K McNevin, BE Rosete et al. J Pediatr Gastroenterol Nutr. 2026;82:1303–1308. A comparison between sodium bicarbonate and ethanol for central line locks in pediatric patients with intestinal failure
Background: Since 2022, there has been growing interest in the use of sodium bicarbonate locks. This dates back to 2018, when Belcher pharmaceuticals managed to get the FDA to designate Ethanol as an orphan drug with a subsequent increase in cost (at that time) to ~$10,000 for a 10-vial pack (10-day supply) (Related post: FDA ‘Safety Initiative’ Now Means an Ounce of Ethanol Costs $30,000). As such, many (?most) children with intestinal failure (IF) no longer had access to Ethanol Lock Therapy which prevents life-threatening infections to their central lines. Sodium bicarbonate has been shown to inhibit bacterial proliferation by impeding bacterial adherence and preventing biofilm formation.15, 16
Methods: A retrospective cohort study was conducted in pediatric patients with IF (19 children who received ethanol locks and 36 with sodium bicarbonate locks) followed by the Intestinal Rehabilitation Program at Seattle Children’s Hospital who received ethanol or sodium bicarbonate locks from 2018 to 2023.
Volume of the lock was calculated based on the documented catheter length when available and by drawing back from the line until blood return was obtained when length unavailable. Ethanol locks were withdrawn from the catheter after the dwell while SBL were flushed.
Key findings:
Rates of CLABSI were similar between the ethanol and sodium bicarbonate lock cohorts (2.03 per 1000 catheter days and 1.59 per 1000 catheter days; p = 0.617)
The sodium bicarbonate group had a lower rate of line replacement (2.21 in the EL group and 0.00 in the SBL group (p = 0.01) and trended toward a lower rate of line repair with1.94 in the EL group and 1.07 in the SBL group (p = 0.23).
Discussion:
“While alternatives exist and may also be effective, SBL has the added benefit of a substantially lower cost. At the time this manuscript was written, based on SCH mediation wholesaler data, the cost of 1 mL of ethanol (Ablysinol®) was $186.66 whereas 1 ml of sodium bicarbonate 8.4% was $0.18.”
My take (borrowed from the authors); Based on these data, SBL should be considered as a primary option for lock therapy in children with IF.
Since the 1980s, direct-to-consumer advertising of prescription drugs has been prevalent in the United States — one of only two high-income countries to permit such ads…Endorsements of prescription drugs on social media can be rapidly disseminated across platforms, complicating regulatory oversight…
Under federal law, a prescription drug is considered to be misbranded if labeling or advertising for the product is false or misleading, which can include omission of material information. According to implementing regulations from the Food and Drug Administration (FDA), fair balance is required in the communication of benefits and risks…when social-media influencers and online pharmacies are the source of drug-related communication, their financial or other relationships to manufacturers or compounding pharmacies can be unclear…
Patient-facing content that now circulates pervasively on social-media platforms can blur the distinction between health-related information about prescription drugs and misleading advertising…
Stronger guardrails are needed to protect the public and to keep pace with the ways in which patients now encounter drug promotion…
The FDA could modernize fair-balance requirements for digital platforms by mandating that information about risks be presented directly alongside claims about benefits (e.g., provided in the same social-media communication, using spoken or visually prominent content), rather than being relegated to fine print or a separate website…
The Protecting Patients from Deceptive Drug Ads Act (S. 652) attempts to modernize oversight by requiring influencers to disclose compensation they receive for prescription-drug promotion to the Open Payments database. It would also authorize civil penalties for entities engaging in paid social-media communication that they know is misleading or that is recklessly false and extend FDA advertising requirements, including fair-balance obligations, to telehealth companies. Under such a regime, regulators could prioritize enforcement actions against high-reach celebrity-endorsement campaigns, since a small number of people have outsized influence and enforcement activities could deter similar behavior.
My take: Paid influencers should be held to the same standards of disclosure about their pharmaceutical endorsements as manufacturers.
Kvernufoss, Iceland. The size of the waterfall can be gaged in part by looking at the people behind the falls.
Background: “Supragastric belching (SGB) significantly impairs quality of life. Although diaphragmatic breathing is recommended as a first-line intervention in clinical guidelines, some patients perceive it as monotonous.”
Methods: “This randomized controlled trial, 72 adult patients with supragastric belching diagnosed according to Rome IV criteria were randomly assigned (1:1) to structured singing therapy (ST) or diaphragmatic breathing at 2 tertiary gastroenterology centers in China. The primary outcome was the treatment response, defined as ≥50% reduction in belching visual analog scale scores.”
Singing Therapy:
“Patients with excessive belching episodes underwent structured ST sessions administered by gastroenterologists using 1 of 4 standardized Chinese folk songs (“The Sea,” “For Whom,” “Story of Spring,” or “The Most Dazzling National Style”), with each session lasting approximately 5 minutes.
Participants were required to:
Perform vocalization with musical accompaniment.
Sustain open-mouth phonation to promote diaphragmatic activation, with real-time feedback provided via visual cues (observation of abdominal expansion in a mirror during inhalation) and tactile cues (light hand placement on the abdomen to monitor respiratory motion and suppress thoracic dominance).
Achieve a target vocal intensity of 80 dB, verified using calibrated smartphone decibel meter applications (Decibel Meter App).
Patients were instructed to perform 5-minute vocal therapy sessions 3 times daily, with additional 5-minute sessions when symptomatic. This regimen was maintained continuously for 7 days.”
Key Findings:
“After 1 week, ST demonstrated a significantly higher response rate than diaphragmatic breathing both immediately postintervention (72.2% vs 38.9%; P = .004) and at 1-month follow-up (50.0% vs 30.6%; P = .032). “
“ST demonstrated greater and more sustained benefits in quality-of-life measures.”
Discussion:
“ST may ameliorate belching through mechanisms potentially shared with DB. First, both interventions likely reduce belching by attentional diversion, as distraction-based attentional modulation has been shown to alleviate belching.21“
“Existing literature indicates that both ST16,28 and DB29 possess anxiolytic effects.”
My take: It will be interesting to see if this therapy will be effective in different populations and in pediatric cohorts. Also, could this treatment lead to more American Idol auditions?
Two pictures of the exterior and interior of the Harpa Opera house in Reykjavkik. The irregular, crystalline shapes mimic the geometric basalt columns found in volcanic rock across Iceland.
Methods: This was a retrospective analysis among US adolescents and young adults (AYAs) that leveraged data from Epic Cosmos,4 a US-based electronic health record database representing more than 300 million patients. AYAs (aged 13-25 years) treated for obesity between May 2022 and January 2026 were included.
Key findings:
The study included 204,148 AYAs (mean [SD] age, 21.3 [3.3] years; 150,051 females [73.5%]) who were treated with GLP-1 RAs (192,013 [94.1%]), metabolic and bariatric surgery (MBS) (9,060 [4.4%]), or a combination of both therapies (3,075 [1.5%])
The proportion of exclusive GLP-1 RA use increased from 88.2% in May to November 2022 to 96.1% from June 2025 to January 2026 (P for trend < .001)
MBS completion decreased from 11.6% to 3.7% (P for trend < .001)
Exclusive GLP-1 RA use was observed in a larger proportion of adolescents vs young adults (97.2% vs 93.3%; P for trend < .001). In contrast, MBS completion was observed in a larger proportion of young adults vs adolescents (5.1% vs 1.7%; P for trend < .001).
My take (borrowed from authors): There has been “a rapid shift in treatment pathways, with pharmacotherapy increasingly functioning as the initial intervention for youths with obesity.”
Methods: In this nationwide Danish registry, a pediatric-onset CD cohort from 1980 to 2022 was identified. Outcomes for patients with and without perianal disease were examined.
Key findings:
There were 2356 patients with pediatric-onset CD, of whom 769 (32.6%) developed perianal CD. The cumulative incidence of perianal CD was 14.0%, 21.1%, and 28.1% after 1, 5, and 10 years. After 30 years, the incidence rate was 45.2%.
A stoma was required in 308 (40.1%) and 147 (9.3%) patients with and without perianal disease, respectively (aHR, 2.8).
Probability of Major Abdominal Surgery in Patients with and without Perianal Disease
When comparing patients with/without perianal disease, the aHR for major abdominal surgery, cancer, and mortality were 1.5, 0.8, and 1.5 , respectively.
Probability of Mortality in Patients with and without Perianal Disease
When comparing patients with/without perianal disease, the aHR for mortality was 1.5. Of mortalities, 35 had perianal disease (4.6%; mortality rate, 2.2/1000 person-years) and 33 did not (2.1%; mortality rate, 1.4/1000 person-years). However, the confidence interval was 0.9-2.7) indicating the precision of this finding is low.
Discussion: “In our study, patients without perianal disease were diagnosed with CD more frequently in recent decades than patients with perianal disease. The differences in distribution of CD diagnosis over calendar years may be due to shorter follow-up among patients diagnosed with CD in recent decades, improved treatment delaying disease progression, and increased detection of milder CD phenotypes over time.”
My take: This study reinforces and quantitates the view that having perianal Crohn’s disease portends an increased risk for severe complications. With improving treatments, perhaps the outcomes will be more favorable now and in decades hence.
The city of Denver makes it’s PBM [pharmacy benefit manager] contract available online. So I grabbed it and had Claude look at it and answer a simple question “Where are they getting ripped off”
Then I asked for a simplified version of the above :
Here it is in plain English. Denver hired UnitedHealthcare to run its employee health plan. Denver pays the actual medical and drug bills itself — United just processes them. That’s what “self-funded” means. The problem is that Denver can’t see what it’s actually paying for drugs.
United buys the drug for one price and charges Denver a different price. It keeps the difference. Say the pharmacy gets paid $40 for a prescription. United bills Denver $100. United keeps $60. Denver never sees the $40. The contract says this out loud in three different places — it’s not hidden, it’s just written in language nobody reads. There’s no cap on how big that gap can be.
Drug companies pay rebates. United keeps all of them and hands Denver a flat number instead. United collects rebate checks from drug manufacturers. Instead of passing those through, it promises Denver a fixed amount per brand prescription (about $740 in 2023). If the actual rebate was $1,500, United keeps the extra $760. The contract literally says any rebates above the fixed amount belong to United. Denver has no right to know what the real number was.
United decides which drugs are “specialty” — and specialty drugs are where the money is. The contract defines a specialty drug as, essentially, “whatever United’s own specialty pharmacy sells.” United also reserves the right to reclassify drugs whenever it wants. Once a drug is labeled specialty and filled at United’s own pharmacy, it drops out of the normal price guarantees entirely. So the most expensive drugs are the least protected.
The most expensive drugs of all — the ones given in a doctor’s office or infusion center — have no price guarantee at all. The contract flatly excludes them. Cancer drugs, infusions, injections administered by a provider. Zero pricing protection.
Denver can’t shop around, and it can’t leave without a penalty. Denver isn’t allowed to negotiate directly with any drug manufacturer. It must use United’s mail-order pharmacy exclusively. And if Denver hires an outside vendor that steers employees to cheaper drugs or cheaper pharmacies, United can cancel all the pricing guarantees. If Denver ends the drug program early, United keeps every rebate it owes.
Denver can’t audit its way out of this. Denver is allowed one audit a year, capped at 300 prescriptions, using a random sample United has to approve. No auditors paid on commission. No computer-based searches for errors. You cannot find a pricing problem across hundreds of thousands of claims by randomly checking 300 of them. The audit rules exist to make sure nothing gets found.
The bottom line for an HR person: the drug program looks free. There’s no fee for it anywhere in the contract. That’s the tell. United isn’t working for free — it’s getting paid out of the drug prices, and the contract is built so Denver can’t measure how much.
Methods: This studied children born between 2010 and 2021 using the French National Health Data System registry (EPI-MERES). PPI use was identified through prescriptions before age 1 year.
Key findings:
There were 703,891 PPI users among the 8,222,100 children included.
The incidence of PPI use was 54.4 per 100 person-years among children with hospital-diagnosed gastroesophageal reflux disease (GERD) (+ 33.6% between 2010 and 2021), and 7.9 per 100 person-years in those without (+ 63.6%).
PPI use was associated with extreme prematurity (aOR=1.91), digestive diseases (aOR=5.60), respiratory diseases, aOR, 2.73, neurological diseases (aOR=1.59), and with high maternal socioeconomic level (first quintile of deprivation index [least deprived] vs fifth quintile [most deprived] (aOR=1.80)
The median age at initiation of PPI treatment decreased over time, supporting the idea that PPI use may have become more commonplace.
Discussion:
The presence of underlying diseases may increase the use of PPIs as it is “consistent with the hypothesis that more frequent interactions with the healthcare system may be closely associated” increased prescriptions of PPIs.
Potential adverse PPI effects: “Early life PPI exposure has been associated with an increased risk of respiratory and gastrointestinal infections. [Also, there are] associations with immune-mediated diseases potentially mediated by microbiome alterations, including asthma,25,26 allergic disorders,26,27 and inflammatory bowel disease.28“
“PPI use in children aged <1 year may be appropriate, especially for esophagitis,1 but is not needed if the symptoms do not interfere with growth and development,1 and there is no evidence supporting empirical PPI therapy for diagnosing GERD in infants.1“
My take: This study shows that PPI use before age 1 has increased sharply in France since 2010. This coincides with high usage in infants elsewhere despite lack of proven efficacy. However, a recent study from Boston showed a declining trajectory of PPI use (see related posts). This indicates that a consistent message that most infants should not be treated with PPIs may be effective.
*Two of the study authors have financial ties to the manufacturer of the ultra-slim endoscopes.
Methods: Ten pediatric subjects (including one that was 2.9 years of age) with suspected or known esophageal varices (EV) underwent surveillance endoscopy using the ultra-slim endoscope (transoral or transnasal endosocpy [TNE]) followed by the standard gastroscope under sedation. Esophageal findings were analyzed using images from both procedures by two independent endoscopists.
Key findings:
EV were identified in 8/10 subjects (Grade I (4), Grade II (3), and Grade II/III (1))
Endoscopic grading matched between both endoscopes in 7/8 (87.5%) cases
Three subjects required endoscopic intervention with either sclerotherapy (n = 1) or band ligation (n = 2)
Limitation: High risk stigmata of recent bleeding such as red wale signs or fibrin plugs were not assessed and documented in this study. These features are important for risk stratification; thus, understanding whether the ultra-slim endoscope reliably identifies these stigmata is needed
In the discussion, the authors note that “our study demonstrates the potential for considering TNE for EV evaluation in a lower cost, lower acuity setting.” In my view, this is a flawed argument, particularly in pediatrics.
For varices, many of the children need therapeutic endoscopic intervention. Thus, outside of a study design, this requires an additional procedure (and additional cost).
In pediatric gastroenterology, most clinicians do their endoscopic procedures in a hospital-based setting and/or in affiliation with hospitals. While this can provide additional safety for risky procedures, this drives up costs. In fact, this study which promotes TNE for cost savings does not report the anticipated costs. However, in a previous study, the cost of TNE exceeded that of a standard endoscopy (including anesthesia) in an endoscopy center. Though, the cost of TNE was less than a standard hospital-based endoscopy (Related blog post: Transnasal Endoscopy in Unsedated Children to Monitor Eosinophilic Esophagitis).
My take: This technology would be better suited for adults with eosphageal conditions. First of all, most adult GI physicians are not employed by hospitals. Thus, there is a much greater likelihood of cost savings. Secondly, avoiding an additional day missing work is usually a bigger factor for adult patients. However, if there is a need for preauthorization for reimbursement of the procedure, this could negate this potential benefit as well.
Background: “In the general population, individuals with discordant tests (PCR+/TOX−) have similar outcomes to PCR− individuals, suggesting that this group represents individuals colonized with C. difficile.[14]”
Methods: In this retrospective study (n=117), outcomes assessed included CDI-directed therapy or escalation of IBD treatment.
Key findings:
79% (93/117) were PCR+/TOX− and 21% (24/117) were PCR+/TOX+
PCR+/TOX+ patients had significantly higher CRP (98 vs 6 mg/L, P = .005)
PCR+/TOX− patients had more severe underlying IBD and higher rates of steroid use (48% vs 21%, P = .02) and were significantly more likely to require IBD therapy escalation (54% vs 25%, P = .004). Multivariable analysis showed PCR+/TOX− status (odds ratio [OR], 3.2) was a significant predictor of IBD treatment escalation. Antibiotic use did not significantly alter the need for escalation among PCR+/TOX− patients.
Discussion:
“Most IBD patients who are PCR+/TOX− are colonized with C. difficile, and IBD treatment could be considered rather than delaying for CDI therapy.”
My take: In patients with IBD, PCR-positivity for C diff is frequently a false positive due to high rates of colonization in this population. Patients who have their infection confirmed with an immunoassay are much more likely to respond to C diff therapy.
Overdiagnosis of Clostridium difficile with PCR Assays In a large adult study with 293 of 1416 hospitalized adults testing positive for C. diff, virtually all CDI-related complications and deaths occurred in patients with positive toxin immunoassay test results. Patients with a positive molecular test result and a negative toxin immunoassay test result had outcomes that were comparable to patients without C difficile by either method
National Civil Rights Museum in Atlanta, GA. One of the powerful exhibits is a Woolworth lunch counter replica with headphones. With your eyes closed, the exhibit challenges you to keep your hands on the counter as one receives menacing threats like ‘Boy, I’m going to kill you.’
JJ Patel, SA McClave. NEJM 2026; 395: 162-174. Nutrition Therapy in Critically Ill Adults
Key points: (for adults)
Early enteral nutrition preserves gut integrity and supports the microbiome, so it is the preferred approach, although contemporary randomized, controlled trials show that early short-term parenteral nutrition is safe when enteral nutrition is contraindicated.
Providing full-dose nutrition early may lead to more metabolic and gastrointestinal complications than restrictive or trophic feeding.
High-dose protein (>2.0 g per kilogram of body weight per day) offers no outcome benefit over standard dosing (≤1.2 g per kilogram per day) and may be harmful in patients with acute kidney injury.
Adverse events with enteral feeding (often called enteral feeding intolerance) are common during critical illness, and the safe delivery of nutrition requires gradual advancement, strategies for prevention of refeeding syndrome, glycemic control (glucose level, <180 mg per deciliter), and avoidance of routine gastric residual volume monitoring.
TIMING, ROUTE AND DOSE OF NUTRITION:
“The receipt of nothing by mouth…impairs gut health by reducing epithelial-cell proliferation, increasing apoptosis, and disrupting mucosal integrity, enteral nutrition supports gut function by enhancing tight-junction protein expression, reducing enterocyte apoptosis, preserving villous and crypt architecture, maintaining Paneth-cell function, supporting gut-associated lymphoid tissue, and helping to sustain commensal microbiota.11,12 The collective evidence from 21 randomized, controlled trials has shown that early enteral nutrition, initiated within the first 24 to 36 hours after ICU admission, leads to better outcomes than delayed delivery or no provision of enteral nutrition.13” [if no contraindications]
“The CALORIES and NUTRIREA-2 trials randomly assigned critically ill adults to receive early enteral nutrition or early short-term parenteral nutrition, and the results showed no between-group differences in 30-day and 28-day mortality, respectively”
“Thirteen randomized, controlled trials questioned the practice of providing full-dose nutrition during the acute phase of critical illness and compared restrictive strategies — such as hypocaloric feeding, permissive underfeeding, and trophic feeding (Table 2) — with full-dose regimens.18–22,36–43 Nine trials showed no significant between-group differences in mortality.18,19,21,37–41,43 Four trials showed that restrictive-dose enteral nutrition led to better outcomes, including reductions in mortality and duration of mechanical ventilation and earlier time-to-readiness for ICU discharge, than full-dose nutrition.20,22,36,42 …Early aggressive full-dose nutrition may cause net harm by increasing the risk of bowel ischemia, refeeding syndrome, overfeeding (exogenous nutrients combined with hepatic gluconeogenesis), suppression of autophagy, increased demand on dysfunctional mitochondria, delivery of excessive fluid volume, and gastrointestinal adverse effects.28“
HIGH PROTEIN NUTRITION:
Several large well-designed studies have looked at higher protein dosing, including the EFFORT Protein Trial, the PRECISE trial and the TARGET Protein trial. Even in patients with preexisting malnutrition which was assciated wiht higher mortality, provision of high protein did not modify this outcome. “These findings were supported by two meta-analyses that showed that a high dose of protein did not lead to better outcomes in critically ill adults than a lower dose.56,57 Moreover, a high dose of protein may be harmful in patients with severe illness and acute kidney injury.”
GASTRIC RESIDUALS:
” A meta-analysis of seven trials (involving 1240 patients) indicated that not monitoring gastric residual volume reduced unnecessary feeding interruptions and showed no between-group differences in the incidence of ventilator-associated pneumonia, the length of ICU stay, or mortality.67 Current evidence does not support the use of gastric residual volume monitoring to reduce the risk of aspiration or pneumonia in ICU patients. Gastric residual volume monitoring may hinder enteral nutrition delivery… Routine monitoring of gastric residual volume — as a marker of adverse events with enteral feeding — should be strongly discouraged.”
Figure 2. Conceptual model of evolution of physiological responses and nutrition strategy across phases of critical illness.
Long Term Outcomes:
“Over the past four decades, survival from critical illness has improved but is marred by substantial loss of lean body mass, which is a major long-term consequence for survivors.4 Loss of lean body mass contributes to acquired muscle weakness and functional disability, which can persist for up to 5 years after the initial ICU admission.74 In healthy persons, resistance exercise combined with protein supplementation has been shown to elicit a greater anabolic response than protein supplementation alone.75“
My take: While this article is geared towards adult patients, my expectation is that the recommendations are largely applicable to pediatric patients. However, there is much more data in adults and pediatric care needs to be adjusted based on size.
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
gutsandgrowth 