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.
CDC Study: “From late August 2024 to early September 2025, the vaccines reduced the risk of Covid-related emergency room and urgent care visits by 76% among children ages 9 months to 4 years, and by 56% among children ages 5-17, according to the study”
Citation: Irving SA, Rowley EA, Chickery S, et al. Effectiveness of 2024–2025 COVID-19 Vaccines in Children in the United States — VISION, August 29, 2024–September 2, 2025. MMWR Morb Mortal Wkly Rep 2025;74:607–614. DOI: http://dx.doi.org/10.15585/mmwr.mm7440a1
Between the end of February and mid-August, funding ceased for 383 studies that were testing treatments for conditions including cancer, heart disease and brain disease. The cuts disproportionately impacted efforts to tackle infectious diseases like the flu, pneumonia and COVID-19, researchers found…
More broadly, the lost research harms patients who could have benefited from a possible new treatment, researchers said in the report published Monday in the journal JAMA Internal Medicine…
“The whole purpose of these clinical trials is to generate evidence on what works and doesn’t work in medicine,” said study co-author Anupam B. Jena with Harvard Medical School. Researchers counted 11,008 NIH-funded studies during the study period. Of those, 1 in 30 lost funding.
This was a retrospective single-center (CHOP) study of 25 children with monogenic IBD who underwent Hematopoietic Stem Cell Transplant (HSCT) (2012-2022).
Key findings:
Seventy-two percent of patients had Crohn’s Disease, and 28% were classified as IBD-unspecified. Ninety-two percent of patients had VEO-IBD, 56% presenting under age 1
At most recent follow-up, 92% of patients achieved sustained medication-free remission of IBD and 60% with prior ostomy underwent re-anastomosis. There was 100% survival at a median follow-up of 3 years
There was significant improvement in growth, hospital days, and severe infections
Disease activity scores at the time of IBD presentation, immediately prior to transplant, 1-year post-transplant, and at most recent follow up if ≥2 years since transplant.
Discussion points:
“Delay of HSCT with the goal of obtaining remission of IBD prior to transplant may prove to be determinantal, as outcomes of HSCT are in general improved for younger patients,20 and medical remission is often unattainable for more severe forms of monogenic IBD. Within our cohort, 32% of patients had moderate or severe disease at the time of transplant despite medical optimization. None of these patients developed intestinal GVHD, which was a rare event in our total cohort”
“HSCT is not without risk, and complications occurred in our cohort, at rates typical of other IEI cohorts”
“The selection of patients who would benefit from HSCT requires multidisciplinary discussion.”
With regard to patient selection, one item that was not included in the discussion was the one patient excluded from their analysis who had a TTC7A gene defect. In the results section, it was explained that the patient with “TTC7A was subsequently excluded as transplant was performed for the indication of SCID alone, rather than treatment of intestinal disease.” More discussion on this point is merited as many centers would NOT have a patient with TTC7A undergo HCST specifically because it cannot correct the underlying bowel disease.
Also, it was noted that one patient with CTLA4 deficiency had undergone HSCT prior to the discovery of the genetic defect. With the more widespread use of genetic testing available now, this discovery may have obviated the need for HSCT as treatment with abatacept is typically effective.
My take: Overall, the authors present impressive results for HSCT for monogenic IBD and strengthen the need for genetic testing in those with early onset disease and those refractory to treatment.
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.
The study by Dellon et al was a 4-year, phase 3, open-label study in patients with EoE who completed up to 52 weeks of BOS therapy (Budesonide oral suspension 2 mg 2/day) in 2 preceding phase 3 studies.
Key findings:
At month 48 of treatment, 50.0% and 58.3% of patients achieved/maintained a histologic response (< or =6 and <15 eosinophils per high-power field, respectively)
Safety:
Treatment-emergent adverse events (TEAEs) occurred in 76.3% of patients; most were mild/moderate in severity and unrelated to study drug.
The most frequently reported BOS-related TEAEs included abnormal adrenocorticotropic hormone stimulation test results (8.4%, 11/131; number of events [m] [ 12) and adrenal insufficiency (2.3%, 3/131; m [ 3). Esophageal candidiasis occurred in 3.1% of patients (4/131)
The study by Biedermann et al explored the use of an orodipsersible tablet for EoE up to 3 years in patients who achieved remission during a 12-week induction. This tablet is not available in the U.S.
Key findings:
At week 96, 80.1% of patients were in histologic remission, defined as peak eosinophils per high-power field of <5, at week 96 vs 91.8% at open label extension baseline
No new safety concerns were observed across 96 weeks of treatment. Suspected symptomatic candidiasis occurred at similar rates to prior BOT studies and was predominantly mild and resolved with treatment
My take: The pharmaceutical budesonide suspension, Eohilia, is labelled by the FDA for use as a 12 week treatment course. Since EoE is a chronic disease, 12 weeks is insufficient. These long-term studies provide data that may address this shortcoming.
Background: “The current gold standard for ranking patients in the waiting list according to their mortality risk is the Model for End-Stage Liver Disease corrected by serum sodium (MELD-Na), which combines 4 serum analytic and objective parameters, namely bilirubin, international normalized ratio (INR), creatinine, and sodium…2“
“The Model for End-Stage Liver Disease (MELD) 3.0 was developed and internally validated in the United States,4 and the gender-equity model for liver allocation corrected by serum sodium (GEMA-Na) was trained and internally validated in the United Kingdom and externally validated in Australia.5… GEMA-Na was associated with a more pronounced discrimination benefit than MELD 3.0, probably owing to the replacement of serum creatinine with the Royal Free Hospital cirrhosis glomerular filtration rate (RFH-GFR)6 in the formula.5“
Methods:
Key findings:
GEMA-AI made more accurate predictions of waiting list outcomes than the currently available models, and could alleviate gender disparities for accessing LT
Discussion Points:
The components of the current scores available for waiting list prioritization provide objective and reproducible information…which in turn are associated with the probability of mortality or clinical deterioration resulting in transplant unsuitability.18 However, this relationship is nonlinear…at a certain point, for the highest values typically found in the sickest patients, the relationship with the outcome risk becomes exponential.5 …GEMA-AI was the only adequately calibrated model and showed the greatest advantage on discrimination”
An “advantage of nonlinear methodologies, and particularly of ANNs [artificial neural network], is their ability to identify patterns of combinations of values that are associated with an increased risk of death or delisting due to clinical worsening. While linear models give a fixed weight to each variable irrespective of its value or the value of other variables in the model, ANNs could capture specific combinations to modulate the weighting.19“
My take: In the movie, iRobot, Detective Spooner instructs the robot: “Sonny, save Calvin.” While things worked out in the movie, it turns out that the robot would usually make a better decision. This study shows that AI has the potential to reduce waiting list mortality by taking advantage of weighing non-linear variables.
Steroids are commonly used and misused for inflammatory bowel disease. This article reviews best practices, steroid formulations/dosing, and potential complications.
For moderate to severe ulcerative colitis (in adults), the authors recommend treatment with 40 mg of prednisone daily. Patients with ASUC (acute severe ulcerative colitis) should be treated with 60 mg of IV methylprednisolone for 3 to 5 days, after which rescue therapy should be initiated
Use of budesonide is recommended as an option for many clinical situations to minimize steroid adverse effects. These situations include mild-moderate UC failing to respond to mesalamine, ileal CD and older patients
Postoperative complications: “In the postoperative period, patients treated with CS had a higher risk of both infectious complications (aOR, 3.69; 95% CI, 1.24–10.97) and major infectious complications (aOR, 5.54; 95% CI, 1.12–27.26) [Abrerra et al].135 Subramanian pooled data from 7 studies showing that preoperative CS use is associated with increased postoperative complications (OR, 1.41; 95% CI, 1.07–1.87) as well as infectious complications.
The authors note that corticosteroids “remain widely available and are an effective short-term option for induction of remission in patients with active UC or inflammatory CD. However, their well-described and significant safety profile warrants proactive strategies to limit their use through non-systemic formulations, short-term exposures, steroid-sparing maintenance options, and most recently, complete steroid avoidance strategies.”
My take: Continuing steroids when they are not effective prior to potential surgery (eg. ASUC) remains a frequent problem. Sometimes, it is difficult to know it they are helping some.
“This 3-paper Series reviews the evidence about the increase in ultra-processed foods in diets globally and highlights the association with many non-communicable diseases. This rise in ultra-processed foods is driven by powerful global corporations who employ sophisticated political tactics to protect and maximize profits. Education and relying on behavior change by individuals is insufficient. Deteriorating diets are an urgent public health threat that requires coordinated policies and advocacy to regulate and reduce ultra-processed foods and improve access to fresh and minimally processed foods. The Series provides a different vision for the food system with emphasis on local food producers, preserving cultural foods transitions and economic benefits for communities.”
In one of the papers, led by Dr. Monteiro, the authors identified 104 studies linking ultraprocessed foods to health conditions, including Type 2 diabetes, obesity, heart disease, kidney disease and Crohn’s disease…
The authors suggested that governments adopt policies, like taxes on sugary drinks and warning labels for certain ultraprocessed foods, especially those high in sugar, fat or salt. They also recommended restrictions on marketing ultraprocessed foods to children and reducing their use in school meals. The proposed policies are similar to those that have worked to reduce smoking rates…
Robert F. Kennedy Jr., the nation’s health secretary, and his “Make America Healthy Again” movement have drawn attention to the links between poor health and ultraprocessed foods. But so far, Mr. Kennedy has focused on reducing the use of artificial colors and certain food additives, efforts that Dr. Popkin said would do little to improve the healthfulness of the food supply. And this year, the Trump administration cut SNAP benefits and programs that funded schools and food banks to purchase foods from local farms.”
M Hook et al. JPGN 2025; DOI: 10.1002/jpn3.70221. Esophageal coin with moth eaten appearance: A cause for caution
This case report describes a penny ingestion by a 10 yo with autism that likely happened nine months before attempted retrieval. The coin was not able to be retrieved due to stricturing but was advanced into the stomach (the authors note advancement into duodenum would be better); in addition, there was an esophageal diverticulum that was identified likely secondary to the caustic damage.
In the discussion, the authors note that “the ‘moth eaten’ appearance is a rare finding that indicates prolonged foreign body retention and unforeseen mucosal injury…It is specific to post-1982 pennies, composed of 97.5% zinc.4 Hydrochloric acid exposure dissolves zinc, forming caustic zinc chloride.”
My take: Future generations will not see this radiologic finding. For now, if this finding is seen, it likely indicates a more difficult foreign body removal.
For those trying to understand the success of the current HBV immunization strategy and why altering the timing of HBV vaccinations is a bad idea, this is a worthwhile article.
Key points:
“To date, more than 1 billion doses of HepB vaccines have been administered worldwide, and they are considered one of the safest and most effective vaccine ever made.1,2,6“
“Because of the high risk for chronic HBV infection, the CDC/Advisory Committee on Immunization Practices (ACIP), WHO, and health ministries of many countries recommend universal HBV vaccination of all infants beginning with a “birth dose” for newborns, preferably within the first 24 hours of birth, followed by completion of the 3-dose infant vaccination schedule…Implementation of routine infant and childhood vaccination, including birth dose HBV vaccine, prevented an estimated 210 million infections globally between 1980 and 2015.4“
“In 1991, with evidence showing substantial number of infants and others at risk were missed by a risk-based approach to HepB vaccination, the ACIP recommended universal HepB vaccination for all infants, with the first dose administered before hospital discharge along with hepatitis B immune globulin (HBIG) for infants born to mothers who tested positive for HBsAg or whose HBsAg status was unknown.5,6,14“
“In 2018, the CDC/ACIP recommendation specified that the birth dose of HepB vaccine should be administered within 24 hours of birth including for preterm infants, regardless of maternal HBsAg status.14 …Timely birth dose HepB vaccination regardless of maternal HBsAg status serves as a safety net for perinatal transmission from HBsAg-positive mothers missed by HBsAg screening programs and protects against the small but non-zero risk of HBV infections from household and other exposures for infants born to HBsAg-negative mothers.”
“HepB vaccination alone prevents 75% to 80% of perinatal HBV transmission.2 The addition of maternal HBsAg screening and further testing for hepatitis B e antigen or HBV DNA if HBsAg test is positive allows for additional interventions to eliminate mother-to-child transmission of HBV.”
US CDC recommendations for HBV vaccination. Decline in reported number of acute HBV infections in the United States in association with CDC recommendations for HBV vaccination, 1980–2022.
My take (borrowed in part from authors): It would be a big mistake to resume the risk-based approach to newborn HepB vaccination. “HepB vaccine is a safe and highly effective vaccine. HepB vaccination prevents an incurable chronic infection and related morbidity and mortality from cirrhosis and HCC. Indeed, HepB vaccine is the first cancer-prevention vaccine…Universal HepB birth dose vaccination regardless of maternal HBsAg status is the most effective as well as the most cost-effective strategy in eliminating HBV infection. Newborns and infants are those at highest risk of chronic HBV infection. Delaying the first dose of HepB vaccine even by a few days exposes the infants to increased risk of developing lifelong infection,18 chronic liver disease, and premature death.”
“Delaying the first vaccine in the series to one-month, four years, or 12 years of age will undermine the vaccine’s effectiveness, and relying on just screening pregnant women for hepatitis B is insufficient.
Although some of the changes that have been discussed by ACIP sound small, they are not grounded in new evidence and would undo more than three decades of a prevention strategy that has nearly eliminated early childhood hepatitis B in the United States.“
The review of pediatric MASLD addresses epidemiology, pathophysiology, natural history, screening, diagnosis, treatment, comorbidity management, outcome monitoring, and transition of care. It also discusses the implications of the 2023 nomenclature revision, which emphasizes evaluating both hepatic steatosis and cardiometabolic risk factors.
Some key points:
Box 1 outlines numerous (32) research priorities, including the need for prospective longitudinal cohort studies.
“Globally, the estimated prevalence of MASLD in children is 7.6%, making it the most common cause of chronic liver disease in children”
Figure 4 describes the interplay between risk factors for MASLD included genetic predisposition, prenatal factors and environmental exposures
Figure 5 summarizes comorbid conditions which include obstructive sleep apnea, prediabetes/diabetes, cardiovascular disease (dyslipidemia, hypertension, left ventricular hypertrophy), anxiety/depression, reduced bone mineral density, renal dysfunction and polycystic ovarian syndrome. Table 6 summarizes evaluation and initial management with most of these conditions. Yearly screening for diabetes in children with MASLD is recommended.
ALT remains most common screening test with >26 U/L for adolescent males and >22 U/L for adolescent females having optimal sensitivity (>80-85%). We recommend “screen for MASLD in children aged 10 years or older with overweight and cardiometabolic risk factors or family history or obesity.” Annual screening recommended if at risk.
Table 2 provides a long list of medications which may promote weight gain. These include antihistamines, steroids, some contraceptives, anticonvulsants, antidepressants, antipsychotics, methotrexate, and doxycycline
Diagnostic evaluation:
Diagnosis of MASLD requires confirmation of steatosis (by imaging or biopsy) in addition to the presence of at least one cardiometabolic risk factor. ALT elevation with a cardiometabolic risk factor is insufficient.
“Consider liver biopsy in cases where there is uncertainty, especially if ALT levels are persistently elevated (>2 times the ULN)”
Table 3 lists inborn errors of metabolism and monogenetic diseases which may cause childhood-onset steatotic liver disease. Evaluation of inborn errors of metabolism should be considered if atypical signs or symptoms, such as early onset (<3 yrs), rapidly progressive, absence of obesity, or other organ involvement (especially neurological)
Table 4 summarizes imaging modalities to assess steatosis and fibrosis in children. Only MRI-PDFF has been validated in children (for steatosis)
Table 5 describes BMI classification in children (WHO and AAP)
Lifestyle treatments are detailed including diet (reduction of added sugars, Mediterranean diets) and exercise
Emerging medications are reviewed. However, practice statement notes “No pharmacotherapies are currently recommended or approved as specific treatments for MASLD or MASH in children…Medications approved for use in children ages 12 years and older to treat obesity or type 2 diabetes may be considered for children with MASLD.”
My take: This is a comprehensive practice guidance. It emphasizes an extensive diagnostic evaluation. The threshold for liver biopsy is relatively low in this guidance. As more data emerges, it is likely that more emphasis will be placed on the use of pharmacotherapies.
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.
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