Hereditary Fructose Intolerance

Clinical characteristics.

Following dietary exposure to fructose, sucrose, or sorbitol, untreated hereditary fructose intolerance (HFI) is characterized by metabolic disturbances (hypoglycemia, lactic acidemia, hypophosphatemia, hyperuricemia, hypermagnesemia, hyperalaninemia) and clinical findings (nausea, vomiting, and abdominal distress; chronic growth restriction / failure to thrive). While untreated HFI typically first manifested when fructose- and sucrose-containing foods were introduced in the course of weaning young infants from breast milk, it is now presenting earlier, due to the addition of fructose-containing nutrients in infant formulas. If the infant ingests large quantities of fructose, the infant may acutely develop lethargy, seizures, and/or progressive coma. Untreated HFI may result in renal and hepatic failure. If identified and treated before permanent organ injury occurs, individuals with HFI can experience a normal quality of life and life expectancy.

Diagnosis/testing.

The diagnosis of HFI is established in a proband with suggestive metabolic disturbances and clinical findings following dietary exposure to fructose, sucrose, or sorbitol and either biallelic pathogenic variants in ALDOB identified on molecular genetic testing or – now rarely – deficient hepatic fructose 1-phosphate aldolase (aldolase B) activity on liver biopsy. Note: Fructose tolerance testing ("fructose challenge") in the diagnosis of HFI should be avoided because it is dangerous and, when used in the past, could result in death.

Potential sources of fructose should be removed immediately if HFI is suspected.

Management.

Treatment of manifestations: Acute manifestations (e.g., lethargy, seizures, or progressive coma and/or renal and hepatic failure) should be managed symptomatically in a hospital setting, including administration of intravenous glucose (dextrose), supportive treatment of hepatic and/or renal insufficiency, and treatment of metabolic acidosis, if present.

Prevention of primary manifestations: Dietary restriction of fructose, sucrose, sucralose, and sorbitol is the cornerstone of HFI treatment. During hospitalizations, special caution is advised to avoid use of fructose-containing intravenous fluids, as well as fructose-containing infant formulas and pharmaceuticals. Given that reduced fruit and vegetable intake is a dietary requirement, daily supplementation with a "sugar-free" multivitamin is recommended to prevent micronutrient deficiencies, specifically water-soluble vitamins.

Surveillance: No formal guidelines for surveillance exist. Once the diagnosis of HFI has been made, periodic evaluation of liver function, renal function, and growth is reasonable, particularly if compliance with the fructose/sucrose/sorbitol/sucralose-restricted diet is not absolute.

Agents/circumstances to avoid: Enteral or parenteral exposure to fructose, sorbitol, sucrose, sucralose, and polysorbate, including fructose, fructose-containing oligosaccharides, high-fructose corn syrup, honey, agave syrup, inverted sugar, maple-flavored syrup, molasses, palm or coconut sugar, and sorghum. In addition, medicines and formulas in which fructose/sucrose may not be listed as a primary component need to be avoided; examples include syrups, enema solutions, some immunoglobulin solutions, and many infant and pediatric nutritional drinks.

Although vaccinations are generally safe in children with HFI, the two potentially harmful vaccines are the sucrose-containing rotavirus vaccines, Rotarix^® pre-established oral suspension and RotaTeq^®, the only rotavirus vaccines approved for use in the US. Any individual with a severe adverse reaction immediately following administration of either vaccine should be thoroughly investigated for the possibility of HFI.

Evaluation of relatives at risk: Presymptomatic diagnosis of HFI is warranted for sibs of a proband in order to avoid life-threatening complications by restricting fructose intake as soon as possible.

Genetic counseling.

HFI is inherited in an autosomal recessive manner. If both parents are known to be heterozygous for an ALDOB pathogenic variant, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being a carrier, and a 25% chance of inheriting neither pathogenic variant. Once the ALDOB pathogenic variants have been identified in an affected family member, carrier testing for at-risk relatives, prenatal testing for a pregnancy at increased risk, and preimplantation genetic testing are possible.

Suggestive Findings

HFI should be suspected in individuals with the following characteristic clinical findings (following dietary exposure to fructose, sucrose, sorbitol, and/or sucralose), metabolic disturbances, and family history.

Note that the clinical presentation of HFI can be multifaceted and nonspecific, making it difficult to suspect based on clinical findings alone. If HFI is suspected, potential sources of fructose need to be removed immediately (see Table 10).

Clinical findings

• Nausea, vomiting, and abdominal distress (including pain, distention, ascites, and hepatomegaly)
• Chronic growth restriction / failure to thrive
• Any individual with a severe adverse reaction (e.g., vomiting, hypoglycemia, lethargy, liver or renal insufficiency) immediately following administration of either of the two sucrose-containing vaccines, Rotarix^® pre-established oral suspension and RotaTeq^®, should be thoroughly investigated for the possibility of hereditary fructose intolerance.

Metabolic disturbances. See Table 1 for characteristic metabolic disturbances.

Other supportive laboratory findings include changes in urine electrolytes and/or amino acids consistent with a proximal renal tubule defect, increased abnormal transferrin isoelectric focusing [Pronicka et al 2007, Quintana et al 2009, Di Dato et al 2019, Magalhães et al 2020], and/or elevations of multiple plasma lysosomal enzymes [Ferreira et al 2017], particularly aspartylglucosaminidase [Michelakakis et al 2009].

Note: The fructose tolerance testing ("fructose challenge") to diagnose HFI can result in death and should not be used.

Family history is consistent with autosomal recessive inheritance (e.g., affected sibs and/or parental consanguinity). Absence of a known family history does not preclude the diagnosis.

Establishing the Diagnosis

The diagnosis of HFI is established in a proband with suggestive metabolic disturbances and clinical findings following dietary exposure to fructose, sucrose, sorbitol, and/or sucralose and EITHER of the following:

• Biallelic pathogenic (or likely pathogenic) variants in ALDOB on molecular genetic testing (Table 2)
  Note: (1) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variants" and "likely pathogenic variants" are synonymous in a clinical setting, meaning that both are considered diagnostic and both can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include any likely pathogenic variants. (2) Identification of biallelic ALDOB variants of uncertain significance (or identification of one known ALDOB pathogenic variant and one ALDOB variant of uncertain significance) does not establish or rule out a diagnosis of this disorder.
• Deficient hepatic fructose 1-phosphate aldolase (aldolase B) activity on liver biopsy

Note: Because of the relatively high sensitivity of ALDOB molecular genetic testing, it is increasingly the preferred confirmatory test for HFI and can obviate the need for liver biopsy.

Molecular genetic testing approaches can include a combination of gene-targeted testing (single-gene testing or multigene panel) and comprehensive genomic testing (exome sequencing, genome sequencing) depending on the phenotype.

Gene-targeted testing requires that the clinician determine which gene(s) are likely involved, whereas genomic testing does not. Individuals with the distinctive findings described in Suggestive Findings are likely to be diagnosed using gene-targeted testing (see Option 1), whereas those in whom the diagnosis of HFI has not been considered are more likely to be diagnosed using genomic testing (see Option 2).

Clinical Description

Hereditary fructose intolerance (HFI) typically manifests when fructose- and sucrose-containing foods are introduced in the course of weaning young infants from breast milk [Ali et al 1998]. Manifestations include nausea, bloating/ascites, vomiting, sweating, abdominal pain, enlarged liver, and growth retardation [Odièvre et al 1978].

Impaired gluconeogenesis following fructose ingestion results in acute hypoglycemia that is refractory to glucagon [Van Den Berghe et al 1973]. Infants who ingest large quantities of fructose may develop lethargy, seizures, and/or progressive coma, or neonates given a 24% sucrose solution for analgesia during minor procedures may develop hypoglycemia leading to death.

Presently, the clinical presentation of HFI can be multifaceted and nonspecific. The classic presentation of the infant transitioning to solids and developing hypoglycemia is still true; however, with fructose-containing components added to infant formulas, clinical presentation can be earlier than five to six months of age [Li et al 2018]. A high index of suspicion for HFI must exist in any instance of an infant with recurrent or profound hypoglycemia, metabolic acidosis, recurrent emesis, liver dysfunction, and/or renal insufficiency, to name just a few sentinel signs and symptoms. Key biochemical features of HFI include hypermagnesemia, hyperuricemia, hypophosphatemia, and metabolic acidosis (see Table 1) [Bouteldja & Timson 2010]. HFI is one of the few inborn errors of metabolism in which hypoglycemia occurs in the immediate postprandial state.

Other variable common findings in HFI include the following.

Liver involvement

• Hepatomegaly with steatosis and lipid vacuolization may remain a persistent complication despite fructose restriction and resolution of initial fibrosis, including in individuals ascertained by family history and treated from birth [Odièvre et al 1978].
• A potential long-term risk of developing hepatic adenoma and fibrosis [Ghannem et al 2020] exists.
• There have been multiple examples of persistent hepatomegaly, non-alcoholic fatty liver disease, and abnormal carbohydrate-deficient transferrin testing [Aldámiz-Echevarría et al 2020, Di Dato et al 2019, Buziau et al 2020]. The pathophysiology underlying these phenomena is unknown.
• Lenticular cataracts with hepatic fibrosis in untreated adolescents and adults [Ananth et al 2003] may occur.

Kidney involvement

• Chronic renal insufficiency, specifically proximal tubular dysfunction, may also persist despite fructose restriction. Typically, resolution of renal disease occurs shortly after starting fructose restriction [Odièvre et al 1978]. In rare historical instances, dietary modification did not affect renal dysfunction [Mass et al 1966, Morris 1968].
• More recently longitudinal study of adults with HFI revealed higher glomerular filtration and higher systolic blood pressure versus controls, potentially predisposing individuals with HFI to greater cardiovascular risk [Simons et al 2020]. Anecdotally, the authors have seen persistent renal tubular dysfunction that progressed to Stage IV chronic kidney disease in an individual in whom HFI was untreated until age five years, and then treated aggressively until the present age of 19 years.
• Chronic renal disease may be a result of early, chronic exposure, as some reported individuals tended to manage themselves with inadequate self-restriction of fructose- and sucrose-containing foods. It may also be in part due to ongoing primary defects in aldolase function and ATPase interaction within the proximal tubule, leading to dysfunctional acid-base regulation, renal tubular insufficiency (manifesting as glucosuria, aminoaciduria, and phosphaturia), and nephrocalcinosis despite strict dietary restrictions [Mass et al 1966, Morris 1968, Lu et al 2001, Steinmann & Santer 2011].

Other

• Coagulopathy [Hosková & Mrskos 1977]
• Isolated poor growth (i.e., in the absence of other symptoms or affected organ systems) [Mock et al 1983]
• Intermittent vomiting in the setting of fructose aversion and pristine dentition [Newbrun et al 1980]

Prognosis. Typically, when complete dietary fructose, sucrose, sorbitol, and/or sucralose restriction is implemented early in life and adherence is maintained (see Management, Prevention of Primary Manifestations), the prognosis for individuals with HFI is excellent (i.e., normal neurocognitive development, health, and life expectancy).

Conversely, when individuals with HFI do not adhere to recommended dietary restrictions, chronic liver and/or renal disease are expected (as detailed above).

Heterozygotes (carriers) are not at increased risk of developing HFI. While carriers are generally asymptomatic, in older publications hyperuricemia was observed in some presumed or obligate carriers, suggesting that heterozygotes may be predisposed to gout/crystal arthropathy [Oberhaensli et al 1987, Seegmiller et al 1990]. This observation was substantiated more recently, when ALDOB heterozygotes showed a postprandial increase in plasma uric acid concentration in response to fructose ingestion compared to controls [Debray et al 2018].

Genotype-Phenotype Correlations

No genotype-phenotype correlations have been identified for HFI; clinical severity and extent of organ damage appear to depend on an individual's nutritional environment.

Nomenclature

"Fructosaemia," a term originally proposed by Levin et al [1963] to describe the presence of abnormal quantities of fructose in plasma, is now considered obsolete. This finding, which is not specific to HFI, is also observed in fructokinase deficiency and other disorders [Hommes 1993].

Prevalence

HFI is rare, making precise prevalence estimates challenging.

Population-based estimates for the prevalence (based on results of carrier testing for common ALDOB pathogenic variants and use of the Hardy-Weinberg principle after correction for the estimated detection rate) are between 1:18,000 and 1:31,000 (Table 3).

It is important to note that the US study that targeted five specific ALDOB variants may have underestimated the prevalence in persons of non-European ancestry [Lazarin et al 2013]. Applying a Bayesian framework to population-based genomic data, Schrodi et al [2015] devised posterior probability density prevalence estimates for HFI; based on available data, prevalence of HFI was estimated as 1:34,461 (95% credible interval 1:16,800 to 1:94,500).

Evaluations Following Initial Diagnosis

To establish the extent of disease and needs in an individual diagnosed with hereditary fructose intolerance (HFI), the evaluations summarized in Table 7 (if not performed as part of the evaluation that led to the diagnosis) are recommended.

Treatment of Manifestations

Management by multidisciplinary specialists, including gastroenterology, nephrology, ophthalmology, and clinical/metabolic nutrition, is recommended.

Prevention of Primary Manifestations

Dietary restriction of fructose, sucrose, and sorbitol is necessary for the treatment/management of HFI (Table 9). Specific ingredients to avoid include fructose, high-fructose corn syrup, honey, agave syrup, inverted sugar, maple-flavored syrup, molasses, palm or coconut sugar, and sorghum.

Also to avoid are medicines and formulas in which fructose/sucrose may not be listed as a primary component, examples of which include syrups, enema solutions, some immunoglobulin solutions, and many infant and pediatric nutritional drinks. When ingredients are listed, the terms "sugar," "table sugar," "natural flavorings," and even in some cases "sugar-free" or "no added sugar" (with no further clarification on the type of carbohydrate used) should raise suspicion for the presence of fructose, sucrose, or sorbitol.

An extensive list of tolerated and non-tolerated sugars in HFI can be found online at a site curated by the Boston University HFI laboratory. Alternatively, for those who have access, a "green, yellow, red" food list is available through Genetic Metabolic Dietitians International (www.gmdi.org). The authors caution against following diets for fructose intolerance (or "fructose malabsorption"), as these are treating a different disease and are not as restrictive as the diets for HFI, and thus could result in exacerbation of HFI.

Dietary restriction should be strictly followed and maintained, especially in infancy. Currently, there are no specific guidelines regarding dietary fructose limits in any age group.

Ensuring adequate vitamin supplementation in the setting of reduced fruit and vegetable intake is imperative. Daily supplementation with a "sugar-free" multivitamin is recommended to prevent micronutrient deficiencies, specifically the water-soluble vitamins.

Tolerance of dietary fructose probably depends on an individual's residual enzyme activity. Furthermore, because actual fructose content in foods may be unreliably reported or difficult to ascertain, adherence to complete dietary restriction of fructose, sucrose, sorbitol, and sucralose may be difficult to attain and unrealistic for some individuals with HFI.

During hospitalizations, special caution should be taken to avoid use of fructose-containing intravenous fluids. Although reported accidental and iatrogenic fructose infusion-related deaths prompted greater awareness of HFI in hospital settings [Locher 1987, Sachs et al 1993, Curran & Havill 2002, Müller et al 2003], danger remains in hospital settings when specific dietary (and infusion) restrictions may not be adequately disclosed [Cox 1993].

The following are recommendations:

• During any hospitalization, all members of the care team should be aware of the diagnosis of HFI, and the patient is advised to always wear a medically approved alert bracelet/necklace that provides information about the diagnosis of HFI.
• "Red flags" should be placed in the patient's chart or medical record to alert practitioners to the HFI diagnosis and to the medical risks associated with exposures to foods and/or medications (oral or parenteral) containing fructose, sucrose, sorbitol, or sucralose.
• For parenteral medications, hospital pharmacists should clear use of medications on a case-by-case basis.
• The 24% sucrose solution (routinely administered to hospitalized neonates for minor procedures) should not be given to neonates known to have HFI.
• Oral fructose challenge is no longer considered a favorable approach to diagnosis of HFI.

Note: Although there is no single list of medications for these or related sugars, an advanced search on www.medicines.org.uk using the search term "fructose OR sorbitol OR sucrose OR sucralose" yielded 1,574 results (accessed 11-18-20). Many such medications are oral suspensions or chewable flavored tabs designed for pediatric use. Also listed were injectable medications including immunoglobulin solutions (e.g., trastuzumab, filgrastim, some intravenous immunoglobulin solutions), vaccines (see Agents/Circumstances to Avoid), and iron supplements, as well as enema solutions and rinsing aids. For many preparations, it may not be apparent that fructose or similar compounds are present.

Surveillance

There are no formal guidelines for surveillance for individuals with HFI (e.g., frequency of subspecialty visits with physicians and/or dieticians with expertise in management of inherited metabolic diseases).

Once the diagnosis of HFI has been made, periodic evaluation of liver function, renal function, and growth is reasonable, particularly if there are concerns regarding compliance with the fructose/sucrose/sorbitol/sucralose-restricted diet.

Note: Isoelectric focusing of transferrin (or N-glycan evaluation by MS/MS) and/or monitoring of plasma lysosomal enzymes (aspartylglucosaminidase aspartylglucosaminidase and alpha-manosidase) may be elevated in untreated HFI, and thus, have been suggested as markers of disease control in HFI. None of these clinically available tests have definitively proven utility in diagnosis or surveillance [Pronicka et al 2007, Michelakakis et al 2009, Quintana et al 2009, Ferreira et al 2017, Di Dato et al 2019, Magalhães et al 2020].

Agents/Circumstances to Avoid

Great care should be taken to avoid enteral or parenteral exposure to fructose, sorbitol, sucrose, sucralose, and polysorbate, as administration of these substances to individuals with HFI can be fatal.

The following resources can be valuable in determining medical and dietary safety:

• Dietary guidance (including prohibited foods) outlined in Table 9
• An extensive list of tolerated and non-tolerated sugars in HFI, and HFI dietary tips, which can be found online at a site curated by the Boston University HFI Laboratory

Note: Fructose tolerance testing ("fructose challenge") to diagnose HFI can be hazardous and should not be used.

Vaccinations are generally safe in children with HFI. An oral or parenteral (intramuscular or subcutaneous) vaccine can be safely given with fructose content up to 2.4 mg/kg per dose [Maiorana et al 2020]. This includes most standardized vaccines in the US and Europe. However, the following are exceptions, based on fructose content relative to the weight of the child:

• The vaccines M-M-RVAXPRO and Proquad^® should ONLY be administered to children with HFI who weigh more than 6.5 kg (as the vaccines contain ~16.5 mg sucrose) [Maiorana et al 2020].
• Rotarix^® white powder and solvent for oral suspension (available in Europe only) contains 22.5 mg sucrose/sorbitol and should ONLY be administered to children with HFI who weigh more than 9.3 kg [Maiorana et al 2020].

Vaccines to be avoided in any child with HFI (regardless of weight) are Rotarix^® pre-established oral suspension and RotaTeq^®, both of which contain >1000 mg sucrose per dose [Maiorana et al 2020]. Note that these are the only licensed formulations of rotavirus vaccine in the US (www.cdc.gov/vaccines/vpd/rotavirus/public) and are routinely administered at ages two months, four months, and six months, typically prior to the discovery that an infant has HFI. Therefore, any child with unexplained vomiting, hypoglycemia, lethargy, or liver or renal insufficiency following rotavirus vaccination should be investigated thoroughly for the possibility of HFI.

Evaluation of Relatives at Risk

Once the ALDOB pathogenic variants in the family are known, molecular genetic testing can be used to clarify the genetic status of apparently asymptomatic older and younger sibs in order to identify individuals who would benefit from fructose restriction (see Prevention of Primary Manifestations) and avoidance of rotavirus vaccinations containing high concentrations of sucrose (see Agents/Circumstances to Avoid).

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Pregnancy Management

There are few reports of management of pregnant women with HFI or pregnancy-related complications in HFI. In general, in familial reports in which pregnancies are not expressly discussed, it appears that HFI in a pregnant mother does not cause harm to the mother or the child provided that strict fructose avoidance is followed during the pregnancy.

In one family a woman with enzymatically documented HFI had three children (presumably from the same father), all of whom also had HFI [Marks et al 1989]. Most complications observed in these children seem to have resulted from their own poorly controlled HFI or comorbidities in early childhood, rather than maternal effects of HFI per se. The first child developed failure to thrive and cirrhosis and died at age six months of E coli sepsis and pulmonary edema. The second child, who had HFI complicated by transfusion-acquired HIV infection, died at age five years from complications of acquired immunodeficiency syndrome. In her third pregnancy, which proceeded normally, the mother was maintained on a strict fructose-restricted diet. The child also had HFI but thrived on a fructose-restricted diet.

Therapies Under Investigation

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Mode of Inheritance

Hereditary fructose intolerance (HFI) is inherited in an autosomal recessive manner.

Risk to Family Members

Parents of a proband

• The parents of an affected individual are obligate heterozygotes (i.e., presumed to be carriers of one ALDOB pathogenic variant based on family history).
• Molecular genetic testing is recommended for the parents of a proband to confirm that both parents are heterozygous for an ALDOB pathogenic variant and to allow reliable recurrence risk assessment. If a pathogenic variant is detected in only one parent, the following possibilities should be considered:
  • One of the pathogenic variants identified in the proband occurred as a de novo event in the proband [Jónsson et al 2017].
  • Uniparental isodisomy for the parental chromosome with the pathogenic variant resulted in homozygosity for the pathogenic variant in the proband.
• Heterozygotes (carriers) are generally asymptomatic and are not at risk of developing HFI (see Clinical Description, Heterozygotes).

Sibs of a proband

• If both parents are known to be heterozygous for an ALDOB pathogenic variant, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being a carrier, and a 25% chance of inheriting neither pathogenic variant.
• Intrafamilial clinical variability has been observed in sibs who inherited biallelic ALDOB pathogenic variants [Caciotti et al 2008].
• Heterozygotes (carriers) are generally asymptomatic and are not at risk of developing HFI (see Clinical Description, Heterozygotes).

Offspring of a proband. Unless an affected individual's reproductive partner also has HFI or is a carrier, offspring will be obligate heterozygotes (carriers) for a pathogenic variant in ALDOB.

Other family members. Each sib of the proband's parents is at a 50% risk of being a carrier of an ALDOB pathogenic variant.

Carrier Detection

Carrier testing for at-risk relatives requires prior identification of the ALDOB pathogenic variants in the family.

Related Genetic Counseling Issues

See Management, Evaluation of Relatives at Risk for information on evaluating at-risk sibs for the purpose of early diagnosis and treatment.

Family planning

• The optimal time for determination of genetic risk and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
• It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are carriers, or are at risk of being carriers.

DNA banking. Because it is likely that testing methodology and our understanding of genes, pathogenic mechanisms, and diseases will improve in the future, consideration should be given to banking DNA from probands in whom a molecular diagnosis has not been confirmed (i.e., the causative pathogenic mechanism is unknown). For more information, see Huang et al [2022].

Prenatal Testing and Preimplantation Genetic Testing

Once the ALDOB pathogenic variants have been identified in an affected family member, prenatal and preimplantation genetic testing for HFI are possible.

Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.

Molecular Pathogenesis

Together with fructokinase and triokinase, the enzyme aldolase B participates in fructose metabolism, mostly in the liver, renal cortex, and intestinal mucosa. Aldolase B splits fructose-1-phosphate into dihydroxyacetone phosphate and glyceraldehyde. Hepatic formation of glycogen from fructose is principally catalyzed by aldolase B.

HFI results from loss of aldolase B function. Normally aldolase B rapidly converts intravenous fructose to glucose, resulting in hyperglycemia; fructose may also be converted to lactate, provoking metabolic acidosis. Accumulation of fructose-1-phosphate in the setting of diminished aldolase B function inhibits gluconeogenesis and glycogenolysis, causes overutilization and diminished regeneration of ATP, and impairs protein glycosylation.

Mechanism of disease causation. HFI is caused by loss of function of the enzyme aldolase B.

Author History

Lachlan Ayres, MB, ChB, MRCP (2015-present)
Peter R Baker II, MD, FAAP, FACMG (2015-present)
Sommer Gaughan, RD, CSP (2015-present)
James Weisfeld-Adams, MB, ChB, FAAP, FACMG; Children's Hospital Colorado (2015-2021)

Revision History

• 18 February 2021 (bp) Comprehensive update posted live
• 17 December 2015 (me) Review posted live
• 15 July 2015 (jwa) Original submission

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