Category Archives: Nutrition

Dr. Danielle Wendel: Management of Short Bowel Syndrome

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Two years ago, Dr. Wendel gave our group a great lecture on short bowel syndrome (SVS). One of the neonatologists in attendance invited her back to provide a state of the art update. While this 2026 lecture covered some of the same issues, there were important updates and insights.

My notes below may contain errors in transcription and in omission. In addition, the information provided is based on what is done in Seattle. However, there is not a lot of evidence for much of what is done in intestinal rehabilitation. Thus, there is variation in practice at different centers and what works for one patient might not work for another. Following my notes, I have included many of her slides.

Diet:

  • Enteral feedings promote intestinal adaptation. Pediatric patients with SBS require much higher calories with enteral nutrition and may have hyperphagia as a compensatory mechanism
  • Breastmilk and/or Standard formula likely help promote intestinal adaptation better than hydrolysates and elemental formulas. In addition, it may help reduce the development of food allergies which are increased in children with SBS
  • Oral feedings have many advantages over NG or GT feedings when feasible. The ability to consume solid foods is quite helpful in reducing diarrhea. Also, encouraging oral feedings may help reduce feeding aversions. As such, GT placement is avoided if possible in Seattle
  • Key diet advice: avoid sweet tasting food/drink, especially in the first few years of life while they are developing their palate/food preferences
  • Feed osmolarity/caloric density: Most children with SBS tolerate lower caloric density (15-20 cal/oz) and more volume orally rather than higher caloric density/lower volume feeds

Parenteral Nutrition:

  • Lipid emulsions: SMOFlipid at 2 gm/day can help prevent essential fatty acid deficiency (EFA). Omegaven may need to be dosed at 1.5 gm/day to prevent EFA. If used for short-term and low dose, standard intralipid can be useful
  • HAL (aka TPN): Typically weaning calories is done before weaning volume. Cycling HAL (delivering over fewer hours) can be started prior to discharge. Watch for tolerance of the glucose infusion rate (JH: I prefer the terms HAL = hyperalimentation or PN=parenteral nutrition. TPN =total parenteral nutrition. Most patients are receiving parenteral nutrition but not total parenteral nutrition.)

Ostomy/Stool Output:

  • Output goals: Most pediatric patients can tolerate output of 50 mL/kg/day of ostomy output  (if being supported by PN), though less than 30 mL/kg/day is more physiologic
  • Iron: Parenteral iron is typically needed. Seattle team prefers ferric carboxymaltose as it may deliver enough iron for 6-12 months in one infusion
  • Acid suppression: While acid suppression can sometimes be beneficial by lowering gastric output, if possible avoid long-term use as it may increase risk of bacterial overgrowth along with other infections
  • Excessive stool output (via stoma or per rectum) is when it is more than the patient’s baseline. This should prompt investigation for potential causes including diet/osmotic agent, bacterial overgrowth and infections
  • Pancreatic enzymes: It is unclear if pancreatic enzymes (PERT, Relizorb) will improve stool output due to lack of data
  • Teduglutide can reduce the need for HAL. It is a hormone (like insulin) and sustained effects are generally not seen when it is stopped. However, especially in patients close to coming off HAL, it may be beneficial

Monitoring:

  • Nutrient deficiencies: Close monitoring for nutrient deficiencies is needed and often even more important when no longer receiving HAL
  • Urine sodium more than 30 is a goal. Sodium depletion interferes with growth and can contribute to other electrolye disturbances (eg. hypokalemia)

CLABSI:

  • Antibiotics: Treatment starts with a broad-spectrum antibiotic and wait to add specific gram-positive coverage unless ill-appearing or gram-positive organism starts growing. Vancomycin is not used frequently in Seattle due to concerns of renal toxicity. In patients with gram-positive infection, linezolid is often used
  • Minimum of 48 Hours For All Fevers: Everyone with SBS and with fever (greater than or equal to 100.4) stays for at least 48 hrs on broad spectrum IV antibiotics
  • Locks: Sodium bicarb locks help prevent CLABSI and appear to have similar infection prevention as ethanol locks. Ethanol locks have been difficult to get coverage.

SIBO:

  • Medications: Metronidazole is generally 1st line agent and gentamicin (IV formulation given enterally) is a 2nd line agent in Seattle. Rifaximin would be potentially their 1st line agent if it were easier to get covered

Related blog posts:

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.

Baby-Led Weaning and Less Picky Eaters

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FDMG Layug-Dionglay et al. J Pediatr Gastroenterol Nutr. 2026;82:801–811. Open Access! The association of baby‐led weaning and picky eating in children aged 2–5 years

Background: Baby‐led weaning (BLW) has emerged over the past decade as an alternative approach to traditional spoon‐feeding. BLW encourages infants to self‐feed nutritious whole foods during family mealtimes, without any pressure. It emphasizes infant autonomy over what, how much, and how quickly to eat from the foods offered.

Methods: A retrospective cross-sectional study was conducted in Metro Manila, Philippines (n=284)

Key findings:

  • Children who underwent strict BLW had a 95.4% lower likelihood of picky eating versus traditionally spoon-fed peers (p < 0.01)

Discussion points:

  • “In this study, picky eaters demonstrated a similar profile: Higher Food Avoidance traits (slowness in eating, satiety responsiveness, emotional undereating), and lower Food Approach traits (enjoyment of food, food responsiveness).”
  • “Strict BLW showed the lowest likelihood of picky eating, suggesting that the positive outcomes of the BLW approach requires consistent self-feeding of at least 90% of the time to experience its best effects. Meanwhile, BLW 51%–90% of the time (Predominant BLW) showed 55% lower likelihood.”
  • Limitation: “This study’s cross-sectional research design limits causal inference. Reverse causation is possible.”

My take: Allowing infants to self-feed likely reduces the tendency towards picky eating.

Related blog posts:

A small section of Iguazu Falls

Have You Read the New “Dietary Guidelines for Americans, 2025-2030”?

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Here’s a link to the new 10-page guidelines: Dietary Guidelines for Americans

Here are critiques:

What’s Good About This Guidance:

  1. Short enough to read and understand
  2. The emphasis of reducing unprocessed foods and clear language
  3. Encouraging early introduction of potential allergens at 6 months of life. This lowers the risk of developing food allergies later.

Some of the questionable advice:

  1. Increasing the protein recommendation to 1.2-1.6 gm per day, up to double prior recommendations. The reason why this level of protein is not a good idea for everyone is noted in a prior blog post: Is a High Protein Diet Beneficial and Safe?. And from the AJC critique: “Pushing protein higher can also crowd out vegetables and fiber, which play a major role in heart health, digestion and overall wellness.”
  2. Backing away from previous advice about alcohol. The current guidance states to “consume less alcohol.” From NY Times: “It is the first time in decades that the government has omitted the daily caps on drinking that define moderate consumption. The guidelines no longer warn of risks like cancer.”
  3. Encouraged changes (more red meat, full-fat dairy) may increase saturated fat intake above stated goal of less than 10%.

The NY Times article on conflicts of interests notes that “Robert F. Kennedy Jr. had promised that his panel, which released new guidelines this week, would have no “conflicts of interest”….Some parts of the guidelines represent such a departure from previous versions that it seems like the administration “handpicked” scientists likely to support those conclusions, “versus undertaking a neutral review of the science,” said Lindsey Smith Taillie, a professor of nutrition at the U.N.C. Gillings School of Global Public Health.”

My take: Overall, the focus on reducing processed foods and decreasing added sugar are worthwhile. The brevity of the guidelines make them accessible. At the same time, the guidelines appear to continue a pattern of RFK Jr of selecting advisers, whether with diet recommendations or with vaccine policy, to support a desired outcome.

Related blog posts:

75% of U.S. Adults Have Obesity When Using New Definition With Anthropometrics

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NM Al-Roub et al.  JAMA Netw Open. 2025;8(12):e2549124. doi:10.1001/jamanetworkopen.2025.49124. Open Access! Body Mass Index and Anthropometric Criteria to Assess Obesity

Background: “Obesity has historically been defined using body mass index (BMI). However, BMI does not account for adipose tissue, limiting its accuracy. The Lancet Diabetes & Endocrinology Commission created a revised obesity definition including anthropometric measures (waist circumference [WC], waist-to-hip ratio [WHR], and waist-to-height ratio [WHtR]),1 encompassing and subcategorizing preclinical obesity (excess adiposity without organ dysfunction or physical impairment) and clinical obesity (a disease).”

Methods: The authors analyzed 14,414 participants representing 237,700,000 US adults. using the 2017-2023 National Health and Nutrition Examination Survey (NHANES)

Key findings:

  • Survey-weighted obesity prevalence was 75.2%
  • Obesity was noted in 100% among adults with BMI of 30 or greater, 80.4% with BMI 25 to less than 30, and 38.5% with BMI less than 25 

Discussion Points:

“These findings demonstrate the impact of anthropometric thresholds, particularly since 80.0% of adults had waist-to-height ratio [WHtR]) above 0.5. Though this value was cited by the Lancet Commission and identifies cardiometabolic risk,1,4,5 the commission emphasized that additional research was required for this cutoff.1“

My take: This is a provocative study indicating that even more U.S. adults could be considered obese when incorporating anthropometric criteria. More data is needed to assess the outcomes of this group that is considered obese with new criteria but not by using BMI criteria.

Related blog posts:

BAPS (Bochasanwasi Akshar Purushottam Swaminarayan Sanstha) Atlanta.
This is a magnificent Hindu spiritual center in Lilburn.
No photos are allowed inside though there are several online (see below).

Russian Roulette: Refusing Vitamin K Version

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R Walrath-Holdridge, USA Today 12/9/25: More parents refusing this shot that prevents serious bleeding at birth

Am excerpt:

“An injection of vitamin K, which helps with blood clotting, within six hours of birth has been a standard practice in the U.S. since 1961.

Since babies are born with low levels of the vitamin, they are more prone to serious bleeding, especially in the brain and gastrointestinal tract, according to the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP)…

Using electronic medical record data, the study’s authors reviewed more than 5 million births at over 40 hospitals across all 50 states between 2017 and 2024. The number of infants who did not receive the shot at birth rose from 2.92% in 2017 to 5.18% in 2024, according to the report…

Since 1961, the AAP has recommended that a single shot of vitamin K be given at birth to protect against bleeding. All babies are born deficient in vitamin K.”

My take: Avoidance of Vitamin K in the newborn period indicates a mistrust of the medical system as well as desire for a more “natural” birth experience. However, this increases the chance than an infant will have permanent severe brain damage. When parents refuse Vitamin K, they are playing Russian roulette with their newborn’s life.

Related blog posts:

Universal Cholesterol Screening: The LEAD Initiative

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JN Flyer et al. The Journal of Pediatrics, Volume 288, 114804. Accelerating Guideline-Recommended Universal Pediatric Lipid Screening: Launch of the LEAD Pediatric Initiative

Background: “Recent studies demonstrate only 11% of youth between 9 and 21 years of
age in the United States (US) had documented lipid screening, and 30%-60% of youth with dyslipidemia may be missed by targeted screening alone (ie, risk factors) compared with ULS [universal lipid screening]. Identification of youth living with familial hypercholesterolemia (FH) has the added benefit of triggering reverse cascade screening of family members, which can further identify at risk youth and adults.”

“In 2024, the Family Heart Foundation (FHF) established the Leveraging Evidence and Data (LEAD) for Pediatric Cholesterol Screening Initiative…The focus was not on creating new screening guidelines, but on developing strategies that will lead to better implementation of the current NHLBI/AAP screening recommendations, and with the overall goal of reducing global ASCVD [atherosclerotic cardiovascular disease] burden.”

“In FH, untreated elevated levels of LDL-C in childhood significantly increase the risk for premature atherosclerotic cardiovascular disease (ASCVD), which is the leading cause of death both in the US and worldwide. However, early initiation of statin therapy for children living with FH reduces the ASCVD risk in adulthood.”

Key points:

“Three common barriers to pediatric ULS were identified.

  • First, many parents and caregivers are not aware of the current pediatric lipid screening guidelines.
  • Second, the major rationale for ULS in young children and adolescents—early identification of a treatable genetic condition—may not be clear to patients, families, and/or clinicians.
  • Third, the values and concerns of families may be dismissed by clinicians if there is a misunderstanding of the rationale for ULS

Practical ways to improve ULS:

  • Improve education of parents and clinicians that ULS can reduce the risk of premature death from the leading cause
  • Point-of-care testing
  • EHR prompts
  • Develop physician “FH champions”

The article notes that a survey in 2017 showed that many PCPs were unaware of the national guidelines. In addition, “few were comfortable prescribing a lipid-lowering therapy.”

Recommended PCP Screening Algorithm:

My take: It is unfortunate that this article, which has an aim to improve awareness for universal pediatric lipid screening (ULS), is not an open access article. Incentives to implement lipid screening could help — screening rates are quite low despite guidelines that were published 14 yrs ago.

Related blog posts:

  • The Case for Universal Cholesterol Screening During Childhood (2024) — An excellent summary of the need/rationale for ULS. Heterozygous FH (HeFH) is the second most common potentially fatal genetic disorder in humans, affecting 1 in 250-300 people.8…Homozygous FH (HoFH) [is] much rarer, occurring in 1:250 000-1:360 000 people.. Proof that screening can make a difference:
  • Treatment Outcomes in Children and Adolescents with Hypercholesterolemia In a 20-year follow-up study, Luirink et al studied a cohort of individuals with genetically confirmed HeFH who had initiated statin therapy in childhood. When compared with their HeFH parents who had not had the benefit of childhood therapy, statins virtually eliminated excess ASCVD risk in adulthood. At age 40, 26% of parents had experienced a cardiac event and 7% had died of ASCVD, whereas only 1% of the those treated as children had needed a vascular procedure (coronary artery stenting) and none had died.

With regard to incentives, a recent commentary (DM Cutler, RS Huckman. NEJM 2025;  2025;393:2177-2180. Has Corporatization Met Its Match? The Challenge of Making Money by Keeping People Healthy) notes that the U.S. health system has financial incentives that rewards care for individuals who are sick rather than keeping patients healthy. “The system focuses its resources primarily on treatment rather than prevention…The dearth of successful business models aimed at keeping people healthy highlights one of the central challenges of the growing corporatization of health care: how to make money producing health, not just health care. The path to doing so will require fundamental changes in the incentives for individuals and institutions and, potentially, broader structural change by policymakers to increase access to or financial support for basic preventive care.”

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.

Wegovy Pill Now FDA Approved

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NBC News 12/22/25: FDA approves Wegovy weight loss pill from Novo Nordisk

An excerpt:

“The Food and Drug Administration on Monday approved a pill version of Wegovy…The Wegovy pill, as it’s called, is first oral version of a GLP-1 drug that has been brought to market for weight loss…

In November, Novo Nordisk reached a deal with the Trump administration to sell the lowest dose of the pill for $149 a month for people who pay out of pocket, in exchange for tariff relief…

Phase 3 clinical trial results published in the New England Journal of Medicine found that people who took the highest dose of the Wegovy pill lost 16.6% of their body weight, on average, after 64 weeks, compared with 2.2% weight loss in the placebo group…

The company expects that the Wegovy pill will be available widely in January.”

Related blog posts:

The Lancet: Ultra-Processed Foods and Human Health

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“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.”

Open Access Links:

Alice Callahan, NY Times 11/18/25: Scientists Call for Global Shift Away From Ultraprocessed Foods

An excerpt:

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.”

Related blog posts:

The Cotswolds, England

New Trend: Oral Medicines Replacing Injections

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  • 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.

Key findings:

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.

Related blog posts:

Diets for Obesity and Steatotic Liver Disease Plus Patient Information from FISPGHAN

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S Karjoo et al. JPGN 2025;81:485–496. Evidence-based review of the nutritional treatment of obesity and metabolic dysfunction-associated steatotic liver disease in children and adolescents

This invited commentary reviews the data for several diets that may improve weight loss and metabolic dysfunction-associated steatotic liver disease (MSALD).

Several points:

  • “Extremely restricted plant‐based diets may have deficiencies of vitamin D, calcium, and vitamin B12 which are nutrients found in animal products, and can be minimized by vitamin supplementation or increasing consumption of fish, mushrooms, egg yolk, cod liver oil, salmon, herring, and sole fish. VitaminB12 supplementation is recommended in plant‐based diets because this vitamin is primarily found in animal products”
  • Table 1 compares the structure of these diets and their advantages/drawbacks
  • “Low to moderate weight loss can be seen in the anti-inflammatory diet, plant-based diets, or Mediterranean diet. These diets are nutritionally complete. However, restrictive plant-based diet carries a risk of micronutrient deficiencies, which can be corrected with appropriate supplementation. These diets are effective in treating MASLD independent of weight loss due to their anti-inflammatory profile.”
  • “The ketogenic diet, certain carbohydrate-restricted diets, and intermittent fasting can lead to more weight loss but carry a higher risk of malnutrition. Children on these diets must be followed by nutritionists.”

My take: Each of the diets reviewed can help MASLD and obesity. Most patients pursuing dietary therapy would benefit from working with a nutritionist.

Related news: TEVA Press release, August 28, 2025: Generic liraglutide (need for daily injections) is now available.

Related blog posts:

Also, related patient advice from Federation of International Societies for Pediatric Gastroenterology, Hepatology, and Nutrition (FISPGAN) –outlines risk factors and prevention tips for metabolic dysfunction-associated steatotic liver disease (MASLD):