Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.
Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon.
Dr. Joseph Segeleon: Good to see you as well, Courtney.
Host: You have narrowed down six timely topics for us. In this specific episode, we’re talking about joint pain in the pediatric patient. Something we don’t always think about in children. Dr. Segeleon, tell us why you chose this specific topic?
Dr. Segeleon: We are just so incredibly fortunate to have a pediatric rheumatologists, and I think when it comes to joint disease in children, unfortunately very often there’s a delay in diagnosis and perhaps sometimes that’s because of the lack of specialty. So I really thought this was pertinent and important information to get out to our providers.
Host: Well, let’s welcome Dr. Grant Severson to the conversation again, we are so glad to have him here.
Dr. Segeleon: Thank you so much for being here. I’m really excited about this topic and I know that our listeners are as well.
Dr. Grant Syverson: Thank you guys very much for inviting me. I’m excited to be here.
Dr. Segeleon: Because you are the pediatric rheumatologists for the Dakotas essentially. And I think the first one to be in the Dakotas, which should tell us a little bit about the training that goes into pediatric rheumatology.
Dr. Syverson: So I grew up in North Dakota originally which is, you know, probably one of the main reasons I moved back here after my fellowship and my initial foray into the workforce. I went to undergraduate and medical school at the university of North Dakota. And then like most pediatric subspecialists, you do a three-year residency. I did that in Milwaukee at the Children’s Hospital of Wisconsin and then you do a secondary training area called a fellowship and that’s another three-year program. And I did that in Milwaukee as well. The fellowship is really to kind of hone down onto your subspecialty, really become an expert in that field. And it’s very focused. It usually consists about a year, a year and a half of just only clinical work and that could be spread out between the three years or compressed into one year, along with two years of research and that’s really so you can get a good understanding of what’s going on in the field of rheumatology. I was fortunate to work with some basic immunologists in Milwaukee and the field of rheumatology is going through, has gone through a lot of exciting times in the last few decades in particular with therapeutics. The types of medications that we have available today are so dramatically better than we had in the past. And that’s a lot of, a lot of that is due to the immunology work that’s been done and I was fortunate to work on some of that.
Dr. Segeleon: Great. Thank you. Well, let’s I know everyone’s excited to hear some of these topics, so let’s get at it, you know, you think of joint problems in generally we right away go to older people. So help help me understand what kind of joint issues first off, can children have joint issues and then what kind of issues can they have?
Dr. Syverson: Yeah. ‘Kids get arthritis, too’ is kind of the Arthritis Foundation’s mantra because that’s probably the number one thing that my patients, families, and then when they explain to their friends and family, what they asked them, like ‘I thought only old people got arthritis?’. So I’ve said arthritis a few times. So for myself kids certainly can have joint pain. Like any of us, we can, all everybody can get wear and tear pain. You know, they get injuries, stuff like that. I am specifically interested in what we would call an auto-immune or inflammatory joint pain. And that’s where your immune system is overactive and starts to attack your joints. A lot of people have heard of rheumatoid arthritis. It’s essentially a similar concept in children. We don’t call it juvenile rheumatoid arthritis because it’s distinct from adults. But it is the same concept in that it is the immune system being overactive and causing inflammation within the joint.
Dr. Segeleon: Great, thanks. You know, as you said, kids complain of, of bumps and bruises and, and, and soreness, and there’s that whole concept of growing pains. So for our providers that are listening, when should a provider be concerned, whether that’s a historical or a symptom or give some advice to our providers out there when they should really start to think about joint illnesses or arthritis, as you mentioned.
Dr. Syverson: Yeah. I mean, certainly kids will have lots of, they run into walls and falls and you have bumps and bruises. I think clues for me that are always red flags are when they stop participating activities. Kids love playing and having fun and so they really, really will not stop doing something unless there’s a problem. Obviously, refusal to walk is a huge red flag. Pain if it’s there for multiple days in a row or if there’s some kind of pattern that occurs. Inflammatory joint pain classically has what we call ‘gelling’ phenomenon. So in the morning, patients with inflammatory arthritis will be stiff and they’ll have held limp in a hard time walking, but as they move around, that actually loosens up. And that’s a classic symptom that actually goes from adults to little tiny kids. And that’s kind of the really classic way they’ll present. Things like growing pains, which, you know, are certainly things that I hear about a lot … those tend to be non-inflammatory. So, they’re not associated with being inactive. They occur more randomly. They do not really interfere with day-to-day activities and they really shouldn’t have any difficulty being able to finish things.
Dr. Segeleon: Good to know. Thank you. Are there things as a provider, I mean, obviously you’re one specialist for a very large region in a very large number of patients. Are there some workups that as a provider I should initiate or I should, should start on my own prior to referring to a specialist?
Dr. Syverson: Yeah, certainly. I mean, you’re going to get lots of kids that come into your clinic for joint complaints and, you know, it’s going to vary in frequency from a little tiny kid to a teenage population. Certainly, if a child is coming in and they have a specific area that they’re complaining about, the biggest thing I would do is make sure you’re always trying to do a focused joint exam. And the nice thing about humans is we have, two of everything. So comparing both sides is a really easy and simple way to determine if there really is something you need to be more worried about. Certainly chronicity… I’ve mentioned that before. So, the longer something’s going on, the more you should be worried about it. It doesn’t necessarily mean it’s a terrible outcome, but it’s more likely to be an issue.
And so kind of easy things you can do kind of in the beginning is, you know, it makes sure they if you want to check a CBC to make sure they don’t have a significant anemia, or if there’s not another more serious process going on, I almost always get inflammatory markers like an ESR or CRP. Now you can have arthritis and have normal inflammatory markers. You can have arthritis and have completely normal labs in general because it’s a clinical diagnosis, history and physical. But if you get an ESR and it’s a hundred, obviously you’re much more worried than if it’s, you know, zero or 20 or like that. And then if it’s something where you have a history of trauma, I certainly think getting an x-ray is a good idea. Most kids that have arthritis are not gonna have any radiographic findings on a plain film. If there’s a specific patient that has a specific joint that you’re really concerned about that you think might be arthritis, an MRI is a very sensitive for that. And it’s a little hard, obviously with little kids because you have to sedate them. If you’re going to get an MRI for arthritis. One thing I would say is try to do it with contrast. In the orthopedic realm, it’s a lot of structural abnormalities and non-contrast MRI is perfect for that, but with the inflammatory processes, if you can get contrast that will give you enhancement of the lining of the joint and will really give you some understanding if there is a chronic inflammatory process.
Dr. Segeleon: Great, thank you. That’s really fantastic information. I really appreciate that. And I know our listeners will appreciate that as well. We talked a little bit about arthritis. Are there other illnesses that can affect joints in children?
Dr. Syverson: Yeah, there’s a lot. So arthritis is definitely the biggest subset of patients I see. There are things that some people may be familiar with, including something called Lupus. Lupus is a more systemic illness and certainly arthritis and joint pain can be part of that. There are patients that have muscle inflammatory diseases that will present not necessarily with joints specifically, but they will have pain and achiness that may be felt to be joint-related. And then there are other inflammatory conditions called vasculitis or inflammation of the blood vessels, which can also present with some pain and extremity complaints.
Dr. Segeleon: Where does where does malignancy fit in to this discussion? Can that present as joint pain?
Dr. Syverson: Yeah. And certainly it’s, you know, the one thing we always keep in the back of her head as it is what we don’t want to find out. Obviously malignancy is a very concerning thing. So for me, the things that are red flags that I always consider and think more about malignancy: pain in the middle of the night that’s happens consistently. Not necessarily once or twice a week, but everyday pain that’s limiting activity throughout the day. Not just in the morning or after certain activities. Refusal to walk. Most kids that have arthritis, even if they have bad arthritis, still like to move because that stiffness gets better when they move around. So, kids that have arthritis will wanna be active while kids that have something that some other process going on often will not want to emulate. And then a lot of those other kids will have a lot of other systemic symptoms: they’re very fatigued, they’re pale they’ll have high fevers and things like that.
Dr. Segeleon: Great. Well, thank you. There is one of you for this region and there’s certainly a lot more orthopedic physicians than there are rheumatologists. Can you give our listeners an idea somewhat when the referral should go to the direction of an orthopedist versus a referral to you? And then why don’t you expand on how somebody refers a patient to you as well?
Dr. Syverson: Well so yeah, there are a lot of orthopedic surgeons in, in North and South Dakota and Minnesota and Iowa and Nebraska. And, you know, certainly they see a lot more kids than I do because injuries and non-inflammatory joint pain is far and away, much more common than inflammatory joint pain. And so from my perspective, I talked about that chronicity again, if something’s going on for weeks and weeks and weeks, and it seems to have a pattern that seems to be worse in the morning, it gets better with activity, that’s probably more likely a chronic inflammatory process. If there’s not really a good history of a specific injury, this probably something… obviously kids cannot, aren’t a hundred percent reliable, but you know, that can sometimes be a clue. Patients that have arthritis will present with swelling, but patients that have a traumatic joint swelling or an overused joint swelling, they will have usually some specific incident that they can relate it to, or they will have things like bruising. They’ll have cutaneous changes that you would expect with, you know, trauma. Little tiny kids that get arthritis, which is the most common age group I see between one to five, they come in with a single swollen joint, they almost always go to ortho first, which is completely fine because our ortho colleagues and I, we get along a lot. I send a lot to them and they spend a lot to me. But they almost always come in with a history of trauma in that they’ve fallen off a chair, which is probably just a red herring that got the parent to look at the joint and see that it’s swollen. And it probably was swollen it for a long time. And it’s nothing against the parent. It’s just that because these processes are so gradual, it’s easy to miss that. As far as referral to me, certainly I have outreach clinics in, I see patients in Fargo and Bismarck and in Sioux Falls. You can contact me at any of those clinics and send, give us a call or set up a referral and through the Sanford network or you can call me through OneCall and I’m happy to discuss patients in labs and figure out a way to treat those things.
Dr. Segeleon: Fantastic. That’s, you know, I feel like in pediatrics and probably for all my primary care colleagues out there rheumatology and children is just one of those subjects that we just can’t get enough of to learn and become familiar with because also we don’t see as many children with that. So really your expertise in the community in the region is incredibly valuable for us. You alluded to earlier on about some of the treatments and, and because so many of us aren’t familiar with children with arthritis, give us a feel for perhaps in a general way, some of the treatments and then also maybe the prognosis and how do children do.
Dr. Syverson: Well, the good news is his prognosis is so much better in today’s day and age, and it was even 10, 15 years ago. The likelihood of a child going into sustained disease-free remission for the rest of their life is, you know, probably 10 times better than it used to be. The approach is, it kind of depends upon how many joints are involved. So if childhood has a single swollen joint, you can be more conservative than a child that has multiple joints. Joint injections with steroids or something we do, those can be helped very, very helpful. Obviously again, with kids, you want to be judicious because you want to not make it. You want to make it as a less stressful experience as possible so we do those with sedation a lot, and most of the time kids tolerate them very well.
We use a lot of non-steroidals. Neproxin is probably the one people hear me say the most, because if you want to get an anti-inflammatory effect, you need to take it consistently every day for the set amount of time and approximately twice a day whereas ibuprofen is four times a day. After that, then we start to getting into therapies that we cause called disease modifying drugs. So methotrexate is probably the one that’s been around the longest and rheumatology it’s used in a lot of different areas in medicine. The good news is it has a really long track record and it has a really good safety profile. Does have a lot of side effects as far as stomach upset and that is probably the biggest limiting thing is that some people will get some associated nausea, but it works really well. And then we’re probably all familiar if you watch any television at all of all of these newer commercials that are called biologics Humira, Embryl, Zeljanz, Cosentyx, all these medications that are on TV all the time that for adult arthritis. The good news is they’re on TV all the time because they’re super effective and they work really well. And over the time we’ve been able to do studies in children that show they’re as equally effective, and those are really have revolutionized peds rheumatology. If you go to, I always tell the families, this… there’s a camp for kids with arthritis. We have one in Minnesota for South Dakota, North Dakota and Minnesota patients. There’s one in Wisconsin, one in Illinois, all over the state country. If you were to go there 20 years ago and look at the campers versus now, you know, you would know who edited arthritis 20 years ago in today’s day and age, you go to camp, you don’t even know. And for me, that’s one of the most fulfilling things. And it’s one of the biggest reasons I went into rheumatology is just that we can do so much and make such an impact for kids that have those diseases.
Dr. Segeleon: Well, thank you. That’s that’s a great message and a great positive way to end this. I want to thank you for first off, I want to thank you for being here. Our children benefit from your experience and benefit from the care that you provide. And we’re very grateful that you’re here. And I know there’s a number of providers out there that have, have learned a lot in the last 20 minutes and really interesting information. For many of us information that is is much needed. So I will turn it back over to Courtney
Host: Dr. Syverson, it was great to meet you and to hear more about your specialty. Thank you for being here. Thanks a lot. It was really fun are called to care. Podcast series. Focusing on children continues with topics from sleep hygiene, to non-accidental trauma right here with our very own Sanford health experts. Thank you both for being here and for all you do. Thank you. We’ll see you soon.