Pediatric Perspectives Summer 2009 - Cleveland Clinic

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Pediatric Puzzler Cleveland Clinic Children’s Hospital Offering Pediatric Care throughout Northeast Ohio Cleveland Clinic Children’s Hospital, Main Campus Cleveland Clinic Children’s Hospital, Shaker Campus Cleveland Clinic Regional Hospitals: Fairview Hospital Hillcrest Hospital Huron Hospital Lakewood Hospital Marymount Hospital Cleveland Clinic Family Health Centers: Avon Pointe Beachwood* Brunswick Elyria Independence Lorain* Solon Strongsville* Willoughby Hills Wooster *also an Outpatient Surgery Center For the most up-to-date list of locations, or for more information about staff and services at each site, visit clevelandclinic.org/peds. Services for Patients By Douglas Rogers, MD Case History: A 6-week-old male infant presented to his pediatrician with a 3-week history of dramatically declining oral intake, emesis and weight loss. The mother reported that feeds took more than an hour. The baby was awake and alert, though pale and thin at 4.1 kg. Examination revealed sunken eyes and a disconjugate gaze; dry mucous membranes; and a grade 2/6 systolic murmur. The baby had a head lag, did not focus on faces and had generalized weakness. The rest of the exam was normal. Initial laboratory studies revealed low sodium (114/mmol/L) and high potassium (7.4 mmol/L) levels. Turn to page 10 for diagnosis Medical Concierge Complimentary assistance for out-of-state patients and families Global Patient Services Appointments Call 800.223.2273, ext. 55580, or email medicalconcierge@ccf.org Complimentary assistance for national and international patients and families Call 001.216.444.8184 or visit clevelandclinic.org/gps 216.444.KIDS (5437) or 800.223.2273. Pediatric Perspectives offers updates on diagnosis and management from specialists at the Cleveland Clinic Pediatric Institute & Children’s Hospital at 9500 Euclid Ave., Cleveland, OH 44195. Chairman Robert Wyllie, MD, welcomes your feedback at 216.444.2237 or wyllier@ccf.org. Please direct correspondence to Editorial Board Co-Chairs: Rita M. Pappas, MD pappasr@ccf.org, 216.444.4998 Jeffrey S. Palmer, MD palmerjs@ccf.org, 216.445.7504 Editorial Board: John DiFiore, MD, Thomas Edwards, MD, Rita Pappas, MD, Jeffrey Palmer, MD, Kathy Whitford, PNP Editor: Cora M. Liderbach Art director: Amy Buskey-Wood Photographers: Tom Merce, Steve Travarca, Willie McAllister The Pediatric Institute & Children’s Hospital is one of 26 institutes at Cleveland Clinic that group multiple specialties together to provide collaborative, patient-centered care. Backed by the full resources of Cleveland Clinic, the institute offers comprehensive medical, surgical and rehabilitative care for infants, children and adolescents. More than 250 pediatric physicians accommodate 500,000 patient visits annually at our Main Campus, Shaker Campus, community hospitals and family health centers. Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute. Pediatric Perspectives is written for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered, and should not replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. © The Cleveland Clinic Foundation 8.09 09-CHP-031 Page 4 | Pediatric Perspectives | Summer 09 | Cleveland Clinic’s toll-free physician number is 800.553.5056
Cleveland Clinic Study Shows Adult Medication to Be Effective Option for Children Severely Allergic to Crohn’s Disease Therapy Pediatric gastroenterologists at Cleveland Clinic Children’s Hospital are the first to report encouraging results from pediatric use of an easily administered medication for adults with Crohn’s disease. About 5 percent of children and adolescents with mod- erate to severe Crohn’s disease develop severe allergic reactions to the standard pediatric regimen, infliximab (Remicade ® ) infusion. Reactions include chest tightness, flushing, shortness of breath, oxygen desaturation, hypotension, elevated tem- perature and/or rash. These symptoms typically develop during or within several hours of the infusion. Efficacy demonstrated over four years A four-year study led by the pediatric gastroenterology team demonstrated positive outcomes for children and adolescents treated with adalimumab (Humira ® ), a re- combinant human IgG1 monoclonal antibody approved in 2007 for use in adults with Crohn’s disease. Its mechanism of action is similar to infliximab, a tumor necrosis factor-alpha antibody, but because the new drug contains only human peptide sequences, it is believed to be less immunogenic. “Adalimumab is an important alternative for children and adolescents who are unable to continue infliximab infusions,” says one of the investigators, Marsha Kay, MD, Director of Pediatric Endoscopy in the Department of Pediatric Gastroenterology and Nutrition. “It has allowed our patients to avoid surgery, has minimized the complications of their disease, and has allowed us to reduce usage of some of their other medications.” The study, published in the Journal of Pediatric Gastroen- terology and Nutrition in July 2008, involved 15 patients treated at Cleveland Clinic Children’s Hospital between January 2003 and March 2007. They ranged in age from 10 to 21 years (average age: 16). Six patients had colitis alone, while nine had ileocolitis. The mean duration of treatment was 6.5 months. Visit clevelandclinic.org/peds Researchers found that 50 percent of the patients re- sponded completely to treatment with adalimumab, while 14 percent had a partial response and 36 percent did not respond to therapy. No serious adverse events were reported. Left: Typical appearance of moderately severe Crohn’s colitis with mucosal exudates and pseudopolyp formation. Right: Crohn’s colitis in a patient on adalimumab. Only mild mucosal friability and small aphthous ulcerations are seen. Ease of use, cost appealing Another attractive aspect of adalimumab is its ease of use, says Dr. Kay. Infliximab must be infused intrave- nously over several hours in a hospital setting or specially designated outpatient area. Adalimumab, on the other hand, can be self-administered or administered by parents by subcutaneous injection at home — an appealing option for the parents of pediatric patients who live great distances from hospitals and clinics. Because adalimumab is less expensive to administer, insurance providers will begin to view the drug as a cost- effective alternative for the treatment of pediatric Crohn’s disease, says Dr. Kay, who expects its cost to drop further. “Other institutions are now offering adalimumab, and I believe it will be adapted as one of the standards of treatment for many reasons,” she says. However, notes Dr. Kay, additional studies are needed to evaluate its efficacy and to determine optimal dosing of the drug in the pediatric Crohn’s disease population. To refer patients to Cleveland Clinic Children’s Hospital gastroenterologists, the largest such specialty group in the region, please call 216.444.9000. Physicians may contact Dr. Kay at 216.444.3564 or kaym@ccf.org. | Pediatric Perspectives | Summer 09 | Page 5
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Pediatric Perspectives Summer 2009 - Cleveland Clinic

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