1. Role of Enteral Nutrition in
Pediatric Crohn’s Disease
Joanna Yeh
Peds GI
Case Conference
May 2012
2. Objectives
• Understand the role of enteral therapy in
treating Crohn’s disease
• Understand the differences in practice
internationally
• Understand the pros and cons of enteral
therapy
3. History
• First case reports in 1970s
• 1984: first controlled study to show elemental
diet induced remission
• 2006: Europe and Japan independently
published guidelines recommending enteral
nutrition as first line induction therapy in
children
• 2010: Similar conclusions by British society
• So why not in U.S.?
4. Pros
• Can induce
remission
• Can maintain
remission
• Reduced steroid
dosage over long
term (growth
retardation,
osteopenia)
• No major side
effects
Cons
• Unpalatability
• Slower to get
results
• Compliance
concerns
• Costs/insurance
• Resource demands
(nutritionist, nurse)
• QOL, psychosocial
6. Why does enteral therapy work?
• Unknown
• Hypotheses:
– Overall nutritional repletion
– Altered gut microflora
– Correction of intestinal permeability
– Decreased synthesis of inflammatory mediators
via reduction in dietary fat
– Elimination of dietary antigen uptake
7. Steroid concerns
• Growth
• Bone mineral density
• Lack of mucosal healing
• Infections
• Psychosocial (depression, anxiety, loss of
concentration, irritability, sleep disturbance)
“A stunted, cushingoid child without GI sx is not a
success story”
8. Growth
• Positive effect of enteral therapy compared to
steroids occurs within 10 week to 6 months
9. Mucosal healing
• New standard to aim for?
• Improved endoscopic and histologic scores
with decreased mucosal inflammatory
cytokines
• Documented in enteral therapy
10. Induction Therapy
• CHOP
– Semi elemental formula
– 90% of caloric needs from formula
– Nocturnal NG feeds (outpatient teaching program)
– Normal diet during day
– 7 days per week for 8-12 weeks
11. Induction therapy
• Cochrane 2007 meta analysis of 6 trials
• Steroids vs. enteral therapy
• Favored steroid therapy
• Adults and pediatrics but more adults
• 3 pediatric meta analysis
• Benefits of enteral therapy differ in children
from adults?
15. 0
20
40
60
80
100
Healing of GI tract
Enteral nutrition Corticosteroids
0
20
40
60
80
100
Clinical improvement
Borrelli O, et al. Clin. Gastroenterol. Hepatol.; 2006
% %
n=19 n=18
P<0.05
Polymeric Diet Alone vs. Steroids for Active
Pediatric CD
(Induction Therapy)
16. Duration of therapy
• Majority of centers use 6-8 weeks
• Inflammatory markers improve in as little as 1
week
• Time to remission 11 days to 2.5 weeks
• NASPGHAN group suggests a period of 3-4
weeks to see if therapy is effective
17. Remission Rates
• Induction
– Range: up to 85% (53-80%)
– CHOP 75% at 12 weeks
– Steroid remission rates = 70-80%
• Maintenance
– 32% at 1 year
– Old studies (1988, 1996) from Canada
• At 12 month, 43% of enteral group relapsed vs. 79% in non
enteral group
– No recent studies
18. Maintenance Therapy
• By itself or with medical therapy
• Options:
– Overnight NG feeds with
normal daytime eating 5 days
per week (CHOP)
– Short bursts of NG feeds every
few months (“European”)
• i.e. 4 week cycles of
exclusive enteral nutrition
q3-4 months
– Oral supplements +/- medical
therapy
19. Partial enteral therapy
• Lack of published data
• UK study of 50 children (Johnson, Gut, 2006)
• 100% of caloric needs seems better than 50%
(15% vs. 42% remission)
• CHOP, unpublished data, allows 10% of energy
intake as regular diet
20. Formula composition
• Comparisons between elemental, semi
elemental, and polymeric (whole protein)
show no significant differences
• ? Fat composition remains unclear, non
significant trend favoring very low fat and low
long chain triglyceride (larger trials needed)
21. Disease location
• Some evidence that enteral therapy works
better in small bowel disease rather than in
colonic disease but overall unclear
• Afzal (2005)
– 11/12 with ileal disease achieved remission
– 32/39 with ileocolonic
– 7/14 with isolated colonic
• Buchanan (2009)
– 10/13 with isolated small bowel
– 15/19 with isolated colonic
22. Reasons Preventing Widespread use of
Enteral Therapy In U.S.
• Side effects: emesis, nausea, diarrhea, NG tube
problems
• Compliance
• Psychosocial (food as an important social event)
• Lack of financial support
• Poor access to dietician/nursing support
• Lack of experience
• Lack of understanding of mechanisms of actions
• Lack of confidence in efficacy
23. Medical Therapies for Crohn’s Disease
• Induction: Steroids, anti TNF
• Maintenance: 6MP/AZA, MTX, anti TNF
• Mucosal healing: anti TNF > 6MP/AZA/MTX
• Improved growth: anti TNF > 6MP/AZA/MTX
Where does enteral therapy fit in?
25. Unanswered Questions
• Phenotype (SB vs. colonic)
• Induction protocol (100% vs. 90%)
• Maintenance protocol
• Induction Maintenance
– Nutritional -> 6MP/AZA/MTX/anti TNF
– Steroid -> 6MP/AZA/MTX/anti TNF
Does induction with enteral therapy result in better
long term outcomes? (height, bone density, mucosal
healing, remission rate, etc.?)
26. Summary
• Enteral therapy is an effective induction
therapy in newly diagnosed Crohn’s (grade A)
• Enteral therapy has an improved adverse
effect profile over steroids (grade A)
• Enteral therapy improves mucosal healing,
linear growth (grade A)
• Enteral therapy can be considered in the
motivated, compliant patient
27. References
• Critch, et al, “Use of Enteral Nutrition for the Control of Intestinal
Inflammation in Pediatric Crohn Disease,” JPGN, Feb 2012.
• Levine, et al, “Consensus and Controversy in the Management of
Pediatric Crohn Disease: An International Survey,” JPGN, April 2003.
• Stewart, et al, “Physician Attitudes and Practices of Enteral
Nutrition as Primary Treatment of Pediatric Crohn Disease in North
America,” JPGN, Jan 2011.
• Heuschkel, et al, “Enteral Nutrition and Corticosteroids in the
Treatment of Acute Crohn’s Disease in Children,” JPGN, July 2000.
• Zachos, et al, “Enteral Nutritional Therapy for Induction of
Remission in Crohn’s Disease,” Cochrane Review, 2007.
• Borrelli, et al, “Polymeric Diet Alone Versus Corticosteroids in the
Treatment of Active Pediatric Crohn’s Disease: A Randomized
Controlled Open-Label Trial,” Clinical Gastroenterology and
Hepatology, May 2006.
