Taking Care of the Whole Child
Robbyn E Sockolow, MD
Associate Professor of Clinical Pediatrics
Director of Pediatric Gastroenterology
New York Presbyterian- Weill Cornell Medical Center
HEALTH SUPERVISION: OUTLINE
• Growth and nutrition
• Disease activity
• Prevention and surveillance
• Psychosocial well being
HEALTH SUPERVISION: OUTLINE
•
Growth and nutrition
• Height, Weight, BMI, Bone Health
•
Disease activity
• Mission = Remission
•
Prevention and surveillance
• Vaccinations
• Cancer screening
•
Psychosocial well being
• Screening for anxiety/depression
AREAS OF SUPERVISION
• Vaccination Status
• Vitamin Status
• Bone Health
• Ophthalmologic health
• Dermatologic health
• Annual PPD
VACCINES
IMMUNOSUPPRESSION:
•
Treatment with glucocorticoids (prednisone 20 mg/d
equivalent, or 2 mg/kg/d if less than 10 kg, for 2 weeks or
more, and within 3 months of stopping).
•
Treatment with effective doses of 6mercaptopurine/azathioprine (effect on safety not
established) and within 3 months of stopping.
•
Treatment with methotrexate (effect on safety not
established) and within 3 months of stopping.
•
Treatment with infliximab/adalimumab (effect on safety not
established) and within 3 months of stopping.
•
Significant protein-calorie malnutrition.
SANDS ET AL INFLAMM BOWEL DIS 2004;10:677
VACCINES THAT ARE KILLED AND CONSIDERED
SAFE
• IM/SC influenza vaccine
• Hepatitis A and B vaccine
• Meningococcal vaccine
• Human Papilloma virus vaccine
• Pneumovax
LIVE VACCINES
• Anthrax vaccine
• Smallpox vaccine
• Intranasal influenza
• Tuberculosis BCG
vaccine
• Measles-mumps-rubella
(MMR)
• Polio live oral vaccine
(OPV)
• Rotavirus (oral)
• Typhoid live oral
vaccine
• Varicella
• Yellow fever
Proportion of subjects achieving a post-vaccination of
Pneumococcal Polysaccharide Vaccine geometric mean
titer (GMT) 1 μ g / 100
Melmed G et al. Am J Gastroenterol 2010; 105:148–154
PEDIATRIC IBD: HEALTH SCREENING
• Confirm vaccine efficacy at diagnosis
• Maximizes time available to immunize
• Titers for Varicella, Hepatitis BsAb and
Hepatitis A IgG, MMR??
• PPD at diagnosis
• Confirm before biologics
VACCINES IN PEDIATRIC IBD:
CONTINUE INACTIVATED VACCINATIONS
Inactivated vaccines—stay on schedule
• Tetanus, Diphtheria, Pertussis (DPT)
• Human Papilloma virus (HPV)
• Influenza (injectable only)
• Pneumococcal
• Hepatitis A and Hepatitis B
• Meningococcal
Melmed GY. Inflamm Bowel Dis 2009;15:1410–1416.
Wasan SK et al., Clin Gastroenterol Hepatol 2010;8:1013–1016
LIMIT LIVE/ATTENUATED VACCINATIONS
NO live or attenuated vaccines if taking IM/Biologics
• Measles mumps rubella (MMR) – wait 6 weeks
• Varicella (titer at diagnosis) – wait 4-12 weeks
• Intranasal influenza
• Oral polio
• Smallpox
• Yellow Fever
Melmed GY. Inflamm Bowel Dis 2009;15:1410–1416.
Wasan SK et al., Clin Gastroenterol Hepatol 2010;8:1013–1016
TRAVEL RELATED LIVE/ATTENUATED VACCINES
• Anthrax
• Bacillus Calmette Guérin (BCG)
• Smallpox
• Oral Typhoid
• Yellow Fever
PEDIATRIC IBD: LIMITS ON
LIVE/ATTENUATED VACCINATIONS
• Consider immunization before initiation of
immunosuppressive therapy
• Consider checking post-vaccine titers
Melmed GY. Inflamm Bowel Dis 2009;15:1410–1416.
Wasan SK et al., Clin Gastroenterol Hepatol 2010;8:1013–1016
BONE HEALTH
PEDIATRIC IBD: BONES AT RISK
• At risk for decreased bone mass
• Often present at diagnosis (disease
related)
• Can be acquired over time (treatment
related)
• Potential for increase in fracture risk
• Vertebral and long bone
Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25
Sylvester FA, et al. Inflamm Bowel Dis 2007;13:42-50
Vitamin D3 & Crohn’s Disease: Manitoba IBD
Registry
Increased prevalence of vitamin D deficiency in
Inflammatory bowel disease
Leslie WD, Miller N, Rogala L, Bernstein CN. Vitamin D status and bone density in recently
diagnosed inflammatory bowel disease: the Manitoba IBD Cohort Study. AJG. 2008 Jun;103(6)
NORMAL BONE VS OSTEOPOROTIC
BONE
Loss of trabecular plates results in weakened bone structure
significantly increasing risk of fractures.
75 yo normal woman
47 yo s/p multiple vertebral
compression fractures
DEXA SCREENING FOR BONE HEALTH:
PEDIATRIC PEARLS
•
•
•
•
•
•
•
Order total body (minus skull)
Need a pediatric experienced site!
Age and sex adjusted Z scores (not T-scores!)
Patient size affects the test—may have to adjust
Interpretation
Z-score < ‐2.0 = significant deficit
Z-score < -1.0 = monitor closely
Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25
Lewiecki EM, et al. Bone 2008;43:1115-1121
Fewtrell et al, Bone densitometry in children assessed by dual x ray absorptiometry: uses
and pitfalls Arch Dis Child 2003: 88; 795-798
PEDIATRIC IBD:WHEN TO OBTAIN DEXA
• Recommended at diagnosis
• Repeat “when clinically indicated”
• Slowed growth velocity (height z-score <2)
• Previous BMD z-score < -1
• Delayed puberty or amenorrhea
• Severe course especially if low albumin
• Prolonged steroid use (> 6 months)
Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25
BONE IN PEDIATRIC IBD: THERAPY
• Control inflammation
• Optimize nutrition
• Monitor growth and development (menses)
• Weight-bearing activity
• Optimize Vitamin D/calcium status
• Specialist if complication occurs
• e.g. Compression fracture
Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25
VITAMIN D IN PEDIATRIC IBD
• Deficiency in >30% of pediatric IBD patients
• Higher risk: Darker complexion, active
disease
• Measure yearly 25-OH level: Later
winter/spring
• Keep level > 32 ng/mL
• 800 to 1,000 IU/day as maintenance (D 3)
• Supplement Calcium 1,000—1,600mg a day
Pappa H, et al. Pediatrics 2006;118:1950 -1961
Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25
CANCER PREVENTION
PEDIATRIC IBD: CANCER SCREENING
• Skin cancer
• 1o prevention (hats, sunglasses, SPF > 30)
• Yearly dermatologic screening
• Especially if using
immunomodulators/Biologics
• Articles for both Thiopurines and Biologics in
Rheum literature
Peyrin-Biroulet et al Gastro 2011 Cesame Group Nancy France
Long MD, et al. Inflamm Bowel Dis 2011;17:1423-1427
Rubenstein et al. Am J Gastroenterol 2009;104:2222-2232
Kramagar et al J Dermat Treat UCSF 2012
PEDIATRIC IBD: CANCER SCREENING
• Colonoscopy
• Screen 7-10 yrs if colonic disease diagnosed
• Yearly if diagnosed with PSC
• Surveillance every 1-2 subsequent years
• Pouchoscopy and cuff biopsies after IPAA
MENTAL HEALTH
ASSESSING PSYCHOSOCIAL WELLNESS
• Situational distress vs prolonged functional impairment
• 25% develop anxiety and/or depression
• Frequent follow up visits allow screening
• Adherence and psychosocial wellness
• Focus on the child/ adolescent
Mackner LM, et al. Inflamm Bowel Dis 2006;12:239-244
Engstrom I. J Child Psychol Psychiatry 1992;33:563-582
Szigethy E, et al. J Pediatr Gastroenterol Nutr 2004;39:395-403
INTERVENTION:DEPRESSION/ANXIETY
• Appropriate referral to a mental health professional
• Cognitive behavioral therapy (CBT): best evidence for
treating anxiety, depression
Szigethy E, et al. Child Adolesc Psychiatr Clin N Am 2010;19:301-318
PSYCHOSOCIAL INTERVENTION:
PEDIATRIC IBD
• Therapeutic relationship
• Support groups, CCFA camp
• ? Role of self-management programs
• ?Role of social networks/websites
Shepanski MA, et al. Inflamm Bowel Dis 2005;11:164–170
Szigethy E, et al. Inflamm Bowel Dis 2009;15:1127-1128