Role of Enteral Nutrition in Pediatric Crohn’s Disease Joanna Yeh Peds GI Case Conference May 2012
Role of Enteral Nutrition in Pediatric Crohn’s Disease
Joanna Yeh
Peds GI
Case Conference
May 2012
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
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.?
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
International Variance
4%
36% 62%
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
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”
Growth
• Positive effect of enteral therapy compared to steroids occurs within 10 week to 6 months
Mucosal healing
• New standard to aim for?
• Improved endoscopic and histologic scores with decreased mucosal inflammatory cytokines
• Documented in enteral therapy
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
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?
Pediatric Meta Analysis
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)
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
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
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
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
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)
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
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
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?
Enteral Therapy in Crohn’s Disease
• Induction: Yes
• Maintenance: Yes
• Mucosal healing : Yes
• Improved growth : Yes
• Serious adverse events : No
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.?)
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
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.