Dr. Claudio Morera shares common gastrointestinal issues in children when to see a doctor, and the services offered at the pediatric GI clinic.

Featured Speaker:

Claudio Morera, MD

Claudio Morera, MD is an Assistant Professor of Pediatrics in Gastroenterology at the Boston University School of Medicine, the Clinical Director of Pediatric Gastroenterology at Boston Medical Center, and an Attending Physician at Boston Children's Hospital. He has lectured on subjects like encopresis, GI bleeding, constipation, and neonatal colestasis both in class and throughout the Boston area. He earned a medical degree and practiced as a physician in his native Venezuela before coming to Massachusetts to begin a fellowship.

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Melanie Cole (Host):  As a parent, you know how common it is that our little kiddos complain of tummy aches and you’re never quite sure if it’s anything to take seriously but if it happens enough, it can get worrisome. When should you take your kids to the doctor and what do these tummy aches really mean? My guest today, is Dr. Claudio Morera. He’s an Assistant Professor of Pediatrics in Gastroenterology at the Boston University School of Medicine and the Clinical Director of Pediatric Gastroenterology at Boston Medical Center. Dr. Morera, I’m so glad to have you on. As a parent of two children, when they were little, I remember the tummy aches happening all the time. What are some of the most common tummy troubles in kids that parents most frequently come to see you about?

Claudio Morera, MD (Guest):  These conditions or these complaints of kids is very common. Many kids complain of abdominal discomfort, how I usually call it or abdominal pain throughout different moments of their life. And most of the time, the vast majority of complaints are isolated and random and doesn’t mean anything particularly serious. Some of the time, I’m sorry are a little bit more frequent and races the concern of the parents and even in those cases, the conditions associated with the complaint of abdominal pain, the vast majority are benign, relatively easy to control conditions by your primary care doctor.

So, in general, most of the time, the abdominal pains are related to benign conditions, relatively easy to treat.

Host:  Okay. So, thank you for saying that and with our kids at different ages, those stomach aches can mean different things. With babies it could mean colic or gas and in toddlers I could be a way to get attention and in teens it could be stress. So, when it comes to kids; when do we know when to bring them to the doctor?

Dr. Morera:  So, the younger the patient, the more concerning it is, particularly in babies and infants that they start showing symptoms of distress, crying, et cetera. We don’t really know whether it is the stomach that is causing the trouble or not. We presume it is, because the baby bends the legs over the abdomen or crawl over or sometimes, they arch their back when they are eating. So, we say, oh their stomach hurts. And yeah, it could be that the stomach hurts. But other times, it’s not the stomach. But we don’t expect the parents to know the difference. So, if a patient is having symptoms of distress with crying and uncomfortability, particularly in association with feedings or defecation; these are the patients that should be evaluated by a provider to make sure particularly if it’s very severe, to make sure there is no urgency. If it’s not severe, and resolves quickly, but repeats, these are the patients that should be evaluated for reflux or constipation or other conditions that are easily to resolve.

The vast majority of babies that are doing otherwise fine, growing okay, eating their meals fine, moving their bowels okay, gaining weight, otherwise happy; these episodes of crying and discomfort that in general happens around the same time of the day; are what we call infantile colic. Colic is a misleading term because we associate colic with abdominal pain. We’re not really sure that it is the abdomen that is hurting in these patients. Because now their stomach doesn’t have a watch to tell you I’m going to start crying from 6 p.m. to 10 p.m. which sometimes happens. So, these patients, have as I said before what we call infantile colic which many times resolves spontaneously between the third and the fifth month of life. And is relatively easily treated and managed by your primary care provider.

But once again, if the pain is significant, the baby never minds, the baby is vomiting or having diarrhea or never mind blood in the poop or anything; this is a patient that should be evaluated quickly. This is an infant. For older patients, there are different considerations that I’m happy to talk more.

Host:  I mean as children grow, one of the things if a kid has strep throat, they get a fever, then they get that stomach ache, then you are like okay maybe it’s strep that seems to go along with it, you take them to your provider. But parents worry Dr. Morera about appendicitis when a child has a stomach ache, right away, a parent thinks oh oh, is this something really severe. Tell us about older children and when we should be concerned and what is kind of normal?

Dr. Morera:  Absolutely. That’s a very good question. And I agree with you. We always have the concern that something more acute and serious that requires a more aggressive intervention is presenting in the patient. So, my general advice, if it doesn’t look right, you should follow your “gut” feeling regarding this thing. But the typical patient let’s say with appendicitis or other more serious conditions is a patient that has a relatively short time of starting the pain that is very severe and cannot be calmed or controlled easily with the typical measures of like some Tylenol or something like that. Of course, if the patient on top of that has fever, severe diarrhea, in your case the patient has for example some sign of other infections, this is a patient that should be evaluated because something more concerning could be going.

In general, these are short lived episodes, it is not like the patient had a pain for half an hour then was better and then the pain happened again two days later or the next morning. This is a pain that is there all the time that doesn’t go away. So, the pain the parents usually can say the pain started this morning around x time and hasn’t gotten any better or he’s been complaining of this pain that is way out of proportion since last night. So, basic clear, relatively short term presentation of the pain. In the case of appendicitis, in general, it’s associated with fever, could be associated with vomiting. In general, it is not associated with changes in the stool pattern. But if you have like a two year old that all of the sudden starts to have severe pain and the patient goes kind of like pale or sometimes limp and then the pain gets better and repeats again; this could be also the manifestation of another concerning problem. But in general, these are acute things. Acute in medicine means short term. Pains that appear relatively quickly and are severe enough.

The pains that are less concerning are the more what we call chronic pains. The pain that presented and then got better and then presented again a few days later or the pain that happens when the child, the seven year old or the six year old is trying to go to the bathroom and can’t go or he hasn’t properly defecated in the last week and now he is complaining of this dull pain particularly if he has to go so then we know that probably this is related to constipation that needs to ba addressed, that needs to be treated but it is less concerning than the prior type of pain they are having. Or this eleven year old child that was doing well during the summer but as soon as classes started, every morning the child complains of pain and has a little bit of reluctance to go to school. Then we know that it’s a bit of anxiety associated with going to school, maybe the child is in a new classroom with new classmates. All these things need to be taken into account.

But if you look at the pattern, these are kind of like two different kinds of pains. One pain in the beginning that is very intense, relatively short lived, started in a very clear time, started like yesterday at x time and it’s associated with like fever or vomiting or diarrhea or other stuff. And the other one that is more not as bad, but more frequent, more unclear for how long it has been going on. The typical thing, well he’s been having this pain for months. But the parents can’t really tell me March or April or whatever. Makes sense? It’s a whole two different kinds of patterns there allow us doctors and the parents to differentiate one from the other.

Host:  Well that was a great explanation and yes, we understand if we have girls that are prepubescent, maybe they have started their period, they get cramps and stomach aches from that. But before we talk about some of the services of the Pediatric GI Clinic at BMC; what do we give a child if it’s an upset stomach and they are a little guy, we’ve heard about Little Tummys, Pepto Bismol, our parents used to give us Kaopectate and now we have probiotics on the market. Can they help with our children with stomach aches if it’s a little bit chronic or not that often and not so severe. Can we give them any of these things Doctor?

Dr. Morera:  There a few things that you can use. For example, a baby with colic that we know is colicky baby because of the characteristics that I said before, baby is doing otherwise fine, eating okay, it’s the time of the day that the baby has the pain there are some reports using certain type of probiotics. There are some other reports using peppermint oil for example in some other babies. There are some herbal remedies that are now over-the-counter based kind of like on chamomile or these type of things that are very useful for those babies. That’s totally fine.

Or an older child for example, the child has gastroenteritis and he’s having fever, and have some vomiting and then had some diarrhea and then it’s very clear that this is kind of like an infection, but the child is complaining of like some stomach ache. You can use antacids for example, regular Maalox, you can use that. If a patient has a fever or strep throat and is complaining of abdominal pain, you can use acetaminophen. So, all these things can help absolutely, but it’s the pain that is not that severe, that is a pain that is in association with other symptoms that are very classical like the example that I said of the gastroenteritis, we can use those remedies.

We have to mindful that if the pain is severe, if the pain is the main symptom that the patient is complaining of or the pain is abrupt and severe; this is a patient that is better to be evaluated than to start giving remedies which can mask what is going on. Okay?

Host:  Yes. Definitely. So, then highlight for us some of the services of the Pediatric GI Clinic at BMC.

Dr. Morera:  So, the Pediatric GI Clinic that we have here at BMC is a multidisciplinary clinic where we have available nutritionists, we have available providers of course and we have nursing specializing in GI, we have the ability to have psychologists specializing in GI. So, it’s a very broad clinic in which we can serve most of the conditions associated with pediatric gastroenterology.

In general, the typical problems that we see in our clinic are patients with gastroesophageal reflux, babies who aren’t gaining weight appropriately, or children with recurrent abdominal pain that has seen their pediatrician and their testings are fine and we are thinking the patient might have irritable bowel syndrome. We see those patients. Patients with problems moving their bowels either too much or too few, like constipation or chronic diarrhea. And then of course, we have patients with certain liver disorders, patients with inflammatory bowel disease like Crohn’s disease or ulcerative colitis, patients with celiac disease, lactose intolerance. So, we see a lot of patients and the advantage of our service here is that we are part of a more broad pediatric subspecialty group that we are all collocated in the same area so it’s very easy for me if I see this patient that has this disease that can affect – produce anemia for example. I have my hematology colleagues like two offices down and I can very briefly and just walk down the hallway and say you know heh, I have this patient here that is seeing me for let’s say Crohn’s disease but his iron or her iron is very low. Can you help me with that? And they take over.

Or I have this other patient that has irritable bowel syndrome and I consider requires some more behavioral management. Then we have a pain clinic that has a psychologist and a nutritionist. So, we have available all those resources for our patients. On top of that, we are very culturally sensitive so patients for example, Hispanic patients, Latino patients that they require their services, we have – we can provide those in a very culturally sensitive way, and this is just an example. So, I am very proud of the quality of service that we can provide to our patients with gastrointestinal problems here at Boston Medical Center.

Host:  Wow, it’s a very comprehensive and as you say multidisciplinary approach to GI issues in kids. wrap it up for us Dr. Morera. Please give us your best advice as parents have so many questions about various tummy troubles with their kids, whether they are little ones or whether they are teenagers and they do worry about thing irritable bowel diseases and that sort of thing. So, please wrap it up. Give us your best advice about when it’s appropriate to see a provider if our children are experiencing stomach aches.

Dr. Morera:  This is a very good question because as I said at the beginning, this is very, very common complaining children. Your pediatrician or your nurse practitioner or primary care doctor is your best friend for your child’s health. You should not feel shy to even call and ask. Johnny has been having these odd abdominal pain for the last three weeks and it only happens in the morning before going to school. Do you think we need something. And many times, by phone, a provider’s office, if your primary care office knows your child and knows what has been going on, has their medical record so they can give you some advice and then ask you pertinent questions that will guide them towards the urgency of the condition and they can tell you well let’s try this and that and then I’ll see you in a month. Or no, no what you are telling me is kind of concerning, why don’t you come tomorrow to see me in the clinic. This type so, don’t feel shy to ask those questions.

As a general lifestyle, we need to make sure that our kids have a healthy diet and balanced diet that they don’t miss meals, that they have enough exercise and water. Like general lifestyle are good for everything not just for gastrointestinal problems. So, basic preventive side which is all these good measures and then there is the part of sticking for information and I would definitely use your primary care’s office as a resource for initial information regarding concerns about abdominal pain.

Host:  Thank you so much Dr. Morera. Great information and really something that parents think about and have concerns about everyday when you’ve got kids. So, thank you so much for joining us and sharing your expertise. And that wraps up this episode of Boston MedTalks with Boston Medical Center. Head on over to our website at www.bmc.org/pediatrics for more information and to get connected with one of our providers. If you found this podcast as informative as I did, please share with other parents, share with people that you know that have kids because we are all going through this together and that way, we learn from the experts at Boston Medical Center together. And don’t miss all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.