Adherence to a Gluten Free Diet in Pediatric Celiac Disease

Posted on October 2, 2026 by gutsandgrowth

L Kallio et al. JPGN Reports. 2026; Epub 9/14/26. Open Access! Factors associated with adherence to gluten-free diet in patients with concomitant celiac disease and type 1 diabetes

Methods: In this study from Finland, the authors compared the baseline characteristics and follow-up data between adherent and nonadherent CeD children with a dual diagnosis (n = 69).

Key findings:

Overall, 72% were found to be adherent to a gluten-free diet (based on self-report)
Adherent patients were detected significantly more often in annual CeD screening than by symptoms

Discussion:

“In Finland, GFD products are easily available, and children receive financial support to cover the additional costs.”

Though, not addressed by the authors, it is widely acknowledged that self-report of GFD adherence tends to overestimate true adherence compared with expert interviews, celiac serology and stool or urine for GIP (gluten immunogenic peptide). The reasons for this include the following:

Unintentional gluten ingestion. This can be due to food cross-contaminated during manufacturing, prepared with shared kitchen utensils, or laced with hidden gluten additives.
Knowledge gaps. A patient might regularly consume a specific product or sauce thinking it is perfectly safe, resulting in high self-reported compliance but low actual compliance
Social desirability and recall bias. The tendency to want to present oneself in a positive light or give the “correct” answer. Additionally, recall bias means people tend to forget minor dietary slips or intentional transgressions that occurred weeks prior.
Lack of symptoms. Many patients assume that if they do not experience immediate gastrointestinal pain, they have successfully avoided gluten.

My take: In this cohort, diagnosis through screening rather than due to symptoms was associated with higher adherence rates, contrary to expectations. Overall, regardless of how a diagnosis was established, there are a large number of individuals with celiac disease with ongoing gluten exposure. This occurs even in individuals who are making a lot of effort to follow this diet.

Related blog posts:

Promising Pilot Study Using Substance P to Screen for Pediatric Aspiration

Posted on October 1, 2026 by gutsandgrowth

DR Duncan et al. J Pediatr 2026; 297: 115212. Association Between Salivary Substance P and Aspiration on Videofluoroscopic Swallow Study in Infants and Toddlers

Background: Substance P (SP) is a neuropeptide signaling molecule that is secreted peripherally as a result of the activation of afferent neurons expressing TRPA1 and is involved in the pathogenesis of swallow dysfunction by (1) decreasing the activation
threshold of transient receptor potential channels, (2) enhancing the sensitivity of neurons in the pharynx, and (3) increasing cough reflex to improve airway protection. Pilot studies in adult populations have shown reduced SP levels in patients with neurologic causes of aspiration, including patients who are elderly and patients with stroke and Parkinson disease.

Methods: The authors recruited children younger than 2 years of age (n=50, mean age 8 months) who underwent VFSS within 3 months of study enrollment. Saliva samples were collected using absorbent saliva collection devices (salimetrics.com) and Substance P (SP) levels were measured by enzyme-linked immunosorbent immunoassays. Patients with laryngeal penetration but not aspiration were excluded.

Key findings:

SP concentrations were 344.7 ± 42.9 pg/mL for patients with aspiration compared with 105.7 ± 40.5 pg/mL for those without aspiration (P < .001).
A cutoff of 65 pg/mL provided 97% sensitivity and 75% specificity for predicting aspiration on VFSS.
In a subgroup analysis with 29 subjects who had VFSS within 1 month of sample collection, a cutoff of 63.2 pg/mL provided 100% sensitivity and 83.3% specificity for predicting aspiration on VFSS. For this subgroup, the SP concentration was 250.9 ± 33 pg/mL for those with aspiration on VFSS compared with 57.1 ± 11.8 pg/mL for those without aspiration on VFSS (P < .001)

A, Boxplot comparing salivary SP concentration between children
with and without aspiration on VFSS in the full cohort.

B, Boxplot comparing SP concentrations in the subgroup of subjects
with saliva sample collection **within 1 month** of VFSS.

Discussion Points:

“SP levels were not affected by comorbidities or acid suppression medications” in this cohort.
“These data suggest that this test could be used to at least screen for who might need a VFSS or who might need thickening while the cause of aspiration is being evaluated.”
“Testing of salivary SP is experimental and only limited to research studies and therefore not widely available at the present time.”

Disclosures: “The funders had no role in the design and conduct of the study. D.D. and R.R. are named inventors on U.S. Provisional Patent Application Serial No. 63/804876, DEVICES AND METHODS FOR DETECTING AND TREATING ASPIRATION IN CHILDREN.”

My take: While this is a pilot study, if the findings are confirmed, this would be a huge advance. It would help triage infants and young children who need VFSS evaluation. A normal value could help many infants avoid a VFSS evaluation. In those with ongoing abnormal values, it could allow fewer followup VFSS evaluations.

Related blog posts:

Impact of Night Shifts on Gut Disorders

Posted on September 30, 2026 by gutsandgrowth

C Pennaneach et al. Clin Gastroenterol Hepatol 2026; 24: 2584-2594. High Prevalence of Disorders of Irritable Bowel Syndrome and Functional Dyspepsia in Night Shift Workers: A Cross-Sectional Study in Australia and the United Kingdom

Background: “Approximately 15% to 25% of the global workforce operates outside conventional daytime hours.^1–3 These schedules typically occur between 6:00 pm and 6:00 am⁴ and typically take 2 forms: fixed night shifts (consistent night-time work) or rotating (alternating between day, afternoon and night). This distinction is physiologically significant; although fixed night workers may partially adapt to their schedule over time, rotating shift workers face continuous circadian disruption due to frequently changing schedules, preventing biological adaptation.⁵ This circadian misalignment creates a particularly vulnerable subset of workers and is associated with increased risk of chronic conditions, including cardiovascular disease,⁶ type 2 diabetes,⁷ and gastrointestinal (GI) disturbances.⁸ These adverse outcomes primarily stem from disruption of central and peripheral biological clocks.⁹“

Methods: This was a cross-sectional study of night shift workers (≥8 shifts/mo between 11 pm and 3 am) in Australia and the United Kingdom from March to July 2024. Participants (n=392) completed validated questionnaires including Rome IV criteria for IBS and FD. Fixed night shift workers constituted 54.1% of the sample, whereas 45.9% worked rotating shifts.

Key findings:

21.3% met Rome IV criteria for IBS, 30.4% for FD, and 24.5% for both conditions. The rates of IBS and FD in this cohort was substantially more than “general estimates of 4.1%” general population estimates (4.1% for IBS and 7.2% for FD),¹⁰“
Most participants (59.9%) reported night shifts negatively affected their GI symptoms, and 16.3% considered changing jobs due to symptoms.

The authors discuss the many ways that circadian disruption can adversely affect the GI tract. In addition, night shift workers are more likely to adopt irregular dietary habits which could be a contributing factor as well.

My take: This study shows that night shift work is associated with high rates of disorders of gut-brain interaction (DGBI) likely due to disturbance in circadian rhythms. It is in agreement with other studies showing that disturbed sleep worsens IBS symptoms (A Patel et al. Aliment Pharmacol Ther. 2016; 44(3):246–258).

Related blog posts:

Treatment Guidelines for Pediatric Irritable Bowel Syndrome
Dr. Carlo DiLorenzo: Advice for Managing DGBIs (Part 2) “Improving Physical activity, Diet and Sleep Often Helps DGBI symptoms”
NPR: Understanding “Sleep Munchies”
More on Staying Up All Night
Negative Study: Nortriptyline for Functional Dyspepsia
Functional Dyspepsia in Clinical Practice
Is Infantile Colic a Biorhythm Disorder?
Rome V: Lower GI Tract and Biliary Disorders of Gut-Brain Interaction in Pediatrics (Part 1)

Fjadrargljufur. Iceland. I would fail spelling in Iceland! There is a powered hang glider in the distance.
This was a good hike with serpentine canyon walls and a long waterfall at the end

ESPGHAN Position Paper: Management of Foreign Bodies (2026)

Posted on September 28, 2026 by gutsandgrowth

O Ledder et al. J Pediatr Gastroenterol Nutr. 2026;83:539–554. Open Access! Foreign body ingestions in children and adolescents: A position paper of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) endoscopy special interest group

In 2015, NASPGHAN’s endoscopy committee published a report on the management of foreign bodies (see: Foreign Bodies in Children -Expert Guidance). This was quite helpful. This ESPGHAN position paper provides updated guidance though many of the recommendations are unchanged.

Overall Treatment Algorithm:

Button Batteries

Blunt Objects/Benign Foreign Bodies

Superabsorbent polymers (SAP) Since these items are translucent, imaging is useful only for identifying the sequelae of the ingestion, but not the SAP itself… In cases of witnessed or suspected ingestion of SAP, emergency endoscopy should be performed to attempt retrieval of the material. If this is unsuccessful, or not completely retrieved, the child should be admitted for close observation with surgical support.

Magnets:

On table ﬂuoroscopy has been suggested to conﬁrm removal of all magnets if there is doubt whether all have been retrieved. (My personal experience is that fluoroscopy is particularly helpful if a colonoscopy is needed.)

Sharp Objects

My take: These guidelines are similar the previous NASPGHAN endoscopy committee recommendations from 2015. They are still worth a read for more context and there are a lot of endoscopy pointers in this report.

“Being a Doctor Will Never Be the Same After A.I.”

Posted on September 27, 2026 by gutsandgrowth

Rachael Bedard. NY Times 9/25/26: Being a Doctor Will Never Be the Same After A.I.

An excerpt:

“I have a confession: A.I. is making me a better doctor. And I worry that it’s making doctors-in-training worse…

I already use the technology in my practice all the time…This summer, I used an A.I. tool — a platform called OpenEvidence, accessible only to health care providers — to help me choose antibiotics for one patient and to interpret unusual bloodwork for another. A.I. reminded me to consider migraines when a woman presented with dizziness. ..

Almost every month, I’m confronted with a complaint or syndrome that I don’t recognize. I’m confident in my mastery over what doctors do — history-taking, reasoning, communicating. I’m less confident about my continued mastery of an ever-evolving universe of facts. Now, the chatbot in my pocket reassures me that I will always know enough, or have access to the cloud-based intelligence that generally does.

All of my students and residents also use OpenEvidence, however, and I worry about the consequences of introducing such a powerful decision aid so early in their careers. Not only have they memorized less than I’d like, but they can seem almost passive in their relationship to their machines…

OpenEvidence is trained exclusively on peer-reviewed evidence and guidelines, and includes citations for all its claims…To use the app well, you must stay skeptical as you scroll…

I’m surprised by how much I learn from, and enjoy, these interactions. More important, my patient care has improved as conversations with the agent push my thinking beyond its usual limits…

Adam Rodman, a physician and A.I. researcher at Harvard Medical School,… said he shared my concern that trainees aren’t benefiting from “productive struggles” as much as their predecessors. “In experienced hands, decision support might cause a little de-skilling, but a little de-skilling probably doesn’t matter much to you,” Dr. Rodman told me. “But if you do that to somebody who has much less skill, the cognitive offloading can cause never-skilling”…

Current doctors-to-be may be the most adversely affected generation when it comes to A.I. They’re training before we know enough about how to teach them well in this new paradigm.

My take: In all aspects of learning, not just medicine, using AI shortcuts may make learners increasingly dependent on their devices, undermine their judgment and hinder developing their own voice. How to best train individuals in this new era remains unclear.

Related blog posts:

Svörtuloft Lighthouse is located at the westernmost tip of the Snæfellsnes Peninsula in West Iceland. It is perched atop a 2.5-mile stretch of pitch-black volcanic lava cliffs.

Long-Term Effectiveness of Dupilumab for Eosinophilic Esophagitis

Posted on September 23, 2026 by gutsandgrowth

S Oliva et al. Clinical Gastroenterology and Hepatology; 2026 (Epub, 9/7/26). Open Access! Long-Term Effectiveness of Dupilumab in Eosinophilic Esophagitis: Results From the DUPEOETALY Study

Methods: This retrospective observational study included 167 patients, median age, 21.5 years, with EoE from 50 Italian centers, unresponsive or intolerant to conventional therapies. Given the real-world design of the study, no standardized protocol mandated patient re-evaluation at fixed follow-up timepoints. Histologic remission was considered having <15 eos/hpf. All patients, however, underwent at least 3 endoscopic assessments: at baseline, after the induction phase (performed between weeks 12 and 24), and at 1-year follow-up. At baseline, 76% had a personal history of atopy, 86.2% had used corticosteroids, and 94% had used proton pump inhibitors.

Key findings:

DSQ score decreased from 22.14 ± 26.63 to 0.21 ± 2.30, EREFS from 4.95 ± 3.43 to 0.07 ± 0.09, and Eos/HPF from 36.80 ± 31.75 to 0.06 ± 0.46.
Improvements increased with treatment duration. By week 72, 98.3% of patients achieved remission criteria (DSQ ≤5, Eos/HPF ≤15, and EREFS ≤2).
No serious or systemic adverse events were reported, and no patients discontinued treatment due to intolerance.

Remission criteria were defined as DSQ ≤5, EREFS ≤2, and <15 eos/HPF,
with complete remission achieved when all 3 were met simultaneously.²⁴

Discussion:

“Only a small proportion of patients in our cohort had a history of esophageal dilation (8.4%), which may suggest a relatively lower burden of advanced fibrostenotic disease…could partially influence remission rates and should be considered when interpreting the generalizability of our findings to populations with more severe structural disease.”

My take: This study supports the long-term effectiveness of dupilumab in pediatric and adult patients with EoE. It is not clear why there was such a high remission rate in this cohort compared to previous reports.

Related blog posts:

How Does Prior Topical Steroids Affect Response to Dupilumab for Eosinophilic Esophagitis In this study, the histologic response rate (<6 eos/hpf) was 61% in those with prior steroid exposure
Dupilumab (Dupixent) for Young Children with Eosinophilic Esophagitis (Published Data)
“Real-World” Dupilumab for Eosinophilic Esophagitis
“Tug” Sign For Eosinophilic Esophagitis and EoE Bowel Sounds Tips
When to Use Dupilumab for Eosinophilic Esophagitis: Multispecialty Guidelines
According to the study which you would never qualify for… (2023)
Landmark Dupilumab Study for Eosinophilic Esophagitis

Some good brief YouTube EoE educational videos for families from GIKids.org (with pharmaceutical funding), links:

Are you having trouble swallowing? (3 minutes)
My Child Chokes When He Eats (1 minute)

The Median Arcuate Ligament Syndrome (MALS) Study For Skeptics Like Me

Posted on September 21, 2026 by gutsandgrowth

MA Nassif et al. J Pediatr Gastroenterol Nutr. 2026;83:397–403. Outcomes of surgical versus conservative treatment inpediatric median arcuate ligament syndrome

Methods: This was a retrospective pediatric study (n=34) evaluating surgical versus conservative management in pediatric MALS. Conservative therapy included the following: 100% pharmacologic, 80% behavioral, 30% botulinum toxin, 20% neurostimulation.

Key findings:

Conservative therapy outcomes (n=10): resolution (20%), improvement (40%), unchanged (40%), and none worsened.
Surgical therapy outcomes (n=24) resolution (21%), improvement (33%), unchanged (17%), worsened (29%); thus, these outcomes are not signiﬁcantly different from the conservative group (p = 0.21). Median hospital stays: 4 days. Postoperative complications occurred in 21%. The one major complication was an intraoperative splenic artery injury in a patient with Ehlers-Danlos Syndrome.
Overall, 60% of children with MALS improved with conservative DGBI‐directed therapy and 54% improved with decompression surgery at long‐term follow‐up (at median 9.8 months), despite a robust short‐term postoperative response (87%). At 20 days postop: 52% reported resolution, 35% improved.

Recent follow‐up data show comparable rates of resolution and improvement between the two groups, with no statistically signiﬁcant difference (p = 0.21).

Discussion points:

Other studies have reported higher response rates for MALS surgery: “The newest and largest‐scale review suggests a 70% symptom relief rate in three of six pediatric studies, with follow‐ups of 6–62 months after laparoscopic MALS release.[28]”
“A more recent study conducted in 2017 determined that only post‐exertional abdominal pain was a predictor of a good surgical outcome.[31]”
“The lack of universally accepted diagnostic criteria for MALS remains a challenge.”

My take: In this study, surgery for MALS did not seem to improve long-term outcome more than DGBI therapy. If one finds celiac artery compression which may be identified in many healthy individuals (10-24% of population), it is unclear to me if an MALS operation is indicated and how to determine when it is indicated.

Related blog posts:

Experts Doubt Benefits of Popular Supplements. Yet, In New Survey – Nearly 80% of Americans Taking Supplements

Posted on September 20, 2026 by gutsandgrowth

Alice Callahan, NY Times, 9/11/26: Americans Love Supplements, but Experts Doubt Their Benefits “A new survey found that 8 in 10 Americans were taking vitamins, protein powders or other supplements. But experts said there is little evidence for many of these products.”

This article was based on a Pew Research Study with 3,554 U.S. Adults: Emma Kikuchi, Brian Kennedy, Pew Research Center, 9/10/26. About 8 in 10 Americans take supplements, and many see them as important to their health “Supplements are a booming industry, with an estimated global value of $209.5 billion in 2025.”

While the PEW Research study indicated that the majority of individuals taking these supplements thought they were very important for their health, the NY Times article stated the following:

“I would guess that well over 80, 90 percent of supplement consumption doesn’t offer any proven benefit to the person who’s taking it,” said Dr. Pieter Cohen, an associate professor of medicine at Harvard Medical School…

There are good reasons to take dietary supplements, for example to treat a nutrient deficiency or to prevent birth defects, said Dr. Eric Topol, a cardiologist and the founder of the Scripps Research Translational Institute. “But that’s the minority,” he added.

People often take omega-3 supplements because they believe they will improve their heart or brain health, for instance, but most clinical trials have failed to find those benefits.

And most people probably don’t need protein supplements, Dr. Topol said…in reality, most people already consume enough protein from the foods they eat, Dr. Topol said…

Supplement use…has increased in recent decades, said Elizabeth Kantor, an epidemiologist at Memorial Sloan Kettering Cancer Center. In June, she and her colleagues published a study that included more than 63,000 U.S. adults, surveyed between 1999 and 2023. Over that time, the researchers found, supplement use climbed to 60 percent from 51 percent of adults.

The rise in supplement use may be driven in part by claims of their benefits on social media, many of which are unsubstantiated, Dr. Topol said.

My take: Most people do not need or benefit from supplements. In addition, some supplements result in adverse outcomes. Supplements are often needed in individuals who are pregnant and those with previous intestinal resections and restricted diets.

Related blog posts:

How Effective Is Treatment of Eosinophilic Esophagitis In Patients with Rumination Syndrome?

Posted on September 18, 2026 by gutsandgrowth

D Yang et al. J Pediatr Gastroenterol Nutr. 2026;83:374–380. Rumination syndrome and eosinophilic esophagitis in children: Defining the relationship

Methods: This was a retrospective cohort study of children with RS and EoE evaluated at our institution from 2016 to 2023.

Key findings:

In this cohort with rumination syndrome, 22 of 230 had EoE. This is a significantly greater prevalence of EoE (10%) among children with RS than in the general population (0.1%).
Among those diagnosed with EoE first (70%), RS diagnosis occurred after a median of 15.4 months.
EoE treatment led to mucosal remission in 73% and improved dysphagia in 41%, but 86% continued to experience regurgitation.
RS treatment, including behavioral therapy and baclofen, improved or resolved regurgitation in 64%.

Improvement in Regurgitation to EoE vs RS ‐based treatments among patients with RS and EoE.
EoE, eosinophilic esophagitis;RS, rumination syndrome

Limitations: retrospective design and potential referral/selection bias in a tertiary care population (specialized center for rumination).

My take: In patients with both EoE and RS, regurgitation continued in 86% of patients who achieved EoE remission. Especially in those without dysphagia, most will need treatment of RS in additon to EoE. In addition, earlier treatment of RS may improve outcomes.

Related blog posts:

Balanced Fluid (like Lactated Ringer’s) vs Saline in Pediatric Sepsis

Posted on September 17, 2026 by gutsandgrowth

Balamuth F, Weiss SL, Long E, et al. N Engl J Med 2026;395:870-881. Balanced fluid or 0.9% saline in children treated for septic shock.

Key finding: No significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline.

MF O’Connor, J Bubeck-Wardenburg. N Engl J Med 2026;395:921-922. Commentary: Fluid Resuscitation in Patients with Sepsis — For Whom the Balance Tolls

From the commentary:

“Balamuth and colleagues report the findings of the Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS), a large, international, pediatric trial evaluating whether treatment with balanced crystalloid fluid (lactated Ringer’s solution, Plasma-Lyte, or Hartmann’s solution according to clinician discretion) is associated with better kidney-function outcomes than therapy with normal saline in patients with sepsis..

Evaluating more than 8000 children who were well matched with respect to the severity of sepsis at initial presentation, the current trial showed that the nature of fluid administered did not significantly affect patient outcomes…This finding contrasts with those of SMART and the SALT-ED trial as well as those of two other trials…^6,7

As appropriately recognized by Balamuth et al., less-severe illness in the participants in the present trial may have limited the ability of the trial to detect an influence of fluid composition on clinical outcome. Taken together, both adult and pediatric studies suggest that the clinical benefit of balanced-fluid administration correlates directly with the degree of cellular homeostatic disruption in patients with sepsis…

It is important to consider that harm has not been associated with the administration of balanced fluids in any clinical study. With the notable exception of patients with intracranial hypertension, the prudent approach may be to use balanced fluids as standard care in patients with sepsis.”

My take: For most children with sepsis, the outcomes are likely to be similar between those receiving balanced fluids and saline. However, sicker patients, which may be difficult to discern initially, may benefit from balanced fluids.

Related blog posts:

Is Lactated Ringer’s Better Than Normal Saline For Routine Use?
Choosing the Right IV Fluids Risk of hypokalemia with isotonic fluids with low potassium content
AAP Recommends Isotonic Maintenance IV Fluids
Optimizing Fluid Resuscitation in Pediatric Acute Pancreatitis
More Data Supporting Lactated Ringers for Acute Pancreatitis

Congratulations to NASPGHAN’S NEWLY ELECTED LEADERS: