J Vandenplas et al. JPGN 2024; 78: 386-413. An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow’s Milk Allergy

In this lengthy report, the authors provide 72 recommendations/statements -as such it does not do a great job focusing on key points.

Some of the points:

• Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow’s milk.
• Overdiagnosis of CMA occurs much more frequently than underdiagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2–4 weeks is recommended as the cornerstone of the diagnosis

Conclusions: “Accurate diagnosis, avoiding under- and overdiagnosis, is mandatory but remains challenging due to the lack of specific symptoms and adequate diagnostic tests…Reintroduction of CM protein in non-IgE-mediated allergy and OFC [oral food challenge] in IgE-mediated allergy are the “gold standard” diagnostic tests, yet these are often not performed by caregivers. As a result, there is a risk of overdiagnosis and the implementation of long-term elimination diets, posing potential nutritional risks. The choice of formula for the treatment of CMA should take into consideration cost and availability of the therapeutic formula. Cow’s milk eHF is the first choice treatment option.”

My take: Only a tiny number of individuals are going to remember 72 recommendations.

Related blog posts:

• Good Bowel Sound Podcasts: Cow’s Milk Intolerance and Hirschspurng Disease
• Overdiagnosis of Milk Allergy in Infancy and New Consensus Recommendations
• Best of Allergy Articles 2021 -Cow’s Milk Allergy/Allergic proctocolitis (Part 4)
• Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 3)
• Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 2)
• Best Allergy Articles 2021-Cow’s Milk Allergy
• Overdiagnosis of Cow’s Milk Protein Allergy in Infants and Formula Industry Influence

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.

GD Toit et al. NEJM Evid 2024;3(6) DOI: 10.1056/EVIDoa2300311. Follow-up to Adolescence after Early Peanut Introduction for Allergy Prevention

Methods: This follow-up trial (followed ~80% of initial randomized cohort) examined the durability of peanut tolerance at age 144 months after years of ad libitum peanut consumption.

Key findings:

• At age 144 months, peanut allergy remained significantly more prevalent in participants in the original peanut avoidance group than in the original peanut consumption group (15.4% [38 of 246 participants] vs. 4.4% [11 of 251 participants].
• Both groups (early peanut avoidance group and early peanut consumption group) had periods of prolonged peanut avoidance between 72 months and 144 months.

My take (borrowed from authors) Peanut consumption, starting in infancy and continuing to age 5 years, provided lasting tolerance to peanut into adolescence irrespective of subsequent peanut consumption.

Related blog posts:

• The Peanut Story -From NEJM Blog
• “Separating Fact from Fiction in the Diagnosis and Management of Food Allergy”
• Peanut Allergy Prevention Guidelines
• LEAP-ON Study: Early Peanuts Prevent Allergies
• The Peanut Story -Skin Patch Chapter
• Best Allergy Articles 2021-Cow’s Milk Allergy
• How Likely/Persistent is Eosinophilic Esophagitis with Peanut Oral Immunotherapy
• Georgia AAP Nutrition Symposium 2019: Food Allergy Immunotherapy
• The “EAT” Study | gutsandgrowth

Links: Prevent Peanut Allergy (National Peanut Board)

E Elkaragy et al. JPGN; 78:800–809. Efficacy of lubiprostone for functional constipation treatment in adolescents and children: Randomized controlled trial

Methods:In this single‐blinded, randomized controlled study with 280 patients (aged 8–18) s with FC, patients were randomized either to a weight‐based lubiprostone dose (n= 140) or conventional laxatives (n= 140), for 12 weeks, followed by4 weeks posttreatment follow‐up. Patients weighing <50 and ≥50 kg were administered lubiprostone 8 mcg TID or 24 mcg BID, respectively.

Key findings:

• Improvement in constipation was achieved in 128 (91.4%) patients in the lubiprostone group, and in 48 (34.3%) patients of the conventional therapy group (p< 0.001) and was sustained after treatment discontinuation
• Mild self‐limited colicky abdominal pain and headache were the most prevalent side effects in the lubiprostone group

In their discussion, they note that a clinical trial by Benninga et al., which was designed to evaluate the efficacy and safety of lubiprostone in patients with FC aged 6–17 years in a placebo-controlled design, concluded that lubiprostone was not superior to placebo in terms of efficacy (18.5% vs. 14.4% response rates), in contrast to this study.¹¹ Some of the factors that could account for the discrepancy: this trial did not enroll patients with a fecal impaction, lower enrollment of patients with prior laxative failure, and shorter duration of constipation.

My take: It is good to see pediatric data for lubiprostone! Particularly for milder constipation, it appears to be effective compared to typical laxatives.

Related blog post: Lubiprostone Study: Ineffective for Pediatric Functional Constipation

In the same issue of JPGN, a separate study showed that antegrade continence enemas may be helpful in children (n=33) with autism and soiling. One safety issue is tube dislodgement. In this study, the authors noted that three patients (9.1%) had inadvertent tube dislodgement, and all tubes were uneventfully replaced. One patient had behavioral issues that prohibited utilization of an ACE.

Related blog posts:

• ACE report -10 year effectiveness
• Pelvic AnoRectal Care Program (PARC)
• Do You Know the Best Way to Use Antegrade Enemas?

JM Sharfstein, LO Gostin. NEJM 2024; 390: 1637-1639: The Public Good on the Docket — The Supreme Court’s Evolving Approach to Public Health

This article provides a great summary of how the current Supreme Court has undermined the ability of Congress, federal agencies and states in their efforts to safeguard public health.

Some excerpts:

The preamble to the U.S. Constitution states that a central aim of government in U.S. democracy is to “promote the general Welfare… From the earliest days of the republic, U.S. courts have upheld public health laws and regulations in large part on the basis of their importance for protecting the well-being of communities…

Under the Constitution, states have the primary responsibility and authority to protect the public’s health and safety — often termed “police powers.” In Gibbons v. Ogden (1824), Chief Justice John Marshall observed that states have a long tradition of enacting “inspection laws, quarantine laws, [and] health laws of every description.” In the landmark Slaughter-House Cases (1873), the Court affirmed the states’ power to safeguard health, even when doing so requires restricting liberties. The foundational 20th-century case is Jacobson v. Massachusetts (1905), which upheld the authority of states to mandate smallpox vaccinations…a social compact that recognizes not only the rights of the individual but also the needs of a community “to protect itself against an epidemic of disease which threatens the safety of its members.”

In recent years, however, the Supreme Court’s majority has increasingly blocked states from using public health evidence to protect community safety. During the Covid-19 pandemic, the Court struck down public health orders in California on the basis of religious-liberty concerns…

For most of our country’s history, the Court consistently upheld a wide variety of firearm-safety laws. But in New York State Rifle & Pistol Association v. Bruen (2022), it struck down a New York law requiring applications for concealed carry permits by demanding that laws regulating firearms be “analogous” to laws enacted in the 18th and 19th centuries — even though current high-capacity, powerful firearms bear little resemblance to guns that existed early in U.S. history…

 For more than 200 years, courts have accepted that Congress has the power to charge federal agencies with carrying out laws to protect the country’s health and safety and the environment…Yet today’s Supreme Court is significantly constraining the authority of Congress to provide broad direction to agencies. In West Virginia v. Environmental Protection Agency (EPA) (2022), the Court announced a new “major questions doctrine,” holding that Congress must, in advance, spell out specific hazards and the actions that an agency may take to address them…

This term, the Court appears to be poised to…invalidate the long-standing Chevron doctrine, whereby judges give deference to expert agencies in resolving ambiguities in the laws they enforce. Absent Chevron deference, judges will be able to substitute their judgment more readily for that of agency scientists…

In FDA v. Alliance for Hippocratic Medicine, the Court will determine whether the FDA can set science-based policies governing access to mifepristone, a medication used for abortion…The case comes in the shadow of the Court’s decision in Dobbs v. Jackson Women’s Health Organization (2022), in which the majority not only abandoned the right to abortion established in Roe v. Wade after nearly 50 years but also criticized the Roe Court for considering evidence about abortion’s relevance to women’s health.

My take: This court’s rulings have already resulted in profound consequences for public health and individual freedoms. In addition for trying to claim “historical” precedents to establish rulings (when it conveniently the interpretation conveniently aligns with their predetermined views), the court is undermining the role of expertise at every turn.

Related blog posts:

• Historically-Stupid Opinion in Bruen Case Endangers Vulnerable to Gun Violence & Ajay Kaul Bowel Sounds Podcast
• Genus Medical Technologies v FDA -Lack of Judicial Deference to FDA Expertise
• The Harms from the Supreme Court’s Bruen Decision
• Supreme Court Justices “Play a Deadly Game”
• Why GlaxoSmithKline v Teva is Important for Medication Affordability and “Please Look at My Baby”
• Public Health Laws Weakened After COVID-19

NY Times 4/24/24, D Lamas: Skepticism Is Healthy, but in Medicine, It Can Be Dangerous

This commentary starts with a sad anecdote about a physician trying to navigate a difficult end of life decision and transitions to a discussion of public trust in medicine.

A few excerpts:

We are at a crossroads in medicine when it comes to public trust. After a pandemic that twisted science for political gain, it is not surprising that confidence in medicine is eroding. In fact, trust in medical scientists has fallen to its lowest levels since January 2019...

But our medical system relies on trust — in face-to-face meetings as well as public health bulletins. Distrust can lead doctors to burnout and can encourage avoidable negative outcomes for our patients. This is partly what is driving increasing rates of measles among unvaccinated children, failure to follow recommended cancer screening and refusal to take lifesaving preventive medications. There are no easy solutions here. But if we do not find ways to restore and strengthen trust with our patients, more lives will be lost.…

When that skepticism shifts into abject and irreparable disbelief, we see some patients make dangerous decisions…Trust can sometimes be repaired by clearly presenting facts and figures, but it is about more than explaining numbers…

Many of our patients started their medical journeys wanting to believe in their doctors. But then the medical system that they wanted to trust failed them, in small ways and large, from haphazardly rescheduled appointments to real medical error…

For her patient and family facing an end of life decision, “they left without a word, carrying with them his bags of belongings and —I can only hope — faith that we had done the best we could.”

My take: Trying to understand distrust and navigate hostility is one of the most difficult challenges that physicians face. It is difficult to witness patients and families make decisions or omissions in care that lead to worsened outcomes.

Related blog posts:

• “Mistrust in Science –A Threat to the Patient-Physician Relationship” (2019)
• NYT: Do You Trust the Medical Profession? (2018)
• “March of Science” (2017)
• Science in a Hyperpartisan Age (2017)

Humor: Skepticism with Scooby-Doo Can Be Dangerous Too (& funny) -last week’s SNL Scooby-Doo skit

TF Danialifar et al. JPGN 2024; https://doi.org/10.1002/jpn3.12151 Open Access! Genetic and acquired sucrase-isomaltase deficiency: A clinical review

Most Common Presentation by Age:

Key points:

• 37 potential SI gene variants, including the four most common variants seen in genetic sucrase-isomaltase deficiency (GSID). Some variants have isomaltase activity and individuals with these variants can tolerate/digest starch
• Children with disorders of gut–brain interaction (DGBI) with a primary complaint of loose stools were found to have a higher prevalence of SI pathologic variants, the vast majority heterozygous, compared with those in a reference consortium database (4.5% vs. 1.3%, respectively).²⁸ Children with DGBI who had primarily abdominal pain did not have a higher prevalence of SI pathologic variants
• Disaccharidase testing: Disaccharidase assay on duodenal mucosal tissue homogenates is currently the gold standard for diagnosing overall SID…One in five cases with pan-disaccharidase deficiency of all four or all five evaluated enzymes may be associated with heterozygous SI mutations and sucrase deficiency.³⁹ A ratio of sucrase to lactase at 1.0 or less has been proposed as a guide to CSID, but may miss cases
• Genetic testing: Genetic tests for four common mutations up to the entire SI gene are commercially available.^9, 39 The test is typically performed using genomic DNA extracted from buccal/cheek swab and blood samples. One specialty laboratory also accepts formalin-fixed paraffin-embedded biopsy tissues and other biopsy samples.
• Diet: Good dietary advice is provided in Table 3 (see below).
• Sacrosidase Treatment: Dosing of sacrosidase is weight-based, with a recommendation of 1 mL for patients weighing less than 15 kg and 2 mL for patients weighing more than 15 kg. The enzyme should be taken with each meal or snack, mixed into 2–4 ounces of room temperature liquid, and divided with half taken before the meal and half taken midway through

Related blog posts:

• Health Benefit from Disease State: Sucrase-Isomaltase Deficiency
• Disaccharidase Deficiencies in Recurrent Abdominal Pain
• Congenital Sucrase Isomaltase Deficiency

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.