School Stress May Trigger IBD Flares in Teens

[Maya142]

Interesting study about stress and school! Anyone see a pattern with their kids? My kiddo's arthritis definitely flares around September but not sure about her IBD...

School Stress May Trigger IBD Flares in Teens
Disease onset and flares were higher at the start and end of academic terms
by Diana Swift, Contributing Writer
June 07, 2018
An annual rhythm of inflammatory bowel disease (IBD) symptoms in adolescents appears to correlate with pressure points in school semesters, according to a provocative preliminary study suggesting that academic stress may foster disease onset and flares.

Reporting in the Journal of Pediatric Gastroenterology and Nutrition, a team led by Richard Kellermayer, MD, PhD, of Baylor College of Medicine in Houston, found that symptoms were more significant during the 5 calendar months coinciding with the start or end of elementary, middle, and high school terms.

"Our finding can direct specific attention to potential pediatric IBD cases depending on time of year," Kellermayer told MedPage Today. "Our results may also aid the timely diagnosis and treatment initiation of pediatric IBD, which has been shown to improve outcomes."

The investigators identified two groups of pediatric patients, ages 6 to 18 and more than 50% of whom were boys, at Texas Children's Hospital in Houston -- a discovery cohort of 169 patients (mean age of 12.39), consisting of a random list of patients who presented during 2009-2015 and contributed data to previous studies, and a validation cohort of 122 remaining patients (mean age of 13.79) from the same time period.

While no seasonal patterns emerged with respect to conception and birth, disease onset was found to be significantly associated (P=0.0218) with the months of August, September, and January (i.e., the beginning of school terms), and December and May (the end of terms). The effect was more noticeable in the slightly older validation cohort.

"This may indicate that older pediatric patients are more susceptible to academic stress-related IBD onset, since high school and middle school [appear to be] more stressful than elementary school in most of the cases," the investigators wrote.

The highest incidence of symptoms occurred in January, when, the authors conceded, viral and bacterial infections may work synergistically with academic stress to exacerbate inflammatory response.

"The importance of this study is that it's looking at environmental stressors that may exacerbate or lead to the development of inflammatory bowel disease," David Suskind, MD, of Seattle Children's Hospital, who was not involved with the study, told MedPage Today." It's very preliminary, but it starts opening the door to what in our environment is causing an increased incidence of inflammatory bowel disease, which has dramatically risen in the past 50 to 100 years."

Suskind added that the fecal microbiome is known to be significantly impacted by environmental factors, including diet, medications such as antibiotics, and daily stress. "So this is an interesting and important line of inquiry to elucidate the environmental causes and triggers of IBD."

The original impetus for the study was to clarify conflicting observations from earlier research on the impact of seasonality. One group, for example, found that the onset of pediatric IBD was linked to seasonal variations, with the highest incidence in the fall and the lowest in the summer, while another group found that "low-vitamin-D months" (i.e., the winter) affected IBD flares, but not onset.

At the physiological level, previous research has noted that the stress of exam time may cause imbalances between pro- and anti-inflammatory cytokines and altered immune responses. Students with a high stress perception have been found to produce significantly more tumor necrosis factor, interleukin (IL)-6, IL-1 receptor antagonist (IL-1Ra), and interferon, and prolonged stress may eventually tip the balance in favor of more pro-inflammatory cytokines.

"Our findings [imply] that onset of IBD may be in part linked to academic stress when added cytokine imbalances may tip the genetically, epigenetically, and 'dysbiotically' susceptible host towards developing the diseases," Kellermayer and associates wrote.

They conceded that the retrospective study could not directly measure academic stress, and that future studies should investigate stress using month-by-month assessments of various immune factors, including cortisol levels. "The recognition of the highest incidences of IBD presentation during the peaks of academic stress may alert primary care physicians to recognize the alarm signs for the diseases, and prompt timely referral to the gastroenterologist."

Suskind said that if stress, and specifically academic stress, proves to be a factor in IBD, "there will probably be non-pharmaceutical interventions we could do such as biofeedback and behavioral modification."

Kellermayer noted that this is the first observational study in pediatric IBD to use a discovery and validation cohort approach to study the seasonality of disease onset, a method that may be more reliable than traditional single-cohort epidemiologic studies, he said.

"One next logical continuation of the work would be to test the effects of academic stress on the intestinal microbiome of high school age students, since the microbiome has been implicated as an important factor in IBD development. Identification of academic stress-related microbiome changes may identify a novel microbe-based preventative measure such as a probiotic against the onset of IBD in susceptible teenagers."

Limitations of the study, the researchers said, were its retrospective nature, the restriction to a small geographical area, possible recall bias in the reporting of time of disease onset, and the potentially confounding effect of winter infections on the spiking of symptoms in January.

 

[Farmwife]

My kiddo did!

 

[my little penguin]

Things to consider
ALL Chronic Conditions flare woth the start of school
Since it’s also the start of cold and flu season
Even non ibd kiddos come home with colds within the first two weeks

My kiddos
Asthma
Crohns and arthritis flares
Since it does the same with colds or illness

 

[Maya142]

That is an excellent point - a lot of kids do bring home colds very soon after school starts (as a teacher, I find kids start getting sick by week 3 usually). And colds very often do mean flares...so that is definitely something to factor in when reading this study.

I have seen at least one definite example of AS flares caused by extreme stress - for example, painful joint injections into her sacroiliac joints without the proper sedation. She was a disaster after the procedure and instead of getting relief from injections she flared. She was in SO much pain that she ended up in the ER and she was then put on 40 mg of Prednisone for a week (CRP and ESR had gone up - even though her ESR never goes up normally).

Interestingly, the same thing had actually happened before when she was 15 - she was given the wrong kind of sedation so she was awake, terrified and in a LOT of pain through the procedure (it is always done on children while they are asleep).

Every other time, when she has been put to sleep for the injections, they have worked well.

 

[ckkelley3]

My 15 year old son was diagnosed with Crohn's in Feb., of this year, and we definitely saw an increase in his Crohn's activity the week before/during final exams.

 

[Bufford]

I'm into my retirement, but I remember 'it' starting in my last year of high school. School was a very miserable stressful part of my life. My parents forced me into taking advanced courses which were well beyond my capability. My marks dissapointed my father greatly adding more stress to my life.
As it was the Crohn's went on undiagnosed for most of my life as doctors knew little about it other than lancing and draining of abscesses around my rectum. Later in life I had to get a colostomy which forced me into taking my retirement early with a reduced pension.
Life was a struggle every inch of the way, living and working with Crohn's, fullfilling my employers expectations and the responsibilities that came with my work, while dealing with the pain. Retirement has been much much better, there is life with Crohn's despite the dark valleys one must cross.