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.

Limitations of MRE and TE in Assessing Liver Fibrosis in Pediatric MASLD

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N Ravanbakhsh et al J Pediatr Gastroenterol Nutr. 2024;79:1192–1198. Comparing imaging modalities in the assessment of fibrosis in metabolic dysfunction-associated steatotic liver disease

In this retrospective review with 77 patients who had liver biopsy-proven MASLD (2017-2023), the authors examined how well magnetic resonance elastoraphy (MRE) and transient elastography (TE) identified fibrosis.

Key findings:

  • Fibrosis was identified in 90% of liver biopsies
  • The area under the receiver operating characteristic curves (AUROC) of MRE and TE for detection of high-grade fibrosis were 0.817 and 0.750, respectively
  • Only 20% of patients had severe fibrosis on liver biopsy; thus, this is a limitation given the small number
Sensitivity in detecting advanced fibrosis, defined on liver biopsy was defined as Metavir Stage ≥ 3.

Conclusion of authors: “MRE and TE did not accurately predict high-grade fibrosis on liver biopsy. Between the two noninvasive imaging modalities, the correlation of identifying high-grade fibrosis was not statistically different.”

My take: Even MRE is not very accurate at identifying fibrosis. Given the huge numbers of individuals (pediatric and adult) with MASLD, the lack of reliable non-invasive markers is a problematic. As effective treatments become available, being able to determine if they are working is essential.

Related blog posts:

Inpatient Admission to Achieve Enteral Autonomy in Children with Intestinal Failure

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Happy New Year!

——-

A Fialdowski et al. J Pediatr 2024; 275: 114226. Achieving Enteral Autonomy in Children with Intestinal Failure Following Inpatient Admission: A Case Series

This retrospective review identified 6 patients (out of 153) who were weaned off parenteral nutrition (PN) as part of an inpatient admission.

Key findings:

  • Except for one admission of 8 days, all of these patients required a prolonged admission 1-5 months.
  • Two of the patients were receiving PN primarily due to abdominal pain in the absence of a recognizable motility disorder.
  • Two of the patients had a suspected factitious disorder imposed on a medical disorder; one received this diagnosis.
  • All patients had chronic feeding intolerance despite favorable prognostic factors including underlying necrotizing enterocolitis (n=1), preserved ileocecal valve (n=5), longer bowel length (n=5), and retention of entire colon (n=5).
  • Post-pyloric feeds aided conversion to EN in 5 patients.

My take: In order to achieve enteral autonomy, hospital admission may be needed for patients who require long-term PN despite favorable prognostic factors.

  • Be prepared for a lengthy stay
  • Anticipate the need for an interdisciplinary team (eg. nutrition, social work, and others).

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From the Lake by Georgia O’Keefe (1924). High Museum, Atlanta.

Early Acid Blocker Use Linked to Lung Disease in CF

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C Liu et al. J Pediatr Gastroenterol Nutr. 2024;79:1124–1133. Open Access! Impact of acid blocker therapy on growth, gut microbiome, and lung disease in young children with cystic fibrosis

Background: Historically, acid suppression has been given as adjuvant therapy to optimize PERT and thereby improve growth and nutritional needs in CF

Methods: This was a prospective cohort of 145 infants followed in 6 CF centers. This was a retrospective study examining the effects of acid blocker therapy and outcomes at 3 years of life in children with cystic fibrosis.

Key findings:

  • Acid blocker therapy (ABT) use before age 3 years was frequent, with 81 (56%) of patients on H2 receptor antagonist (H2RA) or proton pump inhibitor (PPI), and higher among pancreatic insufficient (60%) versus pancreatic sufficient (26%) children.
  • Growth improvements were not significantly greater.
  • Early-onset lung disease was more severe, in persistent ABT users compared to nonusers of ABT.
  • ABT was associated with reduced gut microbiome diversity
CFELD =CF Early-Onset Lung Disease

Discussion:

  • “Results from our FIRST cohort of infants and toddlers with CF showed that prolonged ABT was not associated with significant improvements in growth but instead significant negative alterations to the GM and progression of early-onset lung disease. Evidence from our study is in line with the growing body of literature advocating for more judicious PPI therapy as it has been associated with adverse outcomes such as pulmonary infections, fractures, and anemia.22–24“
  • One limitation, which was NOT discussed in the article, was selection bias. Since there was not randomization of PPI use, it could be that PPI prescription was more common in children with more severe disease.

My take (borrowed in part from authors): Despite the potential for selection bias, it is clear that “acid blockers are not benign.” Given the potential for worse outcomes, PPI prescription should be restricted to those with a clear indication.

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Stopping Insurance Coverage in the Middle of Your Procedure

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Recently, an example of the arbitrary and poorly-conceived nature of many insurance policies played out publicly in the past few weeks.

USAToday 12/5/24: Anthem BCBS drops controversial new plan to cap anesthesia coverage after backlash

Excerpts:

“After receiving intense backlash, a health insurance provider has rolled back its plan to implement a new policy that would have limited its coverage for anesthesia used during procedures…According to a description of the policy on Anthem’s website, billing guidelines would change in some states beginning in February 2025 to cap the amount of anesthesia care the company would cover based on time limits pre-set by the insurer…This would mean that if a patient’s procedure ran long, the insurer would not pay for the care.”

“The proposition concerned not only members of the public, who began making tongue-in-cheek comments online about being woken up mid-surgery to swipe a credit card, but professional organizations, doctors and lawmakers alike.‘

[The goal was]  “implementing practices to “safeguard” its insured against “potential anesthesia provider overbilling”…“This is just the latest in a long line of appalling behavior by commercial health insurers looking to drive their profits up at the expense of patients and physicians providing essential care,” said ASA president Donald E. Arnold”

My take: The surprising part about this story is that the policy was reversed before implementation. Insurance companies are adept at implementing cost-saving policies that do not consider the health consequences.

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Conversations on Palliative Care for Children

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K Wu. NEJM 2024; 391; 2288-2289. Well Known to Us.

This commentary focuses on the personal experience of being an hospital-based physician tasked with taking care of chronically-ill complex and neurologically-compromised children through recurrent and prolonged admissions.

An excerpt:

Teetering on the precipice of death at every admission, they are a testament to how far medicine has come in keeping people alive — and how far it still has to go in treating their underlying conditions. Having realistic conversations about long-term outcomes and palliative care for these patients remains difficult, with pediatricians afraid of disrupting fragile relationships with parents who have endured so much.1

With increasing numbers of such children being admitted to PICUs and limited expansion of capacity,2-4 questions have been raised about the value and necessity of the care provided to them — not in terms of their condition in isolation, but in terms of who else is being deprived of care. Patients with complex, chronic, life-limiting, multiorgan conditions are often described as “well known to us,” but they’re also called “bed blockers” — a label reflecting one answer to the uncomfortable ethical question of which patients are most deserving of limited resources.5 …

Often all I could do was bear witness to their sickness and wellness, their deterioration and recovery, again and again. But in their short lives filled with suffering and struggle and a constant parade of caregivers, I was their pediatrician, and I had become well known to them.

Related blog post: Navigating Difficult Conversations in Children’s GI Healthcare

Efficacy of Mirikizumab in Ulcerative Colitis: LUCENT-3 Study Results

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BESands, et al.  Inflammatory Bowel Diseases, 2024. 30: 2024 2245–2258. Open Access! Two-Year Efficacy and Safety of Mirikizumab Following 104 Weeks of Continuous Treatment for Ulcerative Colitis: Results From the LUCENT-3 Open-Label Extension Study

In this LUCENT-3 study, the authors examined response at 2 years among patients who had response to treatment at 1 year; patients received 200 mg mirikizumab every 4 weeks. The authors stratified patients by induction response and by previous biologic exposure.

Key findings (from Figure 4):

HEMR= histologic-endoscopic mucosal remission
  • No new safety signals were identified, and the discontinuation rate due to adverse events was 2.8%

My take: It is good to see extended data for mirkizumab. Head-to-head trials, though, are needed to better determine which therapies are most effective.

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“Diagnostic Stewardship” –Reducing Unnecessary Clostridioides difficile Treatment by Changing Testing Approach

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D Ilges, et al.  Infection Control & Hospital Epidemiology. Published online 2024:1-6. doi:10.1017/ice.2024.180. Open Access! Positive impact of a diagnostic stewardship intervention on syndromic panel ordering practices and inappropriate C. difficile treatment.

In this retrospective study, the authors examined the impact of removing C diff (Clostridioides difficile) testing from a  gastrointestinal pathogen panel (GIPP) and only testing with preferred method which consisted of glutamate dehydrogenase and toxin antigen immunoassay, followed by toxin gene testing for discrepant result.

Key findings:

  • At baseline (prior to implementing a change), the most common positive target was C. diff (517 of 1,018, 51%), which resulted in treatment for C. difficile infection in 94.9% (337 of 355) of cases.
  • Following GIPP C. diff target removal, GIPP orders decreased from 3.23 to 2.7 per 1,000 patient visits (P < .001). Standalone C. diff testing increased from 0.92 to 3.06 per 1,000 patient visits (P < .001).
  • Outpatient C. diff prescriptions declined over the study, with a mean of 2.36 per 1,000 outpatient visits in the baseline period and 1.81 per 1,000 outpatient visits in the postintervention period (P = <.001). For the inpatient setting, days of therapy (DOT) per 1,000 decreased from 13.77 in the baseline period to 10.58 in the postintervention period, though the reduction did not meet statistical significance (P = .051).

My take: This study shows the benefit of removing C. diff from GIPPs to drive more appropriate testing and targeted treatment. GIPPs, while convenient, often identify C. diff colonization. This approach is cost-effective and reduces harms of unnecessary antibiotic treatment.

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Favorite Books

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Here’s a list of some of my favorite books (not in any specific order):

  • The Nightingale
  • Cutting for Stone
  • Strangers on a LifeBoat
  • Beneath a Ruthless Sun
  • Fire Weather
  • City of Thieves
  • Lonesome Dove
  • The Help
  • Mystic River
  • Where the Crawdads Sing
  • An Officer and a Spy
  • The Little Liar
  • Demon Copperhead
  • The Housemaid
  • Covenant of Water
  • Cloud Cuckoo Land
  • Shantaram
  • The Mountain Sings
  • The Great Alone
  • Project Hail Mary
  • The Great Alone
  • Sun Rays at midnight 
  • Pillars of the Earth
  • The Killing Kind
  • The Kind Worth Killing
  • Gone Girl
  • The Girl with the Dragon Tattoo
  • The Prince of Tides
  • Under the Banner of Heaven
  • The Heaven and Earth Grocery Store
  • Star of Peace
  • House of G-d
  • The Wager
Sandy Springs, GA

Cultivating Compassion in Pediatric Care

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Yesterday’s post discussed communication strategies for GI patients with severe underlying diseases. A related article (S McCarthy. NEJM 2024, 391: 2072-2073. The Care That Saved Me) provides additional insight into the importance families place on the care that they receive.

The author is a pediatric psychologist at a large academic medical center. One of her daughters died at 5 years of age from cancer and she reflects on her experiences and what she learned; though, she states it is a “knowledge I wish I didn’t have.”

An excerpt:

As a clinician, I have identified four practices that I now prioritize in my work, emerging from Molly’s illness and death and my bereavement.

First, strive to illuminate the patient’s personhood… I do make sure to include information that helps me and other clinicians see each patient as an individual,1 illuminating their unique personhood...

Second, make an effort to understand life outside the hospital…“What do you want your health care team to know about you?” and “What makes you happy?” …

Third, cultivate practical compassion…First, I ask parents when they last ate, drank something other than coffee, or slept. If a parent has not eaten or slept, I pause my interview…

Fourth, learn how to sit with darkness, while allowing for light… don’t try to fix a pain I know is unbearable, but I let parents know that they are not alone, that their love for their child is seen and their grief is witnessed...

The biggest thing I have learned is this: our work matters. Those small acts of kindness and moments of connection, seeing the children for who they are, make a difference. Patients and families do not forget them. And during the absolute hardest times, these acts sustain them...the best medical care in the world, the most advanced science, could not save Molly, but the compassionate care that our family received saved me.

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Sandy Springs, GA

Navigating Difficult Conversations in Children’s GI Healthcare

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Recently, Dr. Laurie Jacobs from CHOA’s palliative care team gave our group a provocative update on communication strategies in children with severe illness.  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

  • Having a pre-meeting with other members of health care team is a key part in setting up an effective meeting with parents
  • Delivering news: 1) Provide a straightforward Headline: ‘We are here to discuss xyz’ 2)Be clear. ‘To be clear is to be kind’ 3) Then STOP TALKING.  This let’s the family process
  • Sometimes even delivering bad news can be met with relief by families who have been waiting for a diagnosis
  • Respond to emotion with NURSE mnemonic: Name, Understand, Respect, Support, Explore
  • What if the ‘family doesn’t get it?’ Do they understand (can they repeat back)?  Most often the family has a different perspective; they may think we are wrong
  • Be careful to avoid offering decisions where there are not actual decisions to be made
  • Our own values/beliefs are often introduced even though quality of life is in the eye of the beholder
  • Tube feeds can be considered forms of ‘artificial nutrition.’  There are situations in which families need to know that it is not always required
  • Parenteral nutrition is more invasive and associated with more active parental decision-making
  • Decisions may change based on change in patient circumstances
  • There is not a single right answer with difficult decisions.  There are trade-offs between longevity and QOL
  • Anything that we would allow parents not to start, can be stopped at any time from an ethical standpoint
WOLST =withdrawal of life-sustaining therapies

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