International survey of enteral nutrition protocols used in children with Crohn's disease.

OBJECTIVE: Differing protocols have been utilized in published studies evaluating exclusive enteral nutrition (EEN) in the management of active pediatric Crohn's disease. This study aimed to ascertain the protocols currently utilized in different pediatric centers around the world and to highlight their similarities and differences. METHODS: A questionnaire was circulated to individuals at pediatric centers in countries in Europe, North America and Asia-Pacific. Respondents were asked to indicate the number of children treated with EEN at their centers in the previous years and to provide details of their protocol used for administering EEN to these children. RESULTS: Responses were received from 35 separate centers (42% of those asked). The duration of EEN varied from <6 weeks to >12 weeks, but was most commonly 6 to 8 weeks. Although 23 different formulas were utilized across the centers, most (90%) used polymeric formulas. Flavourings were commonly added to formulas but wide variations existed between centers with the prescription of food and fluids permitted during the EEN period. The reintroduction of food after EEN also varied greatly: the most common recommendations were for an initial low-fiber diet (26%) or the gradual introduction of food quantity as the formula volume decreased (52%). CONCLUSIONS: This questionnaire-based study has shown the wide variations in EEN protocols used in different areas of the world. The development of consistent protocols may enhance the acceptance, efficacy and wider utilization of this therapy.

Effect of exclusive enteral nutrition on bone turnover in children with Crohn's disease.

BACKGROUND: Poor bone acquisition and increased fracture risk are significant complications associated with Crohn's disease (CD). The aim of this study was to determine the effects of 8 weeks of exclusive enteral nutrition (EEN) therapy upon markers of bone turnover in children with newly diagnosed CD. METHODS: Twenty-three children with newly diagnosed CD and 20 controls (without CD) were enrolled. Children with CD were treated with 8 weeks of EEN. Inflammatory markers [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, platelets], nutritional markers (height, weight), and bone markers [C-terminal telopeptides of Type-1 collagen (CTX) and bone specific alkaline phosphatase (BAP)] were measured prior to and following therapy. RESULTS: At diagnosis, children with CD had elevated serum CTX (2.967 +/- 0.881 ng/ml) compared to controls (2.059 +/- 0.568 ng/ml; P = 0.0003). Following the period of EEN, CTX levels fell significantly (2.260 +/- 0.547 ng/ml; P = 0.002), while serum BAP levels (51.24 +/- 31.31 microg/L at diagnosis; control serum BAP = 66.80 +/- 23.23 microg/L; P = 0.07) increased significantly (64.82 +/- 30.51 microg/L; P = 0.02), with both normalizing to control levels. CONCLUSIONS: As well as reducing inflammation, decreasing disease activity, and improving nutrition in children with newly diagnosed CD, EEN therapy also normalized serum markers of bone turnover, suggesting an improvement in bone health. Further investigations of short- and long-term effects of EEN on bone density and overall bone health are now required.

Dietary intakes of children with Crohn's disease.

Approximately 25 % of individuals with Crohn's disease (CD), a life-long relapsing-remitting disease, are diagnosed during childhood and adolescence. Symptoms of CD, including abdominal pain, nausea and diarrhoea, can lead to reduced food intake, which may negatively have an impact on nutritional status during this critical period of growth and development. The aims of the present study were to assess the growth and adequacy of dietary intakes of children with CD at Sydney Children's Hospital, Randwick, and compare with healthy controls. Sixty-three subjects aged 10-16 years were recruited, including: children with active CD (n 18), children with CD in remission (n 23) and healthy controls (n 22). Dietary intake was assessed using a FFQ and compared with current Australian recommended dietary intakes (RDI). Growth and dietary intakes were compared between groups. Subjects with active CD had lower weight and BMI Z scores than children in remission and controls. The energy intakes of children with active CD and those in remission were significantly lower than estimated energy requirements (P = 0.001 and P = 0.03 respectively). Children with active CD did not meet the RDI for Fe and their Ca intake was lower than the RDI (P = 0.04). In conclusion, the dietary intake of children with active CD was impaired, with inadequate intakes of energy, Ca and Fe. Reduced energy intakes during active disease may contribute to poor weight gain and impaired growth. Quantifying nutrient intake and ascertaining requirements for nutritional supplementation are essential components of successful management in paediatric CD.

Exclusive enteral feeding as primary therapy for Crohn's disease in Australian children and adolescents: a feasible and effective approach.

BACKGROUND: Exclusive enteral feeding has been shown to be as efficacious as corticosteroids in inducing remission in children with Crohn's disease (CD), with additional nutritional benefits. The use of polymeric formulae provides superior palatability and acceptance over elemental feeds, but polymeric formulae have not been universally adopted. The present retrospective analysis of enteral feeding in children with Crohn's disease aims to demonstrate the short-term benefits of enteral feeding in children upon disease activity and nutrition parameters. METHODS: The case records of children with CD managed with exclusive enteral nutrition (EEN) by a multidisciplinary team over a 2-year period were reviewed. Data relating to therapy, background disease details, and outcome were collated. Primary outcome measures established were weight change and disease activity (Pediatric Crohn's Disease Activity Index: PCDAI). RESULTS: Twenty-seven children received EEN with polymeric formulae. Fifteen children had newly diagnosed CD and 12 had known long-standing CD. Twenty-four children completed the prescribed period of EEN. Twelve of 15 (80%) newly diagnosed CD and seven of 12 (58%) with long-standing disease entered remission. Children with newly diagnosed CD responding to EEN took all feeds orally and gained an average of 4.7+/-3.5 kg with mean PCDAI decreasing from 37.1+/-10.8 to 6.7+/-5.1 after 8 weeks. In addition, four children continued supplementary polymeric formula (without other medical therapies) and all have maintained remission during an average follow-up period of 15.2 months. CONCLUSION: Exclusive enteral feeds induced remission in 80% of children with newly diagnosed CD (on intention-to-treat basis) when used as sole initial therapy while also improving nutritional status. All newly diagnosed children treated with EEN, who were able to establish feeds, achieved remission. In addition, remission may be prolonged with oral supplementary formula as sole ongoing treatment. Further study of the role(s) of enteral feeds and of longer-term benefits of enteral feeding in children with CD is now required.

Age related clinical features of childhood coeliac disease in Australia.

BACKGROUND: To describe the presenting clinical features of coeliac disease in a single paediatric centre, and to determine if the presenting features vary with age. METHODS: A review was conducted of children who had been referred with clinical suspicion of coeliac disease to the paediatric gastroenterology department of a tertiary paediatric hospital in Sydney, Australia. Coeliac disease was defined using standard histological criteria. Medical records were reviewed retrospectively. RESULTS: Clinical data were available for 74 cases of proven coeliac disease. Only 9% of patients were less than 2 years of age at diagnosis. Pre-school children (age < 5 years) presented with different symptoms to school children (age > or = 5 years). The most common presenting features in younger children were diarrhoea, irritability and weight loss. However, in older children, abdominal pain was the most common presenting feature. CONCLUSION: We found a significant difference in the clinical features of coeliac disease in pre-school compared to school age children.