after eating, so hopefully you all are enjoying the movement. So I'm going to talk us through what they say adolescent EOE. I'm going to be honest. It's a little bit of pediatric EOE, but that's OK. We can handle it. Pediatric and adolescent case number one, which is a 12-year-old. For me, this is pediatrics. I know you guys are worried about your pediatric indication, and I'm thrilled if we can go lower. But for sure, 12-year-olds are officially pediatrics. So this is sort of a classic pediatric case. It's a 12-year-old male, comes in with poor growth. Again, his friends are all starting to hit adolescence, and he seems to look exactly the same and is clearly getting now outstripped by his classmates who are now being picked for baseball teams. And he's still in minor B, so his parents want him to get bigger. But when you start asking, you're getting descriptions of him being a slow eater. He chews very carefully. You can ask, and this child will say, nope, nothing. Nothing gets stuck. He doesn't feel acid reflux. Maybe he has nausea and burping. He does have asthma and seasonal allergies. And mom will start, all parents do this. They'll start telling you when they were a baby, they would vomit easily. But now, this has seemed to get better over the last few years. Okay, so what do you want to do next? Who wants to do blood testing for celiac disease? Wouldn't be a terrible answer, but it is not the right answer. Upper GI, anybody? Endoscopy, anybody? Got some, okay, got some hands, good. And start PPI, BID, should we do that? No, that would be very, very, very old school. We no longer go straight to PPI. We are now doing endoscopy, right? So that's the next thing we want to do. I am going to zip through this, because this, to me, feels very much like, I don't know, we're getting now the same information. But we do diagnose EOE often in school age years. And then again, when they are presenting with their food impactions, the presentation really does differ by age. So initially, it's really more of a feeding disorder. There may be more vomiting that starts to happen. Abdominal pain may or may not be something that kids will start to complain of when they're preteens and teenagers. But you're really not seeing the dysphagia and food impaction until later. And of course, that's all about this natural history of EOE and this concept that we're really worrying about chronic inflammation as why, as adults, they'll have the fibrosinosis and stricture formation. So this concept of progressiveness is something, as we were talking about, that we really are explaining to families right at the get-go. There were some nice reviews more recently about how are children and adults different. And in some ways, they're very similar. So you could try to make a big thing out of these little differences. But the truth is, the big difference is kids are less likely to complain of the actual impaction. But they are noticeably not eating the way that their peers are or their siblings are. And their parents will pick up on that. All right, so another thing we deal with is persistent reflux. So all babies reflux to some extent, but they really should outgrow it by a year to two years of age. And you just have a sense that somebody's just not outgrowing their reflux. That should be a bit of a red flag. The slow eater, last at the table, chews very carefully. I tend to, I ask a question I say to any kid, because I feel like almost any developmental age can answer this, can they feel food go down? You know, you're really not supposed to be able to feel food make its way from your mouth to your stomach. So if the child says, oh yeah, I feel food go down, okay, that starts to be a red flag for me. A lot of overlap with GERD symptoms. And yes, there's one of NIMI's studies, there was one of them. But you know, this really, this concept of GERD symptoms and heartburn can overlap with EOE. The eating behaviors do differ by age. So basically, I don't know if you guys can see this and you have the slides, but you know, infants and toddlers may have longer meals, that could be the complaint. And then they have different coping behaviors. So smaller ones, they may prefer like a texture thing where they're gonna prefer soft foods to more solid foods. So these are kids who can't seem to eat anything crunchy. They may pocket their foods in their cheeks, like when they're toddlers, and they spit food out. As you get older, you start realizing that that's really gross and you don't do it at the table. But you know, when they're little, that's how they're coping. And then really the families are reporting that are having difficulty advancing beyond purees. And then, you know, very different is an adolescent. And I think by the time you're in adolescence, and certainly in grade school too, there is really a sense that they are almost avoiding eating. So this concept of avoidant restrictive food intake disorder, I think a lot of us are interested in how it overlaps with ARFID. And I think ARFID is a gigantic umbrella that probably a lot of different things can play into, but EOE is one of them for us. Any questions on that? Is that okay? So we do think regardless of age, any suspicious symptoms, you should be thinking about endoscopy. It is the only way to make this diagnosis. And then we're always eliciting, you know, like atopic history in the patient themselves or in the family. I think really understanding that the family is coming in. All our pediatric patients are accompanied by their parents. Not one of them has driven themselves there. Even the 21-year-olds come with their parents. And you really can like ask about, you know, you can really get a good family history. So that gets really important. And of course now we are definitely seeing, oh yeah, I have EOE or my husband has EOE. So definitely the parents themselves have this diagnosis, which is just in the last five to 10 years. You know, pediatric appearance, we see all the usual ARF features, but we're rarely gonna see that true stenosis. We'll maybe more see edema and less like a true stricture. I mean, you see them, but they're not as common. But otherwise we really have all the same stuff. I have all the same discussions with my pathologists. And then this concept of it can be a transmural process. So you really need to think about, especially if it's particularly fibrotic and I did get that tug sign, I want my pathologist to go deeper into the cuts to get into the bottom. So, you know, again, I think there's been a lot of tries. They, how's it different from adults? I disagree that kids, we don't see rings. Rings are subtle. So you do learn. I actually think I probably pick up on rings more than my adult colleagues because I'm looking for subtle rings. Everyone knows, I think normal, this is normal esophagus. This is sort of just a classic EOE. These, all this stuff here, I think, oh, I keep trying to figure out where the pointer is. Is there a pointer? There's a pointer. I'm not sure. Okay, here. All this stuff looks like yeast, but of course is more likely gonna be one of these eosinophilic microabscesses. So, and there's degranulation going on. So we, because we don't have the strictures, we rarely need to dilate. But, you know, that is something to think about. We will see edema. We'll see inflammatory narrowing. So really our focus is dealing with that. So, okay, what's that underlying inflammation going on? And is it EOE? And then we want to focus on being done on basically treating the underlying inflammation. And I, you know, what I would say that's really, really important for people to understand is dilation is just doesn't treat inflammation. So, you know, you can keep dilating, but really the goal is to treat the underlying inflammation. Okay, case number two. This little slightly older guy, 16 year old. He's coming in with an acute food impaction. So I think this was a real patient of mine right before the course last year. So this guy was at a barbecue eating a chicken sandwich. He'd felt the food get stuck about eight hours prior. He said, oh yeah, this happens to me about once a year. He said, yes, I might, you know, if I eat too fast, so everyone tells me to slow down. I mean, you know, some of that slow eater is these kids have been told to eat slowly because they will say that food's getting stuck. So someone says to them, you need to chew your food more, right? So we're kind of, the family inadvertently may be perpetuating the slow eating. And then he drinks, you know, sips water, coughing. I think we were talking last night. Some patients will like hop on one foot then hop on the other foot. I mean, they're doing anything they can to try to get it to move. And this guy's uncomfortable. He's breathing well and he's swallowing saliva. Okay, so he's got all the classic things that you would think about. He's a nice kid. He's thin and quiet. You know, has some eczema. That certainly has the history of atopy. Okay, so what do you want to do next? Anybody? And I do get that one, the ER docs. Should we give him some Coca-Cola? No, don't do that. I mean, you can try the glucagon again, but glucagon is like, if this is really edema or inflammation, it may or may not work, right? So it really gets into what is glucagon doing. The thing that could have been a little bit more of a hot topic is do I need to scope this guy right now? Anybody? Who wants me to run in and scope him? Mimi says she does it as a level one trauma. I think my hospital would die if I suggested that. You know, honestly, for me, it gets into what kind of staff do I have? So my endoscopy techs are done at 8 p.m. At UMass, we had techs who were available until I think it was 9 p.m. So that means if I'm gonna run into the ER at, I don't know, nine o'clock, I actually am setting up the scope by myself. That's not so much fun. We were all taking turns being techs yesterday. I'm trying to do a food disinfection by myself. It's like very unpleasant. I mean, I have the OR staff, but they're completely looking to me to tell them what to do. I have a fellow with me. The fellow's looking at me. It's not where, I really, I wanna wait till tomorrow morning. So this guy is handling his own secretions. He's a little uncomfortable, but he's really a nice kid. And I say, sure, we'll do it first thing in the morning. So, yes. If I remember correctly, there was a little bit of food retained in the esophagus, it sounds like. Would it make a difference to you depending on what it was that they ate as to how caustic that food was to the esophagus? No, no, anything stuck in the esophagus long enough is gonna macerate it. The truth is, he did this, this was eight hours ago. He's been working on it himself. I think he's already gonna have a macerated esophagus. Again, this is potentially, this is one of those things that you could have 15 gastroenterologists and do a poll, and they're all gonna do it differently. What I want you to hear is it's much more about, there's some medical indication for this. Nimmy is describing a hospital that is going along with her, supporting her, an ER that's ready to do what she's saying, an OR that can handle it. I don't know why she's able to have that. I'm at a very, very large hospital, 450 beds. We regularly are having, I mean, level one for us is level one trauma. I'm sure Nimmy has it too, but I'm just saying, the surgeons are gonna look at me like I'm crazy with this particular very comfortable-looking kid who had swallowed this eight hours ago. I'm really thinking about, okay, what's involved for me, and that may be terrible to be saying that, but it's very real. In some ways, it's safer to do it once I really have my endoscopy unit. By the way, John Martin's back there snotting, so we won't ask what the man's like. Again, I'm not saying I don't have a great crew. It's just really, it's gonna be your local resources that will determine how fast you wanna do this. All right, so this guy is certainly typical. He's male, he's thin, he's atopic, has a history of food allergy, the family history. Peripheral eosinophilia, are you guys talking about that at all with your people? There's a little bit of literature out there on you can have peripheral eosinophils. It's never something you wanna hang your hat on, so just if you don't have eos in the CBC, that doesn't mean you don't have EOE. Everyone follow all those negatives, okay? But if you've got this person, and they're like, oh, I have some chicken in there, and the ER gets a CBC, and the eos are 8% or 10%, yeah, you're not surprised. I mean, this guy has eosinophilia, and has eosinophilic disease. The spring and the fall is really that seasonality that we've been talking about, which is very real. Okay, I am gonna move very fast. Anybody see anything here they want me to talk about? I can. Okay, so we have diagnosed EOE in my athlete. What should I do next for him? Advise a six-food elimination diet, high-dose PPI, and then follow-up endoscopy in two months. High-dose PPI and no further endoscopy, or starting topical steroids. Anybody? High-dose PPI and follow-up? Yeah, I mean, this guy has never tried anything, and again, I'm sure he has EOE, but there is certainly PPI responsiveness, and that's been very well-described, even at one point was potentially its own condition. But I think we have not had until recently, this slide is missing, your wonderful medicine, but we have not, we have really not had that in the mix. We've had PPI, the steroids, all this stuff, everyone said, and then there is one big difference. Okay, so, yeah, so I think you do need to discuss this with the parents, so that's the big difference, right? It's like I'm dealing with, it looks exactly the same, it's just the shared decision-making isn't just with my patient, okay? A 16-year-old has opinions. They don't ever wanna come back for another endoscopy, but I think the problem is you have the parents involved, and frankly, sometimes a 16-year-old is like, hand me the dupilumab, and then the parents are like, no way, we wanna be natural. I'm in Massachusetts, there is the Republic of Cambridge across the water, and they are very hippie-like, and they have no interest in any medicines for anything, so it's very tricky for all of us. So I think there are communities out there like that, so you are definitely doing this with the parents. All right, PPI and responsiveness. I think, you know, EOE can be highly responsive. It's really quite dramatic for some patients, so this was well-described, actually, by a colleague of mine at Children's in 2006 with Glenn Farood as the senior author on this, but we've all had this experience. You take somebody, they have 100 EOs in every level of the esophagus, you put them on PPI, and it completely goes away. I mean, it is extraordinary. All right, dilation. So I have now had a couple people say, do you dilate? Yes, occasionally we dilate, and again, I think these days we're feeling more confident that it's not going to be at higher risk for perforation than for dilating and other reasons that we dilate, often around congenital anomalies. It really needs to be these high-grade strictures. There is data out there showing dilations in the pediatric EOE is safe. We have very similar goals of our dilation. And of course, now we've played around with what it looks like after you dilate. Some people describe this as an apple core. You basically, you really want to get that sense that you stretch the esophagus and you should see that bleeding. If you don't see the bleeding, you didn't do it, so you didn't do enough. I think FLIP is fascinating. I definitely think this is actually from a poster of mine at DDW in 2015, so we've been playing with this for a while and I think it's probably the future for all dilations to get this technology better. To me, this is so much better than just blindly dilating. Okay, so I want to talk a little bit about oral budesonide. I can't remember if we've really tackled that in this course so we've been talking about it. It's this slurry that we make and this was a randomized placebo-controlled trial that involved two milligrams of budesonide mixed with six packets of Splenda and some water. I mean, it's disgusting, I think. These days, I'll use more maple syrup. It is very difficult to get something that will stick on the esophagus. It's pretty clear that oral viscous budesonide is better than the swallowed Flovent, though that data is now out there. But the whole thing feels like a chemistry experiment. I'm sending the families home to make this thing. We're definitely into off-label. So, suffice it to say, we are a little frustrated with our FDA right now. This is being recorded, which is dangerous, but you guys will be on record with that. All right, so here is another guy. This one was memorable because he actually presented at UMass and my adult colleagues took care of him but then said, we need your help. We don't know what to do. This was, I don't know, 2017, 2018. So, this is a very large guy, so a six foot five quarterback. So, his esophagus was probably 45 centimeters long. It was a big esophagus. So, he came to me for, quote-unquote, second opinion. But basically, his story was he had shown up with a food impaction, he'd had a history of this, and the way he would relieve them was he would drink milk, which is like meh. And then, basically, they were dealing with this really impressive food impaction somewhere in his very long esophagus and they literally couldn't do it with the flexible scope. Surgery got involved and attempted to do it with a rigid scope, but they literally could not reach it. So, ultimately, they did a thoracotomy, esophagoscopy, and they were actually able to get the food out and then he wound up in the ICU for the remainder of his junior year of college. I mean, it was not good. So, after he got better from that, they started him on protonics. He went back to playing football and they had him swallowing the flow vent, which, again, you're gonna swallow the flow vent, it's gonna maybe make it 10 centimeters down. So, he has a long esophagus that this wasn't doing very much with. So, anyway, they did repeat an endoscopy and at that point, they were like, we need help. So, this is his images. You can see, I think it's just fine. Okay, what do you wanna do for this guy? So, he's on that swallowed flow vent. Anybody? Yeah, so that's what I kind of wound up focusing on. It was like funny. I had this very large football player who frankly wanted to be able to eat because he plays football. I can't remember what school he was at, like Salem State or something, but he was like I'm telling him about the six food diet and he's like, yeah, I can't do that. Let's start focusing on dairy, especially because he sort of gravitated towards dairy. I was like, let's just cut that out. And I think I put him on PPI. I may have tried more of a slurry instead. But again, he's at college. So like doing that chemistry experiment in your dorm room, you know, getting, it's just, it's like, come on, that's not going to work. So anyway, we focused on dairy. And you know, I think the history of diet and EOE is fascinating. It's very clear that elemental diets like an amino acid based formula can make an enormous difference. You can literally take somebody from 50 EOs per high powered field down to none. And you know, this is the published original published study from Dr. Kelly. And then I know, you know, it's a difficult diet. So this was sort of early on when we were trying to say to our adult colleagues, hey, you could try this. And they're like, yeah, no one's going to do it. It does. I actually love Nimi's story about having a debate with this guy, Chris Lyakouras. But you know, it's funny because maybe you'll do it if you're really motivated. But it's hard. I think where we are now is without a doubt, you can't do selective diets, or you can do selective diets, but the directed ones are just not useful, empiric. You really have these options of the six food, the four food, the two food, the one food. And of course, you can do an amino acid based formula. You can set. So this gets back into that question, do I send people to an allergist? Well, they've never had anaphylaxis. So you know, we're not really dealing with that. And so then what will the allergist do? They'll test them for the most common allergens. So those are the ones that are really on my menu to eliminate. And so this is like data that we've already talked through. This is how I talk about IgE and non IgE. I'm really into the non IgE world. In terms of the empiric elimination diets, you do have, again, data on six food elimination diets in adults. But it's hard. It's just very, very hard. And I think to not acknowledge that is like doing the patient a disservice. And again, some of them from Cambridge are ready to do whatever, they're ready to cut things out. Most people are like more honest, that it's just not really possible. So I think there's been a lot of trying to figure out, well, what exactly is the food, how to reintroduce, etc. We've been talking through this. But I think this is probably really the most important thing is to recognize that while an elemental diet, this is this thing here, this, this is your amino acid based formula, this is clearly going to be essentially, it's very good at getting rid of eosinophils. Here's your six food data for kids and adults. And here's your here, sorry, here's your one food. This is Karina Venter's data, but she showed a 65% response rate with milk and kids. There's been more data since this, the four food, you're actually seeing just one that one food milk makes all the difference. This one here is the directed, like you do an allergy test, and just take out what the allergist, it's really for me, it's become all about milk, can I get people off milk? And so this is some data on this, this is more data on this, more data on this. I mean, people are really, you know, I think that this at least is giving us something that's reasonable to do more data. Essentially, the less you have to cut out of the patient's diet, the less you have to think about, okay, what are the nutritional implications of that. But you do have nutritional considerations. Every time you tell someone to start cutting things out of their diet, you have to be careful. I do work a lot with dietitians, we haven't necessarily talked about the role of the dietitians in EOE, but they're a big part of our multidisciplinary clinics. And again, this is going to be stuff, you know, that we will talk about with the families. But at this point, it's really a matter of, you know, educating everybody, assessing the child. I mean, I'm, again, dealing with often thin patients. And the football player was, he wasn't thin, he just needed to be able to remain at whatever size he was at. And so he was like trying to eat a lot, so how to help him with that. And then, you know, definitely understanding the barriers to what that's going to be. And if it's that the family doesn't buy it, you know, they don't get it, the allergy test was negative to milk, why am I telling them to take milk out? Okay, let's start talking about that and I'll, I flip past it, but I'll try to explain non-IgE allergy or what you guys are calling type 2 allergy. But I'm really focused on that, that very important, huge arm of the immune system. Okay, two year old, failure to thrive. How am I doing on time? I have no idea. Are we, two more minutes, five more minutes? Okay, no one has asked any questions. Anyone have any questions? Yes. Yes. So, two questions. One, because I'm not a doctor, I don't know if I'm going to be able to do this. I don't know if I'm going to be able to do this. There's just an atopic focus. Do kids grow out of the EOE condition? Have you seen that progress from that age? That is a great question. I do think we have to be very careful getting, calling it EOE, like making that diagnosis and giving a whole line and spiel about this is a chronic progressive disease, and your two-year-old, who I'm about to talk to, is going to have food impactions when they're 40. First off, that's hard to, the two-year-old at that point isn't, but even the parents can't quite get that, and I have definitely seen esophageal eosinophilia disappear, so what is that? And I just had a patient last week that we were talking about it, but just giving this diagnosis can, for some families, they take it very seriously. They're all over their kid. It really impacts quality of life and discussions, and so I think we have to really embrace that and understand that more, that there's clearly a population of kids that it's not EOE, it's more of a transient phenomena. If that, does that answer your question? Okay. And the second question was, in the cases that you just described to us, 12, 16, 21, PPI's prominent, but in a lot of the things that we interact with our pediatricians, steroids is more prominent. Is there a line in the sand that says, all right, younger, I'm gonna go more steroids because I'm gonna treat it intermittently, I'm gonna go PPI's, I'd like to hear that opinion. So, just like was, I think, talked about, we've all just gone through an adjustment in our PPI prescribing habits, and a lot of political correctness right now around PPI. So it's, I will be about to be officially unpopular and perhaps non-politically correct. I've always worried that we did some weird overcorrection with PPI. I am now seeing erosive esophagitis in kids that I had never seen before because we were treating them for reflux. I'm not talking yo-yo, I'm talking peptic disease. I am, and I'm seeing that in very, very young kids. We were giving many, many, many babies PPI. I don't think we needed to give all of those babies PPI, but we needed to give it to some. So it's on us to figure this out more. And I think what you're seeing are my colleagues afraid to give PPI. It's not necessarily being covered by the insurance like it was. Finding a formulation, although there is now, I will tell you, as of two months ago, there is dissolvable omeprazole being made by CVS. I go on Amazon and get like, I think it's 60 dissolvable tabs, like solutabs, for $14. So I told my patient, before I go crazy with the insurance company, can you handle $14 a month for your PPI? And mom said yes, so I said thank you. But I think we haven't had that until very recently. So in other words, I think, I still believe in PPI, and as I talked about, I think there's a lot of overlap between the PP, like GERD and EOE, and then there's PPI responsiveness and all of that. Yes, I think PPI is still where we start. You didn't get a lot of steroids on the PPI? You know, again, I don't think the steroids have been perfect, right? So the steroids are using asthma medications incorrectly, swallowing Flovent, trying to make a slurry. How do I tell my college student to go in his dorm room, open Budesonide splenules, you know, it's very, so anyway, so yes, I think, I'd like an option with, I say to my patients, it's like putting hydrocortisone cream on your esophagus. I'm attempting to do that. I'd like something that does it for real, but it's certainly, it's like putting hydrocortisone cream on eczema. It sort of controls it, but it's gonna flare back. You haven't dealt with that inflammation. Okay, yes, sorry, yeah. I have more in favor than a question. Okay. Can you clarify for the audience, lactose, milk, dairy, whey, especially in the case of 16-year-old athlete who's probably chugging down protein shakes? Yes, yes. And I think this is something that we encounter and everybody's confused, including patients, and we have to be very careful what we're actually saying. And then the other question is, you didn't talk about non-hygiene-mediated allergy. Because I saw you have that. I flipped past it, I flipped. Well, we've been talking about it. Show that picture. All right. So, I mean, I feel, so first off, yes, the thing that's triggering allergy, or the antigen for milk, is not the carbohydrate in the milk, it is the protein in the milk. So it's either casein, or it's whey, or usually it's both. And so going to a lactose-free option, and the parents say, we cut out dairy, we're buying lactate, and I'm like, no. Okay, let's start again, and then I'll try to explain it to them again. So I really need them to cut out the proteins, which is the casein in the whey, and you're absolutely correct. These days, whey powder is everywhere. So, again, my teenage football player is attempting to build his muscles. He's without a doubt doing that muscle milk and the whey proteins and the shakes. He's just bringing out his EOE. And so really explaining that to families, that it's about the protein, to the patients, it's about the protein, gets really important. I did flip past this. This could be a lecture unto itself. I don't want to go too into it, but the bottom line is, so much of allergy, so much of immune-mediated, antigen-triggered, right, phenomena does not involve IgE, which is made by B cells, which can trigger cross-link with mast cells and have them degranulate. So I, okay, here. So that's this part here, right? So your EOE is mostly gonna be, indeed, it's a Th2 differentiation, but it's triggering the EOs this way. And then we also have types two and four, and three, but I think types two and four allergy, so you have four major types of allergy. Type one is immediate hypersensitivity. That's this axis, but the very same antigen-presenting cell that undifferentiated T cell, oh, am I, I'm doing it here, but you guys can't see it. Well, okay, this guy here, undifferentiated, he can also go towards a Th1, you know, basically be triggered to become a Th1 cell, and that is a whole other pathway. Okay, I want to see some nods that you guys at least list out. Okay, good, good, okay. Yeah, so that's such an important phenomena and important for everyone to understand, and I think so amazing that it's the same antigen-presenting cell that gets to decide what it's gonna do, and it does explain why we see these little bits of IgE, but really, they're having a very profound reaction that has nothing to do with the IgE. Did I do okay? Yeah, yeah, well, yeah. You, again, I might be wrong. Non-antigen-indated allergies, Th2, right? So this is IgE right here, right? Okay, and so to get to an IgE allergy, you have to differentiate into a Th2 cell, stimulate through IL-4, the B cell, to make IgE, to milk, right? This Th2 cell could also trigger an EO without making IgE, but you could see how you get it mixed, right? It's doing a little bit of that and a lot of this. You know, there's a lot of complexity to this in terms of, and I don't think it's always, all these cells can do multiple things, so they're sort of triggering multiple things at the same time. Okay, now I'm seeing some nods, so that makes me feel happier, yeah. So I hear a lot of times, like the GIs will send them to the allergist because they don't, maybe they might not understand this. They do not understand it. So do you have like a good way to like how we should verbalize that? Well, so, you know, obviously I've become a believer in this, probably for a number of reasons. I went to medical school at Mount Sinai School of Medicine where I was learning from some amazing immunologists who were all assistant professors at the time and now may go off and win the Nobel Prize. I don't really know, but it's really, you know, it's an amazing place to learn immunology. And then I'm, I don't know, maybe I listened to my patients and they got interested in non-IgE allergy early. Milk protein allergies are very common phenomena in infants. That's almost entirely a non-IgE-mated phenomena. EOE, obviously, there's FPIES, food protein-induced enterocolitis syndrome. So this is just the, you know, in some ways you guys are the tip of the non-IgE world from a GI perspective. All of it causes poor eating, poor growth, you know, so it's like differentiating and trying to decide what's going on is tricky. How to elevate this among my colleagues, I don't know. I think we just need to recognize that we need to keep talking and thinking about it and maybe embrace it as gastroenterologists. I think we've been waiting for the allergist to pick it up and they don't have to. They don't see these patients. We see them. They're all coming in with their poor feeding and discomfort. So I think, you know, I have my influential ways-ish. I'm not on social media, but I stand up in front of large groups and, you know, trying to talk about it. And people are willing to talk about it. It's just, the only thing we know to test for with allergy is this. That's the only thing we have a test for is IgE. The rest of this is a bit of a laboratory study right now, really. Okay, yeah, go ahead. I have a practical question. So I don't know if you saw recently that some information has come out about Splenda and the possible genetic damage caused by sucralose and obviously we're using that in lieu of sugar like honey because we don't want to be giving kids sugar twice a day and the tooth decay associated. So what's the next best thing if we're learning now? I mean, in college, I had a friend who every time she had Splenda, she had a seizure. So I stopped having it right then. But now we're actually showing that there's DNA damage from Splenda. So what's next in terms of mixing BDSM and cholesterol? Yeah, so first off, I think many of us have abandoned Splenda. So that was sort of the original recipe, but frankly, I always worried. I mean, a number of us are in the room to remember saccharin. Remember my grandmother used the little saccharin things and then it was like, ooh, maybe that's cancerous. So I was like, I'm afraid of cancer. So I think it's really been like these non-nutritive sweeteners are problematic. They're related to obesity too, which is a really interesting discussion. So without even, so anyway, I mean, the original recipe, that original study was we'll make a slurry using Splenda. I use, I personally, if I'm gonna use it, which I will, I will say maple syrup. I find most people will have a tablespoon of maple syrup and they can mix it in that. Has anyone done the study to show maybe, there's some like abstracts out there where they're like, yeah, it works. I don't know. Is it sticky? Is it not? In Europe, you can actually get something that's formulated to work. We got very close, I'm sure you guys know this, and they rejected it and it's like, for what? You know, why? And it left us, I think it's left us in a very awkward position. So that gets into the outcomes that the FDA is looking for and I know you guys are way more expert than I am at that, but it's a very tricky discussion, you know, that I think the GI societies need to embrace this, have more conversations with the FDA about, okay, why are you making this so hard? Because it's putting us in a ridiculous place and Splenda, I don't think is the answer. Okay, very quickly, I'm just gonna move to the two-year-old very fast, just because I think he's a little different. So this is a two-year-old. So this is sort of a classic two-year-old. So they're irritable, they're not a very happy guy, they've got eczema, knows, has had a peanut allergy, walks in with an EpiPen, is very small, and his endoscopy shows EOE. So what should I do for him? Just milk, swallowed steroids. So this guy's like a perfect guy to do amino acid-based therapy. I mean, that's what I want. I wanna get him comfortable. He will be like a different child if he's not feeling pain all the time from eating. Is this EOE? I don't know yet, you know, but I will call it that for the moment, it meets criteria. It is allergen-triggered, and this kid will be so happy on how they feel they might even drink it straight, but really, this gets into the therapeutic goals or growth, comfort, happiness. So the little ones, that is absolutely a great indication for the formulas. And yeah, I can sort of talk more about this, but I think we know it's really the key to these little kids. And of course, again, just showing 98%. Okay, should I stop? I do think we have to move on. Okay, good. For our patient experience, please join me in thanking Dr. Liza. My pleasure. Thank you.

EOE

endoscopy

budesonide

elimination diets

non-IgE allergies

pediatric gastroenterologist

symptoms