Providers must listen, recognize GI ‘alarm signals’ in pediatric patients

Gastrointestinal disease often presents differently in pediatric patients, and providers must be aware of even subtle symptoms, such as changes in stool pattern or lags in growth and development, Dedrick Moulton, MD, told Healio.

Although an occasional stomachache or diarrhea is common among children, frequent or more severe symptoms may be indicative of an underlying GI disorder. According to the International Foundation for Gastrointestinal Disorders, 40% to 50% of visits to a pediatric gastroenterologist are related to functional GI disorders, with the majority linked to abdominal pain. Constipation or encopresis is reported among 10% to 25% of those referrals.

Moulton, professor and head of the department of pediatrics at LSU Health New Orleans School of Medicine and pediatrician-in-chief at Children’s Hospital New Orleans, recently spoke at the Color of Crohn’s & Chronic Illness Equity in GI 2023 event, where discussed distinguishing “just a bellyache” from a GI disorder, as well as disparities in pediatric care and how to promote health equity.

He spoke more with Healio in an interview exclusive.

Healio: How is health equity affecting pediatric GI patients right now?

Moulton: When I talk about equitable GI care, the main thing I focus on is what we are missing in how we communicate with this diverse patient population.

We hear much of the same thing: How do we access care, are we getting timely assessments and, in our case as pediatricians or family practitioners, are we recognizing the alarm signals associated with IBD? From there, the question becomes whether we make timely referrals and if there are delays in diagnosis.

Depending on the population you are caring for, salient features that may suggest IBD should also be considered, especially among those for whom IBD is not necessarily as often talked about, like Hispanic and African American people. Recognizing symptoms in marginalized populations is very important.

Healio: What steps should providers take to alleviate these care disparities?

Moulton: Providers must first recognize that there are disparities in health outcomes. If you recognize that and gear your approach toward reducing gaps, that’s the first and most important step. Patients shouldn’t always be treated the same and you never want to be the one creating those gaps.

I use the 20/80 rule, which looks at health outcomes in terms of where the impact is: 20% of health outcomes are related to what happens in the clinic or hospital setting, and 80% are related to social determinants of health. Historically, we focus more on that 20% and don’t think about the 80% having an impact. For example, what good does it do me to write a prescription for something a patient can’t afford or access because they don’t have transportation?

Another thing to consider is the level of mistrust we must overcome from the moment we first meet a patient. This mistrust can be presented in a variety of forms, so we must lead with proper communication — which requires having a translator when necessary — and without bias. If you don’t make that connection with a patient when you first walk into the room, you are at risk of losing the patient altogether.

Healio: How do symptoms present differently in children vs. adults?

Moulton: There are a lot of similarities in terms of presentation, so the main thing you should consider is the disease pattern. Disease often presents much more aggressively, with a widespread pattern, in the pediatric population than in the adult population.

For example, adults with ulcerative colitis often present with a disease that only affects a part of their colon, like their rectum or the left side of their large intestines. In pediatric patients, we most often see the entire colon inflamed, which is a more intense presentation.

Similarly, adults with Crohn’s disease may present with isolated inflammation in the small intestine or the end of the small intestine, whereas in children you may see the small intestine and large intestine significantly affected. They can also present with narrowing from the intense inflammation that, if not treated properly, can lead to early surgery.

A consideration in pediatric patients, which adults generally don’t have, is if they are not growing. The presentation and pain is unique to this population, and IBD can actually interrupt a pediatric patient’s growth and development.

Healio: In what ways should providers differentiate common symptoms from those that need further assessment?

Moulton: There are certain alarm signals you must pay attention to, though some of them are very subtle.

Let’s compare IBS with IBD: They have very similar symptoms, with the difference being you don’t see the level of inflammation or inflammatory patterns in IBS that you see in IBD. I also always tell people to notice their baseline. Take stock of stool pattern, whether there is blood in the stool, if they’re having hard stools and what is happening with weight pattern.

We also look at what happens when they experience pain. There is a difference between a patient who has pain and trouble sleeping because their stomach hurts vs. pain that wakes them up from a dead sleep; those nocturnal symptoms especially can be key.

Location of pain is important, too: If the child is complaining about pain in the right lower side of the belly, that is one of the most common locations for CD or appendicitis. But, if a patient is experiencing pain around the belly button, that is much less specific.

Healio: Following the decision to do a full GI workup, what are the next steps?

Moulton: Depending on where you start the case and who initiated the evaluation, whether it be with a pediatrician or family practitioner, there are certain tests that can be performed to help determine whether IBD should be investigated.

For example, one of the things a pediatrician can do is look at blood counts, as these tests are pretty simplistic. Look for signs of anemia and whether there are elevated markers of inflammation. Are abdominal symptoms driving that inflammation? This initial evaluation is usually the first layer that we will do in our office or, if the patient at a distance, instruct their provider to do.

The next layer of testing, if you’re seeing positive lab features, is endoscopic evaluation. Even if things look normal, tissue samples are necessary to make sure there is no microscopic inflammation.

In the setting of IBD, both adults and pediatric patients should have biopsies to confirm inflammatory pattern and make that distinction between CD or UC.

Healio: Are there certain conditions that are more common among children?

Moulton: There are a lot of conditions that can mimic some of the features of IBD, like IBS, which sometimes can be very tough to distinguish.

Another condition that we look for quite a bit is celiac disease, in which gluten is the driver. But because of so many antibiotic exposures, we also often see small intestine bacterial overgrowth. Other conditions to look out for include eosinophilic esophagitis and pseudo-diarrhea.

Healio: What advice would you give to providers caring for the pediatric GI population?

Moulton: The first thing to do is to learn to listen. Medicine is hard now because most of us are up against a tremendous volume. As clinicians, we’re having to churn out patients quickly and expected to know a lot of things about the patients in a very short period of time. This can lead to a culture of not completely listening when the main thing the patient wants is to be heard and valued.

We need to slow our minds down enough to be able to ask what a patient is most concerned about and what we can accomplish from their current visit. Look at them without bias, listen and understand them completely, and provide your best level of care.

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