Impact of exclusive enteral nutrition on body composition and circulating micronutrients in plasma and erythrocytes of children with active Crohn's disease

Nationwide Real-World Exclusive Enteral Nutrition Practice Over Time: Persistence of Use as Induction for Pediatric Crohn's Disease and Emerging Combination Strategy With Biologics

BACKGROUND

Exclusive enteral nutrition (EEN) is the recommended first-line induction treatment in pediatric patients with active luminal Crohn's disease (CD). We aimed to provide a nationwide overview of evolving EEN practices during an era of increasing biologic use.

METHODS

We analyzed a prospectively identified nationwide cohort of newly diagnosed pediatric patients with CD in Scotland between January 1, 2015, and June 30, 2022. Patients who received EEN for any indication were divided into 6-monthly epochs and examined over time. Differences during the COVID-19 pandemic (March 16, 2020, to July 19, 2021) were examined. Data were retrospectively collected from electronic medical records: demographics, anthropometrics, concomitant treatments, aspects of EEN administration, and remission/response rates. Descriptive statistics and linear regression were used for analyses.

RESULTS

A total of 649 patients with CD were identified (63% male; median age 12.6 [interquartile range, 10.8-14.8] years); 497 (77%) of 649 received EEN as postdiagnosis induction therapy with a median course length of 7.7 (interquartile range, 5.9-8.0) weeks. Including repeat courses, 547 EEN courses were examined. An increasing incidence of CD was observed over time with no significant changes in EEN usage, remission or response rates, nasogastric tube usage, or course completion (all P > .05). Increasing use of EEN combined with biologics (combination induction) as first-line induction was observed over time (P < .001). Considering COVID-19, lower rates of EEN usage were observed (P = .008) with no differences in remission, oral administration, and course completion rates (all P > .05).

CONCLUSIONS

Over the past 7.5 years, except during the COVID-19 pandemic, EEN usage rates have not changed despite an increase in biologic use, although combination induction is an emerging trend.

Micronutrient Status and Prediction of Disease Outcome in Adults With Inflammatory Bowel Disease Receiving Biologic Therapy

BACKGROUND AND AIMS

Micronutrient deficiencies are common in patients with inflammatory bowel disease (IBD), but whether they relate to disease outcomes remains unknown. This study assessed the micronutrient status of adults with IBD on treatment with biologic therapies and explored predictive relationships with disease outcomes.

METHODS

Seventeen micronutrients were measured in the blood of 216 adults with IBD on biologic therapy. Of these, 127 patients (58%) had Crohn's disease (CD), and the majority (70%) received treatment with infliximab. Patients were followed for 12 months and onset of adverse clinical outcomes (eg, requirement for treatment with corticosteroids, hospitalization, or surgical intervention) was recorded, and related to micronutrient status.

RESULTS

Among all patients, the most common deficiencies were for vitamin C (n = 35 of 212 [16.5%]), ferritin (n = 27 of 189 [14.3%]), folate (n = 24 of 171 [14.0%]), and zinc (n = 27 of 210 [12.9%]). During follow-up, 22 (10%) of the 216 patients developed 1 or more adverse clinical outcomes. Patients with CD and zinc deficiency were significantly more likely to require surgery (P = .002) or treatment with corticosteroids (P < .001). In contrast, patients with ulcerative colitis and selenium deficiency were significantly more likely to have a clinical flare of disease (P = .001), whereas those with CD were not. This relationship with selenium remained significant after adjustment for confounders.

CONCLUSIONS

A substantial proportion of adults with IBD present deficiencies for certain micronutrients, with selenium and zinc deficiency predicting adverse disease outcomes. For other micronutrients, deficiencies were less common and should not warrant routine screening. Intervention studies should explore the effect of micronutrient supplementation in modifying disease outcomes in IBD.

Evaluation of Deficient Nutrients in Infants and Toddlers Mainly Taking Amino Acid-Based Elemental Formulas: An Exploratory Study

INTRODUCTION

This study evaluated nutrient deficiencies in infants and toddlers with inflammatory bowel disease (IBD) and eosinophilic gastrointestinal disorders (EGIDs), whose primary nutritional source is elemental formulas (EFs).

METHODS

The nutrient status of children with IBD and EGID aged 6 months to 6 years was evaluated.

RESULTS

Twenty-one children fed with EFs (EF group) and 25 controls (CL group) were enrolled. The selenium level in the EF group was lower than that in the CL group (2.2 μg/dL vs. 9.3 μg/dL; p < 0.01). Although fat-soluble vitamins were deficient in some EF group participants, no significant differences were observed in their concentration and insufficiency proportion. However, ascorbic acid deficiency was more frequent in the EF group, with significantly lower levels (8.6 μg/mL vs. 12.0 μg/mL; p < 0.01). The triene:tetraene ratio was significantly higher in the EF group (0.046 vs. 0.010; p < 0.01). Asparagine and taurine levels were significantly lower in the EF group (asparagine: p < 0.01; taurine: p < 0.01) and tyrosine and phenylalanine levels were higher in the EF group, resulting in a lower Fisher's ratio (p < 0.01).

CONCLUSION

Long-term feeding with EFs can cause deficiencies in essential fatty acids, selenium, and ascorbic acid and also carries a risk of amino acid imbalance in infants and toddlers.

The Role of Diet in Pediatric Inflammatory Bowel Disease

The pathogenesis of inflammatory bowel disease (IBD) involves a complex interaction between genetics, immune response, and the environment. Epidemiologic associations between diet and development of IBD plus the ability of diet to modify the microbiota and modulate immune function have led to the hypothesis that diet can prevent and/or treat IBD. It is well established that the induction of remission and healing of the mucosa in Crohn's disease can be accomplished with exclusive enteral nutrition. Whole food-based alternatives such as the Crohn's disease exclusion diet have shown promising results.

Induction of Remission With Exclusive Enteral Nutrition in Children With Crohn's Disease: Determinants of Higher Adherence and Response

BACKGROUND

Exclusive enteral nutrition (EEN) is the first choice to induce remission and promote mucosal healing in pediatric Crohn's disease (CD). However, full adherence to EEN treatment may be problematic for children with CD.

METHODS

The goal of the current multicenter retrospective study was to define predictive factors of nonadherence to treatment and nonremission at the end of induction treatment. Those data together were analyzed with the ultimate goal of trying to define an individualized induction treatment for children with CD.

RESULTS

Three hundred seventy-six children with CD from 14 IBD pediatric referral centers were enrolled in the study. The rate of EEN adherence was 89%. Colonic involvement and fecal calprotectin >600 μg/g at diagnosis were found to be associated with a reduced EEN adherence. Exclusive enteral nutrition administered for 8 weeks was effective for inducing clinical remission in 67% of the total cohort. Factors determining lower remission rates were age >15 years and Pediatric Crohn's Disease Activity Index >50.

CONCLUSION

Although EEN is extremely effective in promoting disease remission, several patients' related factors may adversely impact EEN adherence and response. Personalized treatments should be proposed that weigh benefits and risks based on the patient's disease location, phenotype, and disease activity and aim to promote a rapid control of inflammation to reduce long-term bowel damage.

ESPEN guideline on Clinical Nutrition in inflammatory bowel disease

The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Dietary Nutrient Intake and Blood Micronutrient Status of Children with Crohn's Disease Compared with Their Shared-Home Environment, Healthy Siblings

(1) The nutritional status of children with Crohn’s disease (CD) is rarely described. This study aimed to assess the dietary intake and blood micronutrient status of children with CD compared with their healthy, shared-environment siblings. (2) Methods: This observational study included children with CD (cases) and their shared-environment siblings (controls). The dietary nutrient intake was assessed with a four-day food/beverage diary and was compared with the recommended daily intakes (RDI). Blood micronutrient concentrations were measured using laboratory methods. The nutritional analyses were completed through a multivariate analysis of variance between groups. Between-group comparisons of single-nutrients were assessed using a Mann−Whitney U-test. Chi-squared analyses compared the proportion of children who did not meet the RDI for each nutrient. The results were significant at 0.05. (3) Results: The dietary intake was similar for most nutrients, except the controls had a lower intake of vitamins A and E, copper, zinc, iron, and selenium (p < 0.05). Children using partial enteral nutrition had significantly higher intakes of many micronutrients. It was common for both groups to not meet the RDI’s—more than 50% of cases for 9 nutrients and more than 50% of controls for 13 nutrients. (4) Conclusion: New Zealand children with CD and their shared-environment siblings did not meet the RDI for several micronutrients. Dietary education and/or micronutrient supplementation may be required.

A Preliminary Study of Modulen IBD Liquid Diet in Hospitalized Dogs with Protein-Losing Enteropathy

Modulen IBD is an enteral liquid diet that can induce remission rates similar to glucocorticoids in children with inflammatory bowel disease. The Modulen IBD liquid diet has not been previously investigated in dogs. Our study aimed to describe the use of the Modulen IBD liquid diet in hospitalized dogs with inflammatory protein-losing enteropathy (PLE), including its tolerance and effects on appetite and gastrointestinal signs, and laboratory parameters during hospitalization. Of the 14 dogs hospitalized for PLE that had an esophagostomy feeding tube placed at the time of endoscopy, 5 were eligible and prospectively enrolled. The Modulen IBD liquid diet was supplemented with whey powder isolate and a multivitamin/mineral blend to ensure the diet was complete and balanced for canine adult maintenance and had a macronutrient profile desirable for PLE. All five dogs tolerated tube feedings with the Modulen IBD liquid diet, allowing an increase of 75 to 100% of the resting energy requirement (RER) by day 3 to 4. The diet was administered without glucocorticoid in all five dogs. All five of these dogs had a resolution of anorexia allowing the voluntary intake of a commercial hydrolyzed protein diet prior to the use of glucocorticoids. Of these five dogs, three (60%) had stable or improved serum albumin concentrations (median % increase: 10.3, range: 0−31.1), four (80%) had improved or normalized serum globulin concentrations (median % increase: 12.9, range: 5.1−66.2) and four (80%) had improved or normalized serum cholesterol concentrations (median % increase: 31.5, range: 4.8−63) 2−3 days after initiating the diet. However, there were no significant differences in these selected biochemical parameters pre- and post-feeding with the diet (p > 0.080). In conclusion, the Modulen IBD liquid diet, fed via an esophagostomy feeding tube was well-tolerated in-hospital and resolved anorexia in all dogs and helped to improve selected biochemical parameters in some dogs. Further studies are needed to assess the long-term effects of feeding this diet on the rate of serum albumin increase and remission in dogs with inflammatory PLE.

Nutrition in Patients with Inflammatory Bowel Diseases: A Narrative Review

Inflammatory bowel diseases (IBD) affect the gastrointestinal tract: they include Crohn's disease (CD) and ulcerative colitis (UC). Each has a different phenotypic spectrum, characterized by gastrointestinal and extra-intestinal manifestations. People living with IBD are very interested in diet, but little is known about the impact of diet on these patients; no guidelines are available yet. In this review, we analyze the dietary patterns of patients with IBD and the approach to the choices of foods both in adults and pediatric patients. Very often, IBD patients report an intentional avoidance of gluten to manage the disease; furthermore, a proportion of IBD patients believe that dairy products worsen their symptoms and that avoidance may help the disease. They have a low compliance with the Mediterranean Diet, which is considered to have potential benefits but is little used in practice. In conclusion, the review underscores the pivotal role of nutritional counselling in IBD patients, and the importance of future clinical studies to evaluate the beneficial effects of dietary recommendations in the management of IBD.

Predictive Fat Mass Equations for Children With Inflammatory Bowel Disease

OBJECTIVE

Evaluate accuracy of skinfold thicknesses and body mass index (BMI) for the prediction of fat mass percentage (FM%) in paediatric inflammatory bowel disease (IBD) and to develop population-specific formulae based on anthropometry for estimation of FM%.

METHODS

IBD children (n = 30) and healthy controls (HCs, n = 144) underwent anthropometric evaluation and dual-energy X-ray absorptiometry (DEXA) scan, as the clinical reference for measurement of body composition. Body FM% estimated with skinfolds thickness was compared with FM% measured with DEXA. By means of 4 prediction models, population specific formulae for estimation of FM% were developed.

RESULTS

No significant difference in terms of FM% measured by DEXA was found between IBD population and HCs (FM% 29.6% vs 32.2%, P = 0.108). Triceps skinfold thickness (TSF, Model 2) was better than BMI (Model 1) at predicting FM% (82% vs 68% of variance). The sum of 2 skinfolds (biceps + triceps; SF2, Model 3) showed an improvement in the prediction of FM% as compared with TSF, Model 2 (86% vs 82% of variance). The sum of 4 skinfolds (biceps + triceps + suprailiac + subscapular; Model 4) showed further improvement in the prediction of FM% as compared with SF2 (88% vs 86% of variance).

CONCLUSIONS

The sum of 4 skinfolds is the most accurate in predicting FM% in paediatric IBD. The sum of 2 skinfolds is less accurate but more feasible and less prone to error. The newly developed population-specific formulae could be a valid tool for estimation of body composition in IBD population and an alternative to DEXA measurement.

Dietary Management in Pediatric Patients with Crohn's Disease

It has been widely endorsed that a multifactorial etiology, including interaction between genetic and environmental factors, can contribute to Crohn's Disease (CD) pathogenesis. More specifically, diet has proven to be able to shape gut microbiota composition and thus is suspected to play a significant role in inflammatory bowel disease (IBD) pathogenesis. Moreover, poor nutritional status and growth retardation, arising from several factors such as reduced dietary intake or nutrient leakage from the gastrointestinal tract, represent the hallmarks of pediatric CD. For these reasons, multiple research lines have recently focused on the utilization of dietary therapies for the management of CD, aiming to target concurrently mucosal inflammation, intestinal dysbiosis and optimization of nutritional status. The forerunner of such interventions is represented by exclusive enteral nutrition (EEN), a robustly supported nutritional therapy; however, it is burdened by monotony and low tolerance in the long term. Novel dietary interventions, such as Crohn's Disease Exclusion Diet or Crohn's Disease treatment with eating, have shown their efficacy in the induction of remission in pediatric patients with CD. The aim of the present narrative review is to provide a synopsis of the available nutritional strategies in the management of pediatric CD and to discuss their application in the dietary management of these patients.

How Can a Polymeric Formula Induce Remission in Crohn's Disease Patients?

Crohn’s disease is an inflammatory bowel disease whose prevalence is increasing worldwide. Among medical strategies, dietary therapy with exclusive enteral nutrition is recommended as a first-line option, at least for children, because it induces clinical remission and mucosal healing. Modulen^®, a polymeric TGF-β2 enriched formula, has good palatability and is widely used. For the first time in the literature, this review outlines and discusses the clinical outcomes obtained with this therapy, as well as the potential mechanisms of action of its compounds. It can be explained by its TGF-β2 content, but also by its protein and lipid composition. Further well-designed studies are required to improve our knowledge and to optimize therapeutic strategies.

Growth Delay in Inflammatory Bowel Diseases: Significance, Causes, and Management

Growth delay with height and weight impairment is a common feature of pediatric inflammatory bowel diseases (PIBD). Up to 2/3 of Crohn Disease patients have impaired weight at diagnosis, and up to 1/3 have impaired height. Ulcerative colitis usually manifests earlier with less impaired growth, though patients can be affected. Ultimately, growth delay, if not corrected, can reduce final adult height. Weight loss, reduced bone mass, and pubertal delay are also concerns associated with growth delay in newly diagnosed PIBD patients. The mechanisms for growth delay in IBD are multifactorial and include reduced nutrient intake, poor absorption, increased fecal losses, as well as direct effects from inflammation and treatment modalities. Management of growth delay requires optimal disease control. Exclusive enteral nutrition (EEN), biologic therapy, and corticosteroids are the primary induction strategies used in PIBD, and both EEN and biologics positively impact growth and bone development. Beyond adequate disease control, growth delay and pubertal delay require a multidisciplinary approach, dependent on diligent monitoring and identification, nutritional rehabilitation, and involvement of endocrinology and psychiatry services as needed. Pitfalls that clinicians may encounter when managing growth delay include refeeding syndrome, obesity (even in the setting of malnutrition), and restrictive diets. Although treatment of PIBD has improved substantially in the last several decades with the era of biologic therapies and EEN, there is still much to be learned about growth delay in PIBD in order to improve outcomes.

Micronutrient deficiencies in children with coeliac disease; a double-edged sword of both untreated disease and treatment with gluten-free diet

INTRODUCTION

In coeliac disease (CD) micronutrient deficiencies may occur due to malabsorption in active disease and diminished intake during treatment with a gluten-free diet (GFD). This study assessed the micronutrient status in children with CD at diagnosis and follow-up.

METHODS

Fifteen micronutrients were analysed in 106 blood samples from newly diagnosed CD and from patients on a GFD for <6 months, 6-12 months and with longstanding disease (>12 months). Predictors of micronutrient status included: demographics, disease duration, anthropometry, gastrointestinal symptoms, raised tissue transglutaminase antibodies (TGA), multivitamin use and faecal gluten immunogenic peptide (GIP). Micronutrient levels were compared against laboratory reference values.

RESULTS

At CD diagnosis (n = 25), low levels in ≥10% of patients were observed for: vitamins E (88%), B1 (71%), D (24%), K (21%), A (20%) and B6 (12%), ferritin (79%), and zinc (33%). One year post-diagnosis, repletion of vitamins E, K, B6 and B1 was observed (<10% patients). In contrast, deficiencies for vitamins D, A and zinc did not change significantly post-diagnosis. Copper, selenium and magnesium did not differ significantly between diagnosis and follow-up. All samples for B2, folate, vitamin C (except for one sample) and B12 were normal. A raised TGA at follow-up was associated with low vitamins A and B1 (raised vs normal TGA; vitamin A: 40% vs 17%, p = 0.044, vitamin B1: 37% vs 13%, p = 0.028). Low vitamin A (p = 0.009) and vitamin D (p = 0.001) were more common in samples collected during winter. There were no associations between micronutrient status with GIP, body mass index, height, socioeconomic status, or gastrointestinal symptom. Multivitamin use was less common in patients with low vitamin D.

CONCLUSIONS

Several micronutrient deficiencies in CD respond to a GFD but others need to be monitored long-term and supplemented where indicated.

Routine abdominal magnetic resonance imaging can determine psoas muscle area in paediatric Crohn's disease and correlates with bioelectrical impedance spectroscopy measures of lean mass

BACKGROUND

Paediatric Crohn's disease (CD) has been associated with undernutrition. Accurate and accessible measures of body composition would provide data to personalise nutritional therapy. We assessed feasibility of MRI-derived measures of psoas cross-sectional area (PCSA) in paediatric CD and correlated with anthropometric and bioelectrical impedance spectroscopy (BIS) measures.

METHODS

MRI small bowel/pelvis images of patients with CD, aged <18 years, were retrieved. Patients with concurrent anthropometric and BIS measurements were eligible for inclusion. The PCSA at L3 was calculated by two assessors and combined. To assess reproducibility of measures we calculated the coefficient of variation (CoV). Age, height-Z-scores, weight-Z-scores and BIS measures were correlated with PCSA. Using normal paediatric data from CT-scans we derived psoas area Z-scores for our cohort.

RESULTS

10 patients were included. Mean age at MRI scan was 14.6 years (11.7-16.3). PCSA was calculated for all MRI scans. There was high reproducibility between measurers, mean CoV 0.099. There was a significant positive correlation between PCSA and BIA-derived fat free mass, Pearson correlation coefficient (PCC) 0.831, p = 0.003. Correlation coefficients for PCSA and Height-for-age Z-score, weight-for-age -Z-score and age were PCC 0.343- p = 0.33, PCC = 0.222- p = 0.54, and PCC 0.6034- p = 0.065, respectively. The mean PCSA Z-score was -1.81, with 70% of the patients having a Z-score < -2.0.

CONCLUSIONS

These data demonstrate the feasibility of deriving measures of body composition from routine MRI imagine. There was significant positive correlation between PCSA and BIS-derived lean mass. Further studies are required to confirm applicability of normal ranges prior to routine clinical implementation.

EEN Yesterday and Today … CDED Today and Tomorrow

The treatment of Pediatric Crohn’s Disease (CD) requires attention both to achieve mucosal healing and to optimize growth, while also maintaining proper bone health. Exclusive Enteral Nutrition (EEN) is recommended as first-line treatment in luminal CD. The therapeutic mechanisms of EEN are being discovered by advances in the study of the gut microbiota. Although the total exclusion of a normal diet during the time of EEN continues to be of high importance, new modalities of dietary treatment suggest a successful future for the nutritional management of CD. In this sense, Crohn’s Disease Exclusion Diet (CDED) is a long-term strategy, it apparently acts on the mechanisms that influence the appearance of inflammation (reducing dietary exposure to products negatively affecting the microbiota), but does so using specific available whole foods to achieve this goal, increases the time of clinical remission and promotes healthy lifestyle habits. The development of CDED, which partly minimizes the problems of EEN, has enabled a turnaround in the treatment of pediatric CD. This review highlights the role of enteral nutrition in the treatment of Crohn’s disease with special emphasis on newer dietary modalities such as CDED.

Influence of Enteral Nutrition on Gut Microbiota Composition in Patients with Crohn's Disease: A Systematic Review

The aim of the study was to systematically and comprehensively evaluate whether exclusive enteral nutrition (EEN) has impact on gut microbiota in patients with Crohn's disease (CD). The databases PUBMED (MEDLINE), SCOPUS and WEB OF SCIENCE were searched. Out of 232 studies, 9 met inclusion criteria. The combined analyzed population consists of 118 patients with CD and treated with EEN with a time of intervention of 2-12 weeks. Studies were conducted in children, with the exception of one study. All applied feeding formulas had similar energy value and composition. The microbiome analysis was based on 16S rRNA gene sequencing of faecal samples. In all studies, EEN treatment decreases inflammatory markers (i.e., hs-CRP and FCP). A change in abundance of numerous bacterial families (Clostridiaceae, Eubacteriaceae, Bacteroidaceae) was noticed, especially in Bacteroidaceae. An increase in families connected to the more severe clinical course (Fusobacteria, Prevotella, Lachnospiraceae) was observed in only 2.5% of CD patients. Our analyses suggest EEN has a beneficial influence on gut microbiome in patients with CD, which is interrelated with clinical patient's improvement and time of disease remission.

Effect of Exclusive Enteral Nutrition on the Disease Process, Nutrition Status, and Gastrointestinal Microbiota for Chinese Children With Crohn's Disease

BACKGROUND

The aim of this study was to prospectively study the effect of exclusive enteral nutrition (EEN) treatment on Chinese pediatric Crohn's disease (CD) patients.

METHODS

Thirty-one newly diagnosed CD patients were enrolled in this study and treated with EEN for 8 weeks. Twelve healthy controls (HCs) donated their fecal samples. Statistical methods were used to compare the differences.

RESULTS

According to the Simple Endoscopic Score for CD (SES-CD) at the end of the EEN treatment, 21 patients with SES-CD ≤4 were classified into the remission group (CD-RE), and 10 patients with SES-CD >4 were classified into the nonremission group (CD-NRE). After EEN therapy, there was a significant decrease in the SES-CD, the weighted Pediatric Crohn's Disease Activity Index (wPCDAI), and fecal calprotectin (FCP) in the CD-RE group (all P < .001). The wPCDAI and FCP also decreased in the CD-NRE group (both P < .05). In terms of nutrition improvement, the CD-RE group patients showed more improvement in weight gain, hemoglobin, and serum albumin level than the CD-NRE group patients (all P < .05). For the microbiota, the CD patients had a lower bacterial diversity and different bacterial community compared with HCs. EEN increased overall diversity and was able to shift the dysbiosis in CD patients toward a healthier state. Absence of improvement in wPCDAI and Shannon index at 2 weeks predicts poor response at the end of EEN.

CONCLUSION

EEN can be used in most Chinese pediatric CD patients to induce remission and improve nutrition.

Improvement of body composition and bone mineral density after enteral nutrition in pediatric Crohn disease

BACKGROUND

The relationship between exclusive enteral nutrition (EEN) and bone status is poorly defined in pediatric Crohn disease (CD).

AIMS

The aim of this study was to investigate the impact of EEN on body composition, nutritional status, and bone mineral density (BMD) in an incident CD cohort.

METHODS

18 newly diagnosed CD children starting EEN for 8 weeks were prospectively enrolled and evaluated at baseline and after 8 (T8), 26 (T26) and 52 weeks (T52) from diagnosis. The Fat Free Mass (FFM) and the Resting Energy Expenditure (REE) were measured through Bioelectrical Impedance (BIA) and the BMD was assessed by dual-energy X-ray (DXA). We compared DXA data of IBD patients to the data obtained in 15 healthy controls.

RESULTS

CD children had a significant lower BMD compared to healthy control both at baseline (p<0.0001), and after EEN therapy at T52 (p=0.0004); although at this latest time point CD children had a significant increase of BMD compared to baseline (p=0.0015). The BIA analysis showed a significant increase at T26 and T52 of FFM and REE. T52. FFM measured by BIA and BMD measured by DXA were significantly correlated.

CONCLUSION

EEN improves nutritional status and bone mineral composition.

Assessment and Interpretation of Vitamin and Trace Element Status in Sick Children: A Position Paper From the European Society for Paediatric Gastroenterology Hepatology, and Nutrition Committee on Nutrition

Assessment of vitamin and trace element status (VTE) is important in the clinical management of the sick child. In this position paper, we present the various assessment methods available to the clinical practitioner, and critically discuss pitfalls with interpretation of their results. There are 4 main approaches to assess the VTE body status of an individual patient including clinical examination, dietary assessment, and measurement of direct and indirect biomarkers of VTE in biological samples. Clinical signs of VTE deficiencies usually present only when body stores are substantially depleted and are often difficult to detect or differentiate from other nonnutrient-related causes. In isolation, dietary assessment of micronutrients can be inaccurate and imprecise, in disease and in individual patient assessment but may be useful to complement findings from other VTE assessment methods. Use of biomarkers is the most common approach to assess VTE status in routine practice but in the presence of systemic inflammatory response and in the absence of appropriate paediatric reference intervals, interpretation of biomarker results might be challenging and potentially mislead clinical practice. The use of a multimodal approach, including clinical examination, dietary assessment, and laboratory biomarkers is proposed as the optimal way to ascertain the VTE status of individual patients. In the presence of acute inflammatory conditions, VTE measurements in plasma should be replaced by biomarkers not affected by systemic inflammatory response or delayed until inflammatory state is resolved.

Predictors of Response to Exclusive Enteral Nutrition in Newly Diagnosed Crohn´s Disease in Children: PRESENCE Study from SEGHNP

Exclusive enteral nutrition (EEN) has been shown to be more effective than corticosteroids in achieving mucosal healing in children with Crohn´s disease (CD) without the adverse effects of these drugs. The aims of this study were to determine the efficacy of EEN in terms of inducing clinical remission in children newly diagnosed with CD, to describe the predictive factors of response to EEN and the need for treatment with biological agents during the first 12 months of the disease. We conducted an observational retrospective multicentre study that included paediatric patients newly diagnosed with CD between 2014–2016 who underwent EEN. Two hundred and twenty-two patients (140 males) from 35 paediatric centres were included, with a mean age at diagnosis of 11.6 ± 2.5 years. The median EEN duration was 8 weeks (IQR 6.6–8.5), and 184 of the patients (83%) achieved clinical remission (weighted paediatric Crohn’s Disease activity index [wPCDAI] < 12.5). Faecal calprotectin (FC) levels (μg/g) decreased significantly after EEN (830 [IQR 500–1800] to 256 [IQR 120–585] p < 0.0001). Patients with wPCDAI ≤ 57.5, FC < 500 μg/g, CRP >15 mg/L and ileal involvement tended to respond better to EEN. EEN administered for 6–8 weeks is effective for inducing clinical remission. Due to the high response rate in our series, EEN should be used as the first-line therapy in luminal paediatric Crohn’s disease regardless of the location of disease and disease activity.

Body composition in children with chronic inflammatory diseases: A systematic review

BACKGROUND & AIMS

Aberrations in body composition are expected in children suffering from chronic inflammatory conditions. The objective is to examine whether children with inflammatory bowel disease (IBD: Crohn's disease and ulcerative colitis), coeliac disease, asthma and juvenile idiopathic arthritis (JIA) have an altered body composition as compared to healthy children.

METHODS

A systematic review, registered in Prospero (registration number: CRD42018107645), was conducted according to PRISMA guidelines. We conducted a search of three databases, Pubmed, Cochrane and Scopus. An assessment of the quality of the study was performed.

RESULTS

Data from 50 studies, 32 with IBD, 8 with coeliac disease, 2 with asthma and 8 with JIA, involving 2399 children were selected for review after applying the eligibility criteria. In all but 4 studies, children with Crohn's disease exhibited decreased amounts of fat mass and fat free mass. Reductions in fat mass were also evident in studies in children with coeliac disease. It is uncertain whether body composition is altered in children with asthma or JIA.

CONCLUSIONS

Children with Crohn's disease manifest with lowered adiposity and lean mass and therefore are likely to be at risk for suffering malnutrition-related clinical complications. Apart from Crohn's disease, data examining body composition in children with chronic inflammatory conditions are scarce and there is a paucity of reports examining the relationship between inflammation and body composition. Interpretation of the current study results is hampered by the low quality of the studies and due to the fact that the analyses have been habitually secondary outcomes.

Recent advances in understanding and managing pediatric inflammatory bowel disease

The landscape of pediatric inflammatory bowel disease is rapidly evolving. The therapeutic advances seen in the adult arena are rapidly being adopted by pediatric gastroenterologists and evaluated in both controlled trials and real-world experience. Though anti-tumor necrosis factor agents have been the primary therapy over the last decade, recently there has been an expansion of therapeutic targets and alternative mechanism of action drugs with a focus on individualized and personalized therapy. By reviewing epidemiology, pathophysiology, and goals of treatment, we hope to frame the discussion of current and novel therapeutics for the pediatric gastroenterologist. As scientific discovery continues to push the envelope in defining our understanding of pediatric inflammatory bowel disease, the current era of therapeutics gives us hope that a cure may be realized soon.

Nutritional approach as therapeutic manipulation in inflammatory bowel disease

Malnutrition is observed more frequently in patients with inflammatory bowel disease (IBD) than in the general population and associated with adverse clinical outcomes. This study aimed to review the current knowledge regarding the efficacy of dietary and nutritional intervention in IBD patients. Exclusive enteral nutrition might be inferior to corticosteroid treatment in adults with active Crohn’s disease (CD) but might even be superior considering the adverse effects of corticosteroid treatment in children. Total parenteral nutrition has no advantage over enteral nutrition, which is considered a more physiologic modality in organ function. Current guidelines do not yet recommend ω3-polyunsaturated fatty acid supplementation for the prevention and maintenance of remission in IBD patients. Dietary fiber supplementation could be effective in the relief of symptoms and maintenance of remission in ulcerative colitis (UC). Although vitamin D may be favorable to clinical course of IBD and bone density. Probiotic supplementation has proven to be effective in preventing and treating pouchitis for UC but is less effective in treating CD. Nutritional interventions not only correct nutritional deficiencies but also improve symptoms and clinical courses of the disease. Hence, nutritional approaches need to be developed to significantly evaluate the effectiveness of dietary interventions used to treat IBD.

Diet and inflammatory bowel disease: The Asian Working Group guidelines

INTRODUCTION

These Asian Working Group guidelines on diet in inflammatory bowel disease (IBD) present a multidisciplinary focus on clinical nutrition in IBD in Asian countries.

METHODOLOGY

The guidelines are based on evidence from existing published literature; however, if objective data were lacking or inconclusive, expert opinion was considered. The conclusions and 38 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

Diet has an important role in IBD pathogenesis, and an increase in the incidence of IBD in Asian countries has paralleled changes in the dietary patterns. The present consensus endeavors to address the following topics in relation to IBD: (i) role of diet in the pathogenesis; (ii) diet as a therapy; (iii) malnutrition and nutritional assessment of the patients; (iv) dietary recommendations; (v) nutritional rehabilitation; and (vi) nutrition in special situations like surgery, pregnancy, and lactation.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 38 recommendations.

Characteristics of polymeric formula and route of delivery of exclusive enteral nutrition have no effect on disease outcome and weight gain in pediatric Crohn's disease

BACKGROUND & AIMS

This study aimed to evaluate the effect of the route of exclusive enteral nutrition (EEN) delivery (orally or via nasogastric (NG) tube) and type of polymeric formula (with taste vs tasteless and isocaloric vs hypercaloric) on the disease outcome and nutritional status in children with Crohn's disease (CD).

METHODS

This was a single center retrospective study which included all CD patients whose active disease at diagnosis was treated with EEN in the period from October 2007 to November 2017. All patients received polymeric formula orally or through a NG tube, which was based on the physicians and child's preference.

RESULTS

A total of 92 CD patients were included in the study (mean age 13.6 ± 3.0 years; 45.7% female). Overall, 42 (45.7%) patients received EEN via NG tube until the end of the EEN period. Remission was achieved in 71 (77.2%) children. There was no difference in the EEN failure status, remission duration, inflammatory markers, and weight gain at the end of the EEN period between oral intake and NG tube groups. None of the factors including age, disease location, type of formula (with taste vs tasteless and isocaloric vs hypercaloric) and mode of delivery (orally vs through NG tube for the whole duration of EEN) demonstrated an association with EEN failure.

CONCLUSION

This study failed to demonstrate an effect of the route of EEN delivery and the characteristics of the polymeric formula on the outcome of treatment in pediatric patients with CD.

Conceptual Model of Lean Body Mass in Pediatric Inflammatory Bowel Disease

Youth with inflammatory bowel disease (IBD) demonstrate deficits in lean mass (LM) placing them at increased risk for future health problems, including reduction of bone mass and impaired bone architecture. Research suggests that deficits in LM are multifactorial, including influences from the disease and its treatment, and health behaviors such as diet and physical activity. Based on a systematic literature review examining factors related to LM deficits in IBD, this article presents a conceptual model to explain the development of LM in youth with IBD. The model considers predictors of LM across 4 domains: demographic; medical; diet; and physical activity. Much existing research is cross-sectional, but suggests multiple factors work together to promote or inhibit LM accrual in youth with IBD. The conceptual model, developed based on empirical findings to date, can be used to understand and further elucidate the process through which LM is developed and maintained, to inform the development of empirically supported clinical interventions, and to guide future research objectives and priorities.

An overview of the role of exclusive enteral nutrition for complicated Crohn's disease

The role and efficacy of exclusive enteral nutrition (EEN) in the treatment of luminal Crohn’s disease (CD) has been well established over the last 2 decades. Consequently, in many centers nutritional therapy is now considered first line therapy in the induction of remission of active CD. However, the use of nutritional therapy in complicated CD has yet to be fully determined. This article aimed to review case reports and clinical trials published in the last decade that have considered and evaluated nutritional therapy in the setting of complicated CD in children and adults. Published literature focusing upon the use of nutritional therapy as part of medical therapy in the management of complicated CD were identified and reviewed. Although there continue to be various interventions utilized for complicated CD, the currently available literature demonstrates that nutritional therapies, especially EEN, have important roles in the management of these complex scenarios. Further assessments, involving large numbers of patients managed with consistent approaches, are required to further substantiate these roles.

Fecal calprotectin is not a clinically useful marker for the prediction of the early nonresponse to exclusive enteral nutrition in pediatric patients with Crohn disease

Exclusive enteral nutrition (EEN) has been recommended as the first-line therapy in children with active Crohn disease (CD). The primary aim of our study was to determine whether it is possible to use the difference between basal fecal calprotectin (F-CPT) and the value at week 2 of EEN to predict clinical response at week 6. We prospectively collected stool samples for F-CPT analysis and clinical and laboratory parameters during EEN from 38 pediatric patients (28 boys, median age 12.8 years) with newly diagnosed active luminal CD. The difference between F-CPT concentrations before EEN and at week 2 did not predict clinical non-response at week 6 (OR 0.9996 95% CI 0.9989-1.0002, p = 0.18); however, it predicted patients who did not achieve clinical remission at week 6 (OR 0.9993, 95% CI 00.9985-0.9998, p = 0.006) with sensitivity of 58%, and specificity of 92% for cut-off of F-CPT increase by 486 μg/g.Conclusions: An early decrease in F-CPT levels in children with newly diagnosed active luminal CD did not predict clinical response at week 6 of EEN induction therapy, and clinical remission was predicted with low accuracy. Therefore, F-CPT cannot be used as a predictor to select the patients in whom EEN should be terminated. What is Known: • The fecal calprotectin (F-CPT) is an important marker of intestinal inflammation. • Approximately 25% of pediatric patients with Crohn disease (CD) do not achieve clinical remission, and there is still no sufficient predictor of response to exclusive enteral nutrition (EEN) treatment. What is New: • The difference between the F-CPT concentrations before EEN treatment and at week 2 did not predict clinical response to treatment at week 6, even if it predicted clinical remission, however, with low accuracy. F-CPT is not a suitable predictor to select the patients for discontinuing of EEN induction therapy.

Exclusive enteral nutrition in pediatric inflammatory bowel disease

PURPOSE OF REVIEW

Nutritional interventions play a central role in the treatment and management of inflammatory bowel disease (IBD) in children. Although malnutrition is a common presenting sign of IBD, nutritional interventions have focused not only on correction of the malnourished state but also on treatment of the primary disease.

RECENT FINDINGS

Exclusive enteral nutrition (EEN) has been the primary therapy utilized in pediatric IBD specifically, Crohn's disease. This intervention provides total calories from formula meeting complete macronutrient and micronutrient needs for a patient. EEN has been shown to improve growth and correct micronutrient deficiencies as well as improve comorbid conditions like osteopenia and anemia. EEN has also been shown to be equally as efficacious as steroids in inducing remission with better mucosal healing.

SUMMARY

EEN is a primary therapy in IBD. Both the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition consider EEN as first line therapy for inducing remission in Crohn's disease.

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.

Exclusive enteral nutrition in Crohn's disease: Evidence and practicalities

Exclusive enteral nutrition (EEN) is the first line therapy for paediatric Crohn's disease, providing a complete nutritional feed whilst simultaneously inducing remission in up to 80% of cases. The effect of EEN on systemic/local intestinal immune function and subsequent inflammation (including barrier permeability, direct anti-inflammatory effects and cytokine signalling pathways), alongside changes in the microbiome (specific species and broad taxonomic shifts, functional changes) are becoming clearer, however the exact mechanism for induction of remission in Crohn's disease remains uncertain. The evidence of efficacy in paediatric Crohn's disease is strong, with selected adult populations also benefiting from EEN. However despite recommendations from all major societies (ECCO, ESPGHAN, NASPGHAN and ESPEN) first-line use of EEN is varied and Europe/Australasia/Canada show significantly more routine use than other parts of North America. Growth and nutritional status are significantly improved with EEN compared to corticosteroids but long-term outcomes are sparse. This review discusses the evidence underlying the use of EEN, highlighting the mechanisms thought to underlie how EEN induces remission in Crohn's disease, when and how to use EEN, including practical issues in both paediatric and adult practice (formulation, compliance, volumes and administration), and summarises the ongoing research priorities.

Review article: the gut microbiome in inflammatory bowel disease-avenues for microbial management

BACKGROUND

The concept of an altered collective gut microbiota rather than identification of a single culprit is possibly the most significant development in inflammatory bowel disease research. We have entered the "omics" era, which now allows us to undertake large-scale/high-throughput microbiota analysis which may well define how we approach diagnosis and treatment of inflammatory bowel disease (IBD) in the future, with a strong steer towards personalised therapeutics.

AIM

To assess current epidemiological, experimental and clinical evidence of the current status of knowledge relating to the gut microbiome, and its role in IBD, with emphasis on reviewing the evidence relating to microbial therapeutics and future microbiome modulating therapeutics.

METHODS

A Medline search including items 'intestinal microbiota/microbiome', 'inflammatory bowel disease', 'ulcerative colitis', 'Crohn's disease', 'faecal microbial transplantation', 'dietary manipulation' was performed.

RESULTS

Disease remission and relapse are associated with microbial changes in both mucosal and luminal samples. In particular, a loss of species richness in Crohn's disease has been widely observed. Existing therapeutic approaches broadly fall into 3 categories, namely: accession, reduction or indirect modulation of the microbiome. In terms of microbial therapeutics, faecal microbial transplantation appears to hold the most promise; however, differences in study design/methodology mean it is currently challenging to elegantly translate results into clinical practice.

CONCLUSIONS

Existing approaches to modulate the gut microbiome are relatively unrefined. Looking forward, the future of microbiome-modulating therapeutics looks bright with several novel strategies/technologies on the horizon. Taken collectively, it is clear that ignoring the microbiome in IBD is not an option.

Research Gaps in Diet and Nutrition in Inflammatory Bowel Disease. A Topical Review by D-ECCO Working Group [Dietitians of ECCO]

Although the current doctrine of IBD pathogenesis proposes an interaction between environmental factors and gut microbiota in genetically susceptible individuals, dietary exposures have attracted recent interest and are, at least in part, likely to explain the rapid rise in disease incidence and prevalence. The D-ECCO working group along with other ECCO experts with expertise in nutrition, microbiology, physiology, and medicine reviewed the evidence investigating the role of diet and nutritional therapy in the onset, perpetuation, and management of IBD. A narrative topical review is presented where evidence pertinent to the topic is summarised collectively under three main thematic domains: i] the role of diet as an environmental factor in IBD aetiology; ii] the role of diet as induction and maintenance therapy in IBD; and iii] assessment of nutritional status and supportive nutritional therapy in IBD. A summary of research gaps for each of these thematic domains is proposed, which is anticipated to be agenda-setting for future research in the area of diet and nutrition in IBD.

Nutritional Therapy in Very Early-Onset Inflammatory Bowel Disease: A Case Report

Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal tract caused by a dysregulated immune response to the fecal microbiota. Very early-onset inflammatory bowel disease (VEO-IBD) refers to a subgroup of pediatric patients with IBD diagnosed before 6 years of age. This subgroup is often characterized by increased severity, aggressive progression, strong family history of IBD, and often poor response to conventional treatments. Nutritional therapies have been utilized to treat IBD, but their role in VEO-IBD is unclear. Disease behavior in VEO-IBD is often different from disease in adolescents and adults, as it is often restricted to the colon and refractory to standard medical therapies. Up to 25% of VEO-IBD patients have an identified underlying immunodeficiency, which may impact response to therapy. While specific mutations in interleukin 10 (IL-10), the IL-10 receptor (IL-10R), and mutations in NCF2, XIAP, LRBA, and TTC7 have been identified in VEO-IBD, polymorphisms in these genes are also associated with increased risk of developing IBD in adolescence or adulthood. We describe two cases in which infants presenting with VEO-IBD achieved clinical remission using exclusive enteral nutrition, a formula-based diet which has been shown to induce remission in older children with active Crohn's disease.

Towards an integrated understanding of the therapeutic utility of exclusive enteral nutrition in the treatment of Crohn's disease

Crohn's disease (CD) is a chronic disease characterized by episodic and disabling inflammation of the gastrointestinal tract in genetically susceptible individuals. The incidence and prevalence of CD is rising rapidly across the world emphasising that disease risk is also influenced by environmental and lifestyle factors, as well as the microbial community resident in the gut. Childhood-onset CD is associated with an aggressive disease course that can adversely impact patient growth and development. There is no cure for CD however new onset and recurrent cases of paediatric CD are often responsive to exclusive enteral nutrition (EEN) treatment. EEN treatment involves the exclusive consumption of an elemental or polymeric formula for several weeks and it is well established as a primary intervention strategy. EEN treatments typically achieve remission rates of over 80% and importantly they are associated with a high rate of mucosal healing, far superior to steroids, which is prognostic of improved long-term health outcomes. Furthermore, they are safe, have few side effects, and improve nutritional status and linear growth. Surprisingly, despite the utility of EEN our understanding of the host-microbe-diet interactions that underpin clinical remission and mucosal healing are limited. Here, we review the current state of knowledge and propose that the induction of autophagy, in addition to modulation of the microbiota and coordinated effects on inflammation and epithelial cell biology, may be critical for the therapeutic effects associated with EEN. A better understanding of EEN treatment will provide new opportunities to restore gut homeostasis and prolong periods of remission, as well as provide new insights into the factors that trigger and perhaps prevent CD.

Food Intake Adequacy in Children and Adolescents With Inflammatory Bowel Disease

OBJECTIVES

Diet assessment is essential in the care of patients with inflammatory bowel disease (IBD). We aimed to study food intake in children with IBD and evaluated the relation of dietary intake with disease activity and nutritional status in these children.

METHODS

This cross-sectional study investigated 68 children and adolescents with IBD (57 Crohn disease, 11 ulcerative colitis). Evaluation included clinical, laboratory, and nutritional assessment including 3 days diet record.

RESULTS

Compared with recommended daily allowance, the intake of patients with IBD was significantly poor for carbohydrates (75%, P = 0.016), calcium (49%, P < 0.05), magnesium (76%, P < 0.05), vitamin A (72%, P < 0.05), vitamin E (57%, P < 0.05), and fiber (44%, P < 0.05) and higher for protein (175%, P < 0.05), iron (112%, P < 0.05), and water-soluble vitamins (118%-189% P < 0.05). Compared with the intakes of healthy children from National Nutritional Survey, the intake of IBD group was lower for calories (78%, P = 0.012), carbohydrates (61% P < 0.05), magnesium (67% P < 0.05), vitamin C (34%, P < 0.05), and fiber (54%, P < 0.05) and high for B12 (141%, P < 0.05). Fifty subjects ate ordinary diets, 7 of 68 children were on exclusive enteral nutrition and 11 of 68 consumed regular food with different polymeric formulas supplements. Compared with children without supplements, children on exclusive enteral nutrition and nutritional supplements (18/68) had significantly better intakes of energy (1870 ± 755 vs 2267 ± 432, P < 0.05), carbohydrates (223 ± 97 vs 292 ± 99, P < 0.05), and all minerals (P < 0.05) and micronutrients (P < 0.05). Dietary intake was not different by disease status (remission or relapse).

CONCLUSIONS

In the absence of nutritional supplements, food intake is inadequate for many nutrients in many children with IBD.

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.

Nutritional perspectives of children with Crohn's disease: a single-centre cohort observation of disease activity, energy expenditure and dietary intake

BACKGROUND/OBJECTIVES

Children with Crohn's disease often demonstrate nutritional recovery during primary therapy at diagnosis, but long-term nutritional support is sometimes necessary. Evidence to inform best nutritional practice including energy and micronutrient requirements is limited. The principal objective of this study was to determine how energy expenditure and physical activity vary with disease activity over the first year following diagnosis.

SUBJECTS/METHODS

Twenty children were studied at diagnosis with Crohn's disease and were followed up over 1 year while receiving treatment according to national guidelines. The majority of children (13) were treated with exclusive enteral nutrition. At study visits, height, weight, bioelectrical impedance, resting energy expenditure by indirect calorimetry, tri-axial accelerometer and blood investigations were performed alongside clinical assessment.

RESULTS

There was no significant effect of disease activity on resting energy expenditure (REE). Physical activity was greater after primary therapy (Z=3.31, P<0.01). Median wPCDAI fell from 58 at diagnosis to 7.5 after primary therapy and was 7.5 at 1 year. Weight s.d.s increased from -1.67 to -0.86 and lean index s.d.s increased from -2.93 to -1.64, although the increase was mostly in the first 2 months. Median height s.d.s was unchanged throughout this study. There was a significant association between dietary intake and weight gain (r=0.8 P<0.01) but not height gain. Persistent micronutrient deficits beyond diagnosis were seen for both iron and vitamin D.

CONCLUSIONS

This study has demonstrated that REE does not change significantly through different phases of disease activity, but physical activity is low at diagnosis. Children with Crohn's disease should be screened for deficiencies of iron and vitamin D.

Diet therapy for inflammatory bowel diseases: The established and the new

Although patients with inflammatory bowel diseases (IBD) have a strong interest in dietary modifications as part of their therapeutic management, dietary advice plays only a minor part in published guidelines. The scientific literature shows that dietary factors might influence the risk of developing IBD, that dysbiosis induced by nutrition contributes to the pathogenesis of IBD, and that diet may serve as a symptomatic treatment for irritable bowel syndrome-like symptoms in IBD. The role of nutrition in IBD is underscored by the effect of various dietary therapies. In paediatric patients with Crohn’s disease (CD) enteral nutrition (EN) reaches remission rates similar to steroids. In adult patients, however, EN is inferior to corticosteroids. EN is not effective in ulcerative colitis (UC). Total parenteral nutrition in IBD is not superior to steroids or EN. The use of specific probiotics in patients with IBD can be recommended only in special clinical situations. There is no evidence for efficacy of probiotics in CD. By contrast, studies in UC have shown a beneficial effect in selected patients. For patients with pouchitis, antibiotic treatment followed by probiotics, like VSL#3 or Lactobacillus GG, is effective. When probiotics are used, the risk of bacterial translocation and subsequent bacteremia has to be considered. More understanding of the normal intestinal microflora, and better characterization of probiotic strains at the phenotypic and genomic levels is needed as well as clarification of the mechanisms of action in different clinical settings. A FODMAP reduced diet may improve symptoms in IBD.

Effect of short-term partial enteral nutrition on the treatment of younger patients with severe Crohn's disease

Background/Aims

To analyze the effect of short-term supportive temporary partial enteral nutrition therapy for treating severe pediatric Crohn’s disease (CD).

Methods

We conducted a prospective, open-label study in pediatric patients with CD (n=78) from January 2007 to December 2011. The CD patients were divided into three groups according to disease severity (mild, moderate, and severe). Seventeen patients with severe CD received short-term partial enteral nutrition (SPEN) in addition to their general diet for 4 weeks after the induction of remission with medical treatment. This SPEN group was further divided into two groups by age (<13 years, ≥13 years). Nutritional parameters and Pediatric Crohn’s Disease Activity Index scores were analyzed at the initial enrollment and following 1 year of treatment for all groups.

Results

Nutritional status improved substantially after 1 year of treatment in the severe CD group. Nutritional status in the SPEN group improved considerably more than that in the non-SPEN group. Additionally, the <13-year-old group demonstrated better nutritional status improvement than the ≥13-year-old group.

Conclusions

SPEN may be effective in pediatric patients with severe CD for improving nutritional status and moderating disease severity.

Systematic review: Body composition in children with inflammatory bowel disease

BACKGROUND

Paediatric inflammatory bowel disease (IBD) is associated with weight loss, growth restriction and malnutrition. Bone mass deficits are well described, little is known about other body composition compartments.

AIMS

To define the alterations in non-bone tissue compartments in children with IBD, and explore the effects of demographic and disease parameters.

METHODS

A systematic search was carried out in the PubMed (www.ncbi.nlm.nih.gov/pubmed) and Web of Science databases in May 2014 (limitations age <17 years, and composition measurements compared with a defined control population).

RESULTS

Twenty-one studies were included in this systematic review, reporting on a total of 1479 children with IBD [1123 Crohn's disease, 243 ulcerative colitis], pooled mean age 13.1 ± 3.2 years, and 34.9% female. Data were highly heterogeneous, in terms of methodology and patients. Deficits in protein-related compartments were reported. Lean mass deficits were documented in 93.6% of Crohn's disease and 47.7% of ulcerative colitis patients when compared with healthy control populations. Lower lean mass was common to both sexes in Crohn's disease and ulcerative colitis, deficits in females with persisted for longer. Fat-related compartment findings were inconsistent, some studies report reductions in body fat in new diagnosis/active Crohn's disease.

CONCLUSIONS

It is clear that almost all children with Crohn's disease and half with ulcerative colitis have reduced lean mass, however, body fat alterations are not well defined. To understand what impact this may have on health and disease in children with IBD, further studies are needed to identify in which tissues these deficits lie, and to quantify body fat and its distribution.

Exclusive enteral nutrition in children with Crohn’s disease

Exclusive enteral nutrition involves the use of a complete liquid diet, with the exclusion of normal dietary components for a defined period of time, as a therapeutic measure to induce remission in active Crohn’s disease (CD). This very efficacious approach leads to high rates of remission, especially in children and adolescents newly diagnosed with CD. This intervention also results in mucosal healing, nutritional improvements and enhanced bone health. Whilst several recent studies have provided further elaboration of the roles of exclusive enteral nutrition in the management of CD, other reports have provided new understanding of the mechanisms by which this intervention acts.

Diet in the pathogenesis and treatment of inflammatory bowel diseases

Some of the most common symptoms of the inflammatory bowel diseases (IBD, which include ulcerative colitis and Crohn's disease) are abdominal pain, diarrhea, and weight loss. It is therefore not surprising that clinicians and patients have wondered whether dietary patterns influence the onset or course of IBD. The question of what to eat is among the most commonly asked by patients, and among the most difficult to answer for clinicians. There are substantial variations in dietary behaviors of patients and recommendations for them, although clinicians do not routinely endorse specific diets for patients with IBD. Dietary clinical trials have been limited by their inability to include a placebo control, contamination of study groups, and inclusion of patients receiving medical therapies. Additional challenges include accuracy of information on dietary intake, complex interactions between foods consumed, and differences in food metabolism among individuals. We review the roles of diet in the etiology and management of IBD based on plausible mechanisms and clinical evidence. Researchers have learned much about the effects of diet on the mucosal immune system, epithelial function, and the intestinal microbiome; these findings could have significant practical implications. Controlled studies of patients receiving enteral nutrition and observations made from patients on exclusion diets have shown that components of whole foods can have deleterious effects for patients with IBD. Additionally, studies in animal models suggested that certain nutrients can reduce intestinal inflammation. In the future, engineered diets that restrict deleterious components but supplement beneficial nutrients could be used to modify the luminal intestinal environment of patients with IBD; these might be used alone or in combination with immunosuppressive agents, or as salvage therapy for patients who do not respond or lose responsiveness to medical therapies. Stricter diets might be required to induce remission, and more sustainable exclusion diets could be used to maintain long-term remission.

Decline in presumptively protective gut bacterial species and metabolites are paradoxically associated with disease improvement in pediatric Crohn's disease during enteral nutrition

BACKGROUND

The gut microbiota is implicated in the pathogenesis of Crohn's disease (CD). Exclusive enteral nutrition (EEN) is a successful treatment, but its mode of action remains unknown. This study assessed serial changes in the fecal microbiota milieu during EEN.

METHODS

Five fecal samples were collected from CD children: 4 during EEN (start, 15, 30, end EEN approximately 60 days) and the fifth on habitual diet. Two samples were collected from healthy control subjects. Fecal pH, bacterial metabolites, global microbial diversity abundance, composition stability, and quantitative changes of total and 7 major bacterial groups previously implicated in CD were measured.

RESULTS

Overall, 68 samples were from 15 CD children and 40 from 21 control subjects. Fecal pH and total sulfide increased and butyric acid decreased during EEN (all P < 0.05). Global bacterial diversity abundance decreased (P < 0.05); a higher degree of microbiota composition stability was seen in control subjects than in CD children during EEN (at P ≤ 0.008). Faecalibacterium prausnitzii spp concentration significantly decreased after 30 days on EEN (P < 0.05). In patients who responded to EEN, the magnitude of the observed changes was greater and the concentration of Bacteroides/Prevotella group decreased (P < 0.05). All these changes reverted to pretreatment levels on free diet, and EEN microbiota diversity increased when the children returned to their free diet.

CONCLUSIONS

EEN impacts on gut microbiota composition and changes fecal metabolic activity. It is difficult to infer a causative association between such changes and disease improvement, but the results do challenge the current perception of a protective role for F. prausnitzii in CD.