

As noted in previous blog posts (see below), allergy testing can lead to unnecessary food restrictions which can in turn lead to numerous subsequent problems. Case in point: YV Virkud et al (NEJM 2020; 383: 2462-2470) report on A 29-Month-Old Boy with Seizure and Hypocalcemia
This boy presented with severe hypocalcemia, rickets, and seizures one year after allergy testing led to additional dietary restrictions. Also, his mother was a vegetarian. At time of allergy testing, IgE testing suggested allergies to milk, cashews, pistachios, egg whites, almonds, soybeans, chickpeas, green peas, lentils, peanuts, and sesame seeds. Many of these foods caused no symptoms with food challenges.
Besides working through the potential reasons for hypocalcemia, the authors make several key points:
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I want to thank all of you who take an interest in my blog, particularly those who give suggestions, references, and encouragement. The following posts were the most popular from the past year.
Related post: Favorite Posts of 2020
This year I had planned to go back to what many consider the best learning conference in our field, the Annual Aspen Conference. This conference alternates yearly between GI topics and liver topics. What has made this conference so great:
Due to the pandemic, this year’s course will be curtailed and online. While this changes the setting, it is still a great opportunity and a heck of a lot easier to attend. It will take place 1:00-2:30 pm Tues, Weds, and Thurs next week (July 14-16). You can register for a day or for all 3 days. Course description and faculty are listed below.
Also, there is a pre-conference SCAVENGER HUNT. (This appears to be mainly to help with promotion of the conference sponsors.) By participating, attendees will be eligible for raffle prizes awarded during the webinar:
• Snowmass Camelback
• Snowmass Winter Gloves
• Snowmass Hat
• Snowmass Socks
The GRAND PRIZE is FREE 2021 CONFERENCE REGISTRATION!
This retrospective study of 487 pediatric patients shows that it takes a long time to normalize celiac serology/anti-tissue transglutaminase antibody (TTG). The median time was 407 days for the 80.5% of patients that normalized their serology in the study time frame. The time was 364 days for those who were considered adherent to a gluten-free diet. Patients with type 1 diabetes were less likely to normalize their TTG levels. Faster normalization occurred in those with lower titers at baseline.
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In this chart review, among 135 children, normal ESR and CRP were observed in 28% of children with Crohn disease and 42% of children with ulcerative colitis.
Related blog post: Do you really need both a ESR and CRP?
This guideline paper details 31 recommendations (some with multiple parts) for the evaluation and management of children with neurologic impairment. The recommendations include detailed evaluations including knee heights, skinfold thickness measures, DXA scan, routine micronutrient bloodwork, along with a low threshold for oropharyngeal dysphagia assessment. The paper has recommendations for evaluations of reflux, constipation, and dental problems. The authors suggest “considering use of enteral feeding if total oral feeding time exceeds 3 hours per day.”
Related blog post: Surgery for reflux works best for those who need it the least
After reading a few commentaries regarding value in medicine (which I will summarize tomorrow), it made me think a little more about value in pediatric gastroenterology.
I recently observed that a pediatric gastroenterologist in another group had a pattern of scheduling a lot of procedures. In pediatric gastroenterology, we are not doing endoscopies to screen for malignancy. The majority of children evaluated in our offices do not have organic disease. In addition, there are a number of variables that can be used to select patients who are most likely to benefit from evaluation. In fact, much of our value comes from this selection process, because non-physicians can be taught to be endoscopic technicians.
My reaction to this volume of cases was that I thought either this practitioner was seeing a ton of patients, had been away and had accumulated a number of cases, or that this was low value care. Though, another possibility is that the physician may be influenced by the “illusion of control” or “therapeutic illusion.” (NEJM full text: The Science of Choosing Wisely –Overcoming the Therapeutic Illusion). According to a recent editorial, “When physicians believe that their actions or tools are more effective than they actually are, the results can be unnecessary and costly care.”
“The therapeutic illusion is reinforced by a tendency to look selectively for evidence of impact — one manifestation of the “confirmation bias” that leads us to seek only evidence that supports what we already believe to be true.”
Whatever the circumstances with regard to endoscopy volume, my intent is not to single out an individual or specific group. My impression is that there are a lot more pediatric endoscopies being done these days and many are not needed. While I recognize that clinicians recommend endoscopy with a great deal of variation, my suspicion is that those who use endoscopy less frequently are likely to see similar outcomes. So, why are there so many low value endoscopies performed?
This blog has highlighted numerous aspects of health care economics. Pharmaceutical companies and hospitals have been criticized for gaming the system. The blog has discussed efforts to improve value like the “Choosing Wisely” campaign. Though, it is interesting to note that even with this campaign, most physician groups rarely identified areas that would affect their financial bottom-line. Among pediatric gastroenterologists, a frequent concern that I hear regards the overuse of CT scans by emergency room physicians.
When I take my car for repairs, I don’t want them doing an expensive overhaul unless it is really needed. If a car needs a muffler change, but the repairman recommended a few thousand dollars of repairs, that would be outrageous. Yet, in many cases with children, who are more precious than cars, the main difference with excessive endoscopic procedures, is that health insurance covers the majority of the costs.
I wonder too whether the frequency of endoscopy procedures actually discourages some families from having endoscopic procedures when they are clearly needed (eg. suspected celiac disease, suspected inflammatory bowel disease).
My take: Financial resources are limited. When physicians do not help utilize resources well, this results in poor care, whether families realize this or not. Ultimately, this will result in increased regulatory burdens for all physicians to more carefully justify what they are doing and/or result in efforts to eliminate financial incentives for unnecessary care. However, as noted previously (Do deductibles work to improve smart spending on health care?), financial incentives often affect both low value and high value care.
Any readers care to comment?
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Several news outlets have summarized a recent study which showed increased risk of psychological problems associated with being a picky eater.
An excerpt of a summary is from NBC news:
Picky eating, even at moderate levels, is linked with psychiatric problems, including anxiety and symptoms of depression in kids, according to a study published Monday in the journal Pediatrics. It found the mental problems worsened as the picky eating became more severe.
“We need to do a better job of giving advice to these parents,” Nancy Zucker, study co-author and associate professor of psychology at Duke University, told NBC News.
“The first take-home message is that you’re not to blame. The second take-home message is that it’s more complicated than we think.”
The study screened more than 1,000 children ages 2 to 5, and found 20 percent were picky eaters. The researchers stress this goes beyond kids who just hate broccoli or have certain dislikes.
More than 17 percent of kids were classified as moderate picky eaters: These children had a very limited range of foods they would eat and they would not try anything else, Zucker said.
About 3 percent were considered severe picky eaters: Their sensitivities to smell or taste were so strong that even eating outside of the home was difficult. As they get older, it could be hard for them to go out with friends or eat at school. …
The researchers also note the term “picky eating” may now be obsolete. They suggest the condition might be better described as avoidant/restrictive food intake disorder (ARFID).
Also from NPR: When a Child’s Picky Eating Becomes More Than a Nuissance
A recent medical position paper (Nobili V, et al. JPGN 2015; 60: 550-61) provides guidance for bariatric surgery intervention in children and adolescents with and without nonalcoholic fatty liver disease (NAFLD).
While the authors acknowledge that bariatric surgery can “dramatically reduce the risk of adulthood obesity and obesity-related diseases,” they advocate its use in adolescents with the following:
Key points:
It is interesting that the authors are so deferential to the Food and Drug Administration. It is clear from their position paper that LAGB has similar evidence supporting its use in adolescents as RYGB. They even note that it has potential for reversibility and “an excellent safety profile with a lower risk of postoperative vitamin deficiencies when compared with biliopancreatic diversion and RYGB.”
Bottomline: Given the continuation of the obesity epidemic, additional pediatric medical expertise will be needed to help evaluate adolescents for bariatric surgery and to follow them postoperatively.
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A recent publication in JPGN indicates that resuming low dose soy-based parenteral lipid can be effective in patients (n=7) whose cholestasis had resolved on a fish oil-based parenteral lipid. It does not resolve the larger question of whether fish oil-based parenteral lipids are truly more effective than soy-based parenteral lipids (see previous blog links below).
Here’s the abstract:
Objectives: Intestinal failure associated liver disease (IFALD) contributes to significant morbidity in pediatric intestinal failure (IF) patients. However, the use of parenteral nutrition (PN) with a fish oil-based IV emulsion (FO) has been associated with biochemical reversal of cholestasis and improved outcomes. Unfortunately, FO increases the complexity of care: as it can only be administered under FDA compassionate use protocols requiring special monitoring, is not available as a 3-in-1 solution and is more expensive than comparable soy-based lipid formulation (SO). Due to these pragmatic constraints a series of patient families were switched to low-dose (1 g/kg/day) SO following biochemical resolution of cholestasis. This study examines if reversal of cholestasis and somatic growth are maintained following this transition.
Methods: Chart review of all children with IFALD who switched from FO to SO following resolution of cholestasis. Variables are presented as medians (interquartile ranges). Comparisons performed using Wilcoxon signed-rank test.
Results: 7 patients aged 25.9 (16.2,43.2) months were transitioned to SO following reversal of cholestasis using FO. At a median follow up 13.9 (4.3,50.1) months there were no significant differences between pre- and post-transition serum alanine and aspartate aminotransferases, direct bilirubin, and weight-for-age z-scores. Due to recurrence of cholestasis, one patient was restarted on FO after four months on SO.
Conclusions: Biochemical reversal of IFALD and growth were preserved after transition from FO to SO in 6/7 (86%) patients. Given the challenges associated with the use of FO, SO may be a viable alternative in select home PN patients.
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