Article by: Zubin Grover , Richard Muir, and Peter lewindon Exclusive enteral nutrition induces early clinical mucosal and transmural remission in pediatric Crohn’s disease Article by: Zubin Grover , Richard Muir, and Peter lewindon

What is Crohn’s disease? Characterized as an relapsing chronic inflammatory disease of the GI tract Frequent relapse and remissions Inflammation induced by fistulas, later replaced by fibrotic tissue Inflammation can affect any portion of the GI tract Mostly occurring in ileum and colon (transmural inflammation) Similar to Ulcerative colitis

Etiology Autoimmune inflammatory response Hereditary Genetics Environmental Factors Diet Stress

Crohn’s Symptoms and Manifestations Abdominal pain Diarrhea Fever May experience manifestations of disease symptoms in other organ systems

Complications Abscesses Anal fissures Bowel obstruction Bowel perforation Bowel resection Fistulas Hyperoaxluria Malnutrition Stricture Ulcers

Crohn’s in Pediatrics 25% of diagnoses are before age 16 May delay growth and development in younger children May have serve malnutrition Growth failure Poor bone density Current treatment include corticosteroids, exclusive enteral nutrition , and biological agents

Hypothesis EEN induces good early mucosal healing and achieving this followed by standard practice early introduction of thiopurine (azathioprine or 6-mercaptopurine \3 months) leads to sustained clinical remission and improved clinical outcomes.

Materials and methods EEN first line of therapy Children ( median age 13.1 ) chose between Nutrison (1 kcal/ml) through nasogastric tube or Nestle 1.2 Target rates were reached in 3-5 days PCDAI, growth parameters, CRP, endoscopy assessment conducted Calls and follow ups conducted to help with compliance https://gastro.cchmc.org/calculators/pcdai/

Statistics Clinical remission was defined as PCDAI<10 Biochemical remission, CRP <5 mg/l with PCDAI<10 Relapse was defined as PCDAI<15 or CRP [5 mg/l with clinically active disease SES-CD: 4–10 mild active disease; 11–19 moderate active and >19 severe active CD. Complete mucosal healing was SES-CD 0; near complete SES 1–3; incomplete >3 Transmural activity : 0–1 no activity, 2–6 mild activity,>7 moderate to severe activity

Results 26/42 completed the study, 6 week minimum 12 completed EEN orally and 14/26 through NG tube Overall improvement comparing values at diagnosis and after treatment 82% were in clinical remission (76 %) in biochemical and clinical remission 42% experience mucosal healing; 30% improved but incomplete healing;11% had no change in mucosal healing status Transmural remission in 21 %; significant improvement in 64 %; no status change in 15 %

Conclusions EEN effective in early weight recovery, biochemical remission, mucosal healing, and clinical response Proven to be more effective in inflammatory phenotype Higher rates of mucosal healing than other therapies , in particular steroids Good endoscopic response reduced relapses and hospitalization No significant outcome with early thiopurines.

Reviewer critique Larger sample sizes needs Longer follow up time Have a other control groups to compare

Summary for Nutrition Interventions Recommended trying EEN low residue nutrition support after diagnosis if tolerated. Progress and educate client on low fat and low fiber ( at times) diet Encouraging small frequent meals high in protein and kcal as tolerated Supplements in Vitamin D, Zinc, Calcium, Magnesium, Folate, Vitamin B12 and iron as needed Est needs using Mifflin-St Jeor Equation

References Crohn's & Colitis. http://www.ccfa.org/what-are-crohns-and- colitis/what-is-crohns-disease/ Crohn's Disease Symptoms and Diagnosis. from //www.seattlechildrens.org/medical-conditions/digestive- gastrointestinal-conditions/crohns-disease-symptoms/ Donnellan, C., Yann, L., & Lal, S. Nutritional management of Crohn’s disease Kansal, S., Wagner, J., Kirkwood, C., & Catto-Smith, A. Enteral Nutrition in Crohn’s Disease: An Underused Therapy. Grover, Z., Muir, R., & Lewindon, P. (2014). Exclusive enteral nutrition induces early clinical, mucosal and transmural remission in pediatric Crohn’s disease. Journal Of Gastroenterology, 49, 638-645. Retrieved April 16, 2015, from EBSCO Discovery Services.