Category Archives: Pediatric Gastroenterology Nutrition Topic

How Many Kids Would Be Good Candidates for Bariatric Surgery?

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WL Shapiro et al. Pediatrics 2024: e2023063916. Prevalence of Adolescents Meeting Criteria for Metabolic and Bariatric Surgery (link includes a ~4 minute video abstract)

Methods: This retrospective cohort study analyzed electronic health record data of 603,051 adolescents aged 13 to 17 years between January 1, 2018, and December 31, 2021

Key findings:

  • 4.4% (1 in 23) of all adolescents met the eligibility criteria for bariatric surgery.
  • 22.2% had obesity (12.9% class 1, 5.4% class 2, and 3.9% class 3).
  • The most frequently diagnosed comorbid conditions were gastroesophageal reflux disease (3.2%), hypertension (0.5%), and nonalcoholic fatty liver disease (0.5%). 
  • The authors estimate that ~1 million U.S. adolescents meet criteria for bariatric surgery though only ~1700 receive this treatment yearly
  • The study strongly demonstrates that the comorbid conditions associated with obesity are underdiagnosed. In some cases this is because the screening is not done; yet, in other cases, despite screening, comorbid conditions go undiagnosed. For example, the prevalence of hypertension based on having at least 3 elevated BP measurements was 10 times higher than the prevalence based on the diagnosis being made (ICD 10) codes

My take: A lot of kids meet criteria for bariatric surgery but few undergo this surgery. If effective anti-obesity medications become more widely adopted (affordable), this may be a preferable option to surgery, especially in the pediatric age group. Surgery could be deferred to those who did not respond. Also, immediate implications of the study are that we need to be more diligent about looking for associated health problems (eg. OSA, HTN, T2DM, MASLD).

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Nutramigen Recall 12/30/23

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12/30/23 FDA: Reckitt/Mead Johnson Nutrition Voluntarily Recalls Select Batches of Nutramigen Hypoallergenic Infant Formula Powder Because of Possible Health Risk

An excerpt:

PARSIPPANY, N.J.–(BUSINESS WIRE)–Reckitt/Mead Johnson Nutrition (MJN), a producer of nutrition products, announced today that it has voluntarily chosen to recall from the U.S. market select batches of Nutramigen Powder, a specialty infant formula for the dietary management of Cows Milk Allergy (CMA) in 12.6 and 19.8 oz cans, due to a possibility of contamination with Cronobacter sakazakii in product sampled outside the U.S. All product in question went through extensive testing by MJN and tested negative for the bacteria...


The following recalled product batch codes and can size associated with each batch were distributed in the U.S.:

  • ZL3FHG (12.6 oz cans);
  • ZL3FMH (12.6 oz cans);
  • ZL3FPE (12.6 oz cans);
  • ZL3FQD (12.6 oz cans);
  • ZL3FRW (19.8 oz cans); and
  • ZL3FXJ (12.6 oz cans).

The products have a UPC Code of 300871239418 or 300871239456 and “Use By Date” of “1 Jan 2025”.

No other U.S. distributed Nutramigen batches or other Reckitt products are impacted...

What Consumers Should Do if They Purchased This Product

Consumers who purchased Nutramigen should check the bottom of the can to identify whether the batch number is affected. Product with the batch codes listed above should be disposed of, or contact us for a total refund. Please contact us at 866-534-9986 or by email at consumer.relations@rb.com and we will help verify if this product was impacted. If you have any concerns, contact your health care provider. For more information, please visit us at www.enfamil.com

Current Approach for FPIES

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Our excellent nutritionist, Bailey Koch, recently gave our group a terrific update on FPIES. Bailey is part of the medical advisory board for THE FPIES Foundation, as is Dr. Benjamin Gold from our group. Here are many of the slides from her lecture.

Link: FPIES foundation action plan sheet:

From International guidelines:

Nowak-Węgrzyn A, Chehade M, Groetch ME, et al. Open Access: International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol. 2017;139:1111-26.

Related blog posts:

From FPIES 2017 Guidelines:

  • #4. “Consider specific IgE testing of children with FPIES to their trigger food because comorbid IgE-mediated sensitization to triggers, such as CM [cow’s milk], can infer a greater chance of persistent disease.
  • ”#8. Conduct food challenges “in patients with suspected FPIES in medically supervised settings in which access to rapid fluid resuscitation is available and prolonged observation can be provided, if necessary.”
  • #14. Do not routinely obtain endoscopic evaluation as part of the evaluation of FPIES.
  • #17. Acute FPIES should be considered a medical emergency. “Approximately 15% of patients can have hypovolemic shock.”
  • #19. Consider ondansetron treatment as an adjunct (if >6 months of age)
  • #21. Do not recommend routine maternal dietary elimination of offending triggers while breast-feeding if the infant is asymptomatic.
  • #23. FPIES can occur to multiple foods.  “The majority of children (65% to 80%) have FPIES to a single food, most commonly CM.”  In one study, 5% to 10% of children reacted to more than 3 foods.
  • #26. Use hypoallergenic formula in infants who can no longer breast-feed and are given a diagnosis of FPIES caused by CM. Most will tolerate extensively hydrolyzed formulas; some may require an amino acid based formula
  • #29. Reviews natural history.  “The age of CM tolerance appears to be around 3 years” but there has been variability in reports. For FPIES due to grains, average age of tolerance is 35 months and other solid foods is 42 months.  The average age for soy is 12 months (later in some studies), for rice 4.7 years and 4.0 years for oats. For CM-FPIES with positive SPT response, a much protracted course has been reported, with older age of tolerance (~13.8 years)

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.

Guilt of Breastfeeding Failure

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In previous posts, this blog (see below) has examined the potential bias of studies reporting better outcomes in breastfed infants along with issues of maternal guilt. A recent commentary explores the issue of feeling guilty when breastfeeding does not go well.

AJ Kennedy. NEJM 2023; 388:1447-1449. Breast or Bottle — The Illusion of Choice

Some excerpts:

Only about 25% of women in the United States exclusively breast-feed for the recommended period.2  After my struggles, these statistics seem realistic to me, but before I went through it myself, I had no concept of how hard it could be…

Around the time my son turned 6 months old…my primary care doctor… gave me the courage to start taking medication and to stop breast-feeding that very week. Though the guilt about stopping has never fully gone away, the joy and happiness in my life quickly returned…

Even after I’ve told them that I might not choose to breast-feed this time around [with 2nd child], multiple doctors have “reminded” me that breast milk has been shown to carry Covid-19 antibodies — yet another reason to feel ashamed if I choose not to breast-feed…I am hopeful that this time around I can embrace formula feeding more quickly if that is the path that works best for me and my baby,…

I encourage the AAP and other national health organizations to consider how their statements on exclusive breast-feeding are perceived by the public. If 75% of us are not meeting this goal [6 months of exclusive breastfeeding], a more patient-centered approach and recommendation is needed.

My take: Breastfeeding does not work for everyone. Parents often feel guilty about perceived short-comings and we need to find a balance in encouraging breastfeeding but acknowledging that formula feeding is a good alternative.

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Lipid Emulsions and Cognitive Outcomes

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M Thanhaeuser et al. J Pediatr 2023; 254: 68-74. Open Access: A secondary Outcome Analysis of a Randomized Trial Using a Mixed Lipid Emulsion Containing Fish Oil in Infants with Extremely Low Birth Weight: Cognitive and Behavioral Outcome at Preschool Age

Methods: This was a retrospective secondary outcome analysis of a randomized controlled trial performed between June 2012 and June 2015. Infants with extremely low birth weight received either a mixed (soybean oil, medium chain triglycerides, olive oil, fish oil) or a soybean oil-based lipid emulsion for parenteral nutrition (up to 3 gm/kd/day). At 5 years 6 months of age, data of 153 of 206 infants (74%) were available for analysis.

Key findings:

My take: The discussion highlights the lack of a positive benefit from the mixed emulsion. However, one of the biggest concerns with lipid emulsions occurs in the setting of lipid emulsion restriction due to parenteral nutrition associated liver disease. Because mixed emulsions are better tolerated, this helps minimize lipid restriction which could result in worsened neurocognitive outcomes.

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Meds for Obesity: AAP Guidelines

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Selected recommendations:

  • In children 10 y and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and adolescents with obesity (BMI ≥95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI ≥85th percentile to <95th percentile). 
  • Pediatricians and other PHCPs should provide or refer children 6 y and older (Grade B) and may provide or refer children 2 through 5 y of age (Grade C) with overweight (BMI ≥85th percentile to <95th percentile) and obesity (BMI ≥95th percentile) to intensive health behavior and lifestyle treatment.
  • Pediatricians and other PHCPs should offer adolescents 12 y and older with obesity (BMI ≥95th percentile) wt loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment. 
  • Pediatricians and other PHCPs should offer referral for adolescents 13 y and older with severe obesity (BMI ≥120% of the 95th percentile for age and sex) for evaluation for metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers. 

My take: As with the AGA, the AAP has now recommended the widespread adoption of pharmacologic therapy for use in patients with obesity. It appears that treatment would be required indefinitely, though, given the likelihood of weight gain when treatment is stopped (reviewed on a future post).

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The Onion’s Take on the New AAP Guidelines:

More is Not Better: Protein for Preterm Infants

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FH Bloomfield et al. NEJM 2022; 387: 1661-1672. Early Amino Acids in Extremely Preterm Babies

My take: For preterm infants <1000 gram, this study showed that the usual dosing of amino acids 2.5 gram to 3.5 gram per day (the placebo group) appeared to have better secondary outcomes (though within confidence intervals) than those who received an additional 1 gram per day.

Slides from video summary:

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Docosahexaenoic Acid (DHA) for Preterm Infants and Intelligence

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JF Gould et al. NEJM 2022; 387: 1579-1588. Neonatal Docosahexaenoic Acid in Preterm Infants and Intelligence at 5 Years

Background: “Because its accretion into the brain is greatest during the final trimester of pregnancy, infants born before 29 weeks’ gestation do not receive the normal supply of DHA.”

In this randomized placebo-controlled study of infants born prior to 29 weeks gestation, DHA supplementation 60 mg/kg/day was given to the study group and cognitive outcomes were measured at 5 yrs. 480 (73%) had an full-scale intelligence quotient (FSIQ) score available — 241 in the DHA group and 239 in the control group.

Key findings:  FSIQ scores were 95.4±17.3 in the DHA group and 91.9±19.1 in the control group. Adverse events were similar in the two groups.

Short take video: DHA in Premature Infants

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What’s in Your Gut and How to Change It

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W Turpin et al. Gastroenterol 2022; 163: 685-698. Open access! Mediterranean-Like Dietary Pattern Associations With Gut Microbiome Composition and Subclinical Gastrointestinal Inflammation

As part of the Genetic, Environmental, Microbial (GEM) Project, the researchers recruited a cohort of 2289 healthy first-degree relatives of patients with Crohn’s disease. Diet was assessed with a food frequency questionnaire. Key finding: A Mediterranean-like dietary pattern is associated with microbiome (increased Ruminococcus, as well as taxa such as Faecalibacterium) and lower intestinal inflammation.

L Zhao et al. Gastroenterol 2022; 163: 699-711. Open Access! Uncovering 1058 Novel Human Enteric DNA Viruses Through Deep Long-Read Third-Generation Sequencing and Their Clinical Impact This study discovered 1058 novel human gut viruses, and these findings can contribute to current viral reference genome, future virome investigation, and colorectal cancer diagnosis. From the editorial: “Previous literature also identified virome signatures associated with certain diseases, such as colorectal cancer14 or inflammatory bowel disease,15 such that a better understanding of the viral dark matter may be used to develop biomarkers to identify individuals at risk or even to influence gut physiology.”

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What is the Best Ferritin Threshold and Why It Needs to Be Checked In 1-Year-Olds

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E Mantadakis. J Pediatr 2022; 245: 12-14. (Editorial) Open access. Serum Ferritin Threshold for Iron Deficiency Screening in One-Year-Old Children nutrition.

N Mukhtarova et al. J Pediatr 2022; 245: 217-221. Serum Ferritin Threshold for Iron Deficiency Screening in One-Year-Old Children. This study included 3153 infants, with 698 included in the final analysis.

Key points:

  • 11.4% had iron deficiency, 3.5% had iron deficiency anemia, 8.2% had anemia, and 76.9% were normal.
  • “The authors showed that the hemoglobin threshold of 110 g/L that  is currently recommended for diagnosing anemia at 1-year-old well-child visit corresponds with a very low serum ferritin (4.42 mcg/L).”
  • In a previous study, TARGet Kids!, “a higher serum ferritin was associated with higher cognitive function, with a serum ferritin of 17 mcg/L corresponding with the maximum level of cognition.” That is, iron deficiency, even in the absence of anemia, can contribute to detrimental cognitive outcomes.
  • Thus, current hemoglobin levels and ferritin need to be revised.  Neither a hemoglobin of 11.0 g/dL nor a ferritin of 12 mcg/L is sensitive in detecting iron deficiency in toddlers.
  • In the U.S., only ~40% of anemia in toddlers is attributable to iron deficiency; thus, checking a ferritin can help determine if iron supplementation is worthwhile.

My take: Iron deficiency anemia is a late indicator of iron deficiency and relying on hemoglobin alone could have irreversible detrimental effects on cognitive outcomes. These articles make a strong argument for the following:

  1. Use a ferritin threshold of at least 18 mcg/L to determine if iron deficient
  2. Check a ferritin along with a hemoglobin at 1-year well-child check. 

Related blog post: Briefly Noted: Ferritin Levels and Cognitive Outcomes

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