Declining Child Health in the U.S.

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CB Forrest, N Halfon. N Engl J Med 2026;395:1147-1149. Declining Child Health in the United States — Addressing the Developmental Ecosystem

This commentary paints a broad picture of declining health for U.S. children and what is needed to change the trajectory. Here are some excerpts:

Child health has been deteriorating in important and alarming ways in the United States…over the past two decades.1 Infants, children, and adolescents in the United States are 80% more likely to die than their peers in other high-income countries…77% of Americans 17 to 24 years of age would be ineligible to enlist in the U.S. military without a waiver, for reasons including obesity, mental health problems, and other medical conditions.2…

Researchers, policymakers, and the media have tended to attribute these trends to independent challenges — an obesity crisis, a mental health crisis, loneliness, gun violence — with distinct programmatic responses and potential remedies supported by separate advocacy groups and funding streams. But many of them have common origins and drivers…Interventions that target a single risk factor may relieve immediate suffering but will generally be insufficient to change developmental ecosystems in ways that can reverse generational declines in health…

At the base of the iceberg are a developmental ecosystem’s foundational values, which are often expressed in shared narratives about childhood: that raising children is chiefly a private responsibility, that markets are the fairest arbiters of who can be healthy…and that public support should be provided for children’s health programs only in exceptional circumstances…

The influence of these beliefs can be observed in the choices that society has made, including spending less than peer countries on early-childhood programs, opting not to regulate digital platforms that profit from the commodification of children’s attention, and organizing health care systems around the treatment of illness, rather than the promotion of healthy development.

The Elephant Rock is a natural rock formation located on the island of Heimaey in the Westman Islands

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More on Measles (October 2026)

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Trisha Pasricha, Washington Post 10/5/26: Measles can erase up to 73 percent of your immune system’s memory

An excerpt:

“My sister says there’s no real difference between a child getting the measles vaccine and just catching measles, since either way the child ends up immune. Is she right?

I wouldn’t describe it as “just catching measles.” In the United States, about 1 in 5 unvaccinated people who get measles is hospitalized, and 1 to 3 of every 1,000 children infected will die, according to the Centers for Disease Control and Prevention…

Children with measles become more susceptible to other infections like ear infections or diarrhea. Today, the most common cause of death among young children with measles is pneumonia…

In a study published in Science in 2015, researchers analyzed decades of childhood mortality data from the United States, England and Wales, and Denmark. They noticed that in the pre-vaccine era, when measles cases spiked, deaths from other infections rose, too — and not just immediately but for the subsequent two to three years…When the measles vaccine arrived, and measles cases fell, deaths from other infectious diseases fell along with them. The scientists estimated that where measles was common, measles infections could have been implicated in as many as half of all childhood deaths from infectious disease.

Center for Infectious Disease Research and Policy, University of Minnesota: “Pennsylvania confirms more than 1,000 measles cases. Nationwide, the Centers for Disease Control and Prevention (CDC) reported 3,887 measles cases as of October 2… Health department officials in South Carolina also have said that the state likely had more measles cases this year than the official count of 997. Doctors in South Carolina aren’t required to report measles-related hospitalizations, according to a report from ProPublica.”

Measles: 99% of the cases (n=1004) are in the unvaccinated which represent 7% of Pennsylvania’s population. Graph courtesy of Neil Stone, MD (via X). All of the deaths have occurred in the unvaccinated.

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PrEggNut Trial: Pregnancy Egg and Peanut Intake Didn’t Prevent Allergy

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DJ Palmer et al. N Engl J Med 2026;395:1090-1099. Trial of a Maternal Diet Rich in Eggs and Peanuts to Reduce Infant Allergy

Methods: For “The PrEggNut Trial,” a multi-site, randomized trial, “pregnant women whose unborn child had at least two biologic family members with medically diagnosed allergic disease were eligible to participate. Participants were assigned in a 1:1 ratio to follow either a diet high in eggs and peanuts that included at least 6 eggs and 60 peanuts per week (high egg–peanut group [n=1070]) or a standard (control) egg and peanut diet that included no more than 3 eggs and 30 peanuts per week (standard-diet group [n=1067]), from before 23 weeks’ gestation until 4 months postnatally during lactation. The primary outcome was IgE-mediated egg or peanut allergy in the infant at 1 year of age.

Key findings:

  • There was no significant difference in the percentage of infants with IgE-mediated egg or peanut allergy between the maternal high egg–peanut group (83 of 1066, 7.8%) and the standard-diet group (89 of 1064, 8.4%) (relative risk, 0.93; P=0.65)
  • A potential limitation of the trial was the lower-than-anticipated prevalence of egg or peanut allergy (8% actual vs. 16% anticipated)

My take: Increased exposure to eggs and peanuts during pregnancy did not reduce allergies in infants. Exposure during infancy, however, can reduce the rates of allergies.

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Proposed Treatment Algorithm for Water Bead Ingestions

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KH Denton et al. J Pediatr: Clin Pract 2026;22:200239. Pediatric Water Bead Ingestion: Experience from a Quaternary Care Children’s Hospital and a Proposed Management Algorithm

Methods: This retrospective chart review identified 36 pediatric patients (median age 2 yrs) who presented to a quaternary care children’s emergency department for water bead ingestion from 2015 to 2024.

Key findings:

  • The majority (n = 28, 78%) were asymptomatic.
  • Only 4 of 52 (8%) imaging studies were abnormal.
  • Endoscopy was performed in 6 (17%) patient encounters, none of which
    successfully retrieved water beads.
  • There were no patients with bowel obstructions or complications.

Discussion:

  • The results are “similar to a prior case series from 2011 to 2016, which examined 110 patients aged 19 years or younger who had called the Texas Poison Control Center for water bead ingestion. The study found that many were managed at home, without any known complications.”
  • “However, there are reports of morbidity and mortality associated with water bead ingestions. A literature review published in 2022 described 43 cases of bowel obstruction
    and 2 deaths following the ingestion of water beads.”
  • “Current NASPGHAN guidelines recommend early endoscopy in cases involving high-risk or potentially obstructive foreign bodies, with emphasis on emergent endoscopy in the case of superabsorbent objects such as water beads…Upon reviewing our data and the current
    literature, we propose a new algorithm for managing pediatric patients presenting with water bead ingestion.“
This “suggested algorithm remains provisional and informed by both experience and available literature to guide clinical decision-making but will require further validation before widespread adoption.”

My take: This article offers a practical approach to manage water bead ingestion and includes appropriate caution and caveats.

The recent ESPGHAN 2026 Position Paper (O Ledder et al. J Pediatr Gastroenterol Nutr. 2026;83:539–554) has not incorporated this suggested algorithm and is similar to previous NASPGHAN recommendations. See blog post on 9/28/26: “In cases of witnessed or suspected ingestion of SAP [superabsorbent polymers], emergency endoscopy should be performed to attempt retrieval of the material. If this is unsuccessful, or not completely retrieved, the child should be admitted for close observation with surgical support.”

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

“Battle of Hospital A.I. vs. Insurer A.I.”

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Reed Abelson , Teddy Rosenbluth. NY Times 4/24/26: Battle of Hospital A.I. vs. Insurer A.I. Is Pushing Medical Costs Higher. Thanks to Seth Marcus for sharing this article.

An excerpt:

In the latest sign that artificial intelligence is fueling higher health care costs, a group of insurers released a report Thursday claiming that hospitals’ use of A.I. was responsible for nearly $1 billion in additional expenses over two years…

Using codes for various medical conditions, hospitals submitted claims for tens of thousands of patients that described their illnesses as more complex in 2024 and 2025 than in 2023. Despite the added conditions, there was no evidence that the patients had received different treatment from the hospitals, according to the analysis by the Blue Cross Blue Shield Association, which represents state Blue Cross plans.

Using A.I. tools, hospitals are collecting more information about their patients, and submitting bigger claims, the association said…

Just as providers are using sophisticated A.I. tools to say their patients are sicker, insurance companies have been accused of using the tools to delay or deny care. The companies have come under intense criticism for their use of A.I. when requiring prior approval of treatments and medicines…

But as more hospitals and doctors use A.I., costs will continue to rise. Benefit consultants and insurers cite it as one of the factors that could lead to double-digit increases next year. A recent survey of employers suggested that costs could go up as much as 11 percent next year for employers unless they cut back on benefits.

My take: By leveraging AI, doctors and hospitals are able to claim that patients have increased complexity to justify higher reimbursement codes. This shift has caught insurance companies flat-footed and increased hospital profitability. When the insurance companies negotiated the rates for each reimbursement code, historical data allowed them to predict the costs based on projected use of each code; these projections are way off now. Using AI to document complexity, these hospital coding changes can no longer be denied as “upcoding” by insurance companies.

Over the long term, I expect insurance companies to work on lower reimbursement for higher-complexity coding. Over the short term, the increase in hospital profits will result in higher insurance costs for patients and businesses.

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Svartifoss (which translates to “Black Falls”), one of the most distinctive and photographed waterfalls in Iceland. The hexagonal basalt columns which frame an 80-foot cascade were formed geologically by lava flowing down a cliff face and cooling incredibly slowly, a process called columnar jointing.

Expert Practice Recommendations for C difficile Infection in Adults

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M Fischer et al. Clin Gastroenterol Hepatol 2026; 24: 2359-2369. AGA Clinical Practice Update on Management of Clostridioides difficile Infection in Adults: Expert Review

This article provides 14 “Best Practice Advice” statements. Since this is geared to adults, some are not applicable for the pediatric age group. I have highlighted five of them:

  • #4: Fidaxomicin (200 mg twice daily oral for 10 days) is a narrower spectrum agent, and given lower recurrence rates, is favored as first-line therapy for nonfulminant C difficile infection. However, given practical considerations, vancomycin (125 mg 4 times daily oral for 10 days) is also acceptable therapy. Metronidazole should not be used outside of fulminant disease.
  • #6: Following treatment of C difficile infection, clinicians should not perform routine test of cure. Stool testing should only be performed for persistent worsening of diarrheal symptoms.
  • #9: Prolonged, low dose, suppressive vancomycin regimen (125 mg daily) for secondary prophylaxis may be considered in patients with multiple recurrent episodes who are not candidates for fecal microbiota-based therapies due to ongoing comorbidities, limited life expectancy, or ongoing/frequent systemic antibiotics or who have failed multiple courses of fecal microbiota-based therapy.
  • #10: Fulminant C difficile infection should be managed by a multidisciplinary team (gastroenterology/infectious disease, surgery, medicine/critical care) and treated with high-dose vancomycin 500 mg every 6 hours (oral or enteral), with metronidazole 500 mg intravenously every 8 hours, and if ileus is present, rectal vancomycin 500 mg every 6 hours should be added.
  • #12: Use of vancomycin is not advised during systemic antibiotic administration to prevent C difficile infection. Probiotics are not advised to prevent an initial or recurrent C difficile infection. To promote restoration of healthy gut microbiota, patients should be instructed to consume a healthy diet including a variety of fruits and vegetables, rich in both soluble and insoluble fiber. ” Although some guidelines suggest OVP in high-risk patients, these recommendations were conditional and based on low-quality evidence.20“
Some of the advice from Table 1 on household prevention of CDI

For recurrent CDI, “experts recommend treating a first recurrence with an agent different from that used initially.” One option discussed by authors and in the treatment algorithms (Figure 2) includes use of a vancomycin taper. After a course of vancomycin 125 mg QID x 14 days, a typical taper would be BID x 14 days, then daily x 14 days, then every 3rd day x 14 days. An alternative is a fidaxomicin EXTEND (200 mg BID days 1-5, then every other day, days 7-25 days.

My take: This is a useful reminder of current best practices for C diff infection (in adults). Updated guidelines in pediatrics would be helpful.

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Dupilumab Rarely Associated with Pediatric Neuroinflammatory and Neuropsychiatric Symptoms

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Yesterday’s post (Incredible Video of Lung Cell Cilia) now has an important addendum: a reader’s comment notes that the winning entry is “being re-evaluated following criticism from other scientists that it was made with AI.” Here is an article from the BBC on this investigation: Tiny image sparks big backlash in Nikon photo contest (https://www.bbc.com/news/articles/ck4gjn1yzprno)

L Mathiesen et al. J Pediatr 2026;297:115201. Pediatric Neuroinflammatory and Neuropsychiatric Syndromes Associated with Dupilumab Treatment for Atopic Dermatitis

This case series of children between the ages of 6 and 16 describes the development of serious neurologic sequelae associated with the use of dupilumab for atopic dermatitis. 3 of 4 children had pre-existing genetic or neurodevelopmental conditions, including ADHD, autism spectrum disorder, an ABCD1 mutation, and homozygous FECH mutations.

Case 1: An 11 year old, with a history of ADHD, “developed poor attention, increased hyperactivity, worsening school performance, and aggression after two months of treatment. Over the subsequent 8 months, symptoms gradually worsened and evolved to include irritability, oppositional behavior, vocal and motor tics, language regression, and ultimately suicidal ideation.” After resolution of his atopic dermatitis, he had ~80% improvement off dupilumab. “However, in the setting of atopic dermatitis exacerbation, dupilumab was restarted and was associated with a rapid decline in mental state within 4 weeks leading to dupilumab discontinuation. He continued to decline, developing severe akathisia, tics, language regression, and transient episodes of confusion. Repeat brain MRI showed bilateral symmetric frontotemporal T2 hyperintensity with hyperperfusion without gadolinium enhancement.” Extensive neuropsychiatric evaluation (genetics, autoimmune, CSF analysis) was otherwise unremarkable.

Three of the patients received intravenous methylprednisolone which was associated with improvement. However, the patient in Case#1 has not returned to baseline.

Imaging from Case 4:

Contrast-enhancing brain lesions were identified in case 4. (A) Axial T2/FLAIR sequences demonstrating multiple areas of signal prolongation at the gray-white junction in the frontal and parietal lobes. (B) Axial T1-post contrast imaging demonstrating heterogeneous contrast enhancement patterns in some lesions.

In their discussion, the authors discuss this “previously unreported association between dupilumab and neuroinflammatory syndromes in 4 pediatric patients with atopic dermatitis.” They discuss potential pathophysiology as well statig that dupilumab “may promote classical proinflammatory immune signaling…Although dupilumab is not expected to cross the intact blood-brain barrier, its potential neurological effects could be mediated through peripheral immune modulation. Systemic IL-4/IL-13 blockade could modulate immune cell trafficking to the central nervous system.”

My take: While neurologic adverse effects associated with dupilumab appear to be rare, there should be a low threshold for discontinuation when new neurological symptoms emerge. Only the first case had a rechallenge with dupilumab. This helped establish likely causality; however, this patient did not fully recover when dupilumab was stopped.

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Incredible Video of Lung Cell Cilia

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Stella Raine Chu, NY Times 9/17/26: Microscopic Videos That Show the Invisible Wonders Around Us

“The winners of this year’s Nikon Small World in Motion competition showcase the wiggly, feathery, undulating beauty of invisible life.” In total, there are seven short videos featured.

1st place: Abnormal beating of airway cilia from a child with a disease called primary ciliary dyskinesia. Cilia are about 1/100th the width of a human hair.

Addendum: **A reader’s comment notes that the winning entry is ” being re-evaluated following criticism from other scientists that it was made with AI.” Here is an article from the BBC on this: Link: Tiny image sparks big backlash in Nikon photo contest

Adherence to a Gluten Free Diet in Pediatric Celiac Disease

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L Kallio et al. JPGN Reports. 2026; Epub 9/14/26. Open Access! Factors associated with adherence to gluten-free diet in patients with concomitant celiac disease and type 1 diabetes

Methods: In this study from Finland, the authors compared the baseline characteristics and follow-up data between adherent and nonadherent CeD children with a dual diagnosis (n = 69). 

Key findings:

  • Overall, 72% were found to be adherent to a gluten-free diet (based on self-report)
  • Adherent patients were detected significantly more often in annual CeD screening than by symptoms

Discussion:

“In Finland, GFD products are easily available, and children receive financial support to cover the additional costs.”

Though, not addressed by the authors, it is widely acknowledged that self-report of GFD adherence tends to overestimate true adherence compared with expert interviews, celiac serology and stool or urine for GIP (gluten immunogenic peptide). The reasons for this include the following:

  • Unintentional gluten ingestion. This can be due to food cross-contaminated during manufacturing, prepared with shared kitchen utensils, or laced with hidden gluten additives.
  • Knowledge gaps. A patient might regularly consume a specific product or sauce thinking it is perfectly safe, resulting in high self-reported compliance but low actual compliance
  • Social desirability and recall bias. The tendency to want to present oneself in a positive light or give the “correct” answer. Additionally, recall bias means people tend to forget minor dietary slips or intentional transgressions that occurred weeks prior.
  • Lack of symptoms. Many patients assume that if they do not experience immediate gastrointestinal pain, they have successfully avoided gluten.

My take: In this cohort, diagnosis through screening rather than due to symptoms was associated with higher adherence rates, contrary to expectations. Overall, regardless of how a diagnosis was established, there are a large number of individuals with celiac disease with ongoing gluten exposure. This occurs even in individuals who are making a lot of effort to follow this diet.

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Promising Pilot Study Using Substance P to Screen for Pediatric Aspiration

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DR Duncan et al. J Pediatr 2026; 297: 115212. Association Between Salivary Substance P and Aspiration on Videofluoroscopic Swallow Study in Infants and Toddlers

Background: Substance P (SP) is a neuropeptide signaling molecule that is secreted peripherally as a result of the activation of afferent neurons expressing TRPA1 and is involved in the pathogenesis of swallow dysfunction by (1) decreasing the activation
threshold of transient receptor potential channels, (2) enhancing the sensitivity of neurons in the pharynx, and (3) increasing cough reflex to improve airway protection. Pilot studies in adult populations have shown reduced SP levels in patients with neurologic causes of aspiration, including patients who are elderly and patients with stroke and Parkinson disease.

Methods: The authors recruited children younger than 2 years of age (n=50, mean age 8 months) who underwent VFSS within 3 months of study enrollment. Saliva samples were collected using absorbent saliva collection devices (salimetrics.com) and Substance P (SP) levels were measured by enzyme-linked immunosorbent immunoassays. Patients with laryngeal penetration but not aspiration were excluded.

Key findings:

  • SP concentrations were 344.7 ± 42.9 pg/mL for patients with aspiration compared with 105.7 ± 40.5 pg/mL for those without aspiration (P < .001). 
  • A cutoff of 65 pg/mL provided 97% sensitivity and 75% specificity for predicting aspiration on VFSS.
  • In a subgroup analysis with 29 subjects who had VFSS within 1 month of sample collection, a cutoff of 63.2 pg/mL provided 100% sensitivity and 83.3% specificity for predicting aspiration on VFSS. For this subgroup, the SP concentration was 250.9 ± 33 pg/mL for those with aspiration on VFSS compared with 57.1 ± 11.8 pg/mL for those without aspiration on VFSS (P < .001)
A, Boxplot comparing salivary SP concentration between children
with and without aspiration on VFSS in the full cohort.
B, Boxplot comparing SP concentrations in the subgroup of subjects
with saliva sample collection within 1 month of VFSS.

Discussion Points:

  • “SP levels were not affected by comorbidities or acid suppression medications” in this cohort.
  • “These data suggest that this test could be used to at least screen for who might need a VFSS or who might need thickening while the cause of aspiration is being evaluated.”
  • “Testing of salivary SP is experimental and only limited to research studies and therefore not widely available at the present time.”

Disclosures: “The funders had no role in the design and conduct of the study. D.D. and R.R. are named inventors on U.S. Provisional Patent Application Serial No. 63/804876, DEVICES AND METHODS FOR DETECTING AND TREATING ASPIRATION IN CHILDREN.”

My take: While this is a pilot study, if the findings are confirmed, this would be a huge advance. It would help triage infants and young children who need VFSS evaluation. A normal value could help many infants avoid a VFSS evaluation. In those with ongoing abnormal values, it could allow fewer followup VFSS evaluations.

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