Inflammatory Bowel Disease (IBD) and Kids – Recognizing the Symptoms

Deborah Howell (Host): Inflammatory bowel disease or IBD, is a chronic disease characterized by chronic inflammation of the gastrointestinal tract. IBD is usually diagnosed early, since many of the signs can be concerning to parents. I'm Deborah Howell, and today we'll talk with Dr. Roy Nattiv, a Pediatric Gastroenterologist at MemorialCare, Miller Children's and Women's Hospital, Long Beach, about why it's important for parents to recognize these early signs so that IBD can be treated and managed in children. Dr. Nattiv, it's so nice to have you with us today.

Roy Nattiv, MD: Thanks for having me. This is fun. I'm glad to be doing this.

Host: All right. Let's dive right in. What causes IBD?

Roy Nattiv, MD: So, IBD is inflammatory bowel disease. It's often confused with IBS. IBS is irritable bowel syndrome. These are different things. Inflammatory bowel disease is an autoimmune disease. So autoimmune diseases in general, you can think of as a dysregulated immune system. An immune system that ordinarily is just fighting bacteria and viruses and parasites and splinters, and things that aren't supposed to be in our body, suddenly is overactive or dysregulated. It starts attacking things in our body that it shouldn't attack. And so inflammatory bowel disease is an autoimmune disease of the intestines. And so, people with inflammatory bowel disease usually have some genetic predisposition for autoimmunity, like there's some other autoimmune diseases in the family.

In these individuals, there is a hyperactive or overactive immune response to some environmental stimulus or other component within the gastrointestinal tract, if that makes sense. So something in these individuals who are already predisposed to some degree to overactive immune systems, triggers their gut immune system to start attacking something in and along the gut. And we're not exactly sure what that stimulus is in these individuals. We suspect that it is some bacteria or some component of their intestinal microbiome or like the normal bacteria of the intestines. We all have bacteria that line our intestines that live with us. And sometimes help us digest food. And, and in these individuals with this overactive immune system, the immune system starts attacking these bacteria that are otherwise supposed to be friendly. And it causes ulcers and inflammation and irritation along the gastrointestinal tract; meaning anywhere from your mouth, all the way down to your rectum.

And that results in pain, discomfort, diarrhea, rectal bleeding, and a host of other symptoms. Sometimes not even confined to the GI tract. And that's kind of the general explanation for IBD. I can go into a lot greater detail, but I hope that makes sense.

Host: That's an excellent explanation. I'm wondering about the difference between IBD and normal digestive issues.

Roy Nattiv, MD: Normal digestive issues are often self-limited, meaning that if you get a stomach bug of bacteria, virus, you eat some bad food or you eat some bad food, you go on vacation somewhere and you pick up a virus or a stomach bug from one of your kids; even the most insidious viruses and bacteria will resolve themselves after a couple weeks. Sure, you may need some antibiotics, you may want to take a probiotic to shorten the duration of that illness. But it's usually self-limited to some degree. IBD is unique in that the natural history of IBD, meaning that if left to its own kind of devices, you will have relapsing and remitting episodes of inflammation.

You will have ulcers and diarrhea and rectal bleeding that might resolve spontaneously. It may take several weeks, it may take several months, but it might go away on its own, and then it'll come back and then it'll come back. It might start coming back more frequently. And with each episode of inflammation, there is an increased risk of some certain complication, like a narrowing of the intestines, a small hole in the intestines, or it might be something a little bit more under the radar, more insidious, like malnutrition, a lack of absorption of certain food proteins or vitamins and, people will lose weight. And the other more I guess the most insidious kind of complication of inflammatory bowel disease, is that over the years, maybe even decades of relapsing and remitting inflammation, you start to get architectural changes, when the skin repairs itself or when the intestines repairs itself.

I say the skin because the intestines is kind of like your skin on the inside. But when the intestines repairs itself, after many, many iterations of inflammation and repair; oftentimes it grows back abnormally and that's cancer. And so ultimately, the most insidious and kind of worrisome complication of inflammatory bowel disease is the development of colon cancer.

Host: Okay. You covered this extensively, but I want to make sure we get all of the symptoms. Can you go over all the symptoms of IBD?

Roy Nattiv, MD: Very often the symptoms can be, because this is a disease that often presents in childhood, early adolescence, is the peak age of presentation. And so us as pediatric gastroenterologists and pediatricians in general, in the community, have to be mindful of some of the symptoms and in kids can vague because kids are often not the greatest historians. And so sometimes the chief complaint can simply be abdominal pain or abdominal discomfort. Now that alone is not sufficient for us to suddenly jump to inflammatory bowel disease cause we know a lot of things can cause a little bit of abdominal discomfort. But the other most common symptoms are diarrhea with or without blood, weight loss and fevers.

And I often, try and educate pediatricians, if you have three out of those four symptoms, it's kind of inflammatory bowel disease until ruled out otherwise. So, abdominal pain, diarrhea with or without blood, weight loss and fevers, three of the four and you got to rule out IBD.

Host: And what's the first step a parent or legal guardian should take if their child is experiencing these symptoms?

Roy Nattiv, MD: Well, they should go see the pediatrician, obviously. And an astute pediatrician will probably send off some simple blood work or even a stool test. There are some really good blood and stool tests to screen for inflammatory bowel disease. And those can be done at the pediatrician's office. And if the pediatrician feels uncomfortable, they can refer to a pediatric gastroenterologist who can run those same tests.

Host: And why is it so important to get ahead of these symptoms in younger kids?

Roy Nattiv, MD: Well kids, as I mentioned previously, the peak age of presentation is early adolescence. And this is a really critical period in the development of children because they're usually going through puberty. And if you have an autoimmune disease, any autoimmune disease including inflammatory bowel disease, that's flying under the radar, during this critical period, they may not reach their full growth potential. Kids are using calories during this age, early adolescence and kind of like the preteen years. They're using calories that they're consuming to grow physically in their anthropometrics, like their height and their weight, and grow developmentally.

Their brain needs to grow. Their body's undergoing a lot of changes. And if those calories are being used to fight disease and illness, then they can't do those otherwise normal developmental things. Their bodies won't achieve full growth potential. And they might be growth stunted or they might incur some developmental delays if it goes on too long.

And so getting ahead of this inflammatory condition is important so they can use those calories for growth and development rather than fighting some underlying illness.

Host: Sure. I see why it's so important. So what are the effects if symptoms are left untreated?

Roy Nattiv, MD: Well, like I alluded to previously if symptoms are left untreated, kids will burn calories fighting this illness rather than using those calories to grow and kids may be growth stunted. Because inflammatory bowel disease and other autoimmune conditions often have a genetic component, it often runs in families. Sometimes I'll see parents and I'll look at the parents and I'll say immediately like, wow, the parent looks growth stunted. And sure enough, they'll recant a history during their childhood in which they had some chronic inflammatory condition. Probably IBD, in my field in which they weren't adequately treated. And you can tell that they kind of didn't reach their full growth potential probably cause during that critical period their body was busy fighting this disease rather than focused on growing physically and developmentally.

Host: So I have to ask then, is it genetic?

Roy Nattiv, MD: So yeah, there is a strong genetic component to inflammatory bowel disease. Now, it's not a monogenic disease, it's typically not a monogenic disease. So it's not what we call like a classic Mendelian pattern of inheritance. It's hard to predict. There have been to date over 250, I think, nearly 300 genes that have been suspected to be involved in the development of IBD. And patients often have small genetic variants in any of these, one of 300 genes. And it's a confluence of kind of various genetic mutations that you inherit from one or both parents, and an environmental stimulus.

So there is a strong genetic component. They say if you have a first degree relative with inflammatory bowel disease, you have a tenfold increased risk in developing IBD. So the incidence is about one in 200, meaning about one in 200 people have inflammatory bowel disease. And if you have a first degree relative, then your risk goes up to about one in 20. And that's something I often counsel parents, cause parents with inflammatory bowel disease often come up to me and ask, well, what's the chance that my child has inflammatory bowel disease?

It's not certain that they'll have inflammatory bowel disease. And it's still only, I say only, but it's about a 5% risk with a first degree relative. So it's still unlikely, but it's still a possibility. And so there is a hereditary component.

Host: And what treatment options are available for children with IBD?

Roy Nattiv, MD: There's a lot of treatment options and parents are unfortunately flooded with media exposure about the various drugs that are used to treat inflammatory bowel disease. Parents often ask me like what is inflammatory bowel disease? And then I'll say, ask your doctor if Humira's right for you. And they immediately remember, and then they're like kind of tuned in and they start hearing all the different medications that are available on TV and on media. But, one of the most overlooked treatments for inflammatory bowel disease is diet. There is a prescriptive diet that can be used in some cases, as a primary treatment for inflammatory bowel disease to kind of calm the immune system of the gut. You can think of it as a low immune diet, but it's very prescriptive. It's not usually something that parents can kind of find online and just Google, like, oh low immune diet. Yes, there are, generally speaking, some low immune diets that can be a supportive treatment, but there are also very specific prescriptive diets that can be used to treat IBD and those need to be instituted together with a pediatric gastroenterologist and a dietician with some expertise in inflammatory bowel disease. In our center we have 10 pediatric gastroenterologists, all of whom have experience in treating IBD.

We have a dedicated IBD nurse practitioner and an IBD dietician, and it really takes a village to institute treatment, especially, a diet as treatment for inflammatory bowel disease. However, I start off by explaining how inflammatory bowel disease is primarily an autoimmune illness. It is an autoimmune illness, and so the mainstay of treatment is really suppressing the immune system a little bit, such that it's not attacking one's own body, the child's own intestines, but still capable of fighting off bacteria, viruses, and all those other things that kids encounter every day.

So generally children with inflammatory bowel disease are treated with some immunosuppressive therapy, whether it's topical for the intestines, kind of like how you would do like a hydrocortisone on your skin if you had like some eczema or some inflammation on your skin. We have topical therapies for the gut, but very often they need systemic immunosuppression, a medication that suppresses their entire immune system at a very low dose.

I didn't get into it, but inflammatory bowel disease also had what we call extraintestinal manifestations, manifestations of disease outside the GI tract, believe it or not. And sometimes they can benefit from some systemic immunosuppression to suppress those manifestations as well, outside the GI tract.

But generally there is some immunosuppression involved. There is some diet as therapy. And there's also a big psychosocial component as you can imagine. Because dealing with an intestinal disease in which kids may suffer a lot of abdominal pain, may have to use the bathroom quite frequently, especially during school, and so, part of the treatment is also treating the psychosocial aspect. And we also have social workers and psychologists that work with our team to address those issues.

Host: I was going to ask you about the IBD Program at Miller Children's and Women's Hospital, and its unique benefits.

Roy Nattiv, MD: We have such a great team here. Our 10 GI doctors have all been trained at top institutions. We've all managed IBD patients for years and we're up to date on all the latest treatments. The unique aspect of our program, is that we have a brick and mortar IBD clinic, where our patients can rotate through, as frequently as once a month, but at least every three months to six months and meet our IBD nurse practitioner. Shout out, generally poll, our IBD nurse practitioner, and she's excellent. And she does a lot of handholding with the patients and the parents, a lot of education and helping them cut through a lot of the red tape that's involved in getting patients the right treatments and getting them those treatments quickly.

And we have our IBD dietician, who's excellent, and is up to date on all the latest treatments that involve dietary changes, whether it's diet as primary treatment or supportive treatment. And we have our social workers and psychologists. And it's great to have pediatric surgeons, pediatric radiologists, an entire cadre of physicians who've seen a lot of inflammatory bowel disease and can help us together make the right decisions for our patients to achieve remission of this disease, sustained remission, so that they don't suffer some of those long term complications that we talked about.

Host: And I suppose every young person is wondering, when am I going to feel better? How soon can a young patient see improvement after seeking treatment?

Roy Nattiv, MD: Young patients can see improvement fairly quickly, if they're following with a strong team. If they have the support of a pediatric gastroenterologist, a nurse practitioner and a dietician. We can institute aggressive treatment early and tuck it away, put it into deep remission, fairly quickly within a matter of days, couple weeks.

Host: That's great. This is such wonderful information, Dr. Nattiv. Thank you so much for being with us today to share your expertise.

Roy Nattiv, MD: My pleasure. I'm happy to do it.

Host: And to learn more about the IBD Program, visit millerchildrens.org/ibd or call 562-933-5437. If you enjoyed this podcast, you can find more like it in our podcast library and be sure to give us a like and a follow if you do. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.