Rising incidence of inflammatory bowel disease among children: a 12-year study

Is breastfeeding safe with azathioprine?

BACKGROUND

Azathioprine is commonly used as an immunosuppressant during pregnancy in the management of various conditions such as connective tissue disorders, inflammatory bowel disease and pregnant women with organ transplant. Continuation of azathioprine through pregnancy and postpartum is vital for maternal reasons. However, there is limited evidence regarding safety of use of azathioprine with breastfeeding.

METHODS AND RESULTS

We report an observational case series of 10 mother-baby pairs managed at a tertiary teaching hospital. Mothers on azathioprine who were keen to breastfeed were counselled antenatally regarding limited short-term and long-term safety data for the babies. Mothers participating in this study completed a questionnaire at every visit. At follow-up visits, babies were examined by a neonatologist for clinical signs of infection and checked for adverse effects on haematological profile.

CONCLUSION

There was no clinically significant adverse effect on haematological profile or immunosuppression in these babies. Our case series supports safety of azathioprine in the short term. However, large numbers are needed to determine long-term safety of azathioprine and breastfeeding.

Air pollution: An environmental factor contributing to intestinal disease

The health impacts of air pollution have received much attention and have recently been subject to extensive study. Exposure to air pollutants such as particulate matter (PM) has been linked to lung and cardiovascular disease and increases in both hospital admissions and mortality. However, little attention has been given to the effects of air pollution on the intestine. The recent discovery of genes linked to susceptibility to inflammatory bowel diseases (IBD) explains only a fraction of the hereditary variance for these diseases. This, together with evidence of increases in incidence of IBD in the past few decades of enhanced industrialization, suggests that environmental factors could contribute to disease pathogenesis. Despite this, little research has examined the potential contribution of air pollution and its components to intestinal disease. Exposure of the bowel to air pollutants occurs via mucociliary clearance of PM from the lungs as well as ingestion via food and water sources. Gaseous pollutants may also induce systemic effects. Plausible mechanisms mediating the effects of air pollutants on the bowel could include direct effects on epithelial cells, systemic inflammation and immune activation, and modulation of the intestinal microbiota. Although there is limited epidemiologic evidence to confirm this, we suggest that a link between air pollution and intestinal disease exists and warrants further study. This link may explain, at least in part, how environmental factors impact on IBD epidemiology and disease pathogenesis.

Usefulness of wireless capsule endoscopy in paediatric inflammatory bowel disease

BACKGROUND

Small bowel endoscopy is critical in revealing an inflammatory bowel disease (IBD) previously undetected and in classifying the IBD patients, i.e. Crohn's disease or ulcerative colitis.

METHODS

A prospective paediatric study on the usefulness of wireless capsule endoscopy (WCE) was performed in 117 children (age range: 4-17 years) with established or suspected IBD and compared with non endoscopic imaging tools. All patients underwent upper and lower gastrointestinal endoscopy.

RESULTS

In Crohn's disease patients (CD, n=44), small bowel lesions were revealed by imaging tools in 8 and by WCE in 18 patients, respectively (p<0.01). No small bowel involvement was observed in 29 ulcerative colitis patients by both imaging tools and WCE. Of 26 unclassified IBD, small bowel lesions typical of Crohn's disease were detected by imaging in 7 and by WCE in 16 (p<0.05). Of 18 patients with suspected IBD, small bowel lesions typical of Crohn's disease were observed in 9 with WCE, vs. only in 4 with imaging (p<0.01). No cases of capsule retention occurred.

CONCLUSIONS

WCE is valuable in revealing small bowel lesions in children with a previous diagnosis of CD and unexplained clinical and laboratory data. It is also helpful in unclassified IBD patients. This tool can influence the management and the course of IBD.

Infliximab-induced psoriasis in children with inflammatory bowel disease

Infliximab is frequently used to treat both inflammatory bowel disease (IBD) and psoriasis. We reviewed the medical records of 73 children with IBD receiving infliximab therapy and identified 6 (8%) cases of infliximab-induced psoriasis. Five (83%) had Crohn disease and 4 (67%) were girls. The psoriatic lesions appeared on the face (n = 5; 83%) and perineum (n = 1; 17%). A median of 13 doses were administered during a median duration of 21 months. All of the patients were continued on infliximab to maintain clinical remission of IBD. Educating children with IBD and their caregivers about this paradoxical phenomenon and periodic dermatology evaluation may promote patient care.

Epidemiology of pediatric inflammatory bowel disease: a systematic review of international trends

BACKGROUND

Temporal trends in the incidence of pediatric-onset inflammatory bowel disease (IBD) are controversial and a wide range of estimates have been reported worldwide. We conducted a systematic review of research describing the epidemiology of childhood-onset IBD to assess changes in incidence rates over time and to evaluate international differences.

METHODS

The following electronic databases were searched for articles published 1950-2009: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane IBD/Functional Bowel Disorders Group Specialised Trial Register. All included studies reported incidence or prevalence of IBD, Crohn's disease (CD) or ulcerative colitis (UC). Two authors independently completed the data extraction form for each eligible study. Choropleth maps demonstrated the international incidence of IBD, CD, and UC. Incidence of CD and UC was graphed using data from studies reporting rates in multiple time periods.

RESULTS

The search yielded 2209 references and review resulted in 139 included studies from 32 countries. A wide range of incidence was reported internationally; however, rates of IBD were not described in most countries. Twenty-eight studies (20.1%) used statistical analysis to assess trends over time, and 77.8% reported statistically significantly increased incidence of pediatric IBD. Of studies calculating statistical trends in CD incidence, 60% reported significantly increased incidence. Of similar UC studies, 20% reported significantly increased incidence.

CONCLUSIONS

Globally rising rates of pediatric IBD (due primarily to the rising incidence of CD) was demonstrated in both developed and developing nations; however, most countries lack accurate estimates. Analyzing incidence trends may help identify specific environmental and genetic risk factors for pediatric IBD.

Drug targeting strategies for the treatment of inflammatory bowel disease: a mechanistic update

The therapeutic management of inflammatory bowel disease (IBD) represents the perfect scenario for drug targeting to the site(s) of action. While existing formulation-based targeting strategies include rectal dosage forms and oral systems that target the colon by pH-, time-, microflora- and pressure-triggered drug release, novel approaches for site-specific delivery in IBD therapy will target the inflamed intestine per se rather than intestinal region. The purpose of this article is to present a mechanistic update on the strategies employed to achieve minimal systemic exposure accompanied by maximal drug levels in the inflamed intestinal tissue. The introduction of biological agents, micro/nanoparticulate carriers including liposomes, transgenic bacteria, and gene therapy opportunities are discussed, as well as the challenges remaining to be achieved in the targeted treatment of IBD.

[Rationale for the use of extracorporeal photochemotherapy in children]

The management of immune diseases in children remains challenging, although significant advances have been made. In addition to pharmacological approaches, extracorporeal photochemotherapy (ECP) is distinctive in its ability to provide immunomodulation without immune suppression or toxicity. However, in practice, this therapy is not widely used because of logistical issues and the lack of robust clinical pediatric studies. Here, we discuss the potential clinical applications of ECP in children and emphasize the need for a rigorous and specifically pediatric clinical evaluation of ECP.

Pediatric inflammatory bowel diseases: coming of age

PURPOSE OF REVIEW

Inflammatory bowel diseases (IBD) comprise a heterogeneous group of distinct intestinal disorders. Here, we discuss the concept of childhood-onset IBD as separate disease forms within a larger multifactorial disease category.

RECENT FINDINGS

There are excellent epidemiological data indicating that the incidence of pediatric IBD, mainly Crohn's disease, is still increasing over the last decades, with indicators of more extensive and more severe disease presentations in children compared to adults, also reflected by higher levels of humoral immune responses. Recent genetic scans allowed to identify particular susceptibility genes for pediatric IBD forms, such as IL27 or probably DcR3. Early postnatal onset forms of IBD might reflect monogenetic causes, as suggested with the finding of IL10 signaling defects that may define a new form of IBD.

SUMMARY

There are good epidemiological, genetic and clinical data to distinguish different forms of IBD, particularly forms starting early in life. Profound insights in the molecular basis of immune dysregulation in IBD have been gained over the last few years. These recent discoveries will nourish and substantially stimulate the future search for precise cause(s) responsible for life-long intestinal inflammation and it will help to explain the still ongoing rise in incidence in childhood IBD.