Expert Discuss Difference of Gastrointestinal Care for Pediatrics, Adults

Shweta S. Namjoshi, MD, MPH, CNSC, a clinical assistant professor in the Division of Pediatric Gastroenterology, Hepatology, & Nutrition at Stanford University School of Medicine discusses the role of the pharmacists in gastrointestinal care and the differences in care for pediatrics and adults.

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Q: How do gastrointestinal symptoms manifest differently in children and adults?

Shweta Namjoshi: Great question, and hanks for having me. I think that while all humans are humans, how we communicate and interact in the world, really changes over the course of our lifetime. With respect to developmental and functional status, so the way that an infant, a toddler, a child in elementary, middle, or high school, a college kid, or someone in their 20s, 30s, and even into sort of elder years, [communication] is going to be very different.

That's the same thing that applies to the gastrointestinal (GI) history, so when, for example, a child with dysphasia, which is the symptom of trouble swallowing, their manifestation of dysphasia, both the history and the exam are going to be very different than an adult. For example, an infant who has food stuck in their esophagus may simply cough, drool, refuse to eat, refuse bottles, refuse food, solids, or even, liquids. They may just act really fussy if they're nonverbal. Whereas a person with sort of more developed verbal skills, and more able-developmental status in their 30s, or 40s, would simply say, “I have something stuck right here.” It's very different, and I think that applies to the entire GI tract.

I think the thing that's really unique about home infusion and about the sort of care that, as pharmacists, and intestinal failure physicians we provide is, the nutrition status can also affect that throughout the lifespan. Those are just some small ways that children and adults are different. People like to say, kids are not little adults, and adults are not big kids.

Q: What are some of the ways children and adults can be treated differently for gastrointestinal issues?

Shweta Namjoshi: One of the biggest differences, I believe, in children compared to adults is this aspect of rapid growth. There is a developmental function to the GI tract that differs with age and stage of development, and that changes over the course of a lifetime. So as clinicians, we have to keep that developmental status in mind. For example, an infant has very, very high metabolic needs, their intestines turnover every few days, and during growth spurts, even every few hours. Their metabolic rate is so high that their infusion needs change really every few weeks, whereas an adult, their metabolic rate may not change, but their functional status and their organ needs may be different. For example, infusion needs for an adult in their 40s is going to look really different than an adult in their 60s. It's going to be very different for an infant who[is] 6 months versus 15 months versus 2 years.

I think outside of the metabolic rate, there's also a developmental aspect to all of our organs. One really simple example is the enzymes that our pancreas makes are not actually mature, right at birth, especially if you're a premature infant, so keeping that in mind with respect to the nutrition plan is really important. Those are just some examples of how that can change throughout the child's life.

Q: Why is it important for children to be treated differently than adults?

Shweta Namjoshi: If the growth and metabolic needs and the developmental aspects of the various organs are not taken into account, there can be really dangerous and severe consequences. While an adult can regain functional status with conditioning and correction of any abnormalities in the prescription or infusion plan, a child may suffer permanent disability from malnutrition if the infusion plan doesn't meet that child's needs. This can include problems related to school function, employment, and physical, social, mental, emotional development. If a child's metabolic needs and organ development are not taken into account with the prescription of the home infusion plan that, parenteral nutrition was a great example, and they're sort of just treated like all other people that, child may not really get the energy intake they need to grow their brain grow their muscles, their bones, and that can have permanent consequences. There is a little bit more urgency and a need for customization in pediatrics compared to adults.

Now, I would argue as someone who's taken care of both children and adults, that adults have similar needs, but the ability for an adult to recover functional status, even though they're older and there's some barriers there, is at somewhat lower risk. I think there's inequities in both categories, especially in home infusion, and I think pharmacists really understand this inequity. There are people who do not have access to home infusion, and because of that, they're in the [emergency room] 94 times a year and travel up to 1000 miles to see care. Pharmacists have a huge role in providing equitable nutrition care for both children and adults.

Q: What role does nutrition play in helping to treat gastrointestinal issues in children?

Shweta Namjoshi: I would say nutrition is part of everything we do in pediatrics. Whether you're a cardiologist, a gastroenterologist, a neurologist, a child cannot optimize organ function without perfect nutrition. Sometimes that's something as simple as ensuring the calorie intake is appropriate. Sometimes it's something more complicated, which is ensuring that the output, whether that's breathing fast, diarrhea, or inflammatory sort of energy utilization is accounted for in the nutrition plan. We collaborate really closely with our pharmacists and our dietitians and our nurses to ensure that nutrition is number 1 for all of our kids. Because something as simple as diarrhea can be treated with appropriate nutrition intake, whether that's [intravenously (IV)] with a home infusion service, or with the right prescription of formula or food.

Nutrition isn't something that's just 1 organ nutrition is liver, GI, psych, neurology, cardiology, it's really kind of very inclusive. Nutrition is at the forefront of everything you do, and I think the pharmacist’s role in that is really key, right? Because if I if I've got a great pharmacist who understands, “Hey, these are the aspects of the home infusion that are important for this child, I need this prescription out this week, I need this prescription out in 2 weeks.” That's key, and these things make a huge difference. Having that close collaboration on the nutrition plan with the pharmacist can be a matter of life and death for some patients, and it can also just maximize quality of life. My sort of overall motto is always I just want kids to be able to do big things, do all the things that they want, their nutrition should never be a barrier. Working with pharmacists who understand that is really important to me.

Q: What should pharmacists know about treating gastrointestinal issues in children? What is important for them to convey to the child's parents?

I think there's sort of 2 separate questions. I would say the first thing I'll talk tackle [is] what to convey to parents first. I would say that, making sure that there's really close communication between pharmacy, the provider, and the family is really important. Some of the techniques we use is having direct communication between the pharmacist and the clinician, so that the parent, pharmacist and clinician can all be on the same page, whether that's something as simple as a rate change on the pump, line care teaching and technique, or something more complicated, like making very sophisticated adjustments, using IV antibiotics at home. These are things that I think are best communicated sort of in a complete model of closed loop communication. I would say that pharmacists really need to make sure that when they're communicating with parents, that the plan is similar to what the clinician discussed, and if there's questions that there's an ability for all 3 to be on the same page together.

What I would say is important for pharmacists to understand about GI conditions is that everyone is different, right? Even when there are set standards, So ASPEN, the American Society for Parenteral and Enteral Nutrition, for example, sets standards for the ingredients in a prescription of TPN. Those ingredients are what we consider maintenance needs, but every child's intake and output are different and so sometimes that formula is not going to work for an individual and it needs to be adjusted. What I've seen as sort of common pitfalls to avoid is the patient is getting maintenance needs of X, Y, or Z micronutrients, but when you look at the patients, they're actually deficient because they have losses due to their anatomy or their underlying pathophysiology. Having that close communication with the gastroenterologist helps the pharmacist understand what are the medical barriers to the nutrition plan, so that the home infusion package can be the best that it can be for that patient, and it sounds so simple, right? It's just fluids, electrolytes, and nutrition. This is lifesaving therapy. I see the flip side of that where people don't necessarily have access to that close, multidisciplinary team.

When they don't have access to that, people can get very sick and there can be tremendous suffering that's preventable and treatable. I encourage all pharmacists to really be part of it, especially those involved in home infusion, to be part of the Learn Intestinal Failure TeleECHO program, which is a great multidisciplinary space for pharmacists, clinicians, dieticians, nurses, surgeons to all learn together how to take care of these chronic complex people, because they deserve that level of sophisticated multidisciplinary care.

Q: How do pharmacists play an essential role in treating children with gastrointestinal issues?

Shweta Namjoshi: Pharmacists are some of my closest colleagues and my patients best advocates. The pharmacist that I work with here at Stanford Children's Health, the pharmacists that are in the community, all throughout California and honestly, throughout the country. They are the key players. Number 1, they keep my kids safe, right? They are that prevention of that Swiss cheese model of errors that can happen. Number 1, I think the pharmacist role is about safety.

Number 2, the pharmacist is a key player in access. Without pharmacy care and without equitable distribution of home infusion services. People suffer tremendously and with great access to pharmacy care, I, as a gastroenterologist, can be empowered to really help children and adults live their best lives. It is 2023; no one with intestinal failure in this country should be dying of intestinal failure. What that requires is great teaching from a home infusion pharmacy, close communication with the gastroenterologist, and access to home infusion services.

I think pharmacists have a role in not only providing the clinical care and the access, but also in being advocates for patients, both at the health policy state and federal legislative level, as well as clinical advocacy saying, “Hey, I know this 1 product, you know is generally hard to get or might be expensive, but let me figure out a way to make it work for this patient.” I think pharmacists beyond the sort of clinical safety are great advocates for our patients.