Latest / Pediatrics in Practice: A CME Podcast / Recognizing IBD in Kids: What Every Pediatrician Should Know

Transcript

Recognizing IBD in Kids: What Every Pediatrician Should Know · Pediatrics in Practice: A CME Podcast

• 0:03
  Mike (Host): Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:07
  Mike, and with me is Dr.
• 0:08
  Julie Bass, medical director of the Inflammatory Bowel Disease
• 0:12
  Program at Children's Mercy.
• 0:14
  Today we're gonna be talking about IBD in pediatrics, exploring how to recognize
• 0:20
  it, when to refer, and how primary care providers can partner in care.
• 0:26
  Dr.
• 0:26
  Bass, welcome to the show.
• 0:28
  Let's start off with how should pediatricians think about IBD
• 0:33
  versus common other forms of pain?
• 0:38
  Julie Bass, DO: IBD is something you definitely wanna think about in a patient
• 0:43
  that's presenting with abdominal pain associated with some of the other red flag
• 0:50
  symptoms that we think about or with pain that is limiting the daily activities,
• 0:57
  is associated with weight loss, vomiting, diarrhea, blood in the stool.
• 1:03
  it really should trigger underlying concern and, and need for further
• 1:08
  workup if the abdominal pain i- is associated with, with some of these
• 1:13
  other things or if it is really causing more issues than just brief
• 1:19
  distractible episodes o- of pain
• 1:22
  Mike (Host): Now does IBD usually is the onset a little bit longer
• 1:27
  in terms of some of the other, conditions that cause abdominal pain?
• 1:32
  Julie Bass, DO: Yes.
• 1:32
  In the setting, it's usually more chronic and not an acute
• 1:36
  condition, but, but not always.
• 1:38
  We've definitely have had patients diagnosed with IBD
• 1:41
  with-- that have presented with shorter amounts of symptoms, or
• 1:43
  it can be, recognized over time.
• 1:46
  And something that's unique to pediatrics, specifically pediatric
• 1:50
  Crohn's disease, would be in a child that maybe has some vague complaints of
• 1:55
  pain but associated, growth concerns.
• 1:58
  That would also be a reason to, to think about possibility of IBD as a diagnosis.
• 2:04
  but in patients who are growing well, have, you know, brief intermittent or
• 2:08
  short episodes of pain, less likely to be IBD and more, more likely to
• 2:14
  be more common, you know, functional pain versus related to other things
• 2:18
  Mike (Host): How often do you see patients who are presenting maybe
• 2:22
  with other symptoms that aren't pain?
• 2:25
  Maybe it's fever or something like that, and that leads you to think that I need
• 2:30
  to maybe work up a bowel situation here
• 2:33
  Julie Bass, DO: that's a great question because we definitely
• 2:35
  have had some strange presentations because IBD patients don't always
• 2:42
  present in your textbook ways.
• 2:44
  so definitely things that are-- we see commonly in kids that maybe
• 2:49
  n- won't have the obvious bowel association with it would be, uh, joint
• 2:55
  complaints, arthritis, arthralgias.
• 2:58
  That would be one of the more common extra intestinal things that we see.
• 3:03
  some less common but definitely things that we do see, uh, the orofacial
• 3:07
  Crohn's disease subtype, so lip swelling or significant mouth sores
• 3:12
  or, perianal lesions, a recurrent perirectal abscess definitely would be a
• 3:18
  concern for inflammatory bowel disease.
• 3:20
  And those things can happen without pain, or stooling symptoms
• 3:27
  Mike (Host): Well, let's go back to, you mentioned some of the red flags.
• 3:31
  What are some of those red flags that should prompt referral immediately?
• 3:36
  Julie Bass, DO: definitely in patients with significant growth concerns, the
• 3:42
  growth concerns would be a big thing.
• 3:44
  the significant pain, a significant arthritis, arthralgias associated with
• 3:50
  any of these GI symptoms, vomiting, diarrhea, blood in the stool, all
• 3:56
  of those things persisting, over time and not an acute period.
• 4:00
  nighttime stooling or nighttime awakening for pain, definitely a red flag.
• 4:06
  Obviously, blood in the stool, multiple stools a day.
• 4:10
  so if you're upwards of four or five plus stools a day, and ne- negative
• 4:15
  infectious studies, those are all, red flags that we would want to, work up
• 4:19
  further for concern of possible IBD
• 4:23
  Mike (Host): if a general practitioner is seeing some of these red flags and
• 4:28
  they definitely want to refer this to you, the specialist, are there some
• 4:32
  initial workup things they can be doing before sending the patient to you?
• 4:37
  Julie Bass, DO: Absolutely.
• 4:38
  It, it's super helpful if, if a patient is presenting with diarrhea and blood
• 4:43
  in the stool right away, wanna get the infectious studies to rule out infection.
• 4:49
  Now, that being said, underlying infection, if this is a recurrent issue,
• 4:53
  then that doesn't absolutely exclude, IBD.
• 4:56
  As we know, patients who have significant colitis are more
• 5:00
  predisposed to getting infections.
• 5:02
  But we wanna make sure that we don't have, any like C.
• 5:05
  diff or giardia or other things.
• 5:07
  So we get a routine culture, Ovine parasite C.
• 5:10
  diff.
• 5:11
  And, a calprotectin is also a great screening stool test that's helpful
• 5:16
  if patients present with those stool studies already done, to give us an
• 5:20
  idea of how high a level of inflammation may be to help us decide how soon
• 5:26
  a colonoscopy may be necessary.
• 5:29
  As far as blood work, a complete blood count monitoring for, anemia,
• 5:35
  specifically, uh, you know, iron deficiency anemia we commonly can see,
• 5:39
  but also we'll see high platelet count.
• 5:41
  we'll, want to also check the liver function profile to monitor for
• 5:47
  any, elevation of the transaminases.
• 5:50
  Wanna check the albumin level.
• 5:51
  With Crohn's disease, we often will see a hypoalbuminemia, inflammatory
• 5:55
  markers, CRP and sed rate help us get an idea, of what may be going on.
• 6:02
  But important to note that normal inflammatory markers does not
• 6:07
  exclude inflammatory bowel disease, but all of those studies are, are helpful for
• 6:12
  us in the beginning of working this up.
• 6:14
  Mike (Host): Yeah, I guess the inflammatory markers really kind of
• 6:16
  depend on, you know, where they're at in a flare-up or something, right?
• 6:19
  Julie Bass, DO: Yes, correct
• 6:21
  Mike (Host): let's back up just for a sec.
• 6:23
  When you-- when we're talking about IBD in, in kids, what's the age
• 6:28
  range here that you normally see?
• 6:31
  Julie Bass, DO: We see all of the ages.
• 6:34
  Honestly, we're seeing more of the very early onset population.
• 6:39
  So, from infancy to six and under is who we typically refer
• 6:43
  to as the very early onset.
• 6:45
  but most commonly we'll see in like the early teen years through teenage
• 6:52
  years, and we follow kids through age 21 if they want to stay with us.
• 6:57
  So, we, we are following kids across all of the ages
• 7:02
  Mike (Host): when you think about, you know, the etiology of IBD, and I know this
• 7:06
  is an, uh, not an easy question to answer.
• 7:08
  What do you tell parents?
• 7:10
  Like what, what's going on here?
• 7:11
  What's the cause?
• 7:12
  Is it…
• 7:13
  Because I'm sure parents want to know, is it something I'm feeding them?
• 7:16
  Is it some…
• 7:17
  Like how, how do you handle all that?
• 7:19
  Julie Bass, DO: It is definitely the million-dollar question.
• 7:22
  And we know it's multifactorial.
• 7:24
  We don't know the exact cause, but we know there's definitely
• 7:28
  a genetic predisposition.
• 7:30
  So, we always ask about family history and have lower threshold to work kids up
• 7:34
  if we know there's any, family members that have inflammatory bowel disease.
• 7:38
  But also, we, we know it's autoimmune.
• 7:41
  We know there's an environmental piece to this, but n-not an exact infection
• 7:46
  that's been identified or exact foods.
• 7:49
  But there's lots of ongoing research looking at, different treatment
• 7:55
  pathways and interest in IBD nutrition and genetics and all of the things.
• 8:01
  So, it's definitely complex, and no two patients behave exactly the same way.
• 8:07
  So, it, it can make, treatment choices very individualized, you know, based
• 8:12
  on discussions with families and disease severity and where it is
• 8:16
  and how we decide the best treatment for each child that is presenting
• 8:22
  Mike (Host): and without proper treatment, w- what are some of
• 8:25
  the poor outcomes that can happen?
• 8:28
  Julie Bass, DO: Uh, those kids who have more severe disease have significant,
• 8:32
  concern for growth issues, definitely, a major concern with Crohn's disease,
• 8:39
  but also nutrient deficiencies, potential need for surgery with both
• 8:44
  Crohn's disease and ulcerative colitis.
• 8:47
  as if you leave Crohn's untreated in more moderate to severe cases, be-
• 8:52
  'cause of the full thickness of the inflammation of the bowel, it can
• 8:57
  progress to, areas of narrowing and, and tunneling, fistulizing disease, a bowel
• 9:04
  obstruction, perianal issues, need for emergent surgery for that population.
• 9:11
  Or our kids with significant colitis, if left untreated, could go on
• 9:16
  to, you know, be hospitalized with fulminant colitis and ultimately,
• 9:21
  may need a colectomy emergently
• 9:24
  Mike (Host): What about the risk of cancer?
• 9:26
  Julie Bass, DO: Leaving uncontrolled inflammation for years and years
• 9:30
  definitely puts our patients at higher risk for colon cancer on down the road.
• 9:34
  Thankfully, that's not something that we see often in, in pediatrics, but
• 9:39
  we definitely counsel our patients and make sure they're aware that, you know,
• 9:43
  having IBD, especially significant colonic inflammation, you'll need to
• 9:47
  have frequent surveillance scoping.
• 9:50
  Like, once you have lived with this disease eight to 10 years, you, at
• 9:54
  that point, you are due for routine surveillance scoping, which for most of
• 9:58
  our patients happens on the adult GI side.
• 10:00
  But that is why they-- we recommend surveillance scoping that often to
• 10:05
  monitor to make sure there are no changes within the, the colon and
• 10:10
  other areas to monitor the inflammation
• 10:13
  Mike (Host): So you've touched on this a little bit when we talked
• 10:15
  about the red flags, but I, I just want to make sure we're very clear
• 10:19
  here for the general practitioner.
• 10:22
  W- when should a community physician refer a patient to a specialist like you?
• 10:30
  Julie Bass, DO: I believe that there should be a, a fairly low threshold if IBD
• 10:35
  is coming up as a potential, diagnosis to consider with any of the lab abnormalities
• 10:42
  or severe symptoms or family history.
• 10:46
  I would err on the side of going ahead with the referral because
• 10:49
  this is definitely not a diagnosis that you want to allow to fester
• 10:53
  and go unrecognized for a long time.
• 10:57
  So I, I would recommend if there's consideration based on any of the things
• 11:03
  that we talked about with symptoms, family history, lab abnormalities, I- there's
• 11:07
  really not a harm in sending the child to, the specialist sooner rather than later.
• 11:13
  And honestly, in our case, it is super helpful if through the referral
• 11:17
  process, if it's escalated through, you know, our, requesting the sooner
• 11:22
  appointments or calling the doc on call, you know, just to alert the concern,
• 11:27
  especially in the sicker patients that we would want to see sooner to
• 11:30
  get a diagnosis and treatment going.
• 11:33
  Mike (Host): What are some of the standard treatments that you, you know, since
• 11:36
  you bring that up, like what, what can parents expect, their child to kind
• 11:41
  of go through in terms of treatment?
• 11:43
  Julie Bass, DO: Thankfully, we've had significant advances in treatment options
• 11:47
  available that in the last 10, 15 years.
• 11:49
  It's really been incredible.
• 11:51
  most of the time at diagnosis, it's still standard to start with
• 11:55
  steroid therapy when patients are presenting pretty inflamed.
• 12:00
  Uh, steroids will get inflammation under control quickly as we're
• 12:04
  finalizing treatment decisions.
• 12:05
  But if we can spare steroids, we do have some therapy
• 12:09
  options that are quick acting.
• 12:11
  And in terms of maintenance, w- all know steroid therapy is not a good option.
• 12:15
  But, there's been a significant advancement in the availability of
• 12:19
  biologic treatments to help heal the disease and, and keep kids in remission.
• 12:26
  we have Remicade and Humira are anti-TNF options, one in infusion
• 12:32
  and one in injection form.
• 12:34
  Now, there are a variety of biosimilars now, available for both of those
• 12:39
  products that are extremely effective agents in helping control disease.
• 12:43
  But we do know that, some patients don't always respond as well or may
• 12:48
  lose response, and thankfully, we have additional biologic options available
• 12:53
  that become great, options for us.
• 12:57
  Uh, we don't have, unfortunately, a great test to tell us which patient will
• 13:03
  respond to which therapy, so we do have to, do kind of trial and error basis
• 13:09
  on some of the available medications.
• 13:11
  as we all know, the medications are unfortunately extremely expensive and
• 13:17
  insurance can be a huge hassle, but we thankfully have an amazing team, we're
• 13:23
  well-versed at how to best navigate these scenarios and get our patients the
• 13:27
  medications that they need to get their gut healed to get them feeling better.
• 13:32
  So we, yes, we have a lot of newer therapies after, Remicade and Humira.
• 13:38
  We have, um, E-Entyvio vedolizumab, which is a, anti-integrin therapy.
• 13:44
  Then Stelara actually just got FDA approval for pediatrics,
• 13:48
  which is an IL-12/23 inhibitor.
• 13:51
  But there are some newer IL-23 inhibitors that have been extremely helpful and
• 13:57
  effective in, in some of our patients.
• 13:59
  Those drugs are Skyrizi and Tremfya.
• 14:01
  I always tell everybody, most of you have heard these co- these commercials on TV.
• 14:06
  lastly, Rinvoq is a small molecule.
• 14:09
  It's a JAK inhibitor that's been extremely helpful and as a rescue therapy for some
• 14:16
  of our patients, especially significant colitis who have not responded or have
• 14:20
  lost response to Remicade or infliximab.
• 14:23
  And it's nice it's an oral option.
• 14:25
  So we have a variety of oral or injectable or infusion options.
• 14:29
  So that's helpful in having conversations with families about
• 14:33
  what works best for, for them.
• 14:35
  Mike (Host): You know, and the biologics, there's no doubt they've
• 14:37
  changed the game here, right?
• 14:39
  I mean, these are-- ha-ha-have made a huge impact.
• 14:42
  But how do you also talk about the, the side effect side of them?
• 14:46
  knocking out TNF-alpha may, may help w-with the inflammatory
• 14:50
  component, but we know the risks, other cancers, other infections.
• 14:54
  Number one, how often do you actually see that?
• 14:57
  Like, what's that side effect rate that you experience as a clinician, and how
• 15:01
  do you, educate parents about that?
• 15:04
  Julie Bass, DO: Th-that's a great question.
• 15:06
  It's definitely a really time-consuming part of what we do in counseling families,
• 15:11
  with all of these medications, especially as we have more and more available.
• 15:15
  Absolute necessity that we have an IBD dedicated pharmacist on our team to,
• 15:19
  to help discuss and, and, navigate some of these decisions with the families.
• 15:24
  we do see, uh, in terms of the infection risk or skin-associated issues with
• 15:30
  the anti-TNF, some people are more predisposed to that th-than others.
• 15:34
  But in general, they're-- thankfully, these meds are really well-tolerated,
• 15:39
  and some of those scarier side effects, thankfully, are incredibly rare.
• 15:44
  we do tell families, of course, we would not prescribe it if we
• 15:49
  did not feel that y-you needed it.
• 15:50
  It's-- And it just really has to be a, a discussion of
• 15:54
  weighing the risks and benefits.
• 15:56
  And, unfortunately, with this disease, for some patients with that moderate to
• 16:00
  severe, type, you really need to fear the complications of the disease more
• 16:05
  than the potential side effect profile.
• 16:08
  And, and that can be a harder conversation with certain families.
• 16:11
  And, some will choose not to treat but over time, as they see how
• 16:16
  things are going, they're, they're definitely gonna change their mind.
• 16:20
  So, it, it-- With all of this, you have to follow closely and follow
• 16:24
  labs, follow stool studies, follow growth, and then kind of make those
• 16:27
  decisions together so everyone can be on the same page for what's best
• 16:32
  Mike (Host): Dr.
• 16:32
  Bass, the, the risk-benefit conversation is never going to end, even with
• 16:37
  the greatest advancements, Right.
• 16:40
  We're always gonna be balancing that and talking to our
• 16:43
  patients and families about.
• 16:45
  but speaking of the future a little bit, right, is there anything being studied
• 16:50
  right now, maybe better biologics or maybe not even biologics, I don't know, that
• 16:55
  you're following and you're excited about?
• 16:58
  Julie Bass, DO: Yeah.
• 16:59
  there's always more and more treatment pathways in the pipeline
• 17:03
  that are exciting to hear about.
• 17:05
  And again, I like to hear about working on certain pathways that would have an
• 17:10
  oral option versus of these other…
• 17:12
  Because sometimes that is the biggest part
• 17:15
  for, what people want to do, and they don't wanna deal with needles or, or some
• 17:20
  don't wanna take a pill, and they like that they can get an injection every eight
• 17:23
  weeks, and that's all that they have to
• 17:24
  do.
• 17:24
  So just all of the effective therapies being available in different
• 17:29
  mechanisms is, is super helpful.
• 17:31
  Um, the dietary piece is fascinating to me.
• 17:35
  Unfortunately, it's not, usually quite enough.
• 17:39
  Other than those with mild Crohn's disease, there's some-- I have had some
• 17:42
  patients that do really well with that.
• 17:44
  in the supplement world, there's actually, um, some products that
• 17:50
  have gained some recognition that, definitely interest some families that
• 17:55
  would prefer, other therapy options if they could try to avoid a biologic.
• 18:01
  So we, we always try to stay ahead of the latest and greatest evidence-based,
• 18:07
  research in terms of what we could consider and offer families that are,
• 18:11
  that are safe and, uh, good options.
• 18:14
  So we definitely see that.
• 18:16
  We are involved in Crohn's and colitis multicenter study,
• 18:19
  a prospective over time.
• 18:21
  There's 12 pediatric IBD centers across the country, and I-I'm really excited
• 18:26
  to, see that because it's specifically looking at patients with active disease
• 18:30
  who are changing therapies or trying di-diet therapy or having surgery and
• 18:35
  looking at those outcomes and trying to identify better markers and which disease
• 18:40
  types may respond best to which therapies.
• 18:43
  So, lots to come.
• 18:45
  It's, it just takes time, especially things are slower on the pediatric side.
• 18:49
  But I do think, just seeing what's become available in my time, uh,
• 18:54
  in IBD, it's been really exciting, and I know there's more to come.
• 18:58
  Mike (Host): Is there any last words you want, the audience to know about I- IBD?
• 19:03
  Julie Bass, DO: I do think in, you know, partnering with our pediatricians for,
• 19:09
  our IBD patients just, you- absolutely we're happy to, to help navigate any
• 19:15
  of these decisions for, for patients and wanna make sure that they're up to date on
• 19:20
  their immunizations, knowing that these patients on biologic therapies can have
• 19:24
  standard immunizations that are not live.
• 19:27
  and then we definitely wanna follow their growth closely if there's any
• 19:32
  concerns with eyes, skin, joints, those types of things, uh, alerting us of it.
• 19:37
  We, we try to make sure our families all know that, but just we, we're
• 19:41
  happy to, partner together in, in taking care of these patients.
• 19:46
  but yeah, we are excited to, to be available and definitely want to
• 19:50
  encourage anybody with any questions or concerns about IBD to, to not hesitate
• 19:56
  to reach out, and we'd be happy to help
• 19:58
  Mike (Host): Dr.
• 19:59
  Bass, this has been fantastic.
• 20:00
  Great information.
• 20:02
  you're very knowledgeable of all this, and it's been very helpful,
• 20:05
  I know, to me just listening.
• 20:07
  So thank you so much And as a reminder to our audience, claim your
• 20:11
  CME credits after listening to this episode by visiting cmkc.link/cmepodcast
• 20:19
  and clicking the Claim CME button.
• 20:22
  If you enjoyed this podcast, please share it and check out the entire podcast
• 20:26
  library of topics of interest to you.
• 20:28
  This is Pediatrics in Practice, a CME podcast.
• 20:32
  I'm Dr.
• 20:32
  Mike.
• 20:33
  Thanks for listening