Dr. Mike Smith (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Mike. And with me is Dr. Julie Bass, medical Director of the Inflammatory Bowel Disease Program at Children's Mercy. Today, we're going to be talking about IBD in pediatrics, exploring how to recognize it, when to refer, and how primary care providers can partner in care.

Dr. Bass, welcome to the show. Let's start off with how should pediatricians think about IBD versus common other forms of pain?

Julie Bass, DO: IBD is something you definitely want to think about in a patient that's presenting with abdominal pain associated with some of the other red flag symptoms that we think about or with pain that is limiting the daily activities, is associated with weight loss, vomiting, diarrhea, blood in the stool. It really should trigger underlying concern and need for further workup if the abdominal pain is associated with some of these other things or if it is really causing more issues than just brief distractible episodes of pain.

Host: Now, does IBD usually—is the onset a little bit longer in terms of some of the other conditions that cause abdominal pain?

Julie Bass, DO: Yes. In the setting, it's usually more chronic and not an acute condition, but not always. We've definitely have had patients diagnosed with IBD that have presented with shorter amounts of symptoms, or it can be recognized over time. And something that's unique to pediatrics, specifically pediatric Crohn's disease, would be in a child that maybe has some vague complaints of pain but associated growth concerns. That would also be a reason to think about possibility of IBD as a diagnosis. But in patients who are growing well, have, you know, brief intermittent or short episodes of pain, less likely to be IBD and more likely to be more common, you know, functional pain versus related to other things.

Host: How often do you see patients who are presenting maybe with other symptoms that aren't pain? Maybe it's fever or something like that, and that leads you to think that I need to maybe work up a bowel situation here.

Julie Bass, DO: That's a great question because we definitely have had some strange presentations because IBD patients don't always present in your textbook ways. So definitely, things that we see commonly in kids that maybe won't have the obvious bowel association with it would be joint complaints, arthritis, arthralgias. That would be one of the more common extraintestinal things that we see. Some less common but definitely things that we do see, the orofacial Crohn's disease subtype. So, lip swelling or significant mouth sores or perianal lesions, a recurrent perirectal abscess definitely would be a concern for inflammatory bowel disease. And those things can happen without pain or stooling symptoms.

Host: Well, let's go back to—you mentioned some of the red flags. What are some of those red flags that should prompt referral immediately?

Julie Bass, DO: Definitely in patients with significant growth concerns, the growth concerns would be a big thing. The significant pain, a significant arthritis, arthralgias associated with any of these GI symptoms, vomiting, diarrhea, blood in the stool, all of those things persisting over time and not an acute period.

Nighttime stooling or nighttime awakening for pain, definitely a red flag. Obviously, blood in the stool, multiple stools a day. So if you're upwards of four or five plus stools a day and negative infectious studies, those are all red flags that we would want to work up further for concern of possible IBD.

Host: If a general practitioner is seeing some of these red flags and they definitely want to refer this to you, the specialist, are there some initial workup things they can be doing before sending the patient to you?

Julie Bass, DO: Absolutely. It's super helpful if a patient is presenting with diarrhea and blood in the stool right away, want to get the infectious studies to rule out infection. Now, that being said, underlying infection, if this is a recurrent issue, then that doesn't absolutely exclude IBD. As we know, patients who have significant colitis are more predisposed to getting infections. But we want to make sure that we don't have any like C. diff or giardia or other things. So, we get a routine culture, ova and parasite, C. diff. And a calprotectin is also a great screening stool test that's helpful if patients present with those stool studies already done to give us an idea of how high a level of inflammation may be to help us decide how soon a colonoscopy may be necessary.

As far as blood work, a complete blood count monitoring for anemia, specifically, you know, iron deficiency anemia we commonly can see. But also, we'll see high platelet count. We'll want to also check the liver function profile to monitor for any elevation of the transaminases. We want to check the albumin level. With Crohn's disease, we often will see a hypoalbuminemia, inflammatory markers, CRP and sed rate help us get an idea of what may be going on. But important to note that normal inflammatory markers does not exclude inflammatory bowel disease. But all of those studies are helpful for us in the beginning of working this up.

Host: Yeah, I guess the inflammatory markers really kind of depend on, you know, where they're at in a flare-up or something, right?

Julie Bass, DO: Yes, correct.

Host: Let's back up just for a sec. When we're talking about IBD in kids, what's the age range here that you normally see?

Julie Bass, DO: We see all of the ages. Honestly, we're seeing more of the very early onset population. So, from infancy to six and under is who we typically refer to as the very early onset. But most commonly, we'll see in like the early teen years through teenage years, and we follow kids through age 21 if they want to stay with us. So, we are following kids across all of the ages.

Host: When you think about, you know, the etiology of IBD, and I know this is not an easy question to answer. What do you tell parents? Like, what's going on here? What's the cause? Because I'm sure parents want to know, is it something I'm feeding them? Like, how do you handle all that?

Julie Bass, DO: It is definitely the million-dollar question. And we know it's multifactorial. We don't know the exact cause, but we know there's definitely a genetic predisposition. So, we always ask about family history and have lower threshold to work kids up if we know there's any family members that have inflammatory bowel disease.

But also, we know it's autoimmune. We know there's an environmental piece to this, but not an exact infection that's been identified or exact foods. But there's lots of ongoing research looking at different treatment pathways and interest in IBD nutrition and genetics and all of the things. So, it's definitely complex, and no two patients behave exactly the same way. So, it can make treatment choices very individualized, you know, based on discussions with families and disease severity and where it is and how we decide the best treatment for each child that is presenting.

Host: And without proper treatment, what are some of the poor outcomes that can happen?

Julie Bass, DO: Those kids who have more severe disease have significant concern for growth issues, definitely a major concern with Crohn's disease, but also nutrient deficiencies, potential need for surgery with both Crohn's disease and ulcerative colitis. As if you leave Crohn's untreated in more moderate to severe cases, because of the full thickness of the inflammation of the bowel, it can progress to areas of narrowing and tunneling, fistulizing disease, a bowel obstruction, perianal issues, need for emergent surgery for that population. Or our kids with significant colitis, if left untreated, could go on to, you know, be hospitalized with fulminant colitis and, ultimately, may need a colectomy emergently.

Host: What about the risk of cancer?

Julie Bass, DO: Leaving uncontrolled inflammation for years and years definitely puts our patients at higher risk for colon cancer on down the road. Thankfully, that's not something that we see often in pediatrics, but we definitely counsel our patients and make sure they're aware that, you know, having IBD, especially significant colonic inflammation, you'll need to have frequent surveillance, scoping.

Like, once you have lived with this disease eight to 10 years, at that point, you are due for routine surveillance scoping, which for most of our patients happens on the adult GI side. But that is why we recommend surveillance scoping that often to monitor to make sure there are no changes within the colon and other areas to monitor the inflammation.

Host: So, you've touched on this a little bit when we talked about the red flags, but I just want to make sure we're very clear here for the general practitioner. When should a community physician refer a patient to a specialist like you?

Julie Bass, DO: I believe that there should be a fairly low threshold if IBD is coming up as a potential diagnosis to consider with any of the lab abnormalities or severe symptoms or family history. I would err on the side of going ahead with the referral because this is definitely not a diagnosis that you want to allow to fester and go unrecognized for a long time.

So, I would recommend if there's consideration based on any of the things that we talked about with symptoms, family history, lab abnormalities, there's really not a harm in sending the child to the specialist sooner rather than later. And honestly, in our case, it is super helpful if through the referral process, if it's escalated through, you know, requesting the sooner appointments or calling the doc on call, you know, just to alert the concern, especially in the sicker patients that we would want to see sooner to get a diagnosis and treatment going.

Host: What are some of the standard treatments that—you know, since you bring that up, like what can parents expect their child to kind of go through in terms of treatment?

Julie Bass, DO: Thankfully, we've had significant advances in treatment options available in the last 10, 15 years. It's really been incredible. Most of the time, at diagnosis, it's still standard to start with steroid therapy when patients are presenting pretty inflamed. Steroids will get inflammation under control quickly as we're finalizing treatment decisions.

But if we can spare steroids, we do have some therapy options that are quick acting. And in terms of maintenance, we all know steroid therapy is not a good option. But there's been a significant advancement in the availability of biologic treatments to help heal the disease and keep kids in remission. We have Remicade and Humira are anti-TNF options, one in infusion and one in injection form.

Now, there are a variety of biosimilars now available for both of those products that are extremely effective agents in helping control disease. But we do know that some patients don't always respond as well or may lose response. And thankfully, we have additional biologic options available that have become great options for us.

We don't have, unfortunately, a great test to tell us which patient will respond to which therapy. So, we do have to do kind of trial and error basis on some of the available medications. As we all know, the medications are unfortunately extremely expensive and insurance can be a huge hassle, but we thankfully have an amazing team. We're well-versed at how to best navigate these scenarios and get our patients the medications that they need to get their gut healed to get them feeling better.

So we, yes, we have a lot of newer therapies. After Remicade and Humira. We have Entyvio (vedolizumab), which is an anti-integrin therapy. Then, Stelara actually just got FDA approval for pediatrics, which is an IL-12/23 inhibitor. But there are some newer IL-23 inhibitors that have been extremely helpful and effective in some of our patients. Those drugs are Skyrizi and Tremfya. I always tell everybody, most of you have heard these commercials on TV.

Lastly, Rinvoq is a small molecule. It's a JAK inhibitor that's been extremely helpful and as a rescue therapy for some of our patients, especially significant colitis who have not responded or have lost response to Remicade or infliximab. And it's nice, it's an oral option. So, we have a variety of oral or injectable or infusion options. So, that's helpful in having conversations with families about what works best for them.

Host: You know, and the biologics, there's no doubt they've changed the game here, right? I mean, these have made a huge impact. But how do you also talk about the side effect side of them? knocking out TNF-alpha may help with the inflammatory component, but we know the risks, other cancers, other infections. Number one, how often do you actually see that? Like, what's that side effect rate that you experience as a clinician, and how do you educate parents about that?

Julie Bass, DO: That's a great question. It's definitely a really time-consuming part of what we do in counseling families with all of these medications, especially as we have more and more available. Absolute necessity that we have an IBD-dedicated pharmacist on our team to help discuss and navigate some of these decisions with the families.

We do see in terms of the infection risk or skin-associated issues with the anti-TNF, some people are more predisposed to that than others. But in general, thankfully, these meds are really well-tolerated. And some of those scarier side effects, thankfully, are incredibly rare. We do tell families, of course, we would not prescribe it if we did not feel that you needed it. And it just really has to be a discussion of weighing the risks and benefits. And, unfortunately, with this disease, for some patients with that moderate to severe type, you really need to fear the complications of the disease more than the potential side effect profile. And that can be a harder conversation with certain families. And some will choose not to treat. But over time, as they see how things are going, they're definitely going to change their mind. So, with all of this, you have to follow closely and follow labs, follow stool studies, follow growth, and then kind of make those decisions together so everyone can be on the same page for what's best.

Host: Dr. Bass, the risk-benefit conversation is never going to end, even with the greatest advancements, right? We're always going to be balancing that and talking to our patients and families about. But speaking of the future a little bit, right, is there anything being studied right now, maybe better biologics or maybe not even biologics, I don't know, that you're following and you're excited about?

Julie Bass, DO: Yeah. There's always more and more treatment pathways in the pipeline that are exciting to hear about. And again, I like to hear about working on certain pathways that would have an oral option versus of these other—Because sometimes that is the biggest part for what people want to do, and they don't want to deal with needles or some don't want to take a pill, and they like that they can get an injection every eight weeks, and that's all that they have to do.

So, just all of the effective therapies being available in different mechanisms is super helpful. The dietary piece is fascinating to me. Unfortunately, it's not usually quite enough. Other than those with mild Crohn's disease, I have had some patients that do really well with that.

In the supplement world, there's actually some products that have gained some recognition that definitely interest some families that would prefer other therapy options if they could try to avoid a biologic. So, we always try to stay ahead of the latest and greatest evidence-based research in terms of what we could consider and offer families that are safe and good options.

So, we definitely see that. We are involved in Crohn's and colitis multicenter study, a prospective over time. There's 12 pediatric IBD centers across the country, and I really excited to see that because it's specifically looking at patients with active disease who are changing therapies or trying diet therapy or having surgery and looking at those outcomes and trying to identify better markers and which disease types may respond best to which therapies.

So, lots to come. It just takes time, especially things are slower on the pediatric side. But I do think just seeing what's become available in my time in IBD, it's been really exciting, and I know there's more to come.

Host: Is there any last words you want the audience to know about IBD?

Julie Bass, DO: I do think in, you know, partnering with our pediatricians for our IBD patients just, absolutely, we're happy to help navigate any of these decisions for patients and want to make sure that they're up to date on their immunizations, knowing that these patients on biologic therapies can have standard immunizations that are not live.

And then, we definitely want to follow their growth closely if there's any concerns with eyes, skin, joints, those types of things, alerting us of it. We try to make sure our families all know that. But just we're happy to partner together in taking care of these patients. But yeah, we are excited to be available and definitely want to encourage anybody with any questions or concerns about IBD to not hesitate to reach out, and we'd be happy to help.

Host: Dr. Bass, this has been fantastic. Great information. You're very knowledgeable of all this, and it's been very helpful, I know, to me just listening. So, thank you so much. And as a reminder to our audience, claim your CME credits after listening to this episode by visiting cmkc.link/cmepodcast and clicking the Claim CME button.

If you enjoyed this podcast, please share it and check out the entire podcast library of topics of interest to you. This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.