Laurie S. Conklin, M.D. Inflammatory Bowel Disease Program Children s National Medical Center
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1 Laurie S. Conklin, M.D. Inflammatory Bowel Disease Program Children s National Medical Center
2
3 CROHN S DISEASE Patchy inflammation Mouth to anus involvement Full-thickness inflammation Variable involvement Fistulas Abscesses Strictures Extraintestinal manifestations Increased risk of cancer ULCERATIVE COLITIS Continuous inflammation Colon only Superficial inflammation Variable involvement Increased risk of cancer Extraintestinal manifestations Indeterminate colitis 10% 15%
4 The etiology of IBD is multifactorial Intestinal Sensing of Bacteria Diet? Geography? Environmental Factors Stress? Susceptibility Genes Immune System IBD Modifier Genes
5 Ng, et al. Gut :
6 Growth/Nutritional Assessment Bone Health Mental Health Immunizations Health screenings
7 Malabsorption Increased metabolic demand Decreased nutrient intake Inflammatory Cytokines (i.e. TNFα, IL-6) Malnutrition Corticosteroids Decreased Growth Velocity Conklin LS & Oliva-Hemker M, Exp Reviews Gastroent 2010
8 Delayed bone age is common in CD
9 Nutritional Failure: Wt % crossing 2 percentiles Weight loss 10% Weight 10% Growth Failure Height % crossing 2 percentiles Height velocity < 3% Height % < 3%
10 Eating can cause significant symptoms in patients with IBD The search for alternate natural or complementary options No specific foods cause IBD or cause flares of disease
11 Ulcerative Colitis Potassium Magnesium Iron Vitamin D Calcium Folate (sulfasalazine) Crohn s Disease Vitamin D Calcium Vitamin B12 Folate Magnesium Iron Potassium
12 Eat small, frequent meals Identify trigger and safe foods Keep a food journal When disease is under control, return to fiber-containing foods
13 10-40% of children with Crohn s have bone mass deficits at diagnosis May affect attainment of peak bone mass Risk of fracture Slowed linear growth Bone modeling and remodeling is affected by proinflammatory cytokines
14 Manage inflammation Optimize nutrition Weight bearing exercise
15 Patients with Crohn s Disease, or exposure to steroids If low BMD, repeat in a year Low BMD and history of fracture may benefit from a referral to a pediatric endocrinologist or Bone Health clinic
16 Prevalence of Vitamin D deficiency in pediatric IBD = 34.6% Oral doses of 2,000 IU vitamin D(3) daily and 50,000 IU vitamin D(2) weekly for 6 12 weeks 1 1 Pappa et al. J Clin Endo Metab 2012: 97:
17 25% of adolescents with IBD may display symptoms of depression **97% of these would have gone unrecognized without being queried Depression correlated with pain, diarrhea, weight loss
18 Cognitive Behavioral Therapy Hypnosis Family/patient support Szigethy E, et al. J Am Acad Child Adolesc Psychiatry 2007;46:1290 Mawdsley, et al. Am J Gastroenterol 2008;103: Shepanski, et al. Inflamm Bowel Dis 2005;11:
19 All inactivated vaccines Diptheria Acellular tetanus Pertussis HBV Haemophilus influenza Inactivated polio Pneumococcus Hepatitis A Influenza
20 (Prednisone> 20 daily or 2 mg/kg/day for at least 14 days) Immunomodulators (6MP, methotrexate) Biologics (infliximab, adalimumab)
21 MMR- avoid, live vaccine Varicella-- * check titers ahead of immunomodulation and vaccinate if time Hepatitis B- check HepB SAg and Ab before starting biologics
22 Uveitis 6.1% pediatric Crohn s with no ophthalmologic complaints had uveitis Findings are independent of bowel inflammation Episcleritis Tends to parallel bowel inflammation.
23 Increased risk for melanoma associated with IBD Possible association with biologics Absolute risk 57/100,000 patient years (44.1/100,000 in normal cohort Non-melanoma skin cancer risk associated with IBD and thiopurines Absolute risk 912/100,000 patient years (623/100,000 in normal cohort)
24 Non-adherence linked to disease severity and poor psychosocial functioning How many doses of your medication have you missed this past week? Behavioral, organizational, educational, familycentered interventions
25 In children with IBD, 43.6% use CAM in addition to prescribed medication Spiritual intervention Nutritional interventions Herbal Remedies Alternative Practices
26 Camp Oasis CCFA Parent support groups
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