When to refer a patient with pediatric Inflammatory Bowel Disease (IBD)?

From the Guidelines

Pediatric patients should be referred to a pediatric gastroenterologist for suspected inflammatory bowel disease (IBD) when they present with persistent gastrointestinal symptoms, particularly chronic diarrhea (lasting more than 2 weeks), rectal bleeding, abdominal pain, unexplained weight loss, growth failure, delayed puberty, or perianal disease, as early referral is crucial for specialized multidisciplinary care and to minimize potential long-term impacts on growth, bone health, and psychosocial development 1.

Key Considerations for Referral

• Persistent gastrointestinal symptoms, such as chronic diarrhea, rectal bleeding, and abdominal pain, warrant referral to a pediatric gastroenterologist for suspected IBD 1.
• Immediate referral is necessary for severe symptoms, including significant weight loss, severe abdominal pain, high fever, or signs of bowel obstruction, to prevent potential complications and ensure timely intervention 1.
• Laboratory findings, such as elevated inflammatory markers (CRP, ESR), anemia, hypoalbuminemia, or fecal calprotectin >150 μg/g, should prompt referral to a pediatric gastroenterologist for further evaluation and management 1.
• Family history of IBD is a significant factor in determining the risk of developing IBD, and earlier referral is recommended for pediatric patients with a family history of the disease 1.

Importance of Early Referral

• Early referral to a pediatric gastroenterologist is essential for pediatric IBD patients, as it allows for comprehensive evaluation, including endoscopy, imaging, and appropriate treatment plans tailored to the developing child's needs 1.
• Delaying referral can lead to prolonged empiric treatments, which may not address the underlying condition, and can result in increased morbidity and potential long-term complications 1.
• Pediatric gastroenterologists can provide specialized care and management, including medication adherence support, which is critical for improving outcomes and reducing hospitalizations in pediatric IBD patients 1.

From the FDA Drug Label

1. 2 Pediatric Crohn's Disease RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy.
2. 4 Pediatric Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Referral for pediatric IBD should be considered when:

• The patient is 6 years of age or older
• The patient has moderately to severely active Crohn's disease or ulcerative colitis
• The patient has had an inadequate response to conventional therapy 2

From the Research

Referral Criteria for Pediatric IBD

When to refer a child for pediatric IBD can be determined by considering the following factors:

• High suspicion of inflammatory bowel disease (IBD) based on presenting symptoms, testing, and risk factors 3
• Presence of alarm symptoms such as rectal bleeding or weight loss, which may indicate the need for rapid referral 3
• Non-specific symptoms that necessitate testing strategies to differentiate between possible IBD and non-organic conditions 3
• Faecal calprotectin levels, which can be used in conjunction with additional measures to aid in diagnosis 4

Diagnostic Testing and Referral

Diagnostic testing for pediatric IBD is not yet definitive, and primary care physicians and general pediatricians must rely on interpreting a combination of symptoms, laboratory parameters, and risk factors to assess the need for specialist referral and diagnosis 3

• A diagnostic strategy using a simple clinical case definition for suspected IBD in combination with a positive faecal calprotectin result can increase specificity and reduce the need for referral to a pediatric gastroenterology center 4
• The Porto diagnostic criteria provide a tool for uniformity in the work-up and criteria used for diagnosis of pediatric IBD, including clinical signs and symptoms, endoscopy, histology, and radiology 5

Treatment and Management

While the question of when to refer for pediatric IBD is focused on diagnosis, it is worth noting that treatment and management of the condition are crucial for patient outcomes:

• Non-biological treatments, such as mesalamine and corticosteroids, remain valuable approaches in the therapeutic armamentarium of IBD 6
• Corticosteroids are still the mainstay of treatment for moderate to severe disease, but their use is largely empirical and solid evidence about therapeutic schemes is lacking 7