Issues in the Management of Paediatric IBD
Issues in the Management of Paediatric IBD
Meeting date: March 31, 2000
Venue: Sky City Conference Centre, Auckland.
Issues relating to the management of inflammatory bowel disease
(IBD) in children were addressed by 3 different speakers at the
Ferring IBD symposium. Dr Simon Chin spoke about the medical
management of paediatric IBD, while nutritional issues were covered
by Dr Alison Wesley, and Professor Spencer Beasley discussed
surgical indications and options ("paediatric" was
defined as less than 19 years of age).
Medical Management
Dr Chin started his presentation by reporting some IBD statistics. In the UK during 1998-1999 there were 5.5 cases of IBD diagnosed per 100,000 people per year; 60% of these cases were Crohn's disease, 23% were ulcerative colitis and 13% were indeterminate colitis. The mean age at diagnosis was 11.9 years, with 3% being diagnosed at less than 5 years of age. Closer to home, information from the Australian Paediatric and Adolescent IBD database, which includes patients aged < 15 years shows that 54% of the 770 patients included had Crohn's disease, 32% had ulcerative colitis and 15% had indeterminate colitis - quite similar to the UK figures. 30 children have been diagnosed with IBD at Starship Children's Hospital in Auckland over the last 5 years, with an equal distribution of Crohn's disease and ulcerative colitis.
Goals
Some of the goals of medical management of IBD in children are
the same as those in adults, namely induction and maintenance
of remission, and to minimise toxicity and side effects. Additional
aims in paediatric patients are normal growth and development,
and to discourage over-restriction of daily activities.
Special issues
For children and their families issues related to the diagnosis
of IBD include the unpredictable nature of symptoms with no "cure",
delayed growth and sexual maturation, adverse cosmetic effects
of corticosteroids, interference with social activities, school
absenteeism, increased depression and low self esteem (especially
in teenagers), parental guilt, over-restriction of social and
sporting activities, and school/social issues such as taking
medication and the availability of toilet facilities.
Ulcerative colitis
Medical treatment varies according to disease severity. 5-Aminosalicylic
acid (5-ASA) preparations such as Pentasa are the mainstay of
therapy in those with mild disease, while corticosteroids are
often required in moderate disease. These are usually tapered
as quickly as possible, while an alternate day regimen might
be tried to decrease effects on growth. Budesonide appears to
be a promising alternative, but few data are available yet. If
a patient with moderate disease does not respond to steroids,
another immunosuppressant such as azathioprine might be tried,
with 70% of patients then able to taper and stop steroid therapy.
Intravenous therapy with steroids and other immunosuppressants
may be required in severe disease.
With respect to azathioprine and 6-mercaptopurine, Dr Chin said that the use of these agents in children is increasing, mainly because of their ability to allow the steroid dosage to be reduced.
US study data show that 90% of patients with mild ulcerative colitis and 80% of those with moderate-to-severe disease achieve remission after 6 months. Overall, 10% of patients will have chronic symptoms and 7% will have long-term, ongoing remission. The extent of disease did not predict disease activity.
Crohn's disease
As for ulcerative colitis, the first "port of call"
in medical therapy is the 5-ASA preparations. These agents are
also useful for the maintenance of remission. Steroids can be
added, at a usual dosage of 1-2 mg/kg/day (maximum 60 mg/day).
Budesonide is also an option. Once again, steroid dosages are
often able to be reduced if azathioprine or 6-mercaptopurine
are added. However 8-10% of patients will be unable to tolerate
these agents.
In a study with a 6.5-year follow-up, 42% of paediatric Crohn's disease patients ultimately required surgery. The outcome after surgery was related to the site of disease.
Other options
Alternative treatments mentioned by Dr Chin included fish oil,
herbal preparations and thalidomide, which has been shown to
be beneficial in some male adolescent patients. The herbal options
are often something that parents feel they would like to explore,
said Dr Chin.
Nutritional Aspects
Nutrition is an important aspect of IBD management in children. Dr Wesley stated that decreased nutrient intake has a big impact on the growth rate in children with IBD, irrespective of any adverse effects of steroids. She continued to stress that although steroid treatment can affect growth velocity, nutrient intake has a much bigger impact on growth parameters.
Some tips for managing paediatric patients include monitoring food intake (eg. a 5-day food diary, in consultation with a dietician), regular height and weight measurement, and monitoring of puberty onset.
In patients with Crohn's disease, disease severity is a major predictor of ultimate height and weight obtained. Most nutrients are absorbed in the small bowel, so disease here has the biggest impact on growth. Similar findings are observed for colonic disease.
What can we do?
oral supplements (but compliance with these decreases over time)
naso-gastric feeding (long-term compliance not very good, especially
in IBD)
gastrostomy feeding (good in selected patients)
One point that Dr Wesley stressed is that nutritional interventions must be performed before bony epiphyseal fusion occurs if growth is to be improved.
Nutrition as primary therapy
This was initially thought to be useful because it is hypoallergenic (elemental formula) and it is absorbed in the duodenum and proximal jejunum therefore the faecal stream is reduced. Elemental diets appear to be more useful for small bowel disease, and sometimes provide an alternative to bowel resection. They may also be useful to decrease relapse after surgery. Collated data from a number of studies (mostly in adults) showed that treatment with steroids was more effective than an elemental diet at inducing and maintaining remission.
Surgery
Professor Beasley also provided some data on the prevalence of IBD in children. He stated that IBD is increasing in children with "more and more presenting younger and younger". New Zealand has shown an increase in the incidence of Crohn's disease from the late '80s and early 90's. There does not appear to have been any increase in the incidence of ulcerative colitis over the same time. Professor Beasley reported that the age at diagnosis of IBD is decreasing and that many patients presenting for the first time are very sick. In addition, the distribution of Crohn's disease in children is wider than that in adults, that is more extensive disease, or disease at a greater number of sites.
Professor Beasley stated that surgery in paediatric IBD is not curative, and relapse is common. For surgery to be effective in increasing growth it is necessary to remove all of the affected bowel and, as for nutritional interventions, must be performed before or up to the first stages of puberty. However, growth can be seen up to 17 years of age after surgery.
Indications for surgery in children with Crohn's disease include:
abscess
stricture/obstruction
steroid-resistant disease
perianal disease
localised disease
steroid-dependent disease with growth failure.
Predictors of the disease-free interval after surgery include longer remission when surgery is for stenosis, fistula or abscess treatment, and shorter remission when surgery is for colonic disease or for persistent disease refractory to medical therapy.
Professor Beasley stressed that good communication between
physicians and surgeons is crucial for the successful management
of IBD in children.
(written by Nicola Ryan)
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