BACKGROUND: Early identification of pediatric patients with Inflammatory Bowel Disease (IBD), including ulcerative colitis and Crohn disease, is important to help clinicians design optimal treatment regimens. Existing endoscopic techniques are effective in identifying disease activity. However, these methods are invasive, expensive, and less amenable to serial measurement. Recent studies have identified potential serologic and fecal biomarkers that may have the potential to provide clinicians with a more objective evaluation of disease activity. In the case of ulcerative colitis (UC), in which disease is confined to the large intestine, the information provided by fecal biomarkers is likely to be more specific than that provided by serologic biomarkers. Fecal lactoferrin (FLA) is one such biomarker that has shown to be useful not only in identifying levels of colonic inflammation, but also for use as a predictor of disease relapse and treatment efficacy. Measurement of fecal lactoferrin, in conjunction with information provided by other diagnostic modalities could expedite patient assessment and treatment. Additionally, it has been suggested that fecal lactoferrin levels may also provide prognostic information about response to treatment and disease outcome in pediatric patients with UC. The goal of this study is to explore the relationship between changes in FLA levels and response to medical therapy in hospitalized pediatric patients with UC. METHODS: Serial stool samples were collected daily from 10 patients admitted for management of severe active UC. Of these 10 patients, 3 responded favorably to standard treatment with intravenous corticosteroid therapy and were discharged to complete a course of oral steroids. 7 were unresponsive to steroid therapy and went on to require rescue (more intensive) medical therapy. Changes in FLA were correlated with steroid response and medical disposition at the time of discharge. RESULTS: A t-test was performed to determine the significance of the differences in percent change in FLA levels between patients discharged on steroids and patients discharged on rescue therapy. Patients discharged on steroids demonstrated a net decrease in FLA levels over the course of the first three days of steroid treatment while patients ultimately requiring rescue medical therapy demonstrated a net increase in FLA levels (mean values = -64.4% and +203.8%, respectively). A difference was found between the averages; however, this value did not reach statistical significance when analyzed with a t-test (p = 0.18). CONCLUSIONS: This study suggests that quantitative FLA levels may prove useful in predicting clinical course and discharge outcome in pediatric patients with ulcerative colitis. Future research in this field should seek larger sample sizes, increased longitudinal sample collection, and the potential for a composite assessment that will yield additional objective measures of disease activity.

INTRODUCTION: The management of pediatric patients with ulcerative colitis (UC) is dependent upon the ability to detect meaningful changes in disease status. This is currently done using validated patient-reported clinical disease activity indices, including the Pediatric Ulcerative Colitis Activity Index (PUCAI). While useful for global assessments completed during ambulatory office visits, the sensitivity of this metric may be insufficient to reflect more subtle changes in disease activity or response to medical therapy in hospitalized patients. Intravenous steroids are typically employed in the management of patients admitted for acute exacerbations of UC symptoms. These are typically manifest by worsening bloody diarrhea, abdominal pain, and worsening anemia. There is presently no way of predicting whether a patient admitted for UC will respond to steroid therapy. Current paradigms dictate a five-day trial before considering a transition to more potent medical or definitive surgical approaches to the management of refractory colitis. The development of more sensitive and reliable biomarkers or disease activity metrics could enable clinicians to more expediently identify steroid non-responders. This would minimize patient morbidity, decrease risk of complication, and lower overall cost of care. Previous studies have demonstrated that changes in fecal lactoferrin (FLA) correlate with disease activity in patients with UC. OBJECTIVES: To analyze the predictive value of FLA in the response to steroid treatment of patients admitted for management of UC. METHODS: We recruited pediatric inpatients with UC in the Division of Gastroenterology, Hepatology and Nutrition at Boston Children’s Hospital who were hospitalized for treatment of a flare of their UC symptoms. After obtaining patient consent, we collected a stool sample on days 1 and 3 of their hospital stay. We sent samples to TECHLAB® Inc. (Blacksburg, VA) to be analyzed for levels of FLA. We compared Day 1, Day 3 and ∆FLA (Day 1 – Day 3) in two patient groups: those that responded to conventional steroid therapy and those that required rescue medical or surgical therapy. We reported statistical significance with the Wilcoxon signed-rank test. RESULTS: Of 67 patients consented for the study, 30 provided stool samples on both days 1 and 3 of their inpatient hospitalization. Of the 30 patients, 63.3% responded to steroids while 36.7% required rescue therapy with immunomodulators. ∆FLA for responders, 43.6μg/mL(-239.0, 331.6) (median(interquartile range)), did not differ significantly from non-responders, -74.1μg/mL(-296.7, 221.7), P = 0.3. CONCLUSIONS: Our findings do not demonstrate that measurement of changes in quantitative FLA over three days can be used to assess acute responses to steroid therapy. Increasing the sample size may allow us to better delineate subtle differences between responders and non-responders to steroid therapy.