Ability of commonly used prediction equations to predict resting energy expenditure in children with inflammatory bowel disease

Exclusive enteral nutrition: An optimal care pathway for use in children with active luminal Crohn's disease

AIM

Exclusive enteral nutrition (EEN) is recommended as a first-line therapy for active luminal paediatric Crohn's disease, by many contemporary consensus guidelines. However, EEN protocols vary internationally. A key enabler for the use of EEN therapy has been identified as the standardisation of protocols. The aim of this study was to develop an optimal care pathway for use of EEN in children with active luminal Crohn's disease.

METHODS

A working group of 11 paediatric gastroenterology dietitians and one paediatric gastroenterologist from Australia and New Zealand was convened to develop a standard optimal care pathway. Seven key areas were identified; clinical indications, workup assessments, EEN prescription, monitoring, food reintroduction, partial enteral nutrition and maintenance enteral nutrition. Recent literature was reviewed, assessed according to the National Health and Medical Research Council guidelines, and consensus statements were developed and voted on. Consensus opinion was used where literature gaps existed.

RESULTS

A total of nineteen consensus statements from the seven key areas were agreed upon. The consensus statements informed the optimal care pathway for children with active luminal undertaking EEN in Australia and New Zealand.

CONCLUSION

This study developed an EEN optimal care pathway to facilitate standardisation of clinical care for children with active luminal Crohn's disease, and hopefully improve clinical outcomes and identify areas for future research.

Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIMS

A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients.

METHODS

A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature.

RESULTS

A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD.

CONCLUSIONS

This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

Time to Relapse in Children with Crohn's Disease Treated with Azathioprine and Nutritional Therapy or Corticosteroids

BACKGROUND

The duration of remission has been shown to be longer in patients initially treated with exclusive enteral nutrition (EEN) compared to corticosteroids (CS). However, no published studies required concurrent immunomodulator [6-mercaptopurine or azathioprine (AZA)] use at the time of diagnosis.

AIMS

The aims of this retrospective study were to compare the duration of remission between patients initially treated with AZA in combination with CS or EEN and identify predictors of early relapse in these patients.

METHODS

Data from 65 newly diagnosed children with CD in clinical remission on either EEN or CS and commencing AZA at diagnosis were included. We compared duration of remission using physician global assessment and carried out Cox regression analysis to identify predictors of early relapse. Patients were followed up to the time of first relapse or for at least 12 months.

RESULTS

There were no differences in the duration of remission between patients initially treated with EEN or CS (p = 0.978). We identified younger age at diagnosis [hazard ratio (HR) 0.87, 95 CI 0.78-0.98, p = 0.016], lower height Z score at diagnosis (HR 0.61, 95 CI 0.44-0.85, p = 0.003), involvement of the upper gastrointestinal tract (HR 2.69, 95 CI 1.27-5.66, p = 0.009), and elevated platelet count at remission (HR 1.004, 95 CI 1.001-1.008, p = 0.021) as independent predictors of early relapse.

CONCLUSIONS

Neither induction regime demonstrated longer duration of remission of CD in patients treated with immunomodulators since the time of diagnosis.

Resting energy expenditure in adult patients with Crohn's disease

BACKGROUND & AIMS

Crohn's disease (CD) is a chronic intestinal disorder of unknown etiology involving any section of the gastrointestinal tract often associated with protein-energy malnutrition (PEM). Increased resting energy expenditure (REE) unmatched by adequate dietary intake is amongst the pathogenetic mechanisms proposed for PEM. Aim of this study was to evaluate REE in CD patients receiving or not immuno-suppressive therapy as compared to controls.

METHODS

36 CD patients (22 M and 14 F, age range 18-55 years) clinically stable and without complications since at least 6 month were studied. REE was evaluated by indirect calorimetry and body composition by BIA. Full biochemistry was performed. Patients were divided into two groups: Group 1 (G1 = 12 patients) without and Group 2 (G2 = 24 patients) with immuno-suppressive therapy.

RESULTS

The two groups were similar for age, height and BMI whereas significantly differed for weight (G1 vs G2: 56.9 ± 7.44 vs 62.3 ± 8.34 kg), fat free mass (FFM: 40.4 ± 5.73 vs 48.2 ± 7.06 kg), fat mass (FM: 17.0 ± 3.55 vs 13.9 ± 5.54 kg) and phase angle (PA: 5.6 ± 1.4 vs 6.5 ± 1.0°). Serum inflammation parameters were significantly higher in G1 than in G2: hs-PCR: 7.76 ± 14.2 vs 7.16 ± 13.4 mg/dl; alfa 2-protein: 11.7 ± 3.69 vs 9.74 ± 2.08 mg/dl; fibrinogen: 424 ± 174 vs 334 ± 118 mg/dl (p < 0.05). REE was higher in G2 vs G1: 1383 ± 267 vs 1582 ± 253kcal/die (p < 0.05) both in men: 1579 ± 314 vs 1640 ± 203 and women: 1267 ± 140 vs 1380 ± 132. Nevertheless, when corrected for FFM, REE resulted higher in G1 than G2 (34.8 ± 4.89 vs 33.0 ± 4.35 kcal/kg, p < 0.05) group, also higher compared to our, age and sex matched, control population (REE/FFM: 30.9 ± 4.5 kcal/kg).

CONCLUSIONS

Our preliminary results show that REE when adjusted for FFM is increased in clinically stable CD patients and mildly reduced by immunosuppressive therapy possibly through a direct action on inflammation and on body composition characteristics.

Validation of predictive equations for resting energy expenditure in Japanese pediatric Crohn's disease patients: preliminary study

BACKGROUND

Predictive equations are often used to estimate resting energy expenditure (REE). Determining the appropriate equation for different patient types, however, remains inconclusive, as in the case of Japanese children with Crohn's disease (CD). The aim of this study was to identify an appropriate predictive equation for measuring REE in Japanese children with CD.

METHODS

Twelve Japanese children with CD managed at the National Center for Child Health and Development in Tokyo, Japan, were studied. REE (kcal/day) was measured using indirect calorimetry. The predictive equations used were the Japanese Dietary Reference Intakes (2010), the Schofield equation, the Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU) equation and the Cunningham equation. Difference between predicted and measured REE was analyzed on Bland-Altman plot.

RESULTS

Japanese Dietary Reference Intakes (2010) had the smallest difference between predicted and measured REE. Weight was the primary predictor of REE on multiple regression analysis. As well, Japanese Dietary Reference Intakes (2010) had the highest ratio of weight to predicted REE (98.5%).

CONCLUSIONS

Of the four equations, Japanese Dietary Reference Intakes (2010) appeared to be the most practical and accurate predictive equation for REE in Japanese children with CD.

Accurate estimation of energy requirements of young patients

The provision of optimal nutritional care is based on accurate estimations of patients' resting energy expenditure. The latter can be calculated with the use of predictive equations or measured with indirect calorimetry (IC). Owing to their ease of use, mathematical equations have largely replaced IC in clinical practice. This article examines the limitations and predictive inaccuracy of commonly used equations in pediatrics, which may contribute to the provision of poor nutritional care and directly affect patient outcomes. In addition, the role of IC is discussed and the physiology of nutrient metabolism, in terms of energy expenditure, is reviewed.

A soybean and fish oil mixture with different n-6/n-3 PUFA ratios modulates the inflammatory reaction in mice with dextran sulfate sodium-induced acute colitis

BACKGROUND & AIMS

Inflammatory bowel disease is a recurrent disease of the gastrointestinal tract. n-3 polyunsaturated fatty acids (PUFAs) are proved to have anti-inflammatory and immunomodulatory properties. This study evaluated the effects of different dietary n-6/n-3 PUFA ratios on the mechanism of alleviating the inflammatory response in mice with dextran sulfate sodium (DSS)-induced colitis.

METHODS

Mice were randomly assigned to 6 groups including 3 non-colitis groups (C, LF, and HF) and 3 colitis groups (DC, DLF, and DHF). Mice in the C and DC groups were fed a common semipurified diet with soybean oil as the fat source. The other groups received an identical component except that part of the soybean oil was replaced by different amounts of fish oil. The n-6/n-3 PUFA ratio of the LF and DLF groups was 4:1, the ratio of the HF and DHF groups was 2:1. After feeding the respective diets for 2 weeks, the colitis groups were given distilled water containing 2% DSS, while the non-colitis groups were given distilled water for 5 days. After that, all mice were sacrificed at the recovery phase after drinking distilled water for another 5 days.

RESULTS

Colitis resulted in higher expressions of colonic inflammatory mediators in colon tissues and colon lavage fluid. Also, colonic peroxisome proliferator-activated receptor (PPAR)-γ and the IκBα/nuclear factor (NF)-κB p65 ratio were lower than those of the non-colitis groups. Compared to the DC group, fish oil-enriched colitis groups had lower inflammatory mediator expressions and higher PPAR-γ protein levels and IκBα/NF-κB p65 ratios in colon tissues. The DHF group had even lower colonic inflammatory gene and higher PPAR-γ protein expressions than did the DLF group.

CONCLUSIONS

These findings suggest that diets enriched with fish oil upregulated PPAR-γ and decreased NF-κB activation that may consequently have reduced luminal inflammatory mediator production. Compared to a n-6/n-3 PUFA ratio 4:1, a ratio of 2:1 was more effective in reducing inflammatory reactions in DSS-induced colitis.

Growth problems in children with IBD

Crohn's disease in childhood causes linear growth retardation, which has a substantial effect on management of this disease. By contrast, growth is rarely a problem in children presenting with ulcerative colitis. Depending on how growth failure is defined, approximately one-third of children with Crohn's disease have growth retardation at diagnosis. Although corticosteroids can suppress growth, decreased height at diagnosis demonstrates that this finding is a consequence of the disease and not merely an adverse effect of treatment. Both inflammation and undernutrition contribute to decreased height velocity. Increased cytokine production acts both on the hepatic expression of insulin-like growth factor 1 (IGF-1) and at chondrocytes of the growth plates of long bones. Growth hormone insensitivity caused by deranged immune function is a major mechanism in growth retardation. Resolution of inflammation is the cornerstone of treatment, but current studies on growth hormone and IGF-1 might yield therapies for those children whose inflammation is refractory to treatment.

Exclusive enteral nutrition induces early clinical, mucosal and transmural remission in paediatric Crohn's disease

BACKGROUND AND AIMS

Exclusive enteral nutrition (EEN) induces clinical and mucosal healing (MH) in Crohn's disease (CD), with MH the best determinant of future outcome. We investigated efficacy of EEN for inducing early clinical, biochemical, mucosal and transmural remission of CD and related early endoscopic response to outcomes at 1 year.

METHODS

In a prospective, open label study 34 children (mean 13.1 years; 21 males) with new diagnosis CD were offered EEN, 26 completed a minimum 6 weeks EEN and underwent paired clinical, biochemical and endoscopic assessment at start and completion using PCDAI, BMI, CRP and Simple Endoscopic Score for CD (SES-CD). A subset, 16/26, had paired MR enterography scored. Early good endoscopic response (complete MH, or near complete, SES-CD 0-3) was related to outcome at 1 year.

RESULTS

EEN improved mean PCDAI (37.88-7.01, p < 0.001; BMI Z scores (-1.54 to -0.54, p < 0.01); weight Z score (-0.79 to -0.08, p < 0.03); CRP (44.86-5.5, p < 0.001); endoscopy (SES-CD 14.28-3.88, p < 0.001) and MRE (5.14-2.79, p = 0.01). Of 26 children, 22 (84 %) achieved clinical remission; 20 (76 %) biochemical remission. Fifteen (58 %) had early good endoscopic response (11 complete, 4 near complete MH) and 3/14 (21 %) had complete transmural remission of ileal CD (MRE-CD: 0-1). Early good endoscopic response was associated with reduced endoscopic confirmed relapse (53 vs. 100 %, p = 0.02), anti-TNF use (33 vs. 88 %, p = 0.01) and hospitalisation (40 vs. 88 %) at 1 year.

CONCLUSIONS

EEN is effective for inducing early clinical, biochemical, mucosal and transmural remission. Early endoscopic remission improves outcomes at 1 year.

No relation between disease activity measured by multiple methods and REE in childhood Crohn disease

BACKGROUND AND AIMS

Increased resting energy expenditure (REE) unmatched by dietary intake is implicated as a cause of poor nutrition in childhood inflammatory conditions. Adequate description of disease activity and correction of REE data for body composition are important to reach reliable conclusions about changes in REE associated with disease. The present study aimed to determine the effect of disease activity measured by clinical status, systemic and stool inflammatory markers on REE in children with Crohn disease using appropriate correction for confounding factors.

METHODS

Sixty children with Crohn disease were recruited from the regional paediatric gastroenterology unit and studied on 1 occasion. REE was measured by indirect calorimetry. Fat-free mass (FFM) was estimated by skinfold thickness. Disease activity was measured using systemic (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and faecal markers of inflammation (lactoferrin, calprotectin) and clinical scores (Paediatric Crohn Disease Activity Index).

RESULTS

Using a multiple regression model, there was no significant change in REE from active or inactive disease (β = 0.03, P = 0.7) nor from CRP (β = -0.05, P = 0.52), ESR (β = -0.07, P = 0.43), faecal calprotectin (β = -0.07, P = 0.38), and faecal lactoferrin (β = 0.01, P = 0.88). REE/kg FFM was not associated with the Paediatric Crohn Disease Activity Index (r = 0.1, P = 0.44), CRP (r = -0.3, P = 0.84) or ESR (r = 0.12, P = 0.4), faecal calprotectin (r = 0.04, P = 0.97), or faecal lactoferrin (r = 0.02, P = 0.87).

CONCLUSIONS

REE corrected for physiologically relevant confounders is not associated with degree of disease activity using clinical tools or systemic and local inflammatory markers, and therefore is an unlikely mechanism for poor nutritional state.

Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease

Exclusive enteral nutrition is an effective yet often underused therapy for the induction of remission in pediatric Crohn disease. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition formed the Enteral Nutrition Working Group to review the use of enteral nutrition therapy in pediatric Crohn disease. The group was composed of 5 pediatric gastroenterologists and 1 pediatric nutritionist, all with an interest and/or expertise in exclusive enteral nutrition. Specific attention was placed upon review of the evidence for efficacy of therapy, assessment of the variations in care, identification of barriers to its widespread use, and compilation of the necessary components for a successful program. The present guideline is intended to aid physicians in developing an enteral nutrition therapy program and potentially promote its use.