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.
Methods: This was a retrospective single-center observational study which included children with IF and CVC who underwent GI endoscopy between 2019 and 2024. Intravenous antibiotic prophylaxis was used in 71.2% of the procedures.
Key findings:
The overall post-endoscopic fever (PEF) rate was 6%, with no significant difference between the group that received prophylactic antibiotics and the group that did not. Specifically, there were 10 with PEF that had received prophylactic antibiotics and 4 that had PEF with no prophylaxis
No infections, including central line-associated bloodstream infections, were observed
5/14 of the cases with PEF had an interventional procedure. The remainder had a diagnostic EGD, colonoscopy or both.
Interventional Cases:
Discussion Points:
“PEF in children with IF was 6%, which is approximately 10 times higher than the recently published 0.55% in pediatric patients following endoscopic procedures by Boster et al.” (see: Must-Read: How to Handle Post-Procedure Fevers)
A strength of this study was that the comparison of children with IV antibiotics versus those without was due to an institutional policy change in 2022. This helps eliminate selection bias in the determination that IV antibiotics were not beneficial in preventing PEF
My take: The high rate (6%) of PEF should be discussed with families prior to endoscopic procedures. The rate was increased (36%) in those with interventional procedures. It is reassuring that no definitive infections were identified despite the fevers.
R Bissonnette et al. NEJM 2025; 393: 1784-1795. Oral Icotrokinra for Plaque Psoriasis
RS Stern. NEJM 2025; 303: 1854-1855. Oral Psoriasis Therapy — For Whom and at What Cost and Risk?
S Wharton et al. NEJM 2025; 303: 1796-1806. Orforglipron, an Oral Small-Molecule GLP-1 Receptor Agonist for Obesity Treatment
In the ICONIC-LEAD study (Bissonnette et al), 684 adolescents and adults participated in a DBPC trial with an oral peptide, icotrokinra, which binds the IL-23 receptor. This medication is of interest as there are ongoing trials with it for inflammatory bowel disease. Other injectable medications targeting IL-23 are already approved for IBD.
Key Findings:
The associated editorial notes that this new therapy is likely to cost ~$70,000 per year. The cost of psoriasis care has increased more than 2000% since 1997. “Because of these high prices, rebates and discounts to pharmacy benefit managers that often guide formulary preferences are likely to govern clinician’s selection of immune-based oral and parenteral therapies for psoriasis.”
In the ATTAIN-1 Trial (Wharton et al), the authors share the results of an oral GLP-1 Receptor Agonist, Orforglipron, monotherapy for obesity.
My take: There are similar injectable alternatives to each of these medications for psoriasis, obesity and diabetes. The availability of oral medications could reduce one barrier to treatment. Cost barriers may preclude their use in many patients when they become available. In addition, long-term outcome data are still needed.
This article reviews the growing health concerns regarding microplastics and nanoplastics (MNPs) specifically regarding the GI tract.
Key points:
“As these [plastic] products degrade, they break down into smaller particles, forming microplastics (< 5 microm) and nanoplastics (<1 microm), collectively referred to as MNPs”
“Although many plastic products are deemed recyclable, in the United States, less than 10% are actually recycled…annual global production projected to reach 1.1 billion tons by 2025. Simultaneously, over 12 billion tons of plastic wastes are expected to accumulate in landfills”
“The average American ingests approximately 5g of plastic per week, equivalent to 1 credit card, and 39,000–50,000 particles annually”
Potential association of MNPs with metabolic-associated steatotic liver disease, liver and pancreatic cancer and inflammatory bowel disease. “Studies have reported significantly higher levels of MNPs in patients with IBD compared with healthy controls.”
In a related article in Gastroenterology and Endoscopy News (October 2025), Dr. Johnson noted that “reduction of plastic intake from bottled water to tap water in one study reduced microplastic intake, the number of particles within human tissues, from 90,000 to 4,000…Avoid heating food in plastics…the effect of microwave increased the evidence of microplastics by over 4.2 million and the nanoplastics, 2 billion, just in three minutes in the microwave.”
My take: Something that almost everyone could agree on – they would like less plastic in their food and environment. How to achieve this is much more difficult.
JM Perrin, TL Cheng. NEJM 2025; 393: 1869-1872. “Truly Prioritizing Child Health — The Missed Opportunities of the MAHA Commission”
This commentary welcomes the attention to child health which was a focus of the MAHA commission. This review provides perspectives on the stated policy aims and on what else is needed.
An excerpt:
The [MAHA] commission has highlighted four specific areas of concern: poor diet, environmental chemicals, lack of physical activity and chronic stress, and overmedicalization. The strategy outlined in the MAHA Commission’s recent report, however, misses real opportunities to address the chronic disease epidemic and “whole-person health”…
The MAHA Commission’s view of the state of U.S. child health ignores leading contributors to rising childhood morbidity and mortality: firearm injuries (the leading cause of death among U.S. children), drug overdoses, and motor vehicle injuries. Most striking is the commission report’s silence regarding the association of poverty with poor child health… which contributes to higher rates of asthma, obesity, and mental health conditions...
The first MAHA priority, children’s diets, has long been a concern of the U.S. child health community, particularly the intake of sugar-sweetened beverages, excessive portion sizes, and food additives. But pediatricians and researchers also know that food insecurity, food-industry marketing practices, and limited access to healthy foods are prime drivers of childhood obesity rates. Nutritious meals require money…
The MAHA strategy recommends marginal changes to the diets of U.S. children, such as reducing the use of food dyes and reducing consumption of ultraprocessed foods, even as the government is increasingly limiting public food assistance.
The commission’s focus on environmental chemicals is appropriate, given that exposures to potentially toxic chemicals in foods, household supplies, cleaning agents, farm supplies, and elsewhere have grown dramatically. The MAHA strategy provides little relief, however: a few research projects and no regulatory change…The MAHA report stops short of recommending the research and regulatory reform necessary for identifying, restricting, and mitigating harmful exposures.
Concerns about physical activity and stress are also justified. Many studies have documented alarming declines in physical activity, examined the causes and effects, and found associations with mental health and well-being… Strengthening early-childhood, school-based, and community-based physical activity programs, as well as social media strategies for promoting lifestyle changes, could improve health and reduce stress among young people, but the MAHA Commission mainly orders schools and communities to increase physical activity.
Finally, the commission has raised concerns about medications, especially stimulants and psychotropic agents…In response, the MAHA Commission primarily proposes studying prescribing patterns and “solutions that can be scaled up to improve mental health.” It does not address more fundamental ways of changing medication use…
Despite its attention to children’s health, the MAHA Commission’s lengthy list of aspirations and recommended changes is unlikely to make a real impact. Instead, next steps should include implementing policies, programs, and research supported by the strong evidence base that clinicians and investigators have built painstakingly for many years.
My take: The policies pursued by the current administration like limiting food dyes do not target the big drivers of poor health outcomes in children.
The authors of this commentary also “chaired the National Academies of Sciences, Engineering, and Medicine (NASEM) study described in “Launching Lifelong Health by Improving Health Care for Children, Youth, and Families”1 [which] provides clear, evidence-based lessons that could help in achieving MAHA objectives.”
Childhood Poverty Rates: Shown is the percentage of children in households with incomes below 60% of the median national income. Data are from UNICEF and reflect averages from 2019 through 2021.
It is well-recognized that patients with prior intestinal malrotation have frequent GI symptoms after repair. This retrospective study with 354 children (using TriNetX EMR database) quantitates these problems compared to a control group.
Key findings:
Symptoms were less severe at years 3-5 post-index for IM group: constipation 29.4%, Abdominal pain 16.4%, Nausea/Vomiting 21.2%, Diarrhea 9.6%, and GERD 22.3%.
My take: While database studies have numerous limitations, it is clear that having a history of intestinal malrotation poses a significant risk of persistent GI symptoms after repair. It will be worthwhile for families to be informed of this at the time of IM repair.
EJ Shapiro. NEJM 2025; 393: 1360-1361. “You Still Going to be Doing This?”
This commentary mirrored a lot of my recent experience. The author is startled at how patients are asking if he will still be taking care of patients in a few years and how he has enjoyed being a clinician.
Here is an excerpt:
At first, I was startled — I’d never seriously considered the timeline of my own career…Whether it was thanks to luck, sound reasoning, some resolution of my cognitive dissonance, or (least likely) an easy disposition, I mostly enjoyed the ride. Medical school flew by…every rotation opening a new world…As a resident, then a fellow, I learned the delicate balance between personal responsibility and teamwork required in caring for patients facing the range of problems…
Then…I …realized that my opinion — no discussion with the team, no attending cosignature, just mine alone — would guide this patient’s care… So many lives shared, some with laughter, less often with tears. Many of them I helped, and some I probably didn’t…
I realize the time has come to try to figure out the answer to, “Are you still going to be doing this?” But the decision doesn’t come easily. On a day-to-day basis, I love what I do, mostly because of the connections with those patients, and the nurses, techs, secretaries, medical assistants, and my partners (some of whom are now in my children’s age group). Also because medicine always changes and always fascinates.
Of course, prior authorizations, electronic medical record snafus, obtuse hospital administrators, and sometimes the clinical demands can feel oppressive… But… when I go into the exam room, close the door, greet the patient, and begin our visit, none of those structural irritants matter. We explore their situation and try to figure out how to move forward. The challenge and respect of that task never really pale…
Still, all the other passions, affections and hobbies, grandchildren, books, and mountains call out…And… I’d rather go when the reaction from the people left behind will be regret rather than relief…
I still have some things to consider before I put that full stop on my medical career, but maybe at some point the choice will become clear — like the one that long ago began it. Everything has its season.
My take: Though I am not ready to retire, I am getting the question from families about when I might and have started to think about the next season.
Recently Dr. Squires gave our group an excellent lecture. I have taken some notes and shared some slides. There may be inadvertent omissions and mistakes in my notes.
Bilirubin is derived from the breakdown of red blood cells.
Each red blood cell contains approximately 250-300 million molecules of hemoglobin. Each molecule of hemoglobin can transport four oxygen molecule; thus a single RBC can carry one billion oxygen molecules
Unconjugated bilirubin binds to albumin and is taken into cell by OAT1B1 membrane transporter. Conjugation occurs in the endoplasmic reticulum.
Three main causes of indirect hyperbilirubinemia: defective bilirubin uptake, defective bilirubin conjugation, and hemolysis. In older patients, medications are another reason for indirect hyperbilirubinemia
Evaluation for hemolysis can include CBC, LDH, Haptoglobin, and retic count
Breastmilk jaundice (aka Lucey-Driscoll syndrome) is a different entity than “suboptimal intake jaundice” (aka breastfeeding jaundice). Suboptimal intake jaundice occurs in the fist week of life. Due to less intake, there are increased delays in meconium passage and increased reabsorption of bilirubin. Breastmilk jaundice which is much less common can result in very elevated indirect bilirubin levels.
With Gilbert, the molecular defect affects the promoter region of the UGT1A1 gene. Defects here are less critical than with Crigler-Najjar. For Gilbert’s, it is like there are fewer exits to reduce bilirubin. Whereas with severe forms of Crigler-Najjar, it is like all of the exits are blocked
Especially in the newborn period, very elevated unconjugated hyperbilirubinemia can result in kernicterus/severe neurologic sequelae. This can occur at older ages as well. The risk is related to the bilirubin to albumin ratio
For Crigler-Najjar, phototherapy is less effective with age and is associated with a reduction in the ratio of body surface area to plasma volume
Recently Dr. Squires gave our group a terrific lecture. I have taken some notes and shared some slides. There may be inadvertent omissions and mistakes in my notes.
Key points:
2023 AASLD Practice Guidance is very helpful and Dr. Squires considers its advice akin to a ‘North Star’
There are several etiologies for the sclerosing cholangitis phenotype – including primary disorders and secondary causes.
Pancolitis is most common presentation of IBD with PSC, often with rectal sparing and backwash ileitis
PSC often has subclinical inflammation and poor growth. PUCAI scores typically underestimate IBD activity
Diagnosis can be challenging – but often “I know it when I see it”
MMP-7 is still being studied as a biomarker. Thus far, it appears a little better than GGT and Alk phos as a marker for biliary injury
ERCP should be avoided as part of diagnostic workup but is important for therapeutic intervention
Deneau et al (Hepatology 2017; 66: 518) study wit 781 children has a wealth of information on natural history. In children, 38% developed portal HTN and 25% developed biliary complications over 10 years. However, once these complications developed, the need for transplantation develops more quickly. Median survival with native liver after the development of portal HTN was 2.8 yrs and it was 3.5 yrs after development of biliary strictures
Cholangiocarcinoma is rare in pediatrics ~1%
ASC (overlap of AIH and PSC) is fairly common in children and often a manifestation of early PSC. Many evolve to PSC without overlap features. Dr. Squires counsels families that most patients will need multiple biopsies to help determine need for ongoing immunosuppression
In patients with IBD, some liver test abnormalities and autoimmune features may be transient. Some watchful waiting may be beneficial prior to extensive evaluation
Multiple factors can predispose to PSC, including EBV infection which is associated with OR 12. Genetics, environment, immune dysregulation, toxic bile acids, microbiome, leaky gut/inflammation are additional factors
SCOPE is very useful prognostic tool
Ursodeoxycholic acid (UDCA) is a first line therapy. However, if no response to treatment, it is likely not beneficial
Oral vancomycin has not been proven to improve liver outcomes in PSC thus far (not recommended by AASLD 2023 Practice Guidance). However, further studies are ongoing and it has been associated with improvement in IBD activity
In response to this morning’s post, 5 Rights and H pylori Treatment, one reader commented: “How often does the susceptibility test come back without a result? Unable to grow out pathogen?”
From the study senior author, Dr. Bonilla: “We ultimately partnered with a specialty lab, Mayo Laboratories, for our H pylori susceptibility testing. Another important point is establishing clear communication with the lab. We now integrate results directly into EPIC so physicians see when a culture is positive and susceptibilities are pending. Final susceptibility reports often take 5–7 business days. In my experience, when we take the time to explain this to families, they are comfortable waiting in order to receive the most effective antibiotics. In the meantime, patients can start a PPI if needed for symptomatic relief.
At present, our culture growth rate is approximately 90%. For the remaining 10% without susceptibility results, we are working to implement a reflex molecular pathway using PCR for detection and, when positive, next-generation sequencing for susceptibilities on FFPE samples. We are also exploring the use of stool samples for the same molecular testing. Our goal is to ensure that all patients receive targeted, effective therapy even when culture is unsuccessful. Broader adoption of molecular techniques will be an important part of the future of pediatric H. pylori care. We are actively generating data to support clinical usefulness, expand access, and hopefully facilitate insurance coverage.”
For medication administration, there are five “rights” that are needed for optimal results:
Right drug
Right dose
Right route (e.g., oral, intravenous, topical)
Right patient
Right time
The recent article below highlights the fact that the “right drug” for H pylori can be dependent on resistance patterns. Previous articles (see below) have shown that the right dose is equally-important to improve cure rates.
C Chan et al. J Pediatr Gastroenterol Nutr. 2025;81:1133–1141. Antimicrobial susceptibility-guided treatment is superior to empiric therapy for Helicobacter pylori infection in children
Methods: Retrospective study with 218 children who had histologically-proven H pylori infection. Susceptibility-guided treatment (SGT) was given to 123 and empiric therapy (ET) to 95. Testing for susceptibility was via a send-out assay to an outside specialty laboratory (Mayo Clinic Laboratories).
Key findings:
Eradication success was significantly higher in the SGT group (89.4%,110/121) compared to the ET group (70.2%, 66/94) (p < 0.001).
Amoxicillin resistance was strongly associated with failure (27.3% vs. 0.9%, p = 0.002), as was dual clarithromycin-metronidazole resistance (36.4% vs. 8.2%, p = 0.018).
My take: This study shows the huge improvement when therapy is adjusted based on known susceptibility.
gutsandgrowth 