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.

Opioid Epidemic Affecting HCV Infection in Adolescents (as well as adults)

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SA Barritt et al. J Pediatr 2018; 192: 159-64. Increasing Prevalence of Hepatitis C among Hospitalized Children Is Associated with an Increase in Substance Abuse

Background:  “After a sustained decline in new HCV cases, in recent years there has been a significant increase in HCV incidence in adults in many areas, primarily associated with the use and abuse of intravenous heroin and prescription opioids.” This study examines this trend in adolescents.

From abstract:

Study design

We examined hospitalizations in children using the Kids’ Inpatient Database, a part of the Healthcare Cost and Utilization Project. We identified cases using the International Classification of Diseases, 9th edition, codes for HCV infection during 2006, 2009, and 2012. Nonparametric tests for trend were used to calculate trend statistics.

Results

From 2006 to 2012 nationally, the number of hospitalizations of children with HCV increased 37% (2.69 to 3.69 per 10 000 admissions; P < .001). The mean age of children hospitalized was 17.6 years (95% CI, 17.4-17.8). HCV cases among those 19-20 years of age represented 68% of the total HCV diagnoses, with a 54% increase over the years sampled (P < .001 for trend). The burden of HCV in children was highest in whites, those in the lowest income quartile, and in the Northeast and Southern regions of the US (all P < .0001). The prevalence of substance use among children with HCV increased from 25% in 2006 to 41% in 2012 (P < .001).

Conclusion

The increases of HCV in hospitalized children are largely in teenagers, highly associated with substance abuse, and concentrated in Northeast and Southern states. These results strongly suggest that public health efforts to prevent and treat HCV will also need to include adolescents.

My take: Despite the availability of highly effective therapy for hepatitis C, the opioid epidemic undermines any prospect for eliminating hepatitis C infections.

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American Academy of Pediatrics: Georgia Chapter Governing Board Meeting

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As usual, I learned a great deal from our recent governing board meeting of the Georgia Chapter of the American Academy of Pediatrics ((AAP).   Here are some notes, including nutrition committee notes at the bottom of this post. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Influenza This Year –Harry Keyserling:

  • 85% of pediatric deaths have occurred in those without influenza vaccine. The vaccine, even when not stopping the influenza (lower efficacy this year), lowers the risk of death.  Probably 50-60% of all Georgia kids are immunized against the flu and  there is a higher rate of immunization (~75%) in younger age (~75%)
  • ‘We are not seeing Tamiflu resistance with this year’s strain’
  • 53 pediatric deaths this year at this point (2/3/18)
  • Children attending public schools have higher rates of vaccination than children attending private schools

Amy Jacobs, Commissioner of Ga Dept of Early Care & Learning (DECAL)

  • decal.ga.gov Website is resource for child care and sponsored meals
  • Georgia Pre-K now in 25th
  • QualityRated.org Useful website for identifying high quality child care
  • ~50,000 children supported with scholarships for childhood care caps.decal.ga.gov 833-442-2277
  • Text “FOODGA” to 877-877 Summer Meal Programs or Call toll free 855-550-7377

Project S.A.V.E.  –Robert Campbell, Richard Lamphier

  • Started in 2004 with the mission of promoting and improving prevention of sudden cardiac arrest (SCA) in children, adolescents and others in Georgia communities..  Website: Project S.A.V.E.
  • Primary prevention: pediatric office, preparticipation physical exams
  • Secondary prevention: after cardiac arrest –emergency action plan
    • Where’s the nearest AED? (Mr. Lamphier’s car).  At our office, GI Care For Kids’ AED –>Formula closet/Stan’s dictation area
    • Is there a plan if an emergency occurs? Name of building, address. Any barriers?
    • Almost always someone is willing to donate AED (~$700) -not a lot of money, this is a process issue much more than a financial one
    • If you wait for an ambulance (~10 minutes) with SCA, you probably won’t need an ambulance –the patient will not survive
  • There are fire drills –last death from fire in Georgia School in 1950s. Schools need emergency action plans in place.  For AEDs to be useful, there is a need for them to be accessible; thus, schools may need to have them in multiple locations.  About 15 pediatric cardiac arrests (data not formally collected) per year in Georgia.

Nutrition Committee Notes:

Nutrition Colloquium: Assessing and Nourishing the High-Risk Feeding Patient

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A recent CHOA Nutrition Colloquium provided a lot of useful information regarding speech language assessment, nutrition assessment, and craniofacial team assessment.

Full slide set: Nutrition Colloquium Jan 2018

Here are a few slides –Thanks to Kipp Ellsworth for coordinating these talks and making slides available. The first group of slides explains who and how to evaluate for feeding problems, the next group discusses the specific role of the craniofacial team, and the last group of slides discusses nutritional management.

 

Probiotics for Prevention of Nosocomial Diarrhea in Children

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A recent review (I Hojsak et al. JPGN 2018; 66: 3-9) examined published trials regarding the role of probiotics in the prevention of nosocomial diarrhea. The review was conducted by a working group on behalf of ESPGHAN.

Key findings:

  • “Recommendation: If probiotics for preventing nosocomial diarrhea in children are considered, the WG [working group] recommends using L rhamnosus GG (at least 10 to the 9th CFU/day, for the duration of hospital stay).
  • Quality of evidence: Moderate
  • Strength of recommendation: Strong
  • Number needed to treat (in order for beneficial effect in one): 12 patients

The authors do not recommend L reuteri DSM17938 due to lack of efficacy; other probiotics did not receive a recommendation either due to lack of data or lack of efficacy.

It is possible that there have been unpublished negative probiotic studies which would alter the calculation of a beneficial effect.

My take: While the working group recommends L rhamnosus GG if probiotics are used to prevent diarrhea, the absolute benefit is low.

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Bright Angel Trail, Grand Canyon

Probiotics for Colic –2018 Update

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There is some debate about whether colic is truly a GI disorder.  A recent commentary (V Sung, MD Cabana. J Pediatr 2017; 191: 6-8) provides some insight.

Key points:

  • “‘Colic’ is a term coined by the ancient Greeks…derived from ‘kolikos,’ meaning crampy pain, sharing its root with the the word colon.”
  • “Since 1994, there have been at least a dozen case-control studies that have indicated differences in the gut microbiota between infants with and without colic.”
  • Studies have had conflicting results with whether calprotectin levels are increased in infants with colic compared with controls.
  • Among probiotics, L reuteri DSM17938 “is the best studied strain.” Despite several studies suggesting efficacy, “the largest and only double-blind randomized trial that included both breastfed and formula-fed infants with colic (n=167) in Australia was ineffective.
  • The commentary reviews a recent study (Fatheree NY et al. J Pediatr 2017; 191: 170-8) “although very small in comparison, adds to this literature, being the second double-blind randomized, placebo-controlled trial of L reuteri DSM17938 shown to be ineffective in breastfed infants with colic.” Sample size =20. “It is the first to document increased fecal calprotectin levels that decrease with reduced crying” …though this “may be reflections of normal levels in healthy young infants, which change over time.”  In addition, this study did not find evidence of systemic inflammation.  The authors speculate that the frequent use of antireflux medications could dampen the effects of probiotics.

My take: We still do not know whether efforts at changing an infant’s microbiome improve clinical outcomes in colic.

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Near Bright Angel Trail, Grand Canyon

NAFLD Guidance from American Association for the Study of Liver Diseases

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Link: AASLD Guidance for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease

This guidance provides a 2018 review of NAFLD and current diagnostic/management recommendations in both adults and children.  Some points from this practice guidance:

  • “Liver-related mortality is the second or third cause of death among patients with NAFLD.” Cardiovascular disease remains the number one and cancer-related mortality is in the top three.
  • “Routine screening for NAFLD in high-risk groups attending primary care, diabetes, or obesity clinics is not advised at this time because of uncertainties surrounding diagnostic tests and treatment options.” Likewise, screening of family members is not recommended.
  • In children: “Because of a paucity of evidence, a formal recommendation cannot be made with regard to screening for NAFLD in children with overweight and obesity.”
  • In patients undergoing evaluation with suspected NAFLD, the authors specifically recommend checking ferritin, iron saturation, and autoantibodies that could indicate autoimmune liver disease.
  • In patients with suspected NAFLD, the authors recommend evaluation for comorbities including dyslipidemia, diabetes, hypothyroidism, polycystic ovary syndrome, and sleep apnea.
  • “Liver biopsy should be considered in patients with NAFLD who are at increased risk of having…advanced fibrosis” and in “whom competing etiologies…cannot be excluded without a liver biopsy.”
  • Pharmacologic therapies are not recommended in those without biospy-proven NASH and fibrosis.  Specifically, the authors suggest consideration of pioglitazone and vitamin E and recommend against metformin, GLP-1 agonists, omega-3 fatty acids, and ursodeoxycholic acid.
  • “Weight loss (7%-10%) is needed to improve the majority of histopathological features of NASH.”
  • In patients with cirrhosis due to NASH, screening for varices is recommended and consideration of screening for HCC.

My take: This practice guidance is quite reasonable.  At this time, more focus on systemic measures to counter overweight and obesity is crucial.  Pharmacologic therapies for NAFLD will need to be effective for the cardiovascular, metabolic, and liver-related problems.

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Bright Angel Trail, Grand Canyon

Crohn’s Disease Diagnosis Identified After Colectomy in Presumed Ulcerative Colitis

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A recent retrospective single-center study (I Jones et al. JPGN 2018; 66: 69-72) identified a high rate of inflammatory bowel disease (IBD) reclassification.  From 2003-2014, 570 children were diagnosed with IBD, including 190 with ulcerative colitis.  29 of these patients underwent colectomy.  Among this select group, 24% (7/29) were subsequently reclassified as having Crohn’s disease, sometimes several years later.  Only two of the seven reclassified patients were younger than 10 years of age at the time of colectomy.

My take: This rate of Crohn’s disease following colectomy is higher than in previous reports (generally 5-10%).  The larger point is that the diagnosis of ulcerative colitis is more uncertain in the pediatric population, particularly in those in the first decade of life.

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Near Bright Angel Trail, Grand Canyon

Pancreatitis -Feedings and Genetics

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KM Ellery et al. J Pediatr 2017; 191: 164-9.  This prospective pediatric study examined 30 patients with mild acute pancreatitis in a “patient-directed nutrition” (PDN) pathway using a low fat diet and compared to a historical control of 92 patients in a “treatment team-directed nutrition” (TTDN) pathway. In the PDN group, patients were allowed a low-fat oral diet (<5 g fat per entrée, <1 g fat per snack, and only 1 entrée or snack at a time) at the time of admission.

Key findings:

  • PDN group had median length of stay of 48.5 hours compared with 93 hours for the TTDN group
  • PDN group was NPO for median of 14 hours compared to 34 hours for TTDN group
  • No patients in the PDN group had complications within 30 days of discharge

Y Xiao et al. J Pediatr 2017; 191: 158-63.  Among 55 pediatric patients with chronic pancreatitis and 14 with acute recurrent pancreatitis, there were 45 and 10 patients respectively who harbored 1 or more mutations in pancreatitis-associated genetic disorders: PRSS1, SPINK1, CFTR, CASR, CTSB, CTRC, KRT8

My take: These two studies indicate that oral feeding in mild acute pancreatitis leads to shorter hospital stays and that pediatric patients with chronic pancreatitis and acute recurrent pancreatitis frequently have predisposing genetic mutations.

Related blog posts:

Near Bright Angel Trail, Grand Canyon

 

The Half Empty Glass: Rumination Outcomes

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Briefly noted:

A Alioto, C DiLorenzo. JPGN 2018; 66: 21-25.  In this study based on patient follow-up questionnaires, among 47 adolescents with rumination syndome who received inpatient treatment, Key findings:

  • ~20% reported complete cessation of rumination for at least 6 months; though, even in this group, 73% had at least some recurrent symptoms.
  • 40% reported a reduction in rumination intensity following discharge and ~80% reported having at least one day with no rumination.
  • Triggers for recurrence of rumination symptoms included stress (51.4%), illness (27%), menstruation (10.8%), and certain foods (18.9%).
  • Treatment of rumination syndrome helped eliminate the need for supplemental tube feedings in the “vast majority of patients.”

One important limitation of this study is the patient selection; this group of inpatients with rumination syndrome at a specialized center likely had more severe rumination syndrome.

My take: Like many GI conditions, the expectation for rumination syndrome should probably be improvement/management rather than resolution/cure.

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