Robbyn E Sockolow, MD

Associate Professor of Clinical Pediatrics

Director of Pediatric Gastroenterology

New York Presbyterian- Weill Cornell Medical Center

Taking Care of the Whole Child

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 6-mercaptopurine/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

• Anthrax vaccine

• Intranasal influenza

• Measles-mumps-rubella (MMR)

• Polio live oral vaccine (OPV)

• Rotavirus (oral)

• Smallpox vaccine

• Tuberculosis BCG vaccine

• Typhoid live oral vaccine

• Varicella

• Yellow fever

LIVE VACCINES

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 ONLIVE/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;53:11–25Sylvester 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;53:11–25Lewiecki 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 (D3)

• 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 FranceLong MD, et al. Inflamm Bowel Dis 2011;17:1423-1427Rubenstein et al. Am J Gastroenterol 2009;104:2222-2232Kramagar 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;11:164–170Szigethy E, et al. Inflamm Bowel Dis 2009;15:1127-1128