robbyn e sockolow, md associate professor of clinical pediatrics director of pediatric...
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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