Pediatric Rheumatology with Dr. Cristina Saez, MD

Introduction to Pediatric Rheumatology 0:00

Hello, welcome to this week's episode of the Baby Manual Podcast. Today, I have the pleasure of talking with Dr. Cristina Saez, MD, who is a pediatric rheumatologist. So, this is especially exciting because most people don't understand what a rheumiologist does, especially like even doctors. Absolutely. Thank you for having me. I mean, I love to talk about what I do every day because I think it's a lot of fun and I'd love I raise awareness for people that end up coming to see me when they might not even know what do.

So I am a pediatric rheumatologist, which means that I have done all the training the general pediatrician has done, but then I did additional training in autoimmune disease in children, specifically auto immune diseases that affect the bones, muscles, and joints. and then any autoimmune condition that affects multiple organ systems. So I think lupus is probably the best example because lubus can affect any part of the body. Really cool. What are some of things that you end up seeing often and what are things maybe parents should watch out for at home to think, you know, maybe we need to see a rheumatologist about this?

I see a ton of different things. I would say that probably the number one thing I'd see most common is joint pain because juvenile arthritis is the probably most commonly rheumatologic diagnosis I've seen in my clinic and does affect a decent amount of children. And I was trying to find the best estimates of the incidence in the United States that I could, and it's about 50,000 children a year end up getting diagnosed with juvenile Certainly something that could happen in a community and something to keep an eye on.

But it's difficult to know what is arthritis because we're very used to what it looks like in adults with maybe deformed hands or your 75 year old grandma

Common Conditions: Juvenile Arthritis and Recurrent Fevers 2:00

that just can't move like she used too, but it presents very differently in kids. And then another thing, especially in younger kind of school age children that I see is recurrent fevers, because there's a group of disorders that can happen in children called autoinflammatory disorders or recurred fever syndromes is another way of thinking about it, where the immune system inappropriately turns on at regular intervals and causes recurrence fever, sometimes mouth sores, joint pain, rashes, a variety of very distressing symptoms.

I would say those are two of the big things that I see in my clinic. Nice. So with arthritis, what ages should parents start looking out for that? And how do you know, like, is it growing pain? Is it arthritis? When is that happening? And just to kind of outline what you might see when you look up this online. So the way we characterize it is juvenile idiopathic arthritis, mechanistically somewhat similar to rheumatoid arthritis that you may have heard of in older adults, but it's kind a different disease and presents a little bit differently.

JIA is the term that I'll use. And there's kind of two peak times in childhood where we see it happen. First is the father age, like two to five years old, and then in teenagers. And so you can imagine in a two-year-old, you might wonder how would I be able to find out if someone has arthritis. So in the littler kids, sometimes kids will complain of joint pain. But really, the thing that I see most often in that age group is stiffness and swelling. So a two-year-old with knee arthritis might cry when you're trying to straighten their legs during diaper changes.

Or I saw a patient a couple weeks ago that had it in her wrist, and so parents described it as, oh, she seems left-handed, even though she's two. She can't write, but it just doesn't seem like she is using her right arm at all. And it does seem, like, man, if she holds her wrists in a very certain position, then she doesn' like to bend it or she cries when we try to bent it. So I think those are the big things. Then with arthritis, the the biggest thing is that symptoms tend to be worse in the morning.

Um, so morning stiffness is maybe a term you might hear when adults talk about arthritis, but the, this concept that the symptoms are worse first thing in the morning and actually improve with activity. So joint pain or symptoms that get worse with the activity is less likely to be arthritis. Are there certain joints that are more likely you to effective than others or could this be anywhere? Yeah. Yeah, definitely can be any where I would say in toddlers more often to big joints. Like the knees.

the ankles, potentially the hip. And then smaller joints like the small joints in the hands tend to be teenagers. Neat. Is it usually on both sides of the body or just like one joint? Yeah. Yeah, yeah. Again, it also depends on the type because there's actually multiple different types of joint arthritis, if you can believe that. So I would say typically when it's the big joints, asymmetric, so it'll be one knee, one ankle and it might not be the same side, like it may be left knee, the right ankle, left elbow.

The older kids that have arthritis in the small joints of the hand, that tends to be symmetric, they tend to have both sides. But I would say in general, not symmetric. So then, you know how sometimes children can get a virus and then have a post-viral arthritis? Yes. Is that related? Can that cause juvenile arthritis later? That is such a good question and arguably the most common type of arthritis we see. So children's immune systems are very immature. just like they are developmentally. And what that means is that their immune systems do not as easily know how to turn on and turn off appropriately.

So this idea of reactive arthritis is something that is decently common in children, doesn't really happen in adults. It's the idea that when a child is faced with a virus of some sort, it can be anything. their immune system not only fights that virus, but inappropriately remains on, so to speak, and then also attacks the joint as well and causes inflammation. And so this is often where I'll meet people, is right after maybe some sort of infection, they have the classic symptoms of arthritis, of joint swelling, stiffness, maybe warmth of the joints.

But the key thing about this, it's short term. And that it normally resolves within, we say, four to six weeks. Sometimes those kids end up needing schedule naproxen or other kind of things in that family that we use.

How Juvenile Arthritis Presents in Children 7:00

But most of the time it gets better. For some people that does end of triggering a more chronic form of arthritis, but that really the big thing is the only way we know is time. I'll often get people that will try to, you know, get certain blood tests done because that's maybe what they heard when grandma was diagnosed with lupus, the blood test helped her find it. But really in juvenile arthritis, blood testing do not help us make the diagnosis. The key thing is the history and then also seeing how long symptoms last.

So the only way that I can tell you if it's reactive arthritis versus the chronic form of arthritis is seeing what happens in the following four to six weeks. If it goes away, then it's like the reactive. kind of depends on the situation, of course, which is probably the answer I'll say for a lot of these things. But juvenile arthritic is really a physical exam diagnosis. I can diagnose it by examining the joints. We will do x-rays sometimes. And the x rays mainly show you the general structure of the bone because there are sometimes some other causes of joint pain that are not in the rheumatologic area and so sometimes I'll use x-rays for that.

And then sometimes, I will do blood tests, but that's mainly kind of looking for other things or potentially other causes of joint pain and inflammation in children. So for example, One of the things we often have to think about is arthritis can actually be one of first symptoms of cancer in children, specifically acute lymphocytic leukemia, the most common form of childhood cancer. And so sometimes I'm trying to piece out, is it something that's just autoimmune in my room, or is actually a sign of some other conditions?

And that, I think, one that we have often to have think you can see that come up in the three to five year old age range sometimes. Do you do any other testing like joint aspirations? Most of the time, no. I think the one kind of exception is sometimes the kids can actually get an infection of a joint and that can cause really sudden onset swelling and pain. And in those instances, sometimes kids do have to get fluid pulled out of the joint. Most of them, that's not me though. So most of time, an infected joint is someone has a fever, really intense joint pain and swelling, and then they end up in the ER and they all do it there.

But in a clinic, we really don't do that often, partially also because it's hard to a lot of fluid to be able to do the testing you would need. And as someone that small, the only time that I think about getting fluid from a joint to send for testing is really in an older teenager. Cause that's the only time where the joint is space is big enough for me to get the couple of CCs of fluid that you, that the lab actually needs to even run any sort of testing. And then what about periodic fever syndromes?

Like how, what makes it a recurrent fever? How often does it have to happen for how long? And, you know, we always used to call these the million dollar workout patients because there's, there can be so many reasons for fever, but um, Yeah, maybe you can help guide parents a little bit. Absolutely. And I feel you in that because unfortunately, because some of the diseases I take care of are so nebulous and there's not necessarily very specific tests that I can do to help diagnose my conditions, I have to do a combination of things.

I end up doing a lot of a things, but that's just the nature of my work. So periodic fever syndromes are really representation of activating in a very regular interval. So there's a whole family of conditions, but I'll mainly talk about, I think PFAPA is probably the best one to talk because that's the most common one

Diagnosing Arthritis and Ruling Out Other Causes 11:00

and something that even pediatricians might manage on their own. PFAPPA stands for periodic fever, aftostomatitis, pharyngitis and adenitis. That means periodic fevers, we already know what that is, astostomatitis which are oral ulcers like canker sores, pharyngitis, the sore throat, and then adenitis though, inflamed lymph nodes. And this is a condition, in the most common period of fever syndrome in children where about once a month, a child will develop fever that is daily, tends to come around the same time of day, or for some people it'll be kind of audited off throughout the day and associated with mouth sores, sore throats, enlarged lymph nodes.

So again, everything that might look like the common, you know, viral sore throat or even strep throat. But the key thing about this, it's happening very regularly and these kids will often get testing for all these infections and it continually comes up negative and The key thing is predictability. Like some of my families with auto-inflammatory syndromes will tell me, yes, I knew, you know, about a day or two when it's about to happen, just because I know this is our monthly schedule. It's time for the fevers again.

And so it is this pattern that we end up being able to characterize as a periodic fever syndrome. Because these symptoms are so regular and there's no other signs of infection. There's not signs a cough or runny nose, which might suggest a cold. It's just these things. And it's tough because the most common cause of recurrent fever in children is recurrence infections. I don't know what you tell your patients, but gosh, you can have more than seven viral illnesses a year, especially if you're in daycare or something like that environment.

So it is really hard to When you first mentioned it, I thought that sounds like every school-aged kid from the beginning of the school year for the first couple of months, but they will usually test positive for something. And that's why it takes a while for us to make this diagnosis, that we really need to prove that it's not a recurrent infection. Yeah. of cough, congestion, runny nose helps. And then the period is David, the fact that it comes very predictably, not one week here, two weeks later than six weeks, later that its regular.

Mm hmm. How high of a fever are we talking? Is this sort of low grade hundred point four range or is it a higher? Typically, it depends, but I would say typically 101 to 103, something in that range. in a true fever, which is as physicians, either we define fever at, or at least we in rheumatology define, fever is 100.4 Fahrenheit or higher or 38 degrees Celsius for my community members that use Celsius in their life. Cool. And now is the fever itself something that needs to be treated? Like should parents be treating it with ibuprofen or acetaminophen or is this something Is it better to let the kid write it out?

I know like an autoimmune fever is different than one with an infection because there's nothing that is trying to kill off, right? Yes. Such a good question. And really at the end of the day, in these conditions, the fever's not harmful to the child in the sense that it's a sign of ongoing damage that's happening to any particular part of their body, but it certainly very distressing. So I tell families that absolutely reasonable to treat the fever if your kid feels uncomfortable, but if they're feeling okay and you want to let them run around, that's also appropriate.

It doesn't mean that there's harm. Um, it just means that if there is something going on that, again, we end up treating because having a fever for three to five days every month is very distressing,

Periodic Fever Syndromes and PFAPA 15:00

very disruptive to family life. These kids can't go to school regularly and the parents have to take off work because their kid is fevering and school won't let him come because they think they are sick. And then what sort of treatment options are there for this? Or is this just a, they outgrow it? Yeah. Good question, because both of the things that you said were correct in that if it's PFAPA, the most common periodic fever syndrome that we see, they actually will throw out of it. Most of them will, by age 10, these fevers will stop.

But we end up often treating it because, as I just said, either these symptoms are often very disruptive to family life. And as a pediatrician, I also want to prioritize things like school attendance and the importance of the learning and development that they get at school. So for that reason, we often end And so sometimes we will use something called steroids, so prednisone, which is our strongest and quickest anti-inflammatory treatment that's used for a variety of conditions to kind of help what we call abort the fever.

So when it comes on to stop the process in its tracks. And then sometimes people will be on daily medication to try to prevent the fevers. One of the common ones we'll use is Colchicine, which is, if you look it up, is also used in gout, but it's used by conditions as well. It's interesting how medicines can have multiple uses. Yeah. If I remember right, Colchiacine is the one that disrupts when the cells are dividing, and so it attacks basically whatever cells that are the fastest dividing in the body at the time, Yeah.

And then, um, polar, I forget what they're called. Yeah, and then neutrophils are the, the cells that ended up being involved in the conditions that we use it for. So that's neutrophyll migration. You realize that children could take colchicine also. I give colcidone all the time for a variety of different things. Do you ever do dexamethasone or like other steroids? Good question. Most of the times I do prednisone. I really try to avoid dexamethasone because dextromethazone is such a potent steroid.

So the reason that that is different than prednisone, is deximethosone lasts 72 hours in the body versus 24 hours that predizone does. And often they don't need something that strong. I try and avoid that because the kind of irritability that you can get with steroids is usually amplified when you use deicemethazones versus prednizones in these conditions. which just breaks my heart for the families because they'll say my little one was a monster for three days because, um, they got three of dexamethasone.

I said, Oh my gosh, I'm so sorry, but that was way too much. Uh, so predisode for sure. So you medrol is does come in an oral is one of the forms of oral steroids. Don't use it that often, partially because the dosing is a little bit different than prednisone. Prednisine we just use so commonly for so many other things and it's a little bit easier to titrate based on the patient's weight because in pediatrics we do everything weight-based and so it is easier for me to play around and find the lowest effective dose using prednizone than some of these other forms of oral steroids that you can get.

That's cool. That makes sense. And yeah, parents should all know that steroids do cause children to have pretty extreme mood swings. Steroids are precursors to hormones in the body and so they act sort of like hormones do in children and they can make them very angry or weepy or hungry or wild, like energized. So yeah, unfortunately is one of the side effects of steroids. And all parents should be aware of that because they might get steroids for croup or something else. You know, there's asthma attacks, all kinds of reasons that we give stories to kids.

Another thing about steroids is you'll read about a lot of side-effects, but I think the key thing is that with steroids, it really depends on the duration. So a couple of days of steroids is not going to carry the same risk of side effects as someone who's on it.

Treatment, Steroids, and Tracking Symptoms 19:30

Some of the patients I take care of who I ended up having on for years and years. So I think anything you read about steroids, please don't be scared if your kid is only taking it for a few days. It's really the short-term things like the, what we've actually called Roidrig that you were just describing and the increased appetite. Those are the key things, but long- term side-effects that it takes a long time, like usually on the order of years for us to see that. Awesome. Anything else that parents should know about or watch out for in terms of rheumatology?

I think the key thing for is try to write things down and look at the pattern of the symptoms. The pattern tells us honestly most of what we need to know. I could probably predict based on just the history that a parent gives, of what kind of realm it's going to end up being, whether it is in something in my world versus not. So really, when you notice things that are weird and the doctors mentioning that you might need to go see a rheumatologist, really try to write down and be as specific as possible about how often things are happening, exactly what symptoms are having every time.

That is so, so important and I think tells you so much more than any one blood test that a doctor might send to try and figure out if it autoimmune or not, Yeah, probably also the time of day that symptoms are happening. Absolutely. Makes the difference. Yeah. What about anything like activity around it or foods or is it worth checking any of that? Sleep, those kind of things. Bathroom. I don't know. Bodying. Probably worth it. Just activity, if certain activities make it worse. And then certainly if a certain food's exacerbated, there are, I have had some patients say that certain foods trigger it and certainly actually celiac disease can present with joint pain and even arthritis.

So knowing if gluten makes some symptoms worse, they think is helpful to know. Again, another thing that I had to think about Yeah, yeah. Well, good. Yeah. So anything that seems like it might be related to the symptoms should also be tracked. Over time. And then pictures. Oh yeah, there's swelling or certainly if there is a rash, please take pictures! Yeah those things change quickly, right? Yes. Yeah. Awesome. Well, thank you so much for being here today. This is super helpful. I think it's great for parents to know that not all joint pain is arthritis in kids, but that children do get arthritis and there are things to watch out for.

And the fevers that a lot of times, yes, it is that they just went back to school and they're getting sick all the time. But if they are coming up negative all of the times and having recurrent feavers, that could be a red flag as well. really great advice that you had with tracking that and all. Thank you so much for being here and have a wonderful day. and you can also check out my YouTube channel. I have lots of videos and shorts that will help you feel empowered as a new parent as I talk about all the common stuff that comes up in the first couple of years of life.

Thank you so much. Have a wonderful day.