Author Archives: gutsandgrowth

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About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times. Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997. For many families, more practical matters about our office include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.

Preliminary Recommendations from NASPGHAN on Zantac/Ranitidine Warnings

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Recently, there have been concerns about zantac (ranitidine).  NASPGHAN has made the following preliminary recommendations:

NASPGHAN has been in conversation with the FDA and would like to offer the following language for you/your office/your division and your patients/parents.

The U.S. Food and Drug Administration has learned that some ranitidine medicines, including some products commonly known as the brand-name drug Zantac, contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables.
The FDA has been investigating NDMA and other nitrosamine impurities in blood pressure and heart failure medicines called Angiotensin II Receptor Blockers (ARBs) since last year, and when it discovered unacceptable levels of nitrosamines the ARBs have been recalled.

The FDA is evaluating whether the low levels of NDMA in ranitidine pose a risk to patients and will post that information when it is available.

It is important to note that although NDMA may cause harm in large amounts, the levels the FDA is finding in ranitidine from preliminary tests barely exceed amounts you might expect to find in common foods.

The agency is working with international regulators and industry partners to determine the source of this impurity in ranitidine. The agency is examining levels of NDMA in ranitidine and evaluating any possible risk to patients. The agency will provide more information as it becomes available.

The FDA is not calling for individuals to stop taking ranitidine at this time; however, patients taking prescription ranitidine who wish to discontinue use should talk to their health care professional about other treatment options. People taking OTC ranitidine could consider using other OTC medicines approved for their condition. There are multiple drugs on the market that are approved for the same or similar uses as ranitidine.

Are There Any Babies with a Normal GI Tract?

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A recent study (S Salvatore et al. J Pediatr 2019; 212: 44-51) examines the role of neonatal antibiotics and prematurity on the development of functional gastrointestinal disorders in the first year of life.

What is most striking, though, in this study is how many of these infants have a GI disorder.

Background: Prospective cohort multicenter study with 934 infants who completed study; n=302 premature, n=320 antibiotic recipients

Key findings:

  • 718 (77%) had at least one functional GI disorder (FGID) based on Rome III criteria, including 47% with colic, 40% with regurgitation, 32% with dyschezia, 27% with constipation, and 4% with functional diarrhea
  • Preterm infants had FGID rate of 86% compared with 73% of full term infants (P=.0001)
  • Use of antibiotics was associated with FGIDs as well, with aRR of 1.16 (P=.001)
  • The prevalence of FGIDs was highest in the first three months of life and then improved markedly by 6 months of age; by 12 months of age, each of the FGIDs was well below 10%.

Limitation: This study relied on parental reports which could overestimate infant’s symptoms.

My take: More than 75% of infants had at least one FGID.

Related blog posts:

Good Food and Bad Food for Crohn’s Disease -No Agreement

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As noted in a previous blog (IBD Briefs August 2019), there have been numerous diets proposed to help with Crohn’s disease.   The chart below illustrates the lack of any consensus.

Related blog posts:

Breifly Noted: Duodenal and Rectal Eosinophilia in Nonceliac Gluten Sensitivity

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A Carroccio et al. Clin Gastroenterol Hepatol 2019; 17: 682-90. This prospective study examined 78 patients with a diagnosis of non-celiac gluten sensitivity (NCGS) based on double-blind wheat challenge.  The authors identified markers of inflammation including eosinophils in the duodenum and rectum of patients with NCGS:  –the mean eosinophil infiltration was more than 2.5-fold the upper limit of normal in rectum and almost 2-fold in duodenum.

Rectal eosinophilia (>9 eos in the rectal lamina propria) had a sensitivity of 94%, specificity of 70%, positive predictive value of 81% and negative predictive value of 89% for NCGS.

My take: (from the editorial,pg 613-4) “In many cases, NCGS is likely a mislabeled functional GI disorder (IBS or FD) induced by wheat proteins or FODMAPs…tissue eosinophilia [is a] potential biomarker..although this observation needs further confirmation.”

Yummy! Though, probably the wrong place for those trying to be gluten-free

Liver Briefs -September 2019

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P Rosenthal et al. Hepatology 2019; 69: 2326-37.  This study examined the efficacy and safety of combined entecavir and Peginterferon for immune-tolerant chronic hepatitis B-infected children (n=60). 48 weeks after completing treatment (week 96), 2 children (3%) achieved the primary outcome of undetectable HBeAg with HBV DNA levels <1000 IU/mL.  These two children were also HBsAg negative/anti-HBs positive. In the other children (55 completed study), the ALT and HBV DNA levels were similar to baseline.  37 children experienced adverse events.  My take: Entecavir/peginterferon is not very effective in immune-tolerant children infected with chronic HBV.

DL Thomas. NEJM 2019; 380: 2041-50. This article reviews the pathway to the global elimination of chronic hepatitis.  Currently, it is estimated that hepatitis C virus (HCV) and hepatitis B virus (HBV) kill more than 1 million persons each year. “In fact, by 2040, deaths from chronic hepatitis are projected to exceed the combined mortality associated with HIV infection, tuberculosis, and malaria.”

JR Dillman et al. J Pediatr 2019; 212: 60-5. This study with 41 patients and 13 patients with biliary atresia prospectively assessed ultrasound shear wave elastography (SWE). The authors found that SWE with a cut-off value of >1.84 m/s had 92% sensitivity and 79% specificity.  Also, in their cohort, GGT >320 had a sensitivity of 100% and specificity of 78%.

Z Younossi et al. Hepatology 2019; 69: 2672-82.  This review provides a global perspective of NAFLD.  25% of the world’s population is currently thought to have NAFLD with highest prevalence in South America at 30.45% and lowest in Africa at 13.5%. This article usggest North America to have 24.1% prevalence rate.

Briefly Noted: Alpha-Fetoprotein Norms for Beckwith-Wiedeman Spectrum

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Alpha-fetoprotein (AFP) levels are increased in >95% of patients with hepatoblastoma.  These levels have to be interpreted carefully in infants as these levels typically are elevated in the first 6-12 months of life.

For patients with Beckwith-Wiedeman Spectrum (BWS), the relative risk of hepatoblastoma has been estimated to be 2280 times greater than the general population.  In addition, in patients with BWS, AFP levels are known to be elevated compared to the general population in the absence of hepatoblastoma as well.

A recent study (KA Duffy et al. J Pediatr 2019; 212: 195-200) obtained 1372 AFP levels from 147 patients to establish normative values.

Table 2 -will be a useful reference. The authors found that AFP values were significantly higher in premature infants with BWS compared to full term and gradually approached normal levels around 12 months of life.

Some example AFP (95% CI) values from the entire cohort:

  • 1 week 5364 (3554-8095)
  • 4 weeks 3134 (2136-4597)
  • 12 weeks 849 (613-1176)
  • 6 months 134 (102-177)
  • 12 months 13.8 (11.1-17.3)

My take: This article will be very useful when monitoring for the risk of hepatoblastoma in patients with BWS

 

 

How Sensory Processing Contributes to Constipation in Children

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A recent cross-sectional study (LM Little et al. J Pediatr 2019; 210: 141-5) which examined sensory processing and constipaiton included 66 children and 66 control children.

Key finding:

  • Children with chronic constipation had significantly higher sensory scores than matched controls.  This included sensory avoiding (P<.001) and sensory sensitivity (P<.05).

The authors utilized the Child Sensory Profile-2 and the Toileting Habit Profile Questionnaire.

The finding that sensory problems contribute to chronic constipation. In those with over-responsiveness, which was more frequent in this study, this can lead to avoidance behaviors.  In under-responsiveness, children may not realized that they need to defecate which can lead to problems as well.

My take: This study suggests that recognition of how sensory problems contribute to chronic constipation could improve counseling/treatment approaches.

Related blog posts:

Salt Creek Falls, OR

Esophagitis in Pediatric Esophageal Atresia

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A recent study (JL Yasuda et al. JPGN 2019; 69: 163-70) shows that esophagitis is common with and without proton pump inhibitor (PPI) therapy in children with esophageal atresia (EA).

Background: This study encompassed 310 patients (34% long gap EA) and 576 endoscopies (median age 3.7 years)

Key findings:

  • Erosive esophagitis was found in 8.7% of patients.
  • 15.2% of patients had esophagitis with >15 eos/hpf; 49% of patients had ≥1 eos/hpf (histologic eosinophilia)
  • 87% of endoscopies were preceded by acid suppression therapy; being on acid suppression reduced the odds for abnormal esophageal biopsy (P=0.011).
  • Histologic esophagitis was “highly prevalent even with high rates of acid suppressive medications use.”
  • For example, among those receiving PPI monotherapy, 150 had normal biopsy and 136 had abnormal biopsy.  Among those off all acid suppression, 30 had normal biopsy and 45 had abnormal biopsy.
  • For erosive esophagitis, this occurred in 12 on PPI and was not present in 274 on PPI therapy. Among those off all acid suppression, 4 had erosive esophagitis and 70 did not.
  • Presence or integrity of fundoplication was not significantly associated with esophagitis.

While this is a large study, the findings have several limitations. This is a single center retrospective study and this center attracts highly complex cases of EA.

My take: In addition to fairly high rates of erosive esophagitis and eosinophilic esophagitis, this study shows a high incidence of microscopic esophagitis, the significance of this is unclear.   This study supports the current recommendations of 3 endoscopies in childhood and perhaps more frequent surveillance in those with more complex EA.

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Sign in Hood River, OR

 

U.S. Federal Policy Change: “Toppling the Ethical Balance”

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A recent commentary (E Sepper. NEJM 2019; 381: 896-8) explains how the current administration’s “Protecting Statutory Conscience Rights in Health Care” policy will create additional problems for patients.

Background:

  • “For nearly 50 years, U.S. federal law has permitted medical professional and religious institutions to refuse, for religious and moral reasons, to provide abortions and sterilizations.”  In addition, there are similar safeguards with regards to professionals who do not want to comply with advance directives.  And, recipients of federal funding like hospitals and clinics are obligated to “not discriminate against individuals that refuse to provide such care.
  • However, “health care providers bear legal and ethical duties to patients. They must provide information about treatment options.”

What is changing?

  • The “Protecting Statutory Conscience Rights in Health Care” policy from the Department of Health and Human Services (HHS) “creates a wide-ranging right to refuse to provide health care services.”  Any entity receiving HHS funding “is barred from requiring anyone to ‘assist in the performance’ of ‘any health service or research activity’ that is contrary to that person’s religious beliefs or moral convictions.”
  • This could include contraception, gender dysphoria treatment, nondiscriminatory care of lesbian, gay, bisexual and transgender patients.  This could affect care for individuals with HIV.
  • “Providers may refuse to refer patients or counsel them about the contested service.”  This is an HHS mandate that affirms an individual provider’s right to not meet the standard of care.
  • This could result in an ICU nurse who will not follow advance directives or a pediatric provider (MD, PA, RN) who will not administer vaccines.
  • In addition, the rule includes no emergency exception.  An ambulance driver could refuse to transport a woman with a miscarriage or ectopic pregnancy to the hospital.

My take: In an effort to pander to religious communities, the administration is giving the green light to medical providers/staff to discriminate and deny services; this denial extends to even providing adequate information.  The results of this policy could result in increased morbidity and even death in those denied services.

Pittock Mansion Hike, Portland, OR