Health Supervision / Management of  IBD in Pediatric patients

Summary of NASPGHAN recommendations:

• Incidence 7/100k (Canada 14/100k)
  
• Estimated prevalence - 20/100k

• Diarrhea and abdominal pain
• Rectal bleeding
• Fever
• Weight loss
• Perianal disease (fistula, skin tag
• Micronutrient deficiency
• Iron
• Zinc
• Folate
• B12
• Vit D
• Calcium
• Deceleration of linear growth
• Erythema nodosum (painful lesions on shins)
• Pyoderma gangrenosum (ulcerated lesions)
• Ocular findings (uveitis, iritis, episcleritis)
• Joint findings
• Psychosocial effects of disease, treatments, and effects on social life/ quality of life

• Initial
• CBC w/ diff
• CMP
• GGT
  
• ESR, CRP
• Amylase, Lipase
• Stool Studies
• Stool Cx (r/o Salmonella, Shigella, Campylobacter, Yersinia, E Coli 0157, and C diff)
  
• C diff (bloody diarrhea)
• O&P
• Occult Blood
  
• Calprotectin
• Review Immunizations
• Consider titers
• PPD or Quant Gold, consider CXR
  
• Hepatitis status; Hep A , Hep B vaccines
  

• MRI enterography (now preferred over UGI with SBFT)
  
• MRI, Pelvis if fistula/perianal disease suspected

• EGD and Colonoscopy with Biopsies
• Wireless Capsule Endoscopy (Pillcam)

3 categories of  patients

1. Clinical Stable patients with Mild UC or Crohns being treated with aminosalicylate therapy
2. Patients in clinical remission being treated with immunosuppresive therapy
3. Presumed disease flare in previously stable patients
   

• Frequency of visit = 4 - 12mo
• Vitals (Ht, Wt, BMI, and BP)
• H&P, assess for:
  
• Abdominal Pain
• Fever
• Blood in stool
• Perianal pain or lesions
• Oral lesions
  
• Weight loss
• Skin lesions/ rashes
• Joint Pain
• Eye or vision changes
• Si/Sx of Asthma
• SMR/Tanner staging
• Nutrition assessment
• 
  
• Labs
• UA (r/o nephritis)
  
• CMP
• CBC
• ESR, CRP
• GGT
• Iron panel if concern for blood loss --> anemia
  
• If extensive Ileal or TI disease - B12, Folate, and Zn levels (esp if Alk Phos is low).
  
• May also have impaired absorption of bile acids --> increased oxalate --> risk for Ca oxalate renal stones
  
• Stool
• Calprotectin
• Bone Health - deficits in bone mass observed in up to 40% of patients
  
• Dual x-ray absorptiometry (DXA) - measure bone mass
• At diagnosis ^1,2 
  
• Repeat no less than 6mo intervals to assess response to therapy
• Do not say "osteopenia" or "osteoporosis"  instead use terms such as ‘‘significant reduction in bone mass com-
  pared with children of the same age and sex’’
• If bone mineral mass deficits Z score < -2, obtain:
• Bone age
• Ca, Mg, Phos
  
• BUN, Cr
• PTH
• Ionized Ca
• TTG IgA
• 25-OH Vitamin D and 1,25 dihydroxy vitamin D levels
• Consider referral to Peds Endo
• Vitamin D Levels
• 25 OH Vit D (annually; typically in spring)
  
• >12.5ng/dL to prevent rickets
• IOM definition of Vit D deficiency is  <20ng/dL
• Adult studies; level needed to suppress PTH in adults >30ng/dL
  
• Referral for
  
• Ophthalmology q1-2yrs
• Cognitive behavioral therapy (CBT)
  

1. If growth stunting present, adjust for skeletal age, height z score, and tanner (SMR) staging
2. The International Society of Clinical Densitometry recommends that children with IBD have a DXA scan of the total body (minus skull) and lumbar spine at diagnosis