Use Of Exclusive Enteral Nutrition Research Articles

The Crohn’s Disease Exclusion Diet: A Comprehensive Review of Evidence, Implementation Strategies, Practical Guidance, and Future Directions

Abstract Dietary therapy is increasingly recognized for the management of Crohn’s disease (CD) over recent years, including the use of exclusive enteral nutrition (EEN) as first-line therapy for pediatric CD according to current guidelines. The Crohn’s disease exclusion diet (CDED) is a whole-food diet designed to reduce exposure to dietary components that are potentially pro-inflammatory, mediated by negative effects on the gut microbiota, immune response, and the intestinal barrier. The CDED has emerged as a valid alternative to EEN with cumulative evidence, including randomized controlled trials, supporting use for induction of remission and possibly maintenance in children and adults. We gathered a group of multidisciplinary experts, including pediatric and adult gastroenterologists, inflammatory bowel diseases (IBD) expert dietitians, and a psychologist to discuss the evidence, identify gaps, and provide insights into improving the use of CDED based on a comprehensive review of CDED literature and professional experience. This article reviews the management of CDED in both children and adults, long-term aspects of CDED, indications and contraindications, selecting the best candidates, identifying challenges with CDED, globalization, the role of the multidisciplinary team, especially of dietitian, and future directions. We concluded that CDED is an established dietary therapy that could serve as an alternative to EEN in many pediatric and adult cases, especially with mild to moderate disease. In severe disease, complicated phenotypes, or with extraintestinal involvement, CDED should be considered on a case-by-case basis, according to physician and dietitians’ discretion. More studies are warranted to assess the efficacy of CDED in different scenarios.

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease.

Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.

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.

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. 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. 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). 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.

SP10.4 Pre-operative use of exclusive enteral nutrition in adult patients with Crohn’s disease: a single centre experience

Abstract Introduction Exclusive enteral nutrition (EEN) in the management of adult patients with Crohn’s disease (CD) is thought to reduce post-operative complications but is under-utilised. This study aims to assess the use of EEN and post-operative outcomes in patients undergoing surgery for CD. Methods Consecutive adult patients at a single NHS Trust with CD undergoing surgery for stricturing, penetrating and medication-refractory disease from January 2018 to December 2021 were included. Patients prescribed at least 6 weeks of EEN prior to surgery (EEN) were compared to those who were not (non-EEN). Outcomes included intestinal failure (IF) requiring parenteral nutrition, post-operative complications, length of stay (LOS), unplanned readmission at 3 months and disease recurrence at 6 months. Results 142 patients were included, comprising 22 EEN and 120 non-EEN patients. There were no cases of postoperative IF in the EEN cohort, whilst 18.3% of non-EEN patients (22/120; p=0.04) developed type one IF. The mean LOS (days) was significantly less in the EEN group (8.3±3.6 vs. 15.9±17.3, p=0.04), as were the complication rates when using a Clavien Dindo score of ≥2 (13.6% vs. 36.7%, p=0.04). Outcomes for unplanned admission at 3 months (OR 0.44, p= 0.3) and disease recurrence at 6 months (OR 0.45, p= 0.3) favoured the EEN cohort but were not significant. Conclusion Consistent with other studies, our study demonstrated a potential benefit in post-operative outcomes in adult patients treated with at least 6 weeks of EEN. To fully utilize the benefits of EEN, potential candidates for surgery who will benefit from EEN need to be identified early.

Dietetic advocacy for long-term use of exclusive enteral nutrition resulted in high-risk surgical avoidance for complicated fibrotic Crohn's disease – A case report

Surgery is often the only therapeutic option for the management of fibrotic Crohn's disease (FCD). Exclusive Enteral Nutrition (EEN), a nutritionally complete liquid formula, is an effective, safe, short-term treatment for Crohn's Disease. No cases were found internationally of adults with FCD on long-term EEN. We report on clinical outcomes and self-reported quality of life (QoL) after longer-term EEN provision in a patient with complex FCD. "Billie", a 54-year-old female, was admitted with ileal FCD diagnosed in 1985. Previous treatments were unsuccessful, including multiple bowel resections. Billie was chronically bedbound with pain and depression. CDAI (Crohn's disease activity index) score was 640 (<150) with ∼3-20 liquid stools/day, and recurrent partial bowel obstructions. Radiological findings were so severe surgeons reluctantly considered surgery but "one more resection will result in short bowel syndrome". Billie trialled EEN given her QoL was "non-existent". Unable to tolerate the taste, EEN was administered via nasogastric tube. After two months, EEN was administered ongoing via percutaneous endoscopic gastrostomy given patient preference and dietetic advocacy. After eight weeks on EEN, Billie's pain predominantly resolved, with bowel motions of ∼1-2/day, and nil bowel obstructions. Twelve months after EEN commencement, Billie's CDAI was 52, with 'no indication for surgical intervention' and was self-reporting that "life is good". After 18 months, Billie remains asymptomatic, and in clinical remission. This unique case is a wonderful example of dietetic advocacy and showcases the positive impact long-term EEN may have on surgical avoidance, clinical outcomes and self-reported QoL.

Current Nutritional Therapies in Inflammatory Bowel Disease: Improving Clinical Remission Rates and Sustainability of Long-Term Dietary Therapies.

Inflammatory Bowel Disease (IBD) includes a spectrum of chronic immune-mediated intestinal diseases thought to be related to the complex interaction between the host immune system and the intestinal microbiome. Research supports the use of nutritional therapy in IBD; however, it is not routinely used in clinical practice. This literature review seeks to advance the understanding of diet and its effect in IBD with a focus on both Crohn's Disease (CD) and Ulcerative Colitis (UC). The contribution of diet to the development and treatment of IBD cannot be overstated. In both pediatric as well as adult IBD, nutritional interventions have been shown to improve clinical symptoms as well as inflammatory burden. The impact of dietary intervention is best exemplified through the use of Exclusive Enteral Nutrition (EEN) in CD. EEN and clinical research on exclusionary whole food diets-Crohn's Disease Exclusion Diet (CDED), Specific Carbohydrate Diet (SCD), low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet, and Mediterranean Diet-are discussed within this review. Current clinical literature supports the elimination of detrimental components and the incorporation of low processed whole foods in the diet. Additional prospective and longitudinal dietary studies on sustainable and long-term dietary options, along with a deeper understanding of the mechanism, are needed to further advance the role of nutritional interventions in IBD.

S2725 Enteral Nutrition in Crohns Disease With Abscess

Introduction: Enteral nutrition has emerged as a treatment option for patients with active Crohn’s disease. We report a patient achieving remission with enteral nutrition in conjunction with ustekinumab. Case Description/Methods: A 29-year-old Caucasian male with Crohn’s disease not on therapy presented with abdominal pain, nausea and vomiting. In the past 3 years, he had multiple visits to urgent care for symptoms, each treated with systemic steroids. On presentation, he had an elevated CRP of 143.9 mg/L and MR enterography showed inflammation in the small bowel and terminal ileum. The patient completed a 7-day course of piperacillin-tazobactam and was started on ustekinumab. He was readmitted 10 days later with WBC of 16.9 10*3/ul, CRP of 305.6 mg/L, tachycardia, night sweats and worsening abdominal pain. Imaging showed continued inflammation of small bowel and terminal ileum with a mesenteric abscess connected to the D4 portion of duodenum by a fistulous tract. Piperacillin-tazobactam was started for 14 days along with 5 weeks of exclusive enteral nutrition (EEN) with BOOST, ∼2145 kcals daily. Repeat imaging showed interval decrease in abscess size and then complete resolution. Disease remission was obtained with alleviation of abdominal pain and weight gain of 5 lbs. Labs normalized with CRP < 3 mg/L, at the end of the 5 weeks of EEN. Discussion: EEN is the administration of a polymeric formula as the sole source of nutrition for a limited period (4-8 weeks). In Crohn’s disease, EEN has been shown to help reach remission in 85-90% of patients. It has special consideration in achieving remission in CD patients who have steroid intolerance or contraindications to systemic steroids. The mechanism of EEN in treatment of Crohns disease is not completely understood but is hypothesized to be multifactorial and potentially involve alterations in gut microbiota, decreasing gut permeability, and allowing restoration of epithelial barrier. Limited studies have been conducted on concomitant use of EEN with biologic agents. These studies have primarily been done looking at anti-TNF agents, such as infliximab, and sustained remission rates. Induction therapy with such agents as ustekinumab take time to have clinical effect, 56% of patients have response in 6 weeks. In this patient, initiation of ustekinumab along with EEN was successful in achievement of clinical remission and reduction in inflammatory markers.

Dietary management of adults with IBD - the emerging role of dietary therapy.

Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.

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

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. 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. 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. 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.

Опыт применения полного энтерального питания для индукции ремиссии у ребенка с болезнью Крона

According to current clinical guidelines, exclusive enteral nutrition (EEN) is an effective and preferred treatment for inducing remission in children with Crohn’s disease (CD), except in cases of severe pancolitis, isolated oral or perianal lesions, stenotic and fistulous forms. This article presents our own clinical experience with EEN in a child with newly diagnosed CD. The combined use of EEN with Modulen IBD formula helped to achieve clinical remission (abdominal pain regression, nutritional status improvement) and reduce laboratory and endoscopic activity. The experience of using EEN in Russia is limited due its low availability and difficulties in achieving compliance. Nevertheless, the possibility of using EEN deserves attention because of its benefits: a lower risk of side effects, faster healing of the intestinal mucosa, a favorable effect on nutritional status and course of the disease. Key words: Crohn’s disease, exclusive enteral nutrition

The role of exclusive enteral nutrition in the pre-operative optimisation of adult patients with Crohn's disease. A systematic review.

To conduct a systematic review in order to bring together the current knowledge about the use of exclusive enteral nutrition (EEN) in the pre-operative optimisation of adult patients with Crohn's disease undergoing intestinal resection. We searched Pubmed, Cochrane Library, ClinicalTrials.gov and the EU clinical trial register to identify experimental and observational studies on the effect of pre-operative EEN on nutritional and clinical outcomes of patients undergoing surgery. Methodological quality was assessed using the Downs and Black checklist. Seven studies were included in the final analysis. Of these 5 were retrospective cohort studies and 2 were retrospective case-control studies. There were 4 ongoing RCTs, however they have not reported data to analyse. Overall the 7 retrospective studies, support that with EEN; body mass index (BMI) does not increase, C-reactive protein decreases (CRP), albumin usually increases and haemoglobin does not significantly change. There were fewer infectious complications in patients who had taken EEN. There was a trend towards fewer stomas but only one of the studies was powered enough to demonstrate significance. There was no significant difference in recurrence rates of Crohn's disease at 12 months in any of the studies. Quality of the studies were either medium or poor. The current data on the use of EEN in pre-operative optimisation is of poor quality and underpowered to demonstrate significance. Randomised controlled trials are needed to demonstrate whether or not EEN can improve outcomes and reduce stoma formation in adult patients undergoing intestinal resection.

Outcomes of exclusive enteral nutrition for induction of disease remission in paediatric crohn's disease in auckland, new zealand: a retrospective observational study

Rationale: Exclusive enteral nutrition (EEN) is the primary first line treatment to achieve disease remission in paediatric Crohn’s disease (CD) in New Zealand (NZ). The aim of this study was to identify paediatric patients in Auckland diagnosed with CD at Starship Child Health and investigate clinical outcomes of EEN use at diagnosis.

Does exclusive enteral nutrition reduce the rate of stoma formation in patients requiring ileocolic resection for Crohn's disease? A single center experience.

Nutrition has a role in achieving and maintaining remission in Crohn's disease. The aim of this study was to determine the impact of a strategy of steroid-avoidance and Exclusive Enteral Nutrition (EEN) for 6 weeks (with a minimum of 4 weeks) in adult patients presenting with acute small bowel Crohn's disease followed by an interval ileocolic resection 4-6 weeks later. Retrospective review of prospectively collected data. Patients were administered exclusive enteral nutrition (EEN) for at least 4 weeks prior to surgery. 24 EEN patients included. Median age of 45 (range 23-73). 17/24 patients tolerated Modulen for at least 4 weeks, 5 were switched to Ensures and 2 a liquid diet. 6 patients underwent surgery earlier than planned. Prior to surgery, there was no change in the mean BMI, albumin increased from a mean of 36g/L (range 25-43) to 40g/L (range 30-48). CRP levels decreased by a mean of 35.8mg/L overall. 19 (79%) of operations were performed laparoscopically. 6 of the cases were re-do operations. All but 3 patients avoided a stoma at the time of the original operation. There were 5 post-operative complications: 1 anastomotic leak in a patient with a BMI of 42, 3 cases of paralytic ileus and 2 wound infections. Median length of stay was 7 days (range 3-76 days). Only 2 patients were readmitted within the 30-day post-operative period. The pre-operative use of EEN appears to avoid unnecessary stoma formation with acceptable clinical outcomes.

Let Food Be Thy Medicine-Its Role in Crohn's Disease.

The food we eat is thought to play a role in both the increasing incidence as well as the course of Crohn’s disease. What to eat and what to avoid is an increasingly important question for both patients and physicians. Restrictive diets are widely adopted by patients and carry the risk of inducing or worsening malnutrition, without any guarantees on anti-inflammatory potential. Nevertheless, exploration of novel therapies to improve long-term management of the disease is desperately needed and the widespread use of exclusive enteral nutrition in the induction of paediatric Crohn’s disease makes us wonder if a similar approach would be beneficial in adult patients. This narrative review discusses the current clinical evidence on whole food diets in achieving symptomatic and inflammatory control in Crohn’s disease and identifies knowledge gaps with areas for future research.

P624 Maintenance of remission after treatment with Exclusive Enteral Nutrition and Azathioprine in paediatric patients with Crohn’s disease

Abstract Background Several studies have shown the efficacy of Exclusive Enteral Nutrition (EEN) in patients with Crohn’s disease (CD) for the induction of remission. ECCO-ESPGHAN guidelines recommend the use of EEN combined with early use of immunosuppressants in paediatric patients with mild-to-moderate CD. However, there is a lack of data to show its efficacy in the long term to avoid or postpone the use of biological treatment. The aim of our study is to know how many of our patients that have achieved remission with EEN and Azathioprine (AZA), required to step up to biological treatment during the follow-up. Methods Retrospective analysis of paediatric patients with Crohn’s disease that were diagnosed at our Unit between 2003 and 2017. We included those patients that achieved clinical remission after treatment with EEN and AZA. We analyse demographics, clinical and follow-up data until February 2019 or until they are transferred to an adult inflammatory bowel disease (IBD) unit. Results We included 91 patients that achieved clinical remission after treatment with EEN and AZA (68.1% males; Mean age at diagnosis: 12.29 years; Median age at diagnosis: 13 years (range 8 months-17 years). The mean time of follow-up was 60.45 months (range: 8–165 months). During this period, 66/91 patients (72.5%), had a flare. Seventeen of those patients (20.2%) received a second cycle of EEN, being effective in 7 (41.2%). Mean time from diagnosis until the second cycle of EEN was 13.76 months (maximum: 110 months). Globally, 64.8% of our patients required to step up to biological therapy with a mean time from onset to biologics of 15.3 months (median 9 months). Seventy-two per cent of those who needed biological treatment started Adalimumab (ADA). During the follow-up, 42.2% of the patients with combo therapy could withdraw AZA, being the main reason (76.3%) clinical and endoscopic remission. Conclusion Even though EEN is an effective treatment for the induction of the remission in paediatric CD, in the long term we are not able to maintain that remission and an important percentage of patients require to step up to biological therapy. The definition of more strict criteria of remission is necessary in order to establish the most suitable maintenance treatment for each patient.

Preoperative enteral nutrition in adults with complicated Crohn's disease: Effect on disease outcomes and gut microbiota

ObjectivesThe use of exclusive enteral nutrition (EEN) in patients with Crohn's disease (CD) before surgical resection can reduce disease activity and improve nutritional status. The mechanism of EEN action is unclear, but it might involve modulation of the intestinal microbiota. The aim of this study was to evaluate the effects (namely changes in gut microbiota) of preoperative EEN in adults with complicated CD referred to surgery. MethodsThis was a prospective study of adult patients with CD referred to surgery. Patients with body mass index <18.5 kg/m2, weight loss >10 %, serum albumin <3 g/dL, or a combination of some or all three, received EEN for ≥2 wk. The effects of EEN on clinical (Harvey–Bradshaw Index [HBI]) and laboratory markers (C-reactive protein [CRP], serum albumin, and fecal calprotectin) and fecal microbiota were analyzed after EEN (before surgery) and 6 mo later. We used 16 S rRNA gene sequencing to determine changes in the fecal microbiota. ResultsFifteen patients were included, of whom 60% were men with a mean age of 45.4 ± 19.1 y. Of those, 10 received EEN. The median duration of preoperative EEN was 41.5 d (15–70 d). During EEN, there was a significant reduction in mean HBI (8.7 ± 1.9 versus 4.1 ± 2.4; P = 0.001) and CRP (11.7 ± 10.3 versus 0.8 ± 0.8 mg/dL; P = 0.008) and an increase in serum albumin (3.1 ± 0.6 versus 4 ± 0.6 g/dL; P = 0.022). Two patients did not require surgery after EEN. The overall microbial composition changed after EEN (Permutational analysis of variance test, P = 0.046) and there was a significant reduction in α diversity (8 ± 2.3 versus 5.2 ± 1.5; P = 0.023). EEN significantly changed the relative abundance of 11 taxonomic operational units (OTUs). At the family level, we found this was mainly due to the decrease in the Enterobacteriaceae family (7 OTUs). Six months after surgery, α diversity was not different from that before or after EEN; at this time point 6 OTUs were significantly different, mainly due to the decrease of Clostridiales order (3 OTUs). The incidence of postoperative complications and hospital length of stay were similar in EEN and immediate surgery groups, as well as clinical and endoscopic recurrence rates 6 mo after surgery. ConclusionsPreoperative EEN improved disease activity and nutritional status in patients with CD referred to surgery. Despite being malnourished, patients given EEN did not have increased postoperative complications compared with well-nourished patients. During EEN, overall microbiota composition changed and α diversity decreased. EEN did not influence postoperative recurrence and gut microbiota 6 mo after surgery.

Nutritional interventions for the treatment of IBD: current evidence and controversies.

Environmental factors, particularly diet, are the focus of current research as potential triggers of inflammatory bowel disease (IBD). Epidemiological cohort data showing a rapid increase of IBD in western countries and the emergence of IBD in developing countries paralleling the introduction of a western diet are indirect arguments linking food and food behaviour to intestinal inflammation. The successful use of exclusive enteral nutrition (EEN), now considered as first-line induction therapy for paediatric Crohn’s disease (CD), is the strongest argument for a link between diet and IBD. Mechanistic studies revealed that EEN impacts intestinal microbiota composition and together with the exclusion of potentially harmful food ingredients this allows the control of intestinal inflammation and induces mucosal healing. However, the exclusivity character of EEN is a major drawback. Based on the data of EEN, the search for more tolerable and still effective diets has begun. Recent reports on the new CD exclusion diet (CDED), CD-TREAT, as well as the specific carbohydrate diet (SCD) provide the first promising results, further underlining the potential of diet to control inflammation in patients with CD by excluding certain food components. Ongoing research is trying to combine nutritional interventions with analyses of intestinal microbiota and their metabolic functions with the aim of correcting the intestinal dysbiosis that characterizes IBD. This research is promising and gives new hope to patients that have been looking for decades for nutritional interventions with the aim of stabilizing their disease course. There might even be potential for disease prevention in high-risk patients by excluding potentially harmful food components.

A nomogram for predicting the response to exclusive enteral nutrition in adult patients with isolated colonic Crohn's disease.

Background:Isolated colonic Crohn’s disease (cCD) responds less well to induction therapy with exclusive enteral nutrition (EEN) compared with ileal or ileocolonic disease in adult patients; therefore, we aimed to identify the factors that influence the response to EEN and develop a predictive nomogram model to optimize the use of EEN in cCD patients.Materials and methods:Eighty-five cCD patients treated with EEN as first-line therapy at our center between 1 June 2012 and 30 June 2018 were retrospectively analyzed as the primary cohort. The primary endpoint was clinical remission after EEN therapy. Potential predictive factors for the efficacy of EEN were assessed by univariate and multivariate analyses, and a nomogram to predict the response to EEN therapy in cCD patients was designed. Another 19 cCD patients were retrospectively included in the validation cohort to verify the accuracy of the nomogram model.Results:The clinical remission rates for the primary cohort and validation cohort were 52.9% and 47.4%, respectively. Pancolitis was the greatest contributor to the risk of failure to respond to EEN [odds ratio (OR) = 4.896; 95% confidence interval (CI) = 1.223–19.607; p = 0.025], lean body mass index (LBMI), colonic lesion features, simple endoscopic scores for Crohn’s disease, C-reactive protein before treatment and ∆prealbumin were also related to the efficacy of EEN in cCD. The nomogram model showed robust discrimination, with an area under the receiving operating characteristic curve of 0.906.Conclusion:Several predictive factors for response to EEN therapy in cCD adult patients were identified, and a promising nomogram that can predict the effect of EEN in cCD was developed.

Exclusive enteral nutrition in children with inflammatory bowel disease: Physician perspectives and practice.

Background and AimExclusive enteral nutrition (EEN) is recognized internationally as the first line of treatment for children with active Crohn's disease (CD). A survey conducted a decade ago demonstrated that 40% of Australian pediatric gastroenterologists did not think EEN to be an appropriate treatment for CD. This study aimed to explore the current attitudes of Australian and New Zealand (NZ) pediatric gastroenterologists toward the use of EEN in children with inflammatory bowel disease (IBD).MethodsAll practicing pediatric gastroenterologists in Australia and NZ were invited via an existing email network to complete an anonymous online questionnaire.ResultsThe questionnaire was completed by 37 respondents (54% response rate), 31 from Australia and 6 from NZ. All respondents felt that EEN definitely or probably has a role in inducing remission for children with newly diagnosed CD. Australian gastroenterologists were more likely to use EEN for relapsed CD or IBD‐unclassified than NZ doctors (P < 0.05). Adherence was reported to be the greatest disadvantage of EEN. Dietitians were believed to play the most crucial role in EEN administration. Variations in EEN protocols included the use of flavorings or fluids during EEN and different patterns of food reintroduction.ConclusionsThese Australia and NZ pediatric gastroenterologists felt that EEN plays an important role in the induction of remission in children with newly diagnosed CD. However, the perceived role of EEN use in other types of IBD varied. EEN protocols varied widely between centers. Attitudes toward the roles of EEN have altered greatly across Australasia over the last decade.

Global Variation in Use of Enteral Nutrition for Pediatric Crohn Disease.

Exclusive enteral nutrition (EEN) is an effective induction treatment for pediatric Crohn disease. Given the center-based variation in use and diversity in practice, we constructed a survey aimed at sharing experience and strategies in administering EEN, stimulating further research, and optimizing therapy. This survey was constructed after consultation with experts and designed to address key knowledge gaps. The survey was disseminated through the Pediatric IBD Porto Group of ESPGHAN, Canadian Children IBD Network, selective experts, and was sent twice through the Pediatric Gastrointestinal-Bulletin Board (PEDGI-BB). Data were collected into REDCap and analyzed using descriptive statistics. In total, 146 participants from 26 countries completed the survey. Sixty-five percentage of participants were general, non-inflammatory bowel diseases (IBD)-focused pediatric gastroenterologists, 21% were IBD-focused, and 10% were dietitians. The most common indications (∼90% use) were for ileocecal and ileocolonic disease (Paris L1 and L3). The most common duration was 8 weeks and 66% preferred oral to nasogastric administration. Most (63%) did not allow any additional intake and 69% instructed patients to continue partial enteral nutrition (EN) after completing treatment. Dietitians were identified as essential to EEN success while the primary challenges of EEN programs were adherence and lack of support. Regional and professional practice differences were observed in EEN indication, age, exclusivity, program structure/support, and cost coverage. We found significant variation in practice and use of EEN with several regional and professional differences. Global variation offers opportunities for research and improving care. This survey establishes a framework and provides resources for collaboration and information sharing.