Inflammatory bowel disease

Twenty five per cent of inflammatory bowel disease presents in childhood. Growth and nutrition are key issues in the management with the aim of treatment being to induce and then maintain disease remission with minimal side effects. Only 25% of Crohn's disease presents with the classic triad of abdominal pain, weight loss, and diarrhoea. Most children with ulcerative colitis have blood in the stool at presentation. Inflammatory markers are usually although not invariably raised at presentation (particularly in Crohn's disease). Full investigation includes upper gastrointestinal endoscopy and ileocolonoscopy. Treatment requires multidisciplinary input as part of a clinical network led by a paediatrician with special expertise in the management of the condition.     

Current diagnosis, management and morbidity in paediatric inflammatory bowel disease

In the 1970s several reports highlighted the long delay in diagnosis often experienced by children with Crohn's disease. In recent years this disorder has attracted much publicity, and many believe that the incidence has increased substantially. The aim of this investigation was to determine whether heightened awareness had shortened the interval to diagnosis, improved clinical management and reduced morbidity. A retrospective study was therefore carried out on 112 children with inflammatory bowel disease (64 Crohn's disease, 41 ulcerative colitis, 7 indeterminate colitis) referred to a paediatric gastroenterology department in the UK between 1994 and 1998. In Crohn's disease the median interval to diagnosis was 47 wk (maximum 7 y). In those without diarrhoea this was longer (66 vs 28 wk; p = 0.005). In ulcerative colitis the median interval was 20 wk (maximum 3 y). Even in severe colitis the median interval was 5.5 wk (range 3-9 wk) and 4 required urgent colectomy soon after referral. Many with unrecognized Crohn's disease had undergone inappropriate treatments, such as growth hormone or psychiatric therapy. Nineteen (17%) had undergone endoscopic investigations in adult units prior to referral. Malnutrition was equally common in Crohn's disease and ulcerative colitis (11%). Short stature was present in 19% with Crohn's disease, and 5% with ulcerative colitis, and was severe in 8% with Crohn's disease. There was a significant correlation between symptom duration and the degree of growth impairment present (r(s) = -0.4; p = 0.004). Conclusion: This study suggests that late diagnosis and inappropriate investigation and management are still significant problems.     

Incidence and prevalence of inflammatory bowel disease in children in South-Western Sweden

Hildebrand H, Brydolf M, Holmquist L, Krantz I, Kristiansson B. Incidence and prevalence of inflammatory bowel disease in children in South-Western Sweden Acta PEdiatr 1994;83:640–5. Stockholm. ISSN 0803–5253
The incidence and prevalence of inflammatory bowel disease were estimated in all children less than 16 years of age living in the city of Göteborg and in three counties in South-Western Sweden, from 1983 to 1987. One hundred and thirty-two patients were classified according to set criteria into one of four diagnostic categories: ulcerative colitis, Crohn's disease, probable Crohn's disease and indeterminate colitis. The crude incidence of inflammatory bowel disease was 5.3 per 100 000 children per year and the prevalence 21.5 per 100000 children. This study lends support to the hypothesis that Crohn's disease has increased among Swedish children. Crohn's disease now appears to be at least as common as ulcerative colitis. Thirty-five of 55 patients first classified as indeterminate colitis or probable Crohn's disease later fulfilled the criteria of ulcerative colitis or Crohn's disease during a mean follow-up period of 4.6 years. This study emphasizes the importance, in epidemiological studies of inflammatory bowel disease, of inciuding those cases where a definite diagnosis of ulcerative colitis or Crohn's disease cannot be established initially and of re-evaluating the initial diagnosis regularly.     

MICI-MINOTS: Linguistic and metric validation of a pediatric questionnaire on knowledge about inflammatory bowel disease

BackgroundTherapeutic education is an essential part of the treatment of chronic diseases, such as inflammatory bowel disease (IBD). The IBD-KID, developed in Canada in English, assesses children's and adolescents’ acquired knowledge about their condition and has been validated in Canadian and Australian populations. However, there is no pediatric questionnaire in French to assess patients’ knowledge about IBD.ObjectiveTo report the linguistic validation process and metric validity of the MICI-MINOTS, the French version of the IBD-KID.MethodThe translation process consisted of three consecutive steps: forward–backward translation, acceptability testing, and cognitive interviews. The IBD-KID consists of 23 questions, but a 24th question about immunomodulatory therapy was added in the MICI-MINOTS. Psychometric testing was conducted with five groups: children with IBD, their parents, children in a control group, their parents, and health workers recruited from the Timone Pediatric Hospital and the Saint-Sébastien Maternal and Child Protection Center, Marseille, France. A total of 15 individuals completed the tool twice, with a 15-day interval. Internal consistency, reliability, external validity, reproducibility, and sensitivity to change were tested.ResultsA total of 38 children with IBD (sex: 20 boys, 18 girls; age: 13.90 [± 2.88] years; 25 with Crohn's disease), 20 children in the control group, 58 parents (every child was included with one parent), and 62 health workers were included in the analysis. Intraclass correlation was 0.94 (95% confidence interval 0.83–0.98) for test–retest assessment. Readability using the Scolarius score corresponded to elementary school level. Among the children with IBD, 89.5% answered all 24 questions. For 23 questions, the mean score of children with IBD was higher than among children in the control group: 9.58 (± 3.01) versus 5.47 (± 3.56), respectively (P < 0.01). Parents of children with IBD scored higher than parents of children in the control group: 10.63 (± 3.16) versus 8.4 (± 3.07), respectively (P = 0.012). In the health workers’ group, pediatric residents (17.82 ± 3.46) scored higher than nurses 11.75 (± 3.4) and ward clerks (8.67 ± 2.40; P < 0.01). Patients’ knowledge score was significantly related to their parents’ knowledge score (r = 0.402, P = 0.012) for 23 questions.ConclusionThe French version of the IBD-KID showed satisfactory psychometric properties to assess knowledge about the disease in French-speaking children.     

Inflammatory bowel disease

Inflammatory bowel disease (IBD) describes a heterogeneous group of chronic inflammatory diseases of the gastrointestinal tract, of which Crohn’s disease and ulcerative colitis are the most common diagnoses. About a quarter of IBD presents in childhood, and the phenotype seen involves a wider disease distribution in both Crohn’s and ulcerative colitis than seen in adult-onset disease. The incidence of IBD appears to be rising and although we understand more about the genetic, immunological and environmental contributors to aetiology, we do not yet fully understand this rise. In paediatric practice, IBD and in particular Crohn’s disease, often results in impaired weight gain, poor linear growth and delayed puberty. Multiple treatment modalities exist for IBD from longstanding treatments such as steroids and immunosuppressants to modern, targeted therapies such as infliximab. This review discusses the current state of the art of clinical practice in relation to paediatric IBD.     

Faecal calprotectin levels in infants with infantile colic, healthy infants, children with inflammatory bowel disease, children with recurrent abdominal pain and healthy children

This study investigated faecal calprotectin concentration, a measure of intestinal inflammation, in infants and children with abdominal pain. Faecal calprotectin was measured by an enzyme-linked immunosorbent assay kit in spot stool samples in 76 infants with typical infantile colic, 7 infants with transient lactose intolerance and 27 healthy infants. All infants were 2-10 wk of age. In addition, 19 children with recurrent abdominal pain (RAP; mean age 11.5 y), 17 with inflammatory bowel disease (IBD; mean age 11.1 y; 10 had Crohn's disease and 7 ulcerative colitis) and 24 healthy children (mean age 5.3 y) were studied. In infants with infantile colic the mean faecal calprotectin concentration was not different from that in healthy infants (278 +/- 105 vs 277 +/- 109 mg kg(-1), p = 0.97) or in infants with transient lactose intolerance (300.3 +/- 124 mg kg(-1), p = 0.60). The calprotectin level was similar in boys and girls and fell significantly with age (p = 0.04). Children with IBD had faecal calprotectin levels (293 +/- 218 mg kg(-1)) much higher than healthy children (40 +/- 28 mg kg(-1), p < 0.0001) and children with RAP without identified organic disease (18 +/- 24 mg kg(-1), p < 0.0001). Conclusion: Faecal calprotectin may differentiate between functional abdominal pain and IBD in school-aged children. In young infants high faecal calprotectin levels are normal.     

Health-related quality of life in paediatric patients with inflammatory bowel disease related to disease activity

Aim: Impaired health‐related quality of life (HRQoL) and an increased risk of psychosocial problems may encounter children and adolescents with inflammatory bowel disease (IBD). Generic HRQoL questionnaires, 15D designed for subjects over 16 years of age, 16D for adolescents aged 12–15 and 17D for younger children, allow comparison to healthy peers and have not been used in children with IBD before. Further, in paediatric IBD patients, HRQoL has not been related to disease activity. We evaluated the applicability of 15D, 16D and 17D questionnaires in the paediatric IBD population and examined how HRQoL is influenced by changes in clinical activity of IBD. Methods: The study subjects recruited at their scheduled, routine appointment in the outpatient clinic of the children's hospital completed the HRQoL questionnaire at baseline and again after 3–5 months. Disease activity was estimated by a three‐level scale. The HRQoL of the study population was compared with that of the age‐standardised general population. Results: Fifty‐five children, aged 7–19 years, were recruited. The HRQoL scores strongly correlated with the activity of the disease (P < 0.001). The two oldest age groups with IBD had lower HRQoL scores than age‐standardised peers (P= 0.001/0.04). There was no gender difference in HRQoL scores. Conclusions: IBD has a considerable impact on the HRQoL of children and adolescents. The generic HRQoL instruments used appeared to be promising tools for examining HRQoL in paediatric IBD patients in different age groups, but larger studies to establish their usefulness in the follow‐up of young patients are still warranted.     

Parent-adolescent agreement on psychosocial symptoms and somatic complaints among adolescents with inflammatory bowel disease

Aim: To investigate parent–adolescent agreement on psychosocial and somatic symptoms in adolescents with inflammatory bowel disease (IBD). Methods: A questionnaire‐based postal survey comprising Finnish adolescents aged 10–18 years with IBD (n = 156) and their parents. Emotional, behavioural and somatic symptoms were measured using the Child Behaviour Checklist (parent report) and the Youth Self‐Report. Results: In paediatric IBD, adolescents and parents agreed on the presence of a psychosocial problem (in subclinical/clinical range) in 5% of the cases but disagreed in 21%. In 74% of the dyads, respondents agreed that no problems existed. Agreement in reporting psychosocial or somatic symptoms was poor to low (κ = 0.00–0.38). The lowest agreement was on anxious/depressed mood (κ = 0.02) and thought problems (κ = 0.00) and the highest on social problems. The parents reported more somatic symptoms in their adolescents than the adolescents themselves (p < 0.001). Conclusion: Young IBD patients and their parents disagree in reporting psychosocial and somatic symptoms of the patients. The adolescents as well as their parents need to be involved; otherwise, many symptoms of clinical significance would go unnoticed.     

Medical management of pediatric inflammatory bowel disease

Inflammatory bowel diseases (IBD) are chronic autoimmune conditions of the gut affecting both pediatric and adult patients. Medical therapy is often successful at inducing and maintaining remission and preventing disease complications. The mainstays of treatment are medications and other therapies that reduce inflammation and suppress the overactive immune system. Here we review current medical therapies for pediatric IBD, discuss future therapeutics, and present current treatment goals and approaches.