Scott Webb (Host): Though IBS seems to get most of the headlines, IBD or inflammatory bowel diseases in children are very real concerns. And my guest today, Dr. Jonathan Moses, is a gastroenterologist and medical director of the IBD Program at Stanford Medicine Children's Health Center for IBD and Celiac Disease. And he's here to discuss IBD and how we can best help our kids to manage their symptoms and live their best lives.

 This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're essentially going to have an overview and talk about the treatment of inflammatory bowel diseases in children and adolescents. And I did one recently on sunscreen, so this one may not be as lighthearted as the sunscreen podcast, but it's great to have you here. Great to have your expertise. I just want to start with maybe the obvious ones. What is IBD? How is it different from IBS? And then also, how is it different from celiac disease?

Dr. Jonathan Moses: Yeah, thank you, Scott. Great questions, and thank you for having me on the podcast. I'll start with the first question. Inflammatory bowel disease, and just a quick overview, is where we have inflammation somewhere in the GI tract, anywhere from your mouth to your bottom, as we say, so stomach, small intestine, colon. It's different for everybody that needs medications to get them into remission. So, remission is when the inflammation has been calmed down, so to speak, and it's not present anymore. And the reason we want to do that is the inflammation can cause a lot of symptoms, things like belly pain, things like diarrhea, blood in the poop, low energy, missing school. So, that's really our goal for inflammatory bowel disease and kind of a quick overview on what it is.

It's different than IBS. IBS is irritable bowel syndrome and IBD is inflammatory bowel disease. So, they are so close off by just one letter. So, we get this a lot from patients, families, the internet, social media, but irritable bowel syndrome is where the nerves in the GI tract are disturbed and they're sensing stuff they shouldn't, so they're a little more heightened and aware than they should be. But the biggest difference is that in IBS, there's no inflammation present. So, there's no real kind of chance for long-term issues or long-term damage or need for medicines that calm down the inflammation. So, that's the biggest difference between the two. That being said, patients with IBD can have IBS, just to make it even more complicated. But for the most part, they're very distinct from each other.

Host: So, IBD and IBS, just one letter separates them, but they are different, but some patients may have both. And how about celiac?

Dr. Jonathan Moses: Celiac disease is another time when the body thinks that something's foreign. In this case, it's typically gluten, which is in our diets in the form of wheat, barley, rye. And the body recognizes the form and actually makes antibodies to it. So, celiac disease is actually an autoimmune disorder, because your body makes antibodies against it. And when these antibodies form, they create inflammation in the GI tract, specifically the upper tract, right past the stomach in what we call the small intestine. So, the biggest difference there is that celiac is controlled by dietary elimination of gluten. And you don't require medicines to control the inflammation, which is very distinct from inflammatory bowel disease. We have to be on medicines that calm down or turn off the inflammatory process.

Scott Webb: Sure. Yeah. Wondering

Host: when we think about IBD, which is essentially what we're talking about here today. Are there different forms of IBD and are some more common than others?

Dr. Jonathan Moses: Inflammatory bowel disease is an umbrella term, and we think of inflammatory bowel disease as really two main different kind of arms, so to speak, or spokes under the umbrella. One is Crohn's disease, and that's where there's inflammation anywhere from your mouth to the bottom, as we say. So, it can be anywhere in your GI tract, in your food pipe, your esophagus, your stomach, your small bowel, your large bowel.

So, the key difference between Crohn's disease and the other one, which is called ulcerative colitis or UC for short, is that we only see the inflammation in the large intestine or the colon. So, the biggest difference between the two is where you see the inflammation. If it's just in the colon or the large intestine, that's ulcerative colitis. And if it's anywhere else outside of that, it's Crohn's disease. And there's some other distinctions, but those are the basic differences. And in kids, we see around 60% have Crohn's and about 40% have ulcerative colitis.

Host: Yeah. And it seems, doctor, like there are just endless commercials for IBS, like everybody seems to know what IBS is. But because IBD is this umbrella term and then you've got Crohn's and you see underneath it, it doesn't seem like I hear about it as much, or maybe it's just not talked about as much. So, it makes me wonder, is IBD on the rise? And if so, do you know why?

Dr. Jonathan Moses: So, IBD is on the rise. We know that especially in young kids under 10, we're seeing more cases over the last 10 years. There's some good research basically from epidemiology databases to show that. The exact reason is not clear, and maybe that we're diagnosing more. We do know that IBD, we don't know the exact cause, but we think there's some environmental and genetic factors that may be played into this. So, we don't have the exact reason why, but we are seeing it increase in kids. And probably why you see more IBS than IBD is that IBS is more prevalent, so more people have IBS than IBD. So, it's just a matter of you're going to hear more about the IBS.

And to be honest, it's sort of in our lexicon. We all have these sort of disorders or diseases or terms. Lactose intolerance is one we all kind of universally recognize for whatever reason. And IBS kind of took on a life of its own over the last 20 years or so, and it's just become sort of a term that we are more familiar with than IBD. And I think one of the other big difference is we've kind of termed IBD the invisible illness because it's all on the inside. It's hard to really know somebody has IBD, especially if they're doing well, but even if they're having some symptoms. So, there's another layer of it's hard to point to somebody and say they have IBD. It's obvious. So, that becomes another kind of challenge for awareness.

Host: Doctor, I'm wondering, we think about a diagnosis and sort of when folks, you know, are generally diagnosed with IBD? Is it when they're kids? Is it when they're older? And what's the split generally, if we think about the big pie, a hundred percent, you know, kids versus adults in terms of the percentages?

Dr. Jonathan Moses: When we look at the pie to start of 100%, we know that about 25% of all patients are diagnosed when they're in the pediatric age range. So, overall, if you take all children and adults in the U.S. with inflammatory bowel disease, about 25% are in the pediatric age range, about 75% are adults.

As far as when they're diagnosed, there's actually two distinct peaks for when we diagnose more patients than others. In the pediatric age range, it's between 10 and 17 years of age. And in adults, it's near 30 and 40. So, it's pretty flat mostly, but with these two distinct peaks in both the pediatric and adult range.

Host: Yeah. And for patients who have been diagnosed with IBD and you've mentioned here that it really needs to be treated. It's just not something you want to leave untreated that will just sort of resolve on its own. Why is it important for them to get care at centers specifically for IBD and what differentiates your program?

Dr. Jonathan Moses: I think that inflammatory bowel disease can probably be managed by any gastroenterologist, at least pediatric gastroenterologists. What we know are the subtle differences between pediatric care and adult care, and there's a few of them. But one of the big ones is that, In the pediatric world, for kids, we try to take a team-based approach. So for example, we have not only our physicians, we have nurse practitioners, we also have a social worker, a dietician, a psychologist, a pharmacist.

So, a center like Stanford, where we have our Center for Inflammatory Bowel Disease and Pediatric Celiac Disease, we're able to offer families what we call a multidisciplinary approach, where you're seeing all these providers. We know that IBD is not just the medicines. We know that there are nutritional issues, school issues, psychosocial issues. These all need to be addressed. And sometimes it's hard to do this in a piecemeal fashion. So, pediatric gastroenterologists around the country are able to manage the medicines, but it's that other part of the care that I think we're able to offer in a more uniform and sort of one-stop shopping approach at Stanford Children's.

Host: Yeah. And that does seem to be the way now, just really comprehensive care for patients and families, multidisciplinary, as you say, sort of one-stop shopping, which is something that we can all get our minds around. I want to have you talk about the diagnostic tools that are available and some of the benefits maybe of the newer and less invasive tools that you're using.

Dr. Jonathan Moses: Yeah. That's a question we get all the time from families. We know that still to really make a diagnosis, we call it gold standard, meaning, you know, if I asked all pediatric gastroenterologists how would they diagnose, it would still be endoscopy with biopsy. So, that's when we take a camera and look on the inside. So, for the moment, that's still our gold standard.

That being said, one of the new modalities I think we're very interested in and that we offer at Stanford Children's, Dr. Ruben Colman heads up the program, is a point-of-care intestinal ultrasound. That means we'll take a probe, like if we were looking at like a baby who's about to be born. And we're actually able to visualize the bowel and see how thick it is. And we know that when the bowel is inflamed, it's thicker than it should be. We can actually see how thick the bowel is. And we have measurements that tell us whether it's inflamed or not inflamed. So, one of the modalities we're really excited about, and it's early on, but it has a ton of promise for not only regular monitoring, but maybe in the future diagnostics is intestinal ultrasound.

Host: Yeah. I've heard that ultrasound's been around for a long time, of course, but it seems like there's newer and really innovative ways of using it that maybe hadn't been thought of before, right?

Dr. Jonathan Moses: Absolutely. And this is one example of that. It really just takes that one kind of idea or that aha moment from one person to really get things going. And that's really what happened, is someone realized very quickly that we don't have to be experts in radiology and see everything in there. We just really have to get good at looking at the bowel and finding it. And once you standardize how thick the bowel is, so we have numbers and cutoffs, that really advances the field where now folks can start doing it elsewhere.

Really, the biggest hurdle is resources. It's really time-intensive to get a program started at a site along with having an expert train. But these are all things that are happening at a really quick pace. And we really expect this to be a modality that's widely available. But for now, it's only a few centers and we're excited to be the only center North in California that offers it for pediatric inflammatory bowel disease at Stanford Children's.

Host: Yeah. And as we're saying, you know, patients who've been especially, you know, already diagnosed, but just in general, in terms of diagnosing and treating IBD, a dedicated center such as the one at Stanford Medicine Children's Health is amazing. Let's talk about some of the therapies for treatment, surgical, non-surgical, the whole gamut, if you will.

Dr. Jonathan Moses: I think that speaks to the multidisciplinary approach is that if you're just seeing a pediatric gastroenterologist, you're kind of tethered to the medicines. Well, having a large team like this does allow us to think about things. So, having a surgeon who is focused in inflammatory bowel disease, especially specific on the pediatric side can make a big difference. And we're lucky enough to have Dr. Faraz Khan as part of our team who sees more patients than a normal surgeon does. So, the more you see, the better you get at it is really the mantra in surgery. So, having him available for consultations and having his expert skills makes a big difference a lot of times for families. Surgery can be very scary for good reason, but sometimes it's actually a very good therapy. And doing it electively or on our own time can make a big difference in outcomes.

The other would be dietary and nutritional therapies. We do have a dietician as part of our team, Farah Mardini, and she's an expert in things like the specific carbohydrate diet, the Mediterranean diet, the anti=inflammatory diet. And these are things that can be offered to families as alternate therapies for mild to moderate disease. And I think that as families think about what therapy they want to start, we're trying to offer more non-medical therapies, whatever possible. There are times where the medicines are really the only thing that are going to help the kids feel better, but we do want to make sure that parents feel like they're getting all the information they can.

And then, finally, integrative therapies like complementary medicines. We do like to offer all we can to our families. And we have Dr. Ann Ming Yeh, who heads up our Integrative Medicine Division at Stanford Medicine Children's Health, and she's also an expert in inflammatory bowel disease. So, these are kind the additional offerings I think we provide that go along with the medical therapies

Host: Yeah. And we touched on this a little bit, sort of the research and clinical efforts and how these things, you know, sort of sometimes by happenstance, but either way, it just takes one person sometimes to go, "Hey, what if we did this?" Right? Yeah, I just want to find out, when we think about the Stanford experts, what are you all working on to improve treatment and options or outcomes for patients with IBD?

Dr. Jonathan Moses: A few things we do at our center, and I think these are things that are so important for, as you said, improving clinical care. We're participating in ImproveCareNow, which is a National Quality Improvement Registry for Pediatric Inflammatory Bowel Disease. About half of the centers in all of the country are enrolled in it. And it allows us to have access to real time data in the sense of remission rates, patients on steroids, how the nutritional status is. So, we are able to in real time help these kids feel better.

We mentioned intestinal ultrasound. I think that's really advancing the field of serial monitoring and maybe one day in diagnostics. And I think these are offerings that we're really excited about. And finally, offering innovative therapies through clinical trials. So, we know that there are lots of medicines out there. Most of them are improved in adults and only a few in kids. And we feel as we participate in these clinical trials, we're able to do two things. We're able to offer families medicines, better access to newer therapies, but also to help build that body of data that is needed to get approval from the Food and Drug Administration. So, we think offering a big slate or a nice menu of clinical trials over the next six to 12 months will provide more options for families for therapies.

Host: Yeah, for sure. And obviously, heroic, if you will, on the part of these families and the children, especially, to participate in these clinical trials, so many will benefit as you're hearing just today about just the advances and where this might be going. And that kind of leads me to my next question is, what are your hopes for patients with IBD in the future?

Dr. Jonathan Moses: I think our hope is always a cure. I think that's always our mantra. We do want to see the science advance to the point where we understand IBD so well that we're able to cure it. Until we get to that point, I think we're really doing everything we can to improve the quality of life. So when we talk about quality of life in kids, it's different than adults. Adults think about work and money and finances, and they should. In kids, we think about days missed from school, activities missed, soccer games missed. So, our goal is to make it so that these kiddos don't miss anything. They're back in school. They're doing what they want to do. And we do ask about this at the visits and make sure that they are leading kind of a full life. And our goal is always to make it so that inflammatory bowel disease does not get in the way of them being a kid.

Host: Yeah. My son is 21 now, but he has IBS. And just exactly what you're saying, when he was a kid, he's still a kid, he'll always be my kid, of course, but when he was younger, a teen, adolescent, that quality of life for him was about being with his friends and hanging out with them and playing sports and those things, and not having to miss those things because of something like IBS, right?

Dr. Jonathan Moses: Absolutely. Yeah. Those are so important to kids in the development. And, you know, just as a last point on that, another big difference with pediatrics and adults is their growth and development. We have a keen focus on that. We have a chance to help these kids not miss their growth potential, because of active inflammatory bowel disease. And that's another thing that we offer on the pediatric side that we're very proud of and we keep a very close eye on.

Host: Doctor, presumably a lot of parents listening to this, I'm a parent as well, and we've all had our kiddos complain of tummy aches, right? It's maybe the most common thing when you're a parent is, "My stomach hurts. My tummy hurts." Okay. So, how do we differentiate? How do we know, you know, the average run of the mill tummy ache, too much of this, not enough of that, whatever? When should we decide then to speak with a professional, whether it's a pediatrician or a specialist, what's the breaking point? Is it when they have a stomachache, you know, all day, every day for a couple of days from your perspective?

Dr. Jonathan Moses: The advice we give is always start with your pediatrician, of course, and make sure that you start with someone you trust who's taking care of your child. But I would say a belly pain that lasts more than a few days. If it's only a one-off, we ate some hot Cheetos and they upset our stomach, then it's probably okay. Once it becomes more of a recurrent daily issue, you definitely want to talk to your pediatrician.

And we talk about belly pain. It's one of the most common chief complaints we see in our office, and as I tell the fellows in the residence, they always ask me, "When do I think about inflammatory bowel disease or other things?" It's really abdominal pain plus something else. So, let's say they have belly pain plus diarrhea. Belly pain plus blood in their poop. Belly pain plus not growing well. That's kind of when that second symptom starts to really kind of raise my radar a little bit. But always starting with a pediatrician is a great place to go. And you're in great hands and a referral to GI is just one step away if needed.

Host: Yeah. Kids are amazing, doctor, and very resilient, especially with what they eat. And you mentioned earlier that we don't know exactly why IBD is on the rise. Could be genetics and some other things. Could it also be diet? Could it be the hot flaming things? Could it be just the American diet in general that's behind this?

Dr. Jonathan Moses: It's entirely possible. You know, we talked earlier about, you know, what are the environmental factors here? And I think that there's some data support that sort of the "Western diet", when it gets introduced into a country, or becomes more prevalent in that country, IBD does go on the rise. Of course, there are a lot of factors that go into that, so it's difficult to make that direct correlation, but it does bring into question the food we're eating, the processing, are these things that are either setting off the inflammation? Are they disturbing the bacteria or the microbiome? And then, that leads to a shift.

So, a lot of this research is ongoing, but these are all great questions to ask. And I think the, advice we usually give families is I think if you eat what we consider a healthy diet, that's always the best way to go. And one of the other reasons we have our dietitian with us is that sometimes that's hard to describe. And sometimes a session with our dietitian can really shed some lighting on exactly what that means for families and kids.

Host: there's almost never a time, Doctor, when I host these, privileged enough to host these for Stanford Medicine Children's Health, where I don't end up with a smile on my face. Even when we're talking about something like IBD, right? It just always comes back to that patient-centered care. And in this case, talking about children and younger people and their families, and I always end up with a smile on my face when I do these. So, same for today, of course. And I just want to give you a chance, take a deep breath. Last question for you. What's your favorite part of your job?

Dr. Jonathan Moses: I would say the favorite part of my job by far, I think, you know, sort of the science and the medicine of inflammatory bowel disease, I find very intellectually engaging as far how to use the medicines and manage care and get kids in remission. But by far, my favorite thing about taking care of kids with IBD is the longitudinal care. And I think when I was in training, my favorite part about general pediatrics was watching these kids grow up. And as an IBD physician, we see these kids very often, almost every three to four months for many years. By far, my favorite thing is watching these kids grow, graduate school, go on to kind of bigger things after college and school.

So, I think that's really the treasure of inflammatory bowel disease for me is to be a part of that phase for these children and young adolescents and watch them succeed and not have IBD limit their ability to go on to do what they want to do.

Host: For sure. Yeah. My son just sort of graduated, if you will, to an adult doctor, you know? And so, he had his last visit with the pediatricians that have had the pleasure of seeing him grow up and treat him for all of his sore throats and everything that the pediatricians see kids for. They sort of celebrated when he was on his way out, you know, cheering him on, on his way to an adult doctor. So, definitely smile on my face. Appreciate this. Great insight, expertise, and information today. So, thank you so much.

Dr. Jonathan Moses: Well, thanks for having me, Scott. I really appreciate it.

Host: And for more information, go to ibd.stanfordchildrens.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.