Use Of Exclusive Enteral Nutrition Research Articles

Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease: Results and Outcomes.

Exclusive enteral nutrition (EEN) for induction of remission in children with Crohn disease (CD) is recommended as first-line therapy, but underutilized in the United States related to real and perceived barriers. We hypothesized that quality improvement (QI) methodology could increase use of EEN. We developed, implemented, and revised an algorithm and a set of tools to facilitate use of EEN. Through a series of Plan Do Study Act cycles, the approach was modified to overcome provider and patient/family barriers. The primary outcome, the percentage of newly diagnosed CD patients who receive EEN per month between July 2013 and October 2015, assessed using statistical process control. Secondary outcomes, including the short pediatric Crohn disease activity index (sPCDAI), body mass index (BMI) z score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after EEN. Among patients newly diagnosed with CD, 73 patients initiated EEN and were included (mean age 12.7 ± 2.9 years, 49% girls, 86% white). Rates of utilization of EEN increased significantly from a baseline of <5% to an average of approximately 50%. Of the 73 patients who started EEN, 37 (50%) completed a minimum of 8 weeks. Of those completing therapy, 25 (71%) achieved remission, with a significant reduction of sPCDAI (33.6 ± 14.4 to 10.7 ± 12.3, P < 0.0001) CONCLUSIONS:: Use of QI methodology to systematically implement tools designed to improve utilization was effective in increasing the use of EEN. Among those completing therapy, EEN was effective in inducing remission.

Enteral Nutrition in the Management of Pediatric and Adult Crohn's Disease.

Genetic and environmental factors are thought to profoundly influence the pathophysiology of Crohn’s disease (CD). Changes in dietary and hygiene patterns affect the interactions between the immune system and environment. The gut microbiome is responsible for mediating host immune response with significant dysbiosis observed in individuals with CD. Diet therapy using exclusive enteral nutrition (EEN) has been studied as primary therapy for the management of CD. EEN may cultivate the presence of beneficial microbiota, improve bile acid metabolism, and decrease the number of dietary microparticles possibly influencing disease and immune activity. In this review, we will address the current evidence on EEN in the management of adult and pediatric CD. In adults, EEN appears to be moderately beneficial for the induction of remission of CD; however, its use is understudied and underutilized. Stronger evidence is in place to support the use of EEN in pediatric CD with the added benefit of nutrition support and steroid-sparing therapy during the growth phase. Overall, EEN is an established therapy in inducing CD remission in the pediatric population while its role as primary therapy of adult Crohn’s disease remains to be defined.

Reasoning Beyond the Potential Use of Exclusive Enteral Nutrition and Other Specified Diets in Children With Ulcerative Colitis.

The incidence of inflammatory bowel disease (IBD) is steadily on the rise in Western and in developing countries paralleling the increase of westernized diets, characterized by high protein and fat as well as excessive sugar intake, with less vegetables and fiber. Furthermore, nutrition is involved in several aspects of pediatric IBD, ranging from disease etiology to induction and maintenance of remission of disease. Exclusive enteral nutrition (EEN) has been shown to induce remission, including in patients with isolated colonic disease, and leads to mucosal healing in Crohn disease. One hypothesis for the beneficial effect of this modality is exclusion of dietary components thought to cause dysbiosis or impair innate immune mechanisms such as the mucous layer, intestinal permeability or colonization and adherence with adherent-invasive Escherichia coli. Although there is not yet definitive data illustrating a role for EEN in the management of active ulcerative colitis (UC), there are several lines of evidence that illustrate that dietary interventions may be helpful. In particular, the key mechanisms of the activity of EEN (namely, changes in the intestinal microflora in Crohn disease) are likely also relevant to UC. Furthermore, the use of EEN in pediatric UC patients may add to a better bone health. Prospective studies are now required to evaluate the role of EEN in UC in children.

Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease.

Few studies have reported the systematic use of exclusive enteral nutrition in the perioperative setting. To test the hypothesis that exclusive enteral nutrition provides a safe and effective bridge to surgery and reduces post-operative complications, in adult patients with Crohn's disease requiring urgent surgery for stricturing or penetrating complications. Patients treated with exclusive enteral nutrition prior to surgery were each matched with two control patients for disease behaviour, type of surgery, age at diagnosis and disease duration. Data on disease phenotype, nutritional status, operative course and post-operative complications were obtained. Twenty-five per cent [13/51] patients treated with exclusive enteral nutrition avoided surgery. Exclusive enteral nutrition had no effect on pre-operative weight, but it significantly reduced serum CRP [median at baseline 36 (interquartile range, IQR: 13-91] vs. pre-operation 8 (4-31) mg/L, P=0.02]. The median (IQR) length of surgery was shorter in patients pre-optimised with exclusive enteral nutrition than controls [3.0 (2.5-3.5) vs. 3.5 (3.0-4.0) hours respectively, P<0.001]. Multivariable logistic regression analysis confirmed that going straight-to-surgery compared exclusive enteral nutrition pre-optimisation was associated with a ninefold increase in the incidence of post-operative abscess and/or anastomotic leak [OR 9.1; 95% CI (1.2-71.2), P=0.04]. Exclusive enteral nutrition frequently down-stages the need for surgery in patients presenting with stricturing or penetrating complications of Crohn's disease; it is associated with a reduction in systemic inflammation, operative times and the incidence of post-operative abscess or anastomotic leak. Further trials are needed to elucidate how exclusive enteral nutrition may improve operative outcomes.

Dietary treatment of Crohn\u2019s disease: perceptions of families with children treated by exclusive enteral nutrition, a questionnaire survey

BackgroundDiet is strongly associated with the aetiology of Crohn’s Disease (CD) and exclusive enteral nutrition (EEN) is the primary induction treatment in paediatric CD. This study explored opinions around the use of EEN and alternative novel, solid food-based diets (SFDs) expressed by paediatric patients with CD, previously treated with EEN and their parents.MethodsThis anonymous questionnaire surveyed families of CD patients treated with EEN over 1 year. Two questionnaire forms were completed; one asking the patients’ opinions and another referring to their main carer. This questionnaire explored participants’ demographic characteristics; acceptability of a repeat EEN course to treat a future flare (EEN repeat); their opinion on how difficult EEN would be compared to an example SFD; and their intention to participate in a future clinical trial assessing the therapeutic efficacy of an SFD in CD.ResultsForty-one families of CD patients were approached with 29 sending replies (71%). Most of our participants were positive on completing another EEN course, however the majority would choose an SFD alternative (Patients:66, Parents:72%). Both patients and their parents rated EEN to be more difficult to adhere to compared to an example SFD (p < 0.05), and their ratings were strongly correlated (EEN:r = 0.83, SFD:r = 0.75, p < 0.001). The majority of our respondents would agree to participate in a clinical trial assessing an SFD’s effectiveness (Patients:79, Parents:72%) for the management of active CD.ConclusionsWhile patients with CD and their families would accept an EEN repeat, the majority would prefer an SFD alternative. CD families surveyed are supportive of the development of solid food-based dietary treatments.

The role of exclusive enteral nutrition in the management of orofacial granulomatosis in children

Orofacial granulomatosis (OFG) is a term used to describe a persistent, painless swelling of lips and orofacial region. It can be associated with ulceration, gingival hypertrophy and cobble stone appearance of the buccal mucosa. OFG is commonly associated with Crohn's disease and can precede the intestinal manifestation of the disease. Exclusive enteral nutrition (EEN) is a recognized treatment for induction of remission for Crohn's disease. The aim of this study was to review the use of EEN in the management of OFG in children. Retrospective review of medical records of all children diagnosed with OFG between 2007 and 2012 was conducted. Presence of comorbidities, progression to inflammatory bowel disease (IBD) and response to EEN was evaluated. Twenty-nine children were included, mean age at diagnosis was 9 years (standard deviation 3.9) years. Ten children had isolated OFG and 19 had OFG and IBD, of which 12 presented with OFG and IBD and 7 developed IBD later. Median time to progression to IBD was 33 months (inter quartile range: 9.8-85.5). Twenty-two children completed 6 weeks of EEN, and 19 showed clinical improvement in the OFG appearance. EEN appears to be an effective treatment option for children with isolated OFG or OFG and IBD.

Pediatric Inflammatory Bowel Disease Among South Asians Living in British Columbia, Canada: A Distinct Clinical Phenotype.

Inflammatory bowel disease (IBD) incidence is increasing among low-risk populations. This study examined a cohort of Canadian South Asian (SA) children with IBD to determine if their disease course differed from non-SA (NSA) children. Children of SA ethnicity diagnosed with IBD between 1997 and 2012 were identified and compared with NSA children. Data on duration and the type of presenting symptoms, disease phenotype, corticosteroid exposure (CS), exclusive enteral nutrition use, time to commencement of immunomodulator (IM), biologic therapy, and surgical intervention were extracted. Overall, 160 SA children were identified and compared with 783 NSA patients (Crohn's disease [CD]: 44% versus 72%; ulcerative colitis [UC]: 43% versus 21%; IBD-Unclassified: 13% versus 7%; P < 0.001). SA patients were predominantly second-generation Canadians (92%) and had shorter symptom duration (2 versus 4 months; P < 0.001). SA CD patients were less likely to have a parent with IBD (1% versus 14%; P = 0.003). SA patients had more extensive colonic disease (CD: 55% versus 35%; P = 0.005; UC: 77% versus 58%; P = 0.006); SA CD patients presented with more complicated disease (B2/B3: 39% versus 27%; P = 0.006) and UC patients presented with more severe disease (49% versus 23%; P < 0.001). In SA CD patients, CS use was higher (70% versus 58%; P = 0.045), and IM and biologic therapy were commenced earlier (P = 0.027; P = 0.047). SA UC patients were more likely to need CS and IM (P = 0.024; P < 0.001). These data describe an ethnically unique clinical phenotype, where SA children have a higher proportion of UC, shorter symptom duration, more extensive colonic disease, and are more likely to require earlier escalation of therapy.

PWE-050 A protocol to avoid corticosteroid exposure prior to crohn’s disease requiring luminal surgery

<h3>Introduction</h3> Corticosteroids (CS) are prescribed to control inflammatory and obstructive symptoms in Crohn’s disease (CD). Preoperative CS are associated with higher risk of all complications post-operatively including sepsis, anastomotic breakdown and venous thromboembolic disease.High doses of CS also preclude a primary anastomosis. In our institution, we have implemented a protocol to prevent CS administration or permit a rapid wean in patients requiring ileal/ileocaecal resection, maximising the use of exclusive enteral nutrition (EEN) or parenteral nutrition (PN). This study aimed to determine the achievability of CS avoidance in this setting. <h3>Method</h3> In patients selected for ileal/ileocaecal resection, EEN (with either Modulen IBD Nestle or Fortisip Nutricia, as tolerated) was prescribed to a target dose of 30 kcal/kg. Acute sepsis was controlled with intravenous and/or oral antibiotics. If EEN was not tolerated because of obstructive symptoms, PN was instituted or surgery expedited. Patients were not offered this protocol if they had minimal symptoms, adequate nutritional status and no CS exposure. <h3>Results</h3> In total, 39 patients with CD had IC resection over a period of 20 months from January 2013. 9 of these underwent urgent surgery due to symptom severity (severe obstruction or suspected cancer where delay not possible [4 of 9 on CS (45%)]. 8 patients with stable symptoms secondary to fibrotic stricture (4 on biologic, 4 on immunomodulator), adequate nutritional status and CS free were not suitable for the protocol. 22 patients with acute symptoms were therefore included. All had penetrating and/or stricturing disease. 8 patients were receiving CS of whom 7 (88%) successfully weaned off CS for greater than 4 weeks using EEN. 1 did not tolerate EEN and proceeded to surgery on CS. A further 11 of 22 patients successfully treated via protocol to avoid CS (EEN n = 7, PN n = 4) 3 patients did not tolerate/declined EEN/PN and proceeded to expedited surgery. Hence, in all patients suitable for the protocol, CS were successfully avoided (14/14 patients, 100%) and wean &gt;4 weeks successful in majority (7/8 patients, 87.5%). CS exposure was successfully avoided in 21 patients via protocol (95.5%). <h3>Conclusion</h3> Aggressive use of EEN or PN provides an effective approach to avoid CS exposure, optimise nutrition and control acute symptoms in patients selected for IC resection. The implementation of the protocol requires close liaison between gastroenterologists, colorectal surgeons and dieticians. The protocol does not delay emergency surgery. <h3>Disclosure of interest</h3> None Declared.

Sa1217 A Protocol to Avoid Corticosteroid Exposure Prior to Crohn's Disease Requiring Luminal Surgery

Introduction Corticosteroids (CS) are prescribed to control inflammatory and obstructive symptoms in Crohn’s disease (CD). Preoperative CS are associated with higher risk of all complications post-operatively including sepsis, anastomotic breakdown and venous thromboembolic disease.High doses of CS also preclude a primary anastomosis. In our institution, we have implemented a protocol to prevent CS administration or permit a rapid wean in patients requiring ileal/ileocaecal resection, maximising the use of exclusive enteral nutrition (EEN) or parenteral nutrition (PN). This study aimed to determine the achievability of CS avoidance in this setting. Method In patients selected for ileal/ileocaecal resection, EEN (with either Modulen IBD Nestle or Fortisip Nutricia, as tolerated) was prescribed to a target dose of 30 kcal/kg. Acute sepsis was controlled with intravenous and/or oral antibiotics. If EEN was not tolerated because of obstructive symptoms, PN was instituted or surgery expedited. Patients were not offered this protocol if they had minimal symptoms, adequate nutritional status and no CS exposure. Results In total, 39 patients with CD had IC resection over a period of 20 months from January 2013. 9 of these underwent urgent surgery due to symptom severity (severe obstruction or suspected cancer where delay not possible [4 of 9 on CS (45%)]. 8 patients with stable symptoms secondary to fibrotic stricture (4 on biologic, 4 on immunomodulator), adequate nutritional status and CS free were not suitable for the protocol. 22 patients with acute symptoms were therefore included. All had penetrating and/or stricturing disease. 8 patients were receiving CS of whom 7 (88%) successfully weaned off CS for greater than 4 weeks using EEN. 1 did not tolerate EEN and proceeded to surgery on CS. A further 11 of 22 patients successfully treated via protocol to avoid CS (EEN n = 7, PN n = 4) 3 patients did not tolerate/declined EEN/PN and proceeded to expedited surgery. Hence, in all patients suitable for the protocol, CS were successfully avoided (14/14 patients, 100%) and wean >4 weeks successful in majority (7/8 patients, 87.5%). CS exposure was successfully avoided in 21 patients via protocol (95.5%). Conclusion Aggressive use of EEN or PN provides an effective approach to avoid CS exposure, optimise nutrition and control acute symptoms in patients selected for IC resection. The implementation of the protocol requires close liaison between gastroenterologists, colorectal surgeons and dieticians. The protocol does not delay emergency surgery. Disclosure of interest None Declared.

Toward enteral nutrition for the treatment of pediatric Crohn disease in Canada: a workshop to identify barriers and enablers.

The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dietary management of pediatric CD. Workshop participants ranked the exclusivity of enteral nutrition; the health care resources; and cost implications as the top three barriers to its use. Conversely, key enablers mentioned included: standardization and sharing of protocols for use of enteral nutrition; ensuring sufficient dietetic resources; and reducing the cost of EEN to the family (including advocacy for reimbursement by provincial ministries of health and private insurance companies). Herein, the authors report on the discussions during this workshop and list strategies to enhance the use of EEN as a treatment option in the treatment of pediatric CD in Canada.

P-134 The Optimum Length of Enteral Nutritional Therapy for Induction of Remission in Paediatric Crohnʼs Disease

BACKGROUND: Liquid diets were first used in Crohn's disease (CD) to provide preoperative nutritional support, but many of these patients unexpectedly went into remission before operation. Subsequent studies have confirmed the efficacy of enteral nutrition for induction of remission in children with CD and this is first line therapy with the UK. The length of treatment varies in the published paediatric studies from 3 to 10 weeks, with treatment continuing to scheduled end regardless of remission status. The use of exclusive enteral nutrition can avoid exposure to corticosteroids and associated side effects, but lengthy treatment courses may be daunting and affect adherence. No study has investigated the impact of the length of treatment in children on remission or relapse rates. Our aim was to complete a randomised controlled feasibility trial investigating whether the length of treatment with enteral nutrition in paediatric patients impacts on remission rates and withdrawal from therapy. METHODS: The study was completed in Royal Manchester Children's Hospital, a tertiary paediatric unit within the UK with approximately 400 children diagnosed with IBD. Patients aged 8 to 17 years with a diagnosis of CD were considered for inclusion. Exclusion criteria included: Gastrostomy in situ, Severe CD requiring corticosteroids or surgery, treatment with other therapies within 12 weeks prior to randomisation or anti-TNF agents within the last 6 weeks prior to randomisation. Consent was obtained and baseline characteristics collected. Patients were randomised by a concealed, third-party process. Regimens were of 4, 6, 7, 8, and 10 weeks exclusive polymeric enteral nutrition, with predetermined formulations. Outcomes assessed at baseline and 10 weeks included disease activity, health related quality of life, adverse events and withdrawal rates. RESULTS: Thirty-eight patients with flare ups of CD were considered to start polymeric diet within the study period. Twenty-seven were eligible for inclusion and 12 consented for inclusion (Randomised length of therapy 4 Weeks n = 3, 6 weeks n = 3, 7 weeks n = 2, 8 weeks n = 3, 10 weeks n = 1). The most cited reason for not consenting for inclusion were that 10 weeks was too long for therapy (n = 6) and 4 weeks too short (n = 4). All patients who received exclusive enteral nutrition had gained weight at 4 week review (Mean = 4.4 kg) and final 10 week review (Mean = 7.1 kg). There was no difference in rates of remission between patients treated with 4, 6, or 7 weeks therapy. No patients completed 8 or 10 weeks diet. No significant adverse events were encountered. Withdrawal rates were 63% with reasons including lost to follow up (n = 4), need for steroids (n = 2) and patient not willing to stop therapy at predetermined time (n = 1). CONCLUSIONS: This is the first randomised controlled trial investigating the impact of the enteral nutritional therapy for induction of remission in Paediatric Crohn's disease. This feasibility trial has demonstrated the safety of all lengths of therapy, as well as supporting the possible equivalent efficacy of shorter lengths of therapy. A full randomised controlled trial is warranted to investigate further. Difficulties highlighted in this feasibility trial can inform future study design and will be highlighted in detail.

P-133 Barriers to Exclusive Enteral Nutrition for Induction of Remission of Childhood Crohnʼs Disease

BACKGROUND: Studies have confirmed the efficacy of enteral nutrition for induction of remission in children with Crohn's Disease (CD) and this is first line therapy with the UK. The use of exclusive enteral nutrition can avoid exposure to corticosteroids and associated side effects, but lengthy treatment courses may be daunting and affect adherence, with previous studies identifying this can be a barrier to accepting such treatments. We recently completed a randomised controlled feasibility trial investigating whether the length of treatment with enteral nutrition in paediatric patients impacts on remission rates and withdrawal from therapy. The aim of this element of the trial was to identify barriers to accepting or continuing enteral nutrition for induction of remission of Crohn's disease in children. METHODS: The study was completed in Royal Manchester Children's Hospital, a tertiary paediatric unit within the UK with approximately Patients were randomised to receive 4, 6, 7, 8, or 10 weeks exclusive polymeric enteral nutrition. Patients were interviewed at baseline, 4 and 10 weeks by the principle investigator. They were specifically asked about their views on the therapy, tolerability and compliance issues. The investigator kept a field journal of these interviews. At completion of the study, these notes were analysed by a researcher who had no direct involvement in the study. A thematic analysis using a grounded theory methodology was employed. The analysis proceeded through 3 stages, consisting of open, axial, and selective coding, with constant comparison taking place throughout each phase. Each stage provided categories that could be used to explore the themes of the data in relation to the aims of the study. RESULTS: Analysis of 75 diary entries led to 203 open items coded. Eleven themes were synthesized at the axial level leading to 4 selectively coded themes. The first theme was efficacy. Whilst parents often preferred this to the option of corticosteroids, they were concerned that shorter courses may not be effective. The second theme was tolerability. Children often elected to take corticosteroids rather than exclusive liquid diet, commenting that in particular lengths of therapy would be intolerable. The third theme was adverse events. Parents were very concerned with side effects associated with other medications, whilst children were less concerned with such issue. The final theme was the length of therapy. There was general consensus that shorter lengths of therapy would be extremely beneficial, with more tolerability and acceptability amongst children, but only if efficacy can be demonstrated at shorter durations. CONCLUSIONS: This is the first study to investigate barriers to accepting or continuing enteral nutrition for induction of remission of CD amongst children using a robust qualitative methodology. Parents are keen to use exclusive enteral nutrition as they perceive a lower risk of long term side effects. However, children are very concerned with the tolerability of particularly longer causes, expressing that they would prefer shorter lengths of therapy. Further research to investigate if such shorter courses of therapy are efficacious is needed.

Pediatric Crohn&amp;#39;s disease: epidemiology and emerging treatment options

Pediatric Crohn&#39;s disease: epidemiology and emerging treatment options Shivani Kansal,1&ndash;3 Anthony G Catto-Smith1,2 1Department of Paediatrics, University of Melbourne, 2Department of Gastroenterology, The Royal Children&#39;s Hospital Melbourne, 3Murdoch Children&#39;s Research Institute, Melbourne, VIC, Australia Abstract: There has been a dramatic increase in the incidence of Crohn&#39;s disease over the last two to three decades worldwide, which has affected both the developed world and increasingly also the developing world. Crohn&#39;s disease is a disease of youth and can have a profound effect on the growing child, both in terms of growth and skeletal health as well psychosocial maturation. Environmental risk factors appear to be crucially important, but it is not clear at present whether improved hygiene, especially in childhood, influences immunological conditioning, or whether there is a direct impact on the gut from a disturbed gut microbiota. Genetic variation appears to relate to how the host interacts with its microbiota, determining susceptibility rather than causation. The outcome is a sustained immune response, clinically presenting as a relapsing/remitting disease process. There is no current cure for Crohn&#39;s disease; treatments are designed to reduce symptoms and control inflammation, initially by inducing a remission, then trying to maintain it. Historical therapies have included 5-aminosalicylic acid-based drugs, corticosteroids, and immunomodulators. Two approaches which are gaining increasing interest are the use of exclusive enteral nutrition and biologicals. Enteral nutrition is a remarkably effective approach, though there is a limited understanding of its mechanism and difficulties in acceptance among the medical community. Biologicals are a class of drugs which specifically target molecules and pathways central to the inflammatory process; they are also very effective, but patients can develop a secondary loss of response as a result of antibodies to the biological agent. Infection and the development of secondary malignancies have provided concerns with these very potent agents and with combination therapies, but inadequately controlled disease appears to pose a bigger threat for many patients than the side effects of medications. A wide range of alternative therapies are also being explored, such as the manipulation of gut flora and pathways which might influence immune responsiveness. The marked recent increase in Crohn&#39;s disease, especially in children, has prompted a large research effort which to date has led to a better knowledge of the biology of the disease and more effective treatments. These therapies need to be used judiciously to optimize benefit and minimize side effects. Keywords: inflammatory bowel disease, ulcerative colitis, tumor necrosis factor, biologicals, microbiota, enteral nutrition

PRESENT; PREScription of Enteral Nutrition in pediaTric Crohn's disease in Spain.

Exclusive enteral nutrition (EEN) is one of the therapeutic strategies used to induce remission in pediatric Crohn's disease (CD). Although its use is recommended in clinical practice guidelines and consensus documents, the frequency of this practice in Spain is unknown. A 70-item questionnaire ( PREScription of Enteral Nutrition in pediaTric Crohn's disease in Spain) was drafted and distributed through the SEGHNP (Spanish Society for Pediatric Gastroenterology, Hepatology and Nutrition) e-mail list. We received information from 51 Pediatric Gastroenterology Units. Of the 287 patients newly diagnosed with CD in 2011-2012 at these centres (139 in 2011, 148 in 2012), 182 (63%) received EEN (58% in 2011 and 68% in 2012). 26% of the patients who received EEN in the period studied (64/246) did so during relapses. All the physicians (100%) who responded to the questionnaire believe that EEN is effective in inducing clinical remission in mild to moderate CD. However, 24.5% of respondents never use EEN during relapses. The enteral formulas used most often used were polymeric formulas specific for CD (70.6%) and the preferred administration route was oral, with 60.8% using flavouring and 9.3% allowing a variable percentage of calories in the form of other foods. 65% use 5-ASA together with EEN, 69% use antibiotics and 95% immunomodulators (thiopurines). The duration of EEN tends to be 8 weeks (47.1%), and transition to regular diet was achieved sequentially over a variable period of time. Regarding barriers and limiting factors for the use of EEN, those most frequently reported include lack of acceptance by the patient and/or family (71%), lack of time and/or ancillary staff (69%) and difficulty in convincing the patient and/or family of the suitability of treatment (43%). EEN use rates are similar to those of other European questionnaires. Tools that facilitate acceptance by the patient and family are needed. Increasing the time dedicated to this therapeutic modality is likewise important. Given the disparity of criteria for indicating treatment with EEN, it would be useful to have widely accepted clinical practice guidelines or protocols that facilitate the decision to use it.

Enteral nutrition as treatment option for Crohn's disease: in kids only?

Inflammatory bowel disorders (IBD) are characterized by chronic and recurrent inflammatory reactions of the intestinal mucosa resulting in progressing ulcerating lesions. Research over the past decade clearly identified in patients with Crohn's disease (CD) a marked dysregulation of the intestinal microbiome (dysbiosis) as one trigger factor in these inflammatory processes, particularly in patients with a high genetic risk. When treating patients with CD, most drugs aim to control the inflammatory process (either by inhibiting inflammatory pathways or by reducing the activity of immune cells). Given the importance of the disturbed interaction between the microbiota and the host immune system, there might be a different therapeutic approach in targeting directly the intestinal microflora. There are good data to believe that the use of exclusive enteral nutrition (EEN) is one such option. Historically, enteral nutrition (EN) was used as supplemental nutritional therapy in CD patients with planned resection surgery. This treatment option showed unexpected and very powerful anti-inflammatory effects, and it was rapidly introduced as induction therapy for active CD. Several clinical trials and case series confirmed the efficacy of EN to induce remission in approximately 80% of patients equaling the potential of steroids. It is well established that EN has this strong anti-inflammatory potential only when given on an exclusive basis, without any additional food. This raises major compliance issues, probably one of the reasons why it is less used in adult patients. A recent study demonstrated that EEN has a specific effect on the intestinal microbiota, which is markedly different from steroid-induced remission, while all patients obtained complete clinical remission. These observations give a first basis for the understanding of the impact of EEN on dysbiosis in patients with CD.

Use of Exclusive Enteral Nutrition Is Just as Effective as Corticosteroids in Newly Diagnosed Pediatric Crohn’s Disease

The efficacy of exclusive enteral nutrition (EEN) in induction of remission in pediatric Crohn's disease (CD) is reported to be equivalent to that of corticosteroids (CS). Our objective was to compare the efficacy of EEN and CS in inducing remission in pediatric onset CD and the effects of the treatment on nutritional status and bone mineral density (BMD). Medical charts were retrospectively studied for patients diagnosed with CD between 2000 and 2010 at the Stollery children's hospital in Edmonton, Alberta. Anthropometric and dual-energy X-ray absorptiometry (DXA) data were collected to assess effects of therapy; clinical remission, relapse, and severity were defined on the basis of the pediatric Crohn's disease activity index. To induce remission at first presentation, 36 patients (mean age 12.9 years) received EEN and 69 (mean age 11.2 years) received CS. Remission (88.9% in the EEN group versus 91.3% in the CS group (p=0.73) at 3 months) and relapse (40.6 vs. 28.6%, respectively (p=0.12) over 12 months) were similar in both treatment groups. Thirty-four patients had paired DXA scans at the time of diagnosis and one year later: 16 given EEN and 18 given CS. Change in BMD spine z-scores based on bone age adjusted for height and chronological age was greater for EEN patients but not statistically significant (Δz-score 0.30 vs. 0.03, p=0.28). EEN has similar efficacy to corticosteroids; however, EEN may lead to better BMD accrual. EEN should be preferred to corticosteroids as first-line therapy for induction of remission in pediatric CD.

Use of exclusive enteral nutrition in adults with Crohn’s disease: A review

Exclusive enteral nutrition (EEN) is well-established as a first line therapy instead of corticosteroid (CS) therapy to treat active Crohn's disease (CD) in children. It also has been shown to have benefits over and above induction of disease remission in paediatric populations. However, other than in Japanese populations, this intervention is not routinely utilised in adults. To investigate potential reasons for variation in response between adult studies of EEN and CS therapy. The Ovid database was searched over a 6-mo period. Articles directly comparing EEN and CS therapy in adults were included. Eleven articles were identified. EEN therapy remission rates varied considerably. Poor compliance with EEN therapy due to unpalatable formula was an issue in half of the studies. Remission rates of studies that only included patients with previously untreated/new CD were higher than studies including patients with both existing and new disease. There was limited evidence to determine if disease location, duration of disease or age of diagnosis affected EEN therapy outcomes. There is some evidence to support the use of EEN as a treatment option for a select group of adults, namely those motivated to adhere to an EEN regimen and possibly those newly diagnosed with CD. In addition, the use of more palatable formulas could improve treatment compliance.

Use of exclusive enteral nutrition in paediatric Crohn's disease in The Netherlands

Background and aimsA six-week course of exclusive enteral nutrition (EEN) is recommended as first treatment in active paediatric Crohn's disease (CD). We aimed to assess short-term and long-term outcome of EEN, and to identify predictive factors of treatment success. MethodsThe medical records of newly diagnosed paediatric CD patients initiating EEN as remission induction therapy between January 2008 and October 2011 were retrospectively studied. Treatment outcome was assessed using a previously described pattern recognition model. Results77 CD patients (median age 13.9years, 57% male) initiated a six-week course of EEN, combined with azathioprine maintenance treatment in 92%. Patients received EEN as either hyperosmolar sip feeds or polymeric formula by nasogastric tube. In patients completing a six-week course of EEN (n=58), complete remission was achieved in 71%, partial remission in 26%, and no response in 3%. Complete remission rates were higher in children presenting with isolated ileal/ileocaecal disease and malnutrition. Nineteen patients discontinued EEN before the intended treatment period due to worsening of symptoms (n=9) or adherence issues (n=10). Non-adherence occurred more often in older children, females, children from non-Dutch parents, and patients taking hyperosmolar sip feeds compared with polymeric formula by nasogastric tube. The likelihood of relapsing disease within the first year after EEN treatment was 59%. ConclusionA six-week course of EEN is effective in newly diagnosed paediatric CD, with response rates that seem to be influenced by disease location and nutritional status, but not by type of formula. Non-adherence occurs frequently and limits the success of this treatment in everyday clinical practice.

Exclusive enteral nutrition in the treatment of children with Crohn’s disease in Sweden: a questionnaire survey

The general use of exclusive enteral nutrition (EEN) as therapy for children with Crohn's disease (CD) in Sweden has not previously been studied. Thus, the aim of this study was to investigate how EEN is used as therapy in Sweden for children with CD. A questionnaire was sent to all 37 paediatric units in Sweden that treat children with inflammatory bowel disease. The response rate was 78%, which covers nearly 90% of Sweden's paediatric population between 0 and 17 years of age. Ninety-six per cent of the units used EEN as a treatment option for children with CD, and 65% of the units used EEN as their primary therapy in newly diagnosed CD. The standard duration of EEN was 6 weeks, but the questionnaire revealed a span of 4-8 weeks. The use of polymeric formula was just as common as a combination of polymeric and elemental formulas. Fifty-seven per cent used oral nutrition supplements, and 81% allowed some extent of concomitant feeding, the addition of food and fluids, during EEN. All units used enteral nutrition to some extent as maintenance therapy after EEN was discontinued. In Sweden, EEN is used as therapy for children with Crohn's disease (CD), but the EEN protocols vary as to choice of formula and type of food and fluids allowed during EEN. Standardized EEN protocols would enable multicentre studies in Sweden, with the objective of investigating how EEN treatment can be improved and employed in the most efficient way.

Physician Attitudes and Practices of Enteral Nutrition as Primary Treatment of Paediatric Crohn Disease in North America

The use of exclusive enteral nutrition (EEN) in children with Crohn disease has not been universally adopted by North American paediatric gastroenterologists. This is in stark contrast to their European counterparts. The present study aimed to define attitudes and practice patterns of EEN use by members of the North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition. Members were contacted by e-mail and provided with access to a Web-based survey. Surveys were completed by 326 of 1162 (30.7%) eligible North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition members from North America (86% United States, 14% Canada). Thirty-one percent of respondents reported never using EEN, 55% reported sparse use, and 12% reported regular use. Physicians in Canada reported significantly more use than those in United States (P < 0.001). Currently working and previously working in a centre where EEN was used were highly correlated with both the perceived appropriateness of EEN and the regularity of its use (P < 0.01). More American physicians than Canadian physicians reported that concurrent medical therapy was necessary to induce remission (P < 0.001). Canadian respondents were more likely to use maintenance therapy than American respondents (P = 0.02). Compliance issues were seen as the main disadvantages of EEN and as the major barrier to increased use by nonregular users. There are significant variations in the patterns of use and the acceptance of EEN between Canada and the United States, with Canadian physicians showing a greater use of EEN. The use of EEN appears influenced by the extent to which physicians are exposed to its use both in their training and in their current practice setting.