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Taking Care of the Whole Child

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

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Taking Care of the Whole Child

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  1. 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

  2. Health Supervision: Outline • Growth and nutrition • Disease activity • Prevention and surveillance • Psychosocial well being

  3. 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

  4. Areas of supervision • Vaccination Status • Vitamin Status • Bone Health • Ophthalmologic health • Dermatologic health • Annual PPD

  5. Vaccines

  6. 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 Dis2004;10:677

  7. Vaccines that are killed and considered safe • IM/SC influenza vaccine • Hepatitis A and B vaccine • Meningococcal vaccine • Human Papilloma virus vaccine • Pneumovax

  8. Live Vaccines • Smallpox vaccine • Tuberculosis BCG vaccine • Typhoid live oral vaccine • Varicella • Yellow fever • Anthrax vaccine • Intranasal influenza • Measles-mumps-rubella (MMR) • Polio live oral vaccine (OPV) • Rotavirus (oral)

  9. 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

  10. 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

  11. 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

  12. 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

  13. Travel Related Live/Attenuated Vaccines • Anthrax • Bacillus Calmette Guérin (BCG) • Smallpox • Oral Typhoid • Yellow Fever

  14. 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

  15. Bone health

  16. 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

  17. 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)

  18. Loss of trabecular plates results in weakened bone structure significantly increasing risk of fractures. Normal Bone vs Osteoporotic Bone 75 yo normal woman 47 yo s/p multiple vertebral compression fractures

  19. 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

  20. Fewtrell et al, Bone densitometry in children assessed by dual x ray absorptiometry: uses and pitfalls Arch Dis Child 2003: 88; 795-798

  21. 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

  22. 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

  23. 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

  24. Cancer Prevention

  25. 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 Gastroenterol2009;104:2222-2232 Kramagar et al J Dermat Treat UCSF 2012

  26. 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

  27. Mental health

  28. 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

  29. 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

  30. 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

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