Category Archives: Uncategorized

Confusing Guidance and “Conditional” Recommendations for Probiotic Use in Pediatric Irritable Bowel Syndrome and Functional Abdominal Pain

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R Francavilla et al. J Pediatr Gastroenterol Nutr. 2026;83:3–6. Open Access! From evidence to advice: How uncertainty shapes probiotic guidance in pediatric irritable bowel syndrome

Key points:

  • “Recent guidance documents of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) on probiotic use in pediatric irritable bowel syndrome (IBS) do not simply converge toward a shared recommendation.1–3 Rather, they illustrate an evolution in how scientific uncertainty is operationalized in clinical advice. “
  • “The ESPGHAN Position Paper Probiotics for the Management of Pediatric Gastrointestinal Disorders represents the most structured approach among the three documents, treating probiotics as strain-specific interventions evaluated against predefined clinical outcomes.1 In functional abdominal pain disorders, healthcare professionals may recommend Limosilactobacillus reuteri DSM 17938 to reduce pain intensity, while in pediatric IBS Lactobacillus rhamnosus GG may be recommended to reduce pain frequency and intensity. These recommendations are accompanied by explicit dosing ranges, defined clinical targets, and formal appraisal of evidence certainty (moderate) and strength of recommendation (weak).”
  • “The joint ESPGHAN/NASPGHAN guideline on treatment of IBS and functional abdominal pain—not otherwise specified in children aged 4–18 years represents a shift in emphasis.2 L. rhamnosus GG is conditionally suggested as a therapeutic option for pediatric IBS, supported by moderate overall certainty of evidence and a small, reported effect size. Multistrain probiotics and synbiotics are likewise framed as options that may be suggested, but with low certainty of evidence. In contrast to earlier ESPGHAN position papers, the guideline does not specify detailed dosing regimens, treatment duration, or stopping rules.”
  • “This reframing extends further in the European and North American guidance addressing IBS and functional abdominal pain in childhood.3 …Within this framework, probiotics are positioned less as therapies to be prescribed and more as adjunctive measures to be discussed with families, including in primary care settings.”

Conclusions from authors: “At a policy level, conditional recommendations do not operate in a neutral context…Probiotics are widely available, variably regulated, and commonly perceived as harmless. In pediatric IBS, where symptoms are chronic, placebo responsiveness is high, and pharmacological options are limited, conditional guidance may be interpreted as tacit approval for routine use, regardless of modest effect sizes…their use may drift from deliberate intervention toward habitual supplementation.”

My take: I rarely recommend probiotics for pediatric IBS. Even simple dietary changes are much more likley to be beneficial. In addition, there is a concern about the lack of quality control in the production of probiotics.

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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

Guidelines for Hirschsprung’s Disease

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D Rossi et al. J Pediatr Gastroenterol Nutr. 2026;83:185–207. Open Access! Updated European Reference Network for rare Inherited and Congenital Digestive and Gastrointestinal Anomalies guidelines for the management of rectosigmoid Hirschsprung’s disease 2025

These guidelines cover recommendations for diagnosis, pre- and postoperative care, poor functional outcomes, long-term follow-up, and Hirschsprung’s-associated enterocolitis.

Some specific recommendations:

Diagnosis:

Preoperative Care:

  • Routine screening for all patients with rectosigmoid Hirschsprung’s disease (HSCR))with ultrasound for congenital anomalies of kidney and urinary tract (CAKUT) and systematic assessment of nutritional status.

Operative Care:

Hirschsprung’s-Associated Enterocolitis:

  • Table 9 provides extensive advice for bowel management strategies/evaluation in children with fecal incontinence.
  • Table 11 discussed genetic testing, noting that RET gene should be considered. Genetic counseling is recommended in those patients with a family history of Hirschsprung’s disease.

My take: This article provides good advice for optimizing care for patients with Hirschsprung’s disease.

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Diagrams of 3 common pull-through operations for Hirschsprung disease.
From left to right: full-thickness rectosigmoid dissection (Swenson), a recto-rectal pouch procedure (Duhamel), and an endorectal dissection (Soave). JPGN 2023; 76(4):533-546.

Impact of 5‐Aminosalicylic Acid Discontinuation in Children with Ulcerative Colitis Receiving Biologic Therapy

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G D’Arcangelo et al. J Pediatr Gastroenterol Nutr 2026; 83: 96-107. Open Access! Impact of 5-Aminosalicylic acid discontinuation in children with ulcerative colitis on biologic therapy: A propensity score-matched study

Background: Several adult-based studies have found that discontinuing 5-ASA at the initiation of anti-TNF therapy is not associated with worse clinical outcomes. “Ungaro et al. analyzed data from over 3500 patients in the United States and Denmark and found no increased risk of adverse outcomes following mesalamine discontinuation after the initiation of anti-TNF therapy.18 Based on this evidence, the American Gastroenterological Association recommends discontinuing mesalamine in patients with moderate-to-severe UC who are starting biologics or small molecules and achieve remission.19 However, this recommendation is based on low-quality evidence, and pediatric guidelines do not offer a similar directive.2“

Methods: Retrospective, multicenter, case–control study which included 227 pediatric patients in the final analysis after matching (85 [37.5%] cases and 142 [62.5%] controls].

Key findings:

  • Children who discontinued 5-ASA were at higher risk of courses of steroids (Log-Rank p = 0.003) and hospitalization (p = 0.08). This finding persisted with multivariate Cox regression analysis.
  • “Fixed timepoint analyses showed a statistically significant increase in the odds of adverse outcomes at the 6-month follow-up (including hospitalizations and acute severe colitis), with no significant differences detected at 12, 18, or 24 months, and only a non-significant trend toward higher hospitalization risk over time.”

My take: This is an intriguing study with a small sample size of pediatric IBD patients. Given the findings in adults, it is customary to stop 5-ASA at the time of initiation of biologic therapy. However, this study indicates that pediatric patients—who often present with more extensive and severe disease—may have some benefit from overlapping these therapies, especially during the first six months. A prospective pediatric study would be helpful.

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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

Elevated Amylase is Common in Pediatric Patients with Inflammatory Bowel Disease

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F Vázquez López et al. J Pediatr Gastroenterol Nutr. 2026;83:79–86. Hyperamylasaemia in paediatric inflammatory bowel disease: Aetiology, outcomes and genetic determinants

Methods: This was a retrospective study with 334 pediatric patients, followed for ≥2 years (study duration was 7 years). Elevated amylase was considered to be above the laboratory’s reference range (102 U/L).

Key findings:

  • Hyperamylasaemia was found in 62/334 patients (18.6%), with 29% of these presenting at diagnosis
  • Hyperamylasaemia resolved in 77% of patients; in the majority (85%), spontaneously and in the remainder after medication withdrawal
  • One patient developed acute pancreatitis and one had recurrent pancreatitis

My take: It is best to avoid routinely checking an amylase if pancreatitis is not suspected; it could lead to ‘a wild goose chase.’ Most cases of elevated amylase are benign and self-limiting.

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A deer in the middle of the Chattahoochee at Island Ford

Sheila McBrayer: Swallow Dysfunction and Swallow Evaluation in Infants

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Recently, Sheila McBrayer SLP gave our group a terrific update on swallow dysfunction and swallow studies in infants. She is a nationally-certified speech-language pathologist with more than 20 years of experience at Children’s Healthcare of Atlanta. She has led initiatives in advanced swallowing assessment, worked to standardize instrumental swallowing assessments across the hospital campuses, and presented at regional and national conferences on NICU feeding topics. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

Key points:

  • Video fluoroscopic swallow study )VFSS) is preferred nomenclature over modified barium swallow (MBS) or oral pharyngeal motility study (OPMS)
  • Study duration is important.  Watch swallow for 2:30 minutes if feasible (KE McGrattan, et al Ped Radiology 2020; 50: 199-206)
  • Clinical evaluation accurately identifies aspiration in 56.7% in one study (may be better in a lower risk population).  Thus, if concerned about aspiration, an objective study (e.g. VFSS) is needed
  • Analysis of sounds during feeding may provide insight into risk of aspiration
  • Ongoing efforts to standardize evaluation protocol.  BaByVFSSimP tool (for bottle feeding)
  • Common impairments: increased sucking prior to bolus movement, disorganized lingual motion, late/incomplete laryngeal closure, disorganized or decreased pharyngeal transport, esophageal retention, and suck-swallow ratio variability
  • If unilateral cord dysfunction, feed infant with position to allow the better functioning vocal cord to be lower
  • When to care about penetration: deeper (e.g. touching vocal folds) and more frequent penetration.  Deeper penetration should be considered as similar risk as aspiration on swallow study
  • Thickening feeds can be difficult

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

Endoscopic Ischemic Polypectomy for Polyposis Disorders

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S Kurasawa et al. JPGN Reports. 2026; DOI: 10.1002/jpr3.70188. Open Access! Endoscopic ischemic polypectomy for small intestinal polyps in a 7-year-old girl with juvenile polyposis syndrome

Background: “Funayama et al.4 described the technique of endoscopic ischemic polypectomy (EIP) in detail in both pediatric and adult patients with Peutz–Jeghers syndrome (PJS). Subsequently, EIP was reported to be a safe and effective treatment for 269 small intestinal polyps in 22 pediatric PJS cases.5” Here the authors describe the use of this technique for a child with juvenile polyposis syndrome (JPS).

Key findings:

  • During a two-hour double-balloon enteroscopy (DBE) for a 7 yo child, “17 pedunculated polyps, all with a visually assessed size range of 7–15 mm, EIP was performed using the “crossed-clip strangulation method,” in which the first hemostatic clip was deployed with the aid of a distal attachment and rotated 90°, followed by placement of a second clip crossing the first at a 90° angle (Figure 1)…Subsequently, anemia and hypoalbuminemia did not recur, and growth was satisfied.”

(A) Pedunculated polyp in the small intestine. (B) The first hemostatic clip was placed on the stalk of the polyp. (C) A second hemostatic clip was placed on the stalk of the polyp at a 90-degree angle to the first clip.

Discussion Points:

  • “EIP does not involve electrocautery, eliminating the risk of thermal injury and offering a safer alternative for small bowel lesions.”
  • “A limitation of EIP is the inability to retrieve resected polyps…It should only be used for lesions that appear clearly benign.”
  • There is a risk of detached polyps migrating into the lower gastrointestinal tract and inducing intussusception. This can be mitigated by managing distal small intestinal polyps first.

My take: EIP appears to be useful for inidividuals with numerous small intestinal polyps.

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Does Isolated Ulcerative Proctitis Increase the Risk of Rectal Cancer?

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AH Everhov et al. Gastroenterol 2026; 171: 158-160. Open Access! Incidence of Rectal Cancer in Patients With Isolated Ulcerative Proctitis: A Population-Based Cohort Study

Methods: Using a prospective nationwide registry (SWIBREG) (1997-2023), there were 15,957 individuals diagnosed with isolated proctitis and matched to 158,079 population comparators. Median followup for patients with isolated proctitis was 10.8 years.

Key findings:

  • Rectal cancer incidence was 0.11% in patients and 0.09% in comparators at 5 years and 0.16% and 0.21%, at 10 years.
  • During follow-up, inflammation remained limited to the rectum in 60% of patients, whereas 23% developed left-sided colitis and 17% developed extensive colitis

Discussion Points:

  • “Results from this nationwide study indicate patients with isolated proctitis have no elevated rectal cancer risk with respect to the general population.”
  • “40% of patients experienced disease extension” which is similar to prior studies.
  • “European (European Crohn’s and Colitis Organisation)9 and US (American College of Gastroenterology)10 guidelines endorse standard population screening in limited-extent disease, and our data support these recommendations.”

My take: This should provide a lot of reassurance for our patients with isolated proctitis.

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Camp Weekaneatit 2026

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Last Sunday, along with my colleagues, Jeff Lewis, and Nirav Patel, I helped check in kids for Camp Weekaneeatit! (glutenfreecamp.org). This is a gluten-free camp for youth with ​Celiac Disease and ​Gluten Intolerance. This year’s staff shirt was “S’more Fun Without Gluten;” though, I elected to wear my T-shirt from 2018.

The camp was started more than 15 years ago by my partners, Dr. Jeff Lewis and Dr. Bill Meyers.

The camp is located just north of Atlanta at Ft Yargo (Winder, Georgia). The ~125 participants come from all over the U.S including Texas, Michigan, Ohio, Massachusetts, Colorado, Arizona, Florida, South Carolina, and Alabama. There was one kid, whose father is a marine, who flew in from Japan!

Most of the campers have come several times and have had a great experience. Here is an excerpt from a letter from a camper’s parent:

“My daughter was at camp with you this summer.  I can’t tell you how much fun she had.  She was diagnosed with celiac when she was just 2, so she has never known a world where she could just relax and be like everybody else.  Camp gave her so much freedom, and she grew so much in just one week.  Today is her birthday and her first day of school.  Her camp friends have already texted to wish her happy birthday!…This is the first time she has had friends with celiac disease — I can only imagine how much more supported that makes her feel…  I asked her what it was like to not have to ask a million questions before every bite she ate.  She said, “I felt like I didn’t even have celiac disease all week. I felt like a normal person.” 

Last year enrollment started in the middle of November for summer 2026. Space is limited!

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Eosinophilic Esophagitis: Aerodigestive Disease Perspective

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TA Temtem, K Liu, KL Kennedy, BD Gold. Pediatr Gastroenterol Nutr. 2026; Online ahead of print. Eosinophilic esophagitis: An aerodigestive perspective

This review article highlights the management and high frequency of eosinophilic esophagitis in children with complex aerodigestive disease disorders. Congratulations to my colleague Dr. Benjamin Gold, one of the contributors, and our aerodigestive disease team for this publication.

Key points:

  • “Special populations such as esophageal atresia/tracheoesophageal fistula and those patients requiring laryngotracheal reconstruction (LTR) should undergo esophagogastroduodenoscopy with biopsies to evaluate for EoE, even in absence of typical symptoms”
  • “The prevalence of EoE in aerodigestive patients ranges from 3.7% to 25% (Table 1).”
  • “The clinical presentation of EoE can range from typical symptoms of feeding difficulty to atypical presentations of chronic cough, recurrent croup, hoarseness, or inflammatory consequences found at the time of airway evaluation.3, 4, 12“
  • Delays in the diagnosis of EoE for 6 years or more are common. “Studies demonstrate…a 9% increased risk of stricture for each additional year of undiagnosed EoE.”
  • “Patients undergoing LTR are also managed by aerodigestive teams and should have screening esophagogastroduodenoscopy (EGD) prior to surgery, as untreated EoE can result in graft failure.10“
  • “Management of aerodigestive patients with EoE is similar to the general population…A limitation of topical steroids is that oral is the only route of administration.”

Critique:

  • The authors note that “in a review of 251 EoE patients, 14% of the patients who were initially evaluated by otolaryngology presented with isolated airway complaints and an absence of GI symptoms.14” However, in my experience, many ENT physicians are not asking questions like ‘how long does it take your child to eat? or ‘does your child need to drink a lot of fluid to help them swallow?’
  • The authors conclude that “it is imperative for the aerodigestive clinician to recognize the range of EoE presentations and thus, with a higher index of suspicion, reduce diagnostic delay. EA/TEF patients are at high risk of EoE and should undergo routine surveillance EGD, even in the absence of symptoms.” In my experience, the threshold for arranging a triple endoscopy is quite low for the aerodigestive team. This messaging​, though, is important for patients seen outside the aerodigestive clinic.
  • There is no discussion of cost and redundancy in this article. Many aerodigestive patients, prior to going to the multispecialty clinics, already have GI, pulmonary and/or ENT physicians. Communication among their specialists could obviate the need for aerodigestive evaluation in many patients.

My take: This article provides a useful review of EoE in the aerodigestive disease population and highlights how respiratory symptoms can be the main clinical presentation.

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Atlanta Botanical Gardens