Overview
Definition:
IBD-related growth failure is defined as a significant deviation from expected growth trajectories (e.g., height velocity < 25th percentile or crossing 2 major percentile lines downwards) in children with Inflammatory Bowel Disease (IBD), typically Crohn's disease or Ulcerative Colitis
It is a multifactorial complication reflecting disease activity, nutritional deficits, and endocrine dysfunction.
Epidemiology:
Growth failure affects approximately 20-30% of children with IBD at diagnosis, with Crohn's disease having a higher prevalence of growth impairment than Ulcerative Colitis
Early onset IBD (<10 years) is associated with a greater risk of severe growth deficits
It is a significant cause of morbidity and impacts long-term adult height.
Clinical Significance:
Addressing IBD growth failure is critical for optimizing long-term health outcomes, including achieving adult height potential, preventing bone mineral density deficits, and improving overall quality of life
It necessitates a multidisciplinary approach involving pediatric gastroenterologists, endocrinologists, dietitians, and psychologists.
Clinical Presentation
Symptoms:
Delayed puberty
Significantly shorter stature compared to peers or siblings
Reduced growth velocity noted on growth charts
Complaints of fatigue or weakness
Abdominal pain, diarrhea, or rectal bleeding may coexist and contribute to nutritional deficiencies.
Signs:
Height below the 3rd percentile or a significant downward crossing of percentile channels
Reduced weight-for-height ratio
Signs of malnutrition (e.g., loss of subcutaneous fat, muscle wasting)
Delayed secondary sexual characteristics (pubertal staging)
Pallor suggesting anemia.
Diagnostic Criteria:
Growth failure is diagnosed based on standard growth charts (e.g., WHO or CDC) using parameters like height-for-age, height velocity, and BMI-for-age
A persistent downward crossing of two major percentile channels or a height SDS of less than -2.0 is generally considered significant
Correlation with IBD activity is key.
Diagnostic Approach
History Taking:
Detailed birth and perinatal history
Family history of growth problems or endocrine disorders
Previous growth pattern assessment
Dietary intake assessment
Duration and severity of IBD symptoms (pain, diarrhea, blood per rectum)
Medications used for IBD
Pubertal status.
Physical Examination:
Accurate anthropometry: height, weight, head circumference (in infants), BMI
Assessment of pubertal development (Tanner staging for genitalia and pubic hair in boys, breasts and pubic hair in girls)
Evaluation for signs of chronic illness, malnutrition, and systemic involvement of IBD
Skeletal survey may be indicated if metaphyseal widening or other bone abnormalities are suspected.
Investigations:
Baseline IBD assessment: Complete Blood Count (CBC) for anemia, ESR/CRP for inflammation, inflammatory markers (fecal calprotectin)
Nutritional assessment: serum albumin, prealbumin, iron studies, Vitamin D, B12, folate levels
Endocrine evaluation: Bone age X-ray (hand-wrist), IGF-1 and IGFBP-3 levels, thyroid function tests (TSH, free T4), morning cortisol, sex hormones (LH, FSH, testosterone/estradiol) if pubertal delay is suspected
Genetic testing if specific syndromes are suspected.
Differential Diagnosis:
Constitutional growth delay
Familial short stature
Malnutrition from other causes (e.g., celiac disease, food allergies)
Genetic syndromes (e.g., Turner syndrome, Noonan syndrome)
Endocrine disorders unrelated to IBD (e.g., primary hypothyroidism, growth hormone deficiency)
Chronic illness affecting growth independently of IBD.
Management
Initial Management:
Aggressive control of IBD inflammation is paramount
Optimization of nutritional status through dietary counseling and supplementation is essential
Referral to a pediatric endocrinologist for assessment of endocrine involvement and growth hormone deficiency.
Medical Management:
Nutritional support: High-calorie, high-protein diet
Oral nutritional supplements
Enteral nutrition (nasogastric or gastrostomy tube feeding) if oral intake is insufficient
Micronutrient supplementation (iron, calcium, vitamin D)
Pharmacological therapy for IBD (e.g., 5-ASAs, corticosteroids, immunomodulators, biologics) to achieve remission
Growth Hormone (GH) therapy: Indicated for documented GH deficiency or in severe cases of IBD-related growth failure refractory to other measures
Dosing typically 0.05 mg/kg/day SC, adjusted based on IGF-1 levels and growth response.
Surgical Management:
Rarely indicated for growth failure itself, but may be required for complications of IBD (e.g., strictureplasty, bowel resection) which can indirectly impact nutritional status and growth
Post-surgical nutritional support is crucial.
Supportive Care:
Regular growth monitoring (height velocity, weight gain, SDS) every 3-6 months
Psychological support for the child and family to cope with chronic illness and growth concerns
Education about IBD and its impact on growth
Collaboration between gastroenterology, endocrinology, and nutrition teams.
Complications
Early Complications:
Exacerbation of IBD symptoms due to nutritional deficits or stress of investigations
Weight loss and worsening malnutrition
Anemia.
Late Complications:
Irreversible short adult stature
Osteopenia/osteoporosis due to chronic inflammation, malabsorption of calcium and vitamin D, and corticosteroid use
Impaired pubertal development and fertility issues
Increased risk of metabolic bone disease.
Prevention Strategies:
Early and aggressive treatment of IBD to achieve and maintain remission
Proactive nutritional assessment and intervention
Prompt diagnosis and management of endocrine deficiencies
Judicious use of corticosteroids
Regular growth surveillance from diagnosis.
Prognosis
Factors Affecting Prognosis:
Severity and duration of IBD
Age at diagnosis
Extent of disease involvement
Nutritional status at diagnosis
Promptness and effectiveness of IBD and endocrine management
Response to growth hormone therapy if indicated.
Outcomes:
With aggressive and multidisciplinary management, many children can achieve significant catch-up growth and a near-normal adult height
However, severe or long-standing IBD may lead to permanent short stature
Long-term monitoring for bone health and pubertal development is essential.
Follow Up:
Regular follow-up with pediatric gastroenterology and endocrinology teams is crucial
Monitoring of growth parameters, IBD activity, nutritional status, bone mineral density, and pubertal progression
Adjustments to therapy based on response and disease activity.
Key Points
Exam Focus:
IBD growth failure is a multifactorial issue requiring integrated pediatric gastroenterology and endocrinology care
Early diagnosis and aggressive treatment of IBD are fundamental
Nutritional optimization and consideration of GH therapy are key management components
DNB/NEET SS questions often focus on the diagnostic workup and management principles.
Clinical Pearls:
Always plot growth parameters on standardized charts from diagnosis
Consider growth failure even with mild GI symptoms if growth is faltering
Assess bone age early to predict final height potential
Multidisciplinary team approach is non-negotiable
GH therapy is an adjunct, not a replacement for IBD control and nutritional support.
Common Mistakes:
Attributing all growth failure solely to IBD without investigating for concurrent endocrine issues
Delaying aggressive nutritional support
Inappropriate use or overuse of corticosteroids without adequate monitoring of growth and bone health
Failing to achieve IBD remission as a primary goal.