Improving the Diagnosis and Treatment of Iron Deficiency and Anemia in Children With Inflammatory Bowel DiseaseImproving the Diagnosis and Treatment of Iron Deficiency and Anemia in Children With Inflammatory Bowel Disease https://pediatricsnationwide.org/wp-content/themes/corpus/images/empty/thumbnail.jpg 150 150 Lauren Dembeck Lauren Dembeck https://pediatricsnationwide.org/wp-content/uploads/2021/03/Dembeck_headshot.gif
- April 14, 2023
- Lauren Dembeck
Iron deficiency with and without anemia is under-recognized and under-treated in children with inflammatory bowel disease.
Anemia is the most common extr-aintestinal manifestation of inflammatory bowel disease (IBD), which includes conditions such as Crohn’s disease and ulcerative colitis, and iron deficiency is the most prevalent cause of anemia in children with IBD.
Several factors can contribute to iron deficiency anemia in children with IBD. Intestinal inflammation and some medications used to treat IBD can interfere the body’s ability to absorb iron and other nutrients. Patients may also have decreased appetite and avoid certain foods due to gastrointestinal symptoms, which can result in malnutrition and contribute to iron deficiency.
“There are several challenges to diagnosing iron deficiency in pediatric IBD, including limitations of currently available lab tests, lack of standardized screening methods, and lack of awareness, in addition to treatment barriers such as adherence, side effects, availability and cost. The under-treatment of iron deficiency may have significant impacts on patient outcomes and quality of life,” says pediatric gastroenterologist Jennifer L. Dotson, MD, MPH, who is co-director of the Center for Pediatric and Adolescent Inflammatory Bowel Disease at Nationwide Children’s Hospital.
In a recent study published in the Journal of Pediatric Gastroenterology and Nutrition, Dr. Dotson and colleagues demonstrated that quality improvement methods can be used to improve screening and treatment rates for iron deficiency and iron deficiency anemia in children with IBD.
The Center for Pediatric and Adolescent Inflammatory Bowel Disease at Nationwide Children’s cares for over 800 children, adolescents and young adults with IBD, with approximately 120 patients newly diagnosed each year. At the start of the study, the center had no standardized approach to screen for or treat iron deficiency in children newly diagnosed with IBD. Jennifer Smith, MS, RD, CSP, the team’s IBD dietitian, lead the charge.
Their multidisciplinary team developed and implemented an easy-to-follow algorithm to facilitate screening for and treating iron deficiency in patients newly diagnosed with IBD. They then used a series of Plan-Do-Study-Act (PDSA) cycles to refine the approach to increase screening and treatment of iron deficiency.
“Using PDSA cycles is a common quality improvement tool. It involves creating an informed plan, putting it into action, monitoring and studying the outcomes, and then integrating what we learned back into the process to further refine and/or scale up. This process of continual learning and improvement is embedded in our daily culture at Nationwide Children’s,” explained Dr. Dotson, who was the senior author of the study and is also an associate professor of clinical pediatrics at The Ohio State University College of Medicine.
The team first established a pre-intervention (baseline) rate of iron deficiency screening and treatment using data from all patients diagnosed with IBD at the center between January 2017 and December 2018. Following development and implementation of the algorithm, they evaluated patients newly diagnosed with IBD between January 2019 and July 2021 for process improvement.
The study’s primary outcome was the percentage of patients newly diagnosed with IBD who were screened for iron deficiency within 60 days of diagnosis, and the secondary outcome was the percentage of patients diagnosed with iron deficiency who were started on treatment within 30 days of iron deficiency diagnosis. The researchers compared the baseline rate of iron deficiency screening and treatment with the subsequent monthly rates.
“By tracking the data continuously, it allowed us to see if our interventions were changing our practice and helped to generate new strategies for improvement,” added Ms. Smith.
A total of 298 patients were newly diagnosed with IBD between January 2019 and July 2021.
The researchers found that the rates of iron deficiency screening increased from 20% at baseline to over 90%. Of the 232 patients screened during the improvement period, 88% were diagnosed with either iron deficiency anemia (65%) or iron deficiency (23%). Of the 205 patients with IBD and iron deficiency anemia or iron deficiency during the improvement period, 77% began treatment within 30 days of diagnosis, compared with approximately 60% at baseline.
“The systematic implementation of an algorithm and using quality improvement techniques effectively improved screening rates for iron deficiency (with or without anemia) in children newly diagnosed with IBD,” said Dr. Dotson. “Further work is needed to ensure timely and effective treatment.”
This quality improvement initiative was funded by the NASPGHAN Foundation/CPNP Nutrition Grant 2019 awarded to Jennifer Smith.
Smith J, Jacobson-Kelly A, Donegan A, Boyle B, Maltz RM, Michel HK, Dotson JL. Diagnosis and Treatment of Iron Deficiency and Anemia in Youth With Inflammatory Bowel Disease. Journal of Pediatric Gastroenterology and Nutrition. 2023 Mar 1;76(3):313-318.
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