Saudi Journal of Gastroenterology
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2016  |  Volume : 22  |  Issue : 2  |  Page : 106-108
Impact of pediatric inflammatory bowel disease on linear growth: Data from a national cohort study in Saudi Arabia


1 Department of Pediatrics, Head, Pediatric Inflammatory Bowel Disease Research Group, Member of Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
2 Al Mofarreh PolyClinic, Department of Gastroenterology, Riyadh, Saudi Arabia
3 Department of Pediatrics, Faculty of Medicine and Inflammatory Bowel Disease Research Group, King Abdul Aziz University, Riyadh, Saudi Arabia
4 The Children's Hospital, Division of Gastroenterology, Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
5 Department of Pediatrics, Section of gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

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Date of Web Publication11-Mar-2016
 

   Abstract 

Background/Aim: Linear growth impairment (LGI) is one of the most important features peculiar to children with inflammatory bowel disease (IBD). The aim of this report is to define the impact of IBD on the linear growth of children in the Kingdom of Saudi Arabia (KSA). Setting and Design: Multicenter retrospective study. Patients and Methods: Data from a cohort of newly- diagnosed children with IBD from 2003 to 2012 were analyzed retrospectively. The diagnosis of IBD was confirmed in accordance with the published criteria. Length/height for age was measured at diagnosis. The World Health Organization (WHO) reference was used and LGI was defined by length/height for age <-2 standard deviation.
Chi-square test was used to test the significance of estimates and a P < 0.05 was considered significant. Results: There were 374 children from 0.33 to 16 years of age, including 119 ulcerative colitis (UC) (32%), and 255 Crohn's disease (CD) (68%) patients. The prevalence of LGI was 26%, 28%, and 21% in IBD, CD, and UC, respectively. In children below 10 years, LGI was significantly more common in CD (P = 0.010), while in UC children, it was more common in older children (P = 0.011). Conclusion: This study demonstrates a prevalence of LGI consistent with that reported in the literature, but higher in CD children with early onset (<10 years) and in older children with UC, underscoring the importance of monitoring growth in children with IBD in the Saudi population. Prospective studies are needed to define the impact of IBD on growth velocity, puberty, and final adult stature.

Keywords: Growth impairment, inflammatory bowel disease, Saudi children, short stature

How to cite this article:
El Mouzan MI, Al Mofarreh MA, Saadah OI, Al-Hussaini AA, Al-Saleem KA, Al Mehaidib AI. Impact of pediatric inflammatory bowel disease on linear growth: Data from a national cohort study in Saudi Arabia. Saudi J Gastroenterol 2016;22:106-8

How to cite this URL:
El Mouzan MI, Al Mofarreh MA, Saadah OI, Al-Hussaini AA, Al-Saleem KA, Al Mehaidib AI. Impact of pediatric inflammatory bowel disease on linear growth: Data from a national cohort study in Saudi Arabia. Saudi J Gastroenterol [serial online] 2016 [cited 2020 Jun 6];22:106-8. Available from: http://www.saudijgastro.com/text.asp?2016/22/2/106/178524


Inflammatory bowel disease (IBD) refers to two main clinical entities, ulcerative colitis (UC) and Crohn's disease (CD). Linear growth impairment (LGI) is also called growth failure, short stature, stunting in preschool children, and short stature in older children and adolescents. It is one of the most important features peculiar to children and adolescents, and maintenance of normal growth is considered one of the indicators of IBD control and success of therapy.[1] Assessment of linear growth at diagnosis before any drug intervention allows estimation of the impact of IBD on growth. Although less common in UC than in CD, the prevalence of LGI at diagnosis has been reported in some Western populations varying from 20 to 88%.[2],[3] Pediatric IBD is increasingly reported in the Kingdom of Saudi Arabia (KSA) with an intermediate incidence between Western and Southeast Asian populations.[4] The lack of data from developing countries on the impact of IBD on growth prompted this report.


   Patients and Methods Top


Data from a cohort of newly-diagnosed children with IBD from 2003 to 2012 were analyzed retrospectively. The sample consisted of all children from birth to 16 years of age who were diagnosed in pediatric gastroenterology centers across the KSA. The diagnosis of IBD was confirmed in all cases in accordance with published criteria.[5],[6] Length for age (<3 years of age) and height for age (>3 years of age) were measured at diagnosis. The World Health Organization (WHO) standards and reference standard deviation (SD) charts were used as reference.[7],[8] The length and height for age at diagnosis for each patient were plotted on the corresponding chart. LGI was defined by length or height for age <-2 SD.[7],[8] Age stratification analysis was performed in accordance with Paris classification separating children <10 years from older children.[9] Chi-square test was used to test the significance of prevalence estimates and a P < 0.05 was considered significant.

This study is part of the characteristics of IBD in Saudi children, approved by the Institutional Review Board, College of Medicine, King Saud University (No. 10/2647/IRB).


   Results Top


There were 374 children from 0.33 to 16 years, including 119 UC (32%), and 255 CD (68%) cases. The prevalence of LGI at diagnosis is presented in [Table 1], which shows the rates as 26%, 28%, and 21% in IBD, CD, and UC children, respectively. The prevalence of LGI in CD was higher than in UC (28% vs. 21%); the difference, however, was statistically not significant (P = 0.137). However, in children below 10 years, LGI was significantly more common in children with CD than in those with UC (P = 0.010). By contrast, in older children, LGI was significantly more common in children with UC than in those with CD (P = 0.011). [Table 2] depicts gender-related variations in the prevalence of LGI and indicates no significant difference in the prevalence of LGI between male and female children with UC (P = 0.436), CD (P = 0.918), or IBD (P = 0.598).
Table 1: Age-related prevalence of linear growth impairment

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Table 2: Gender-related prevalence of linear growth impairement

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   Discussion Top


The etiology of growth impairment in children and adolescents with IBD is multifactorial. Chronic malnutrition resulting from inadequate caloric intake as a result of anorexia and abdominal pain, chronic inflammation, effect of proinflammatory cytokines, disturbed insulin-like growth factors, and drug therapy are the main contributing factors.[10],[11],[12],[13],[14],[15] The advantage of assessing growth at diagnosis is important as it excludes the effects of drugs such as steroids on growth, thereby reflecting the impact of the disease on growth. In this analysis, we chose to use the WHO reference for two reasons. The first was the unavailability of SD reference for Saudi children at the time of the study. The second reason is that using the WHO international reference facilitates comparison with other studies from other countries. However, taking into consideration the background prevalence of LGI in the general population defines more precisely the impact of IBD.

The 26% prevalence rate of LGI in IBD reported in this study is within the 15–40% reported in a Cochrane meta-analysis.[16] However, even after substracting the 11% prevalence of LGI in the Saudi preschool and school-age normal children,[17],[18] the adjusted prevalence of LGI of 15% (26-11) in Saudi children with IBD is still in the lower limit of the range.[16] In addition, the 17% (28-11) adjusted prevalence of LGI in CD children is higher than the 9.5% reported in a population-based registry from northern France.[19] Although not statistically significant (P = 0.137), the more common prevalence of LGI in CD than in UC in this report is in line with most studies from the West.[20],[21],[22],[23] This difference between CD and UC at diagnosis may be explained by the more widespread and longer duration of CD before diagnosis as reported in the literature.[24],[25]

In this study, age stratification revealed no significant difference in the prevalence of LGI in IBD children in either age group. However, LGI was significantly more common in young children with CD and older children with UC, a finding not documented in the literature. The relatively more widespread colonic inflammation in young children with CD reported in the literature [25],[26],[27] may at least partially explain the greater impact of disease on the linear growth of younger children. Finally, there was no significant difference between males and females in any age group of either UC or CD.

In conclusion, this is the first study from a developing country that demonstrates the prevalence of LGI within the range reported in the literature. However, the higher impact of IBD on linear growth in CD children with early onset (<10 years), as well as in older children with UC, a pattern rarely documented in the literature, underscores the importance of age stratification to identify the impact of IBD on linear growth. In addition, the result of this study is a reminder for physicians caring for children and adolescents with IBD to monitor the growth regularly and to manage any impairment early. Prospective studies are needed to define the impact of IBD on growth velocity, puberty, and final adult stature.

Acknowledgement

The authors extend their appreciations to the Deanship of Scientific Research at King Saud University for funding this work through Research Group No. RG-1436-007.

 
   References Top

1.
Ruemmele FM, Veres G, Kolho KL, Griffiths A, Levine A, Escher JC, et al.; ECCO/ESPGHAN. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014;8:1179-207.  Back to cited text no. 1
    
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Kanof ME, Lake AM, Bayless TM. Decreased height velocity in children and adolescents before the diagnosis of Crohn's disease. Gastroenterology 1988;95:1523-7.  Back to cited text no. 3
    
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El Mouzan MI, Saadah O, Al-Saleem K, Al Edreesi M, Hasosah M, Alanazi A, et al. Incidence of pediatric inflammatory bowel disease in Saudi Arabia: A multicenter national study. Inflamm Bowel Dis 2014;20:1085-90.  Back to cited text no. 4
    
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Bousvaros A, Antonioli DA, Colletti RB, Dubinsky MC, Glickman JN, Gold BD, et al.; North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; Colitis Foundation of America. Differentiating ulcerative colitis from crohn disease in children and young adults: Report of a Working Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Crohn's and Colitis Foundation of America. J Pediatr Gastroenterol Nutr 2007;44:653-74.  Back to cited text no. 6
    
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World Health Organization (WHO). WHO Child Growth Standard: Methods and Development. Geneva, Switzerland: Department of Nutrition for Health and Development, World Health Organization (WHO); 2006.  Back to cited text no. 7
    
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Levine A, Griffiths A, Markowitz J, Wilson DC, Turner D, Russell RK, et al. Pediatric modification of the Montreal classification for inflammatory bowel disease: The Paris classification. Inflamm Bowel Dis 2011;17:1314-21.  Back to cited text no. 9
    
10.
Koniaris SG, Fisher SE, Rubin CT, Chawla A. Experimental colitis impairs linear bone growth independent of nutritional factors. J Pediatr Gastroenterol Nutr1997;25:137-41.  Back to cited text no. 10
    
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Wine E, Reif SS, Leshinsky-Silver E, Weiss B, Shaoul RR, Shamir R, et al. Pediatric Crohn's disease and growth retardation: The role of genotype, phenotype, and disease severity. Pediatrics 2004;114:1281-6.  Back to cited text no. 11
    
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Paganelli M, Albanese C, Borrelli O, Civitelli F, Canitano N, Viola F, et al. Inflammation is the main determinant of low bone mineral density in pediatric inflammatory bowel disease. Inflamm Bowel Dis 2007;13:416-23.  Back to cited text no. 12
    
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Ballinger AB, Savage MO, Sanderson IR. Delayed puberty associated with inflammatory bowel disease. Pediatr Res2003;53:205-10.  Back to cited text no. 13
    
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Corkins MR, Gohil AD, Fitzgerald JF. The insulin-like growth factor axis in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr2003;36:228-34.  Back to cited text no. 14
    
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Wong SC, MacRae VE, McGrogan P, Ahmed SF. The role of pro-inflammatory cytokines in inflammatory bowel disease growth retardation. J Pediatr Gastroenterol Nutr 2006;43:144-55.  Back to cited text no. 15
    
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Newby EA, Sawczenko A, Thomas AG, Wilson D. Interventions for growth failure in childhood Crohn's disease. Cochrane Database Syst Rev 2005:CD003873.  Back to cited text no. 16
    
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El Mouzan MI, Foster PJ, Al Herbish AS, Al Salloum AA, Al Omar AA, Qurachi MM. Prevalence of malnutrition in Saudi children: A community-based study. Ann Saudi Med 2010;30:381-5.  Back to cited text no. 17
    
18.
El Mouzan MI, Al Herbish AS, Al Salloum AA, Foster PJ, Al Omar AA, Qurachi MM. Prevalence of short stature in Saudi children and adolescents. Ann Saudi Med 2011;31:498-501.  Back to cited text no. 18
    
19.
Vasseur F, Gower-Rousseau C, Vernier-Massouille G, Dupas JL, Merle V, Merlin B, et al. Nutritional status and growth in pediatric Crohn's disease: A population-based study. Am J Gastroenterol 2010;105:1893-900.  Back to cited text no. 19
    
20.
Motil KJ, Grand RJ, Davis-Kraft L, Ferlic LL, Smith EO. Growth failure in children with inflammatory bowel disease: A prospective study. Gastroenterology 1993;105:681-91.  Back to cited text no. 20
    
21.
Lee JJ, Escher JC, Shuman MJ, Forbes PW, Delemarre LC, Harr BW, et al. Final adult height of children with inflammatory bowel disease is predicted by parental height and patient minimum height Z-score. Inflamm Bowel Dis 2010;16:1669-77.  Back to cited text no. 21
    
22.
Markowitz J, Grancher K, Rosa J, Aiges H, Daum F. Growth failure in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 1993;16:373-80.  Back to cited text no. 22
    
23.
Hildebrand H, Karlberg J, Kristiansson B. Longitudinal growth in children and adolescents with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 1994;18:165-73.  Back to cited text no. 23
    
24.
El Mouzan MI, Al Mofarreh MA, Assiri AM, Hamid YH, Al Jebreen AM, Azzam NA. Presenting features of childhood-onset inflammatory bowel disease in the central Saudi Arabia. Saudi Med J 2012;33:423-8.  Back to cited text no. 24
    
25.
Castro M, Papadatou B, Baldassare M, Balli F, Barabino A, Barbera C, et al. Inflammatory Bowel Disease in Children and Adolescents in Italy: Data from the Pediatric National IBD Register (1996-2003). Inflamm Bowel Dis 2008;14:1246-52.  Back to cited text no. 25
    
26.
Heyman MB, Kirschner BS, Gold BD, Ferry G, Baldassano R, Cohen SA, et al. Children with early-onset inflammatory bowel disease (IBD): Analysis of a pediatric IBD consortium registry. J Pediatr 2005;146:35-40.  Back to cited text no. 26
    
27.
De Greef E, Mahachie John JM, Hoffman I, Smets F, Van Biervliet S, Scaillon M, et al. Profile of pediatric Crohn disease in Belgium. J Crohns Colitis 2013;7:e588-98.  Back to cited text no. 27
    

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Correspondence Address:
Mohammad I El Mouzan
Department of Pediatrics, Gastroenterology Division, PO Box 2925, Riyadh - 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.178524

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