Elaine Buchanan

The use of exclusive enteral nutrition for induction of remission in children with Crohn’s disease demonstrates that disease phenotype does not influence clinical remission

Background  Exclusive enteral nutrition (EEN) achieves variable remission rates in patients with Crohn’s disease (CD).

Clinical progress in the two years following a course of exclusive enteral nutrition in 109 paediatric patients with Crohn's disease

Exclusive enteral nutrition (EEN) is an effective first line treatment for active paediatric Crohns disease (CD).

Impact of exclusive enteral nutrition on body composition and circulating micronutrients in plasma and erythrocytes of children with active Crohn's disease†

Background: Nutritional therapy is the primary treatment for active pediatric Crohns disease (CD) in the UK/Europe, improving disease activity and anthropometry. This study assessed changes in micronutrient status during exclusive enteral nutrition (EEN). Methods: Seventeen children (male/female: 8/9; median age: 12.7 years) with active CD were treated exclusively for 6–8 weeks on a polymeric feed (Modulen IBD; Nestle, UK). Body impedance was measured at baseline, during EEN, and posttreatment on normal diet and converted to z‐scores of fat and lean mass. Blood samples for nutrient analysis were collected from 13 children at baseline, end of EEN, and posttreatment. Results: Lean but not fat mass improved at the end of EEN (initiation vs. end of EEN; fat mass [z‐score]: −0.5 vs. −0.3; P = 0.141; lean mass [z‐score]: −2.1 vs. −0.8; P < 0.0001). At baseline several children presented with suboptimal concentrations of carotenoids, trace elements, vitamin C, B6, and folate in plasma but not in erythrocytes. EEN improved concentrations for several nutrients, but more than 90% of patients had depleted concentrations of all carotenoids. The latter improved on normal diet but other micronutrients, which improved during EEN, returned toward pretreatment concentrations. Conclusions: Lean but not fat mass improved at the end of EEN. Median concentrations for several plasma micronutrients improved on EEN but carotenoids were depleted. These findings may have implications for clinical practice and producers of enteral feeds. As plasma concentrations for many micronutrients can be affected by the acute phase response, measurements in erythrocytes may be a better marker of actual body stores. (Inflamm Bowel Dis 2012;)

The epidemiology of anemia in pediatric inflammatory bowel disease: prevalence and associated factors at diagnosis and follow-up and the impact of exclusive enteral nutrition.

Background:Anemia is poorly studied in pediatric inflammatory bowel disease. This study explored the epidemiology and associated factors of anemia at diagnosis, after 1 year, and during treatment with exclusive enteral nutrition (EEN). Methods:Three cohorts were included: (1) a representative population of newly diagnosed inflammatory bowel disease children (n = 184); (2) patients currently receiving care with data available at diagnosis (n = 179) and after 1 year (n = 139); and (3) 84 children treated with EEN. Results:At diagnosis, 72% were anemic. Abnormal inflammatory markers were more common in Crohn’s disease with severe anemia (severe versus no anemia [%]: raised C-reactive protein; 89% versus 48%; suboptimal albumin; 97% versus 29%; P < 0.002). Anemic children with Crohn’s disease had shorter diagnosis delay and lower BMI than nonanemic patients (severe versus mild versus no anemia, median [interquartile range]; diagnosis delay [months]: 3 [3.9] versus 6 [10] versus 8 [18], P < 0.001; BMI z score [SD]: −1.4 [1.4] versus −1.3 [1.5] versus −0.2 [1.4], P = 0.003). Extensive colitis was associated with severe anemia in ulcerative colitis. The proportion of severely anemic patients decreased from 34% to 9% and mild anemia doubled at 1 year. After EEN, severe anemia decreased (32% to 9%; P < 0.001) and the hemoglobin concentration increased by 0.75 g/dL. This was observed only after 8 weeks of treatment. Disease improvement and low hemoglobin at EEN initiation but not weight gain were associated with hemoglobin improvement. Conclusions:Anemia is high at diagnosis and follow-up and should receive more attention from the clinical team; however, the focus should remain suppression of inflammatory process in active disease.

Detailed assessment of nutritional status and eating patterns in children with gastrointestinal diseases attending an outpatients clinic and contemporary healthy controls

Background/objectives:In the era of modern multidisciplinary clinical management, very little is known about the prevalence and presentation of malnutrition in children with gastrointestinal disorders (GastroD) particularly employing composite, global measures of nutritional status.Subjects/methods:Anthropometry, body composition, dietary intake, eating habits and grip strength were assessed with bedside methods in 168 patients from outpatient gastroenterology clinics (n, median (IQR) years; Crohn’s disease (CD): n=53, 14.2 (11.6:15.4); ulcerative colitis (UC): n=27, 12.2 (10.7:14.2); coeliac disease: n=31, 9.3 (7.5:13.6); other GastroD: n=57, 9.8 (7.2:13.8)) and compared with 62 contemporary healthy controls (n, median (IQR): 9.8 (6.9:13.8)) and the results of the recent UK, National Diet and Nutritional Survey (NDNS).Results:Children with CD had lower BMI z-scores than controls (median (IQR): −0.3 (−0.9:0.4) vs 0.3 (−0.6:1.4); P=0.02) but only 2% were classified as thin (BMI z-score <−2 s.d.). The prevalence of obesity in children with UC was 19%, 6% in CD, 11% in children with other GastroD and 15% in controls. No difference was found in grip strength measurement between groups. Except for CD children, the proportion of patients with suboptimal micronutrient intake was similar to that of controls and the cohort of children from the latest NDNS. A higher proportion of children with CD had suboptimal intake for riboflavin, vitamin B6 and calcium and consumed significantly more meat products, juices (including carbonated drinks), spreads/jams and crisps and savoury snacks and significantly fewer portions of dairy, fish, fruits and vegetables compared with healthy controls.Conclusions:GastroD affect children’s body composition, growth, strength, dietary intake and eating habits, particularly CD, but to a lesser extent than expected.

Percutaneous endoscopic gastrostomy placement in paediatric Crohn's disease patients contributes to both improved nutrition and growth

This paper describes the outcomes of gastrostomy feeding in patients with Crohns disease (CD).

Comparison of the paediatric Yorkhill malnutrition score (PYMS) with other paediatric screening/assessment methods

All inpatients should be screened for malnutrition but validated paediatric tools for use by nursing staff are scarce. The Paediatric Yorkhill Malnutrition score (PYMS) was developed based on ESPEN guidelines. Its development, performance, criterion validity, inter-rater reliability and impact on clinical practice have been assessed. This study compared the PYMS with other similar paediatric tools. Two research dietitians screened malnutrition using the PYMS, the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) and the paediatric Subjective Global Nutritional Assessment (SGNA) in inpatients (1–16 years) from a tertiary paediatric (n = 225) and district general hospital (n = 22). Two hundred and forty seven children consented to the study. The prevalence of malnutrition varied between the different tools. Compared to PYMS, STAMP identified more patients as being at risk, while SGNA identified fewer (Table 1).

Is exclusive enteral nutrition enough for children with Crohn's disease?

Data on micronutrient deficiencies in paediatric Crohn’s disease (CD) are scarce. Exclusive enteral nutrition (EEN) is increasingly used as the primary therapy for active paediatric Crohn’s disease, improving disease activity and nutritional status (1) . The aim of the present study was to assess the effect of EEN on circulating levels of a range of micronutrients in children with active CD. Thirteen children (six boys) with active CD were treated exclusively for 8 weeks on a polymeric feed (Modulen IBD1; Nestle, Croydon, Surrey, UK). Blood samples for nutrient analysis (Table) were collected at baseline, end of treatment and post-treatment on normal diet (1‐4 months post treatment). At baseline several children presented with suboptimal levels of carotenoids, trace elements, vitamins C and B6 and folate in plasma (Table). Treatment with EEN improved the levels for many nutrients but the plasma levels of antioxidant carotenoids further deteriorated. The latter were improved on normal diet but those micronutrients that had improved returned towards previous levels.