgical bowel resection in children with Crohn's disease

BACKGROUND

Despite advances in medical therapies, many children with Crohn's disease (CD) will require bowel resection. Although previous registry studies have attempted to identify risk factors for surgery, the effect of immunomodulators and biologics (IMB) on surgical indications has not been well characterized.

METHODS

We reviewed a series of 125 children with CD who underwent bowel resection with reanastomosis between 1977 and 2011 and were followed up for at least 6 months. We compared patients who underwent surgery for perforating disease (abscess or internal fistula) and patients who were operated on for medically refractory or fibrostenosing disease. Between these 2 groups, we examined medications received before surgery. Other demographic and disease-specific covariates were examined.

RESULTS

Of the 82 patients who received IMB before surgery, only 19 patients (23%) required surgery for a perforating complication of CD, whereas 63 patients (77%) required surgery for strictures or medically refractory disease. In contrast, of the 43 patients who did not receive IMB preoperatively, 20 patients (45%) developed a perforating complication and 23 patients (53%) required surgery for strictures or refractory disease. These differences across groups were significant, with a lower rate of operation for perforating disease among patients receiving preoperative IMB therapy (P = 0.007).

CONCLUSIONS

In our surgical cohort, children with CD who were treated with IMB were less likely to have surgery for perforating disease. This finding raises the possibility that the administration of IMB in children who require surgery may be associated with a difference in disease behavior.

Nutrition in pelvic radiation disease and inflammatory bowel disease: similarities and differences

Due to the intestinal inflammation, tissue damage, and painful abdominal symptoms restricting dietary intake associated with both diseases, patients with intestinal pelvic radiation disease (PRD) or inflammatory bowel disease (IBD) are at increased risk to develop protein calorie malnutrition and micronutrient deficiencies. In the current paper, we review the nutritional management of both diseases, listing the similar approaches of nutritional management and the nutritional implications of intestinal dysfunction of both diseases. Malnutrition is prevalent in patients with either disease and nutritional risk screening and assessment of nutritional status are required for designing the proper nutritional intervention plan. This plan may include dietary management, oral nutritional supplementation, and enteral and/or parenteral nutrition. In addition to managing malnutrition, nutrients exert immune modulating effects during periods of intestinal inflammation and can play a role in mitigating the risks associated with the disease activity. Consistently, exclusive enteral feeding is recommended for inducing remission in pediatric patients with active Crohn's disease, with less clear guidelines on use in patients with ulcerative colitis. The field of immune modulating nutrition is an evolving science that takes into consideration the specific mechanism of action of nutrients, nutrient-nutrient interaction, and preexisting nutritional status of the patients.

Modifications in endoscopic practice for pediatric patients

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

Immunization status in children with inflammatory bowel disease

Inflammatory bowel diseases have an increased risk of infections due to immunosuppressive therapies. To report the immunization status according to previous recommendations and the reasons explaining a delay, a questionnaire was filled in by the pediatric gastroenterologist, concerning outpatients, in six tertiary centers and five local hospitals, in a study, from May to November 2011. One hundred and sixty-five questionnaires were collected, of which 106 Crohn's diseases, 41 ulcerative colitis, and 17 indeterminate colitis. Sex ratio was 87:78 M/F. Median age was 14.4 years old (4.2-20.0). One hundred and nine patients (66 %) were receiving or had received an immunosuppressive therapy (azathioprine, infliximab, methotrexate, or prednisone). Vaccines were up to date according to the vaccine schedule of French recommendations in 24 % of cases and according to the recommendations for inflammatory bowel disease in 4 % of cases. Coverage by vaccine was the following: diphtheria-tetanus-poliomyelitis 87 %, hepatitis B 38 %, pneumococcus 32 %, and influenza 22 %. Immunization delay causes were as follows: absence of proposal 58 %, patient refusal 41 %, fear of side effects 33 %, and fear of disease activation 5 %. Therefore, immunization coverage is insufficient in children with inflammatory bowel disease, due to simple omission or to refusal. A collaboration with the attending physicians and a targeted information are necessary.

Effectiveness and cost-effectiveness of measuring fecal calprotectin in diagnosis of inflammatory bowel disease in adults and children

BACKGROUND & AIMS

The level of fecal calprotectin (FC) can predict the onset of inflammatory bowel disease (IBD) with high accuracy and precision. We evaluated the cost-effectiveness of using measurements of FC to identify adults and children who require endoscopic confirmation of IBD.

METHODS

We constructed a decision analytic tree to compare the cost-effectiveness of measuring FC before endoscopy examination with that of direct endoscopic evaluation alone. A second decision analytic tree was constructed to evaluate the cost-effectiveness of FC cutoff levels of 100 μg/g vs 50 μg/g (typically used to screen for intestinal inflammation). The primary outcome measure was the incremental cost required to avoid 1 false-negative result by using FC level to diagnose new-onset IBD.

RESULTS

In adults, FC screening saved $417/patient but delayed diagnosis for 2.2/32 patients with IBD among 100 screened patients. In children, FC screening saved $300/patient but delayed diagnosis for 4.8/61 patients with IBD among 100 screened patients. If endoscopic biopsy analysis remained the standard for diagnosis, direct endoscopic evaluation would cost an additional $18,955 in adults and $6250 in children to avoid 1 false-negative result from FC screening. Sensitivity analyses showed that cost-effectiveness of FC screening varied with the sensitivity of the test and the pre-test probability of IBD in adults and children. Pre-test probabilities for IBD of ≤75% in adults and ≤65% in children made FC screening cost-effective, but it was cost-ineffective if the probabilities were ≥85% and ≥78% in adults and children, respectively. Compared with the FC cutoff level of 100 μg/g, the cutoff level of 50 μg/g cost an additional $55 and $43 for adults and children, respectively, but it yielded 2.4 and 6.1 additional accurate diagnoses of IBD per 100 screened adults and children, respectively.

CONCLUSIONS

Screening adults and children to measure fecal levels of calprotectin is effective and cost-effective in identifying those with IBD on a per-case basis when the pre-test probability is ≤75% for adults and ≤65% for children. The utility of the test is greater for adults than children. Increasing the FC cutoff level to ≥50 μg/g increases diagnostic accuracy without substantially increasing total cost.

Thickened gastrointestinal wall findings on computed tomography in children: a reason for endoscopy?

OBJECTIVES

Bowel wall thickening on computed tomography (CT) scans in children may raise concern for inflammatory bowel disease (IBD). The significance of this radiological finding is unclear. Our purpose was to evaluate the clinical outcomes with regard to IBD in children with no known underlying disease, presenting with abdominal pain and thickened bowel wall on CT scan.

METHODS

A retrospective analysis of pediatric patients with abdominal pain and CT findings of thickened bowel wall was performed between 2006 and 2010. Endoscopic findings, clinical variables, and follow-up assessments were evaluated.

RESULTS

Fifty-six patients presenting with abdominal pain and thickened bowel wall findings on CT scan were identified. Overall, 30 (54%) had terminal ileum wall thickening, 17 (30%) had isolated colonic wall thickening, and 9 (16%) had other small bowel wall thickening. Of the 56 patients, 21 (38%) underwent endoscopy, of which 14 (67%) had positive findings-11 (79%) had histologic evidence of chronic colitis, and 5 (36%) had duodenitis/ileitis. Ultimately, 11/56 (20%) were diagnosed as having IBD, 8/56 (14%) with functional abdominal pain/constipation, 9/56 (16%) appendicitis, 10/56 (18%) infectious gastroenteritis, and 18/56 (32%) with miscellaneous diagnoses. Median levels of erythrocyte sedimentation rate, C-reactive protein, albumin, and platelet count were significantly abnormal in the IBD group compared to the non-IBD group. Additional follow-up of those who did not undergo endoscopic evaluation revealed no new diagnoses of IBD.

CONCLUSIONS

The presence of thickened bowel wall on CT scans is a nonspecific finding in children. Laboratory evaluation may help distinguish which patients require additional evaluation and endoscopy.

Colorectal considerations in pediatric patients

Colorectal disease in pediatric patients includes a spectrum of diseases, many of which have a significant impact on quality of life and warrant long-term follow-up and treatment into adulthood. Although many diseases, such as inflammatory bowel disease and colon cancer, are managed similar to adults, other disease processes are more common to pediatric patients and are the focus of this article.