PROBLEMS IN DIAGNOSIS OF IBD IN CHILDREN

Children and adolescents with inflammatory bowel disease (IBD) present unique challenges to physicians and all health-care providers. The mo st important aspect is that children are not small adults. They are ch aracterized by a highly dynamic state of growth and physical change as well as a constant alteration in psychological status. It will not be difficult to recognize IBD, even in children, when it presents with c lassical symptoms such as bloody diarrhoea, abdominal pain and weight loss. However, some children will present with abdominal pain and depr ession. Not infrequently these children are diagnosed as being depress ed and are seen and treated by psychologists and psychiatrists for dif ferent periods of time. In addition, several children will be initiall y diagnosed as having a bacterial gastroenteritis with a proven positi ve faecal culture. It seems to be the triggering event in these childr en, and if adequate therapy fails, colonoscopy is indicated. Recently, Beattie et al. showed that in children seen for chronic abdominal pai n simple routine blood tests including full blood count and erythrocyt e sedimentation rate are almost always abnormal in children with IBD. But most importantly, growth retardation is common in children with IB D and is more often found in Crohn's disease (CD) than in ulcerative c olitis (UC). Faltering growth is a sign of a catabolic situation. Ther efore, it is essential to follow the growth of children at the beginni ng and during treatment of IBD. Growth retardation can be the first sy mptom of IBD and is often already present before other symptoms of IBD become apparent. Rarely, extra-intestinal manifestations, particularl y arthritis, can be the first and sometimes only initial symptom for m onths to years in children with IBD. About 2% of all patients with IBD present before the age of 10 years, but 30% present between the age o f 10 and 19 years. A significant proportion of young patients with IBD will develop the disease just prior to or during puberty. Adolescent growth is characterized by rapid accumulation of lean body mass and an y inflammatory disease occurring at this time is likely to have a majo r impact on nutritional status and growth. This rapid growth requires an appropriate increase in nutritional substrates and failure to achie ve catch-up growth may ultimately lead to poor cumulative growth over time. Most of the growth retardation is seen in children with CD, appr oximately 30%. However, also in UC 15% will show a reduction in growth . The higher percentage in CD could be due to the disease itself or to the relative subtlety of the intestinal manifestations of CD, mainly abdominal pain and general malaise. Not only growth, but also delayed puberty, is a sign of an ongoing disease that most likely needs more i ntensive treatment. It has been shown that the severity of disease act ivity plays a more important role in the occurrence of growth retardat ion than steroid treatment. Therefore in paediatrics it is important t o state that growth retardation during medical treatment equals undert reatment. In contrast to adults, the potential benefit of nutritional therapy should be seriously considered in addition to aggressive medic al therapy including steroids and other immunosuppressive agents such as azathioprine. The most convincing evidence that malnutrition is pri marily responsible for growth failure is based on depletion studies. T he malnutrition itself is caused by ongoing inflammation and loss of a ppetite. Recommendations for nutritional therapy include an increase i n energy and protein intake to 150% of recommended daily allowances fo r height and age. Some studies have shown the benefit of nocturnal nas ogastric infusion as supplements of daily intake. Importantly, nutriti onal support has been shown to be as effective as steroids in achievin g remission of disease in children. Furthermore, no significant differ ences have been shown in studies using elemental versus polymeric diet s. In conclusion, growth can be considered as an important marker of c ontrol of disease activity and success of therapy. The major challenge to physicians in the diagnosis and treatment of IBD in children is to recognize growth failure. In addition, pubertal depression in combina tion with weight loss should raise the suspicion of IBD.