Iron deficiency anemia in hospitalized pediatric patients with ulcerative colitis: what is the status of preventing IDA and is there room for improvement?
Manely, Sarah Husai
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BACKGROUND: Anemia is a common extra-intestinal manifestation of disease in patients with inflammatory bowel disease (IBD), and iron deficiency anemia (IDA) represents the most prevalent form of anemia in this population ((Gasche, Dejaco et al. 1997) (Plantz, Maxwell et al. 2016)). IDA can result from a combination of decreased dietary iron intake, impaired intestinal absorption, and excessive gastrointestinal (GI) bleeding, all of which can lead to decreased iron stores and poor iron utilization. Furthermore, chronic IDA in children with IBD can adversely influence development and cognition, as well as contribute to the increased fatigue and decreased stamina observed in these patients (Laass, Straub et al. 2014). Treatment of IDA in pediatric patients with IBD can be with either oral iron supplementation or parenteral iron infusions, and both can result in an improvement in iron parameters and subsequent improvement in patient overall quality of life. However, there is wide variability in physician practice with respect to the identification and treatment of IDA in pediatric patients with IBD. OBJECTIVE: To assess physician practice at Boston Children’s Hospital with respect to the identification and treatment of IBD-related IDA in a population of patients admitted for management of a flare in their underlying ulcerative colitis. This information will be useful to develop initiatives directed at improving recognition and management of IDA in this population. METHODS: The Institutional Review Board (IRB) at Boston Children's Hospital (BCH) approved the study protocol. Patient electronic medical records were reviewed and abstracted from subjects with ulcerative colitis (UC) that were treated at BCH between January 2005 and January 2013. Each patient was assigned a study identification number to protect private health information, and this data was stored in a computer file behind the hospital’s internet firewall. Inpatient and outpatient office notes, as well as clinical data, were reviewed to track the identification of patients with anemia as well as physician management practices. All of the information collected was stored in the Research Electronic Database Capture (REDCap) and used for analysis. RESULTS: A total of 243 patients met initial inclusion criteria. Subsequent review of the electronic medical records revealed that only 178 patients had complete data available for use in our analysis. 55.5% of the 178 study subjects were anemic at admission, with a mean hemoglobin value of 9.32 g/dL (SD 1.89) and a mean MCV value of 77.49 fl (SD 10.24). None of the patients in this cohort had iron studies (plasma iron, ferritin, total iron binding capacity) included in their admissions laboratory testing. Only 24 patients received oral iron supplementation during their hospital stay while none received IV iron infusions. Over half of the total patient cohort (78.7 %,) were not prescribed oral iron supplementation at the time of discharge. 84% of patients that were discharged anemic remained anemic at the time of their first post-discharge ambulatory visit. Less than half of the total patient cohort (30.34%) had iron studies included in their follow-up ambulatory laboratory testing. Patients that were given iron supplementation at the time of discharge showed increased gains in their hemoglobin levels at follow-up compared to patients with no iron supplementation at the time of discharge (p <0.0001). CONCLUSION: These data suggest that there is a low prevalence with respect to the identification and treatment of IDA and anemia in pediatric patients with ulcerative colitis (UC) at admission, discharge, and follow-up clinic visits. A secondary finding was a statistically significant increase in hemoglobin levels in anemic patients treated with some form of iron supplementation. As a result, our data support both the need to improve recognition of IDA in pediatric patients admitted for a UC flare as well as document the clinical value to this effort. Additional studies are necessary to determine if improved iron surveillance and therapy will improve patient quality of life, linear growth, and cognition in patients with IBD.