1. 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

2. 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

3. Etiology Autoimmune inflammatory response Hereditary Genetics
Environmental Factors
Diet
Stress

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

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

6. 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

7. 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.

8. 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

9. 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

10. 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 %

11. 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.

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

13. 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

14. References
Crohn's & Colitis. colitis/what-is-crohns-disease/
Crohn's Disease Symptoms and Diagnosis. from // 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, Retrieved April 16, 2015, from EBSCO Discovery Services.