Robert M. Beattie

Systematic Review of the Evidence Base for the Medical Treatment of Paediatric Inflammatory Bowel Disease

Objective: To systematically review the evidence base for the medical (pharmaceutical and nutritional) treatment of paediatric inflammatory bowel disease. Methods: Key clinical questions were formulated regarding different treatment modalities used in the treatment of paediatric (not adult-onset) IBD, in particular the induction and maintenance of remission in Crohn disease and ulcerative colitis. Electronic searches were performed from January 1966 to December 2006, using the electronic search strategy of the Cochrane IBD group. Details of papers were entered on a dedicated database, reviewed in abstract form, and disseminated in full for appraisal. Clinical guidelines were appraised using the AGREE instrument and all other relevant papers were appraised using Scottish Intercollegiate Guidelines Network methodology, with evidence levels given to all papers. Results: A total of 6285 papers were identified, of which 1255 involved children; these were entered on the database. After critical appraisal, only 103 publications met our criteria as evidence on medical treatment of paediatric IBD. We identified 3 clinical guidelines, 1 systematic review, and 16 randomised controlled trials; all were of variable quality, with none getting the highest methodological scores. Conclusions: This is the first comprehensive review of the evidence base for the treatment of paediatric IBD, highlighting the paucity of trials of high methodological quality. As a result, the development of clinical guidelines for managing children and young people with IBD must be consensus based, informed by the best-available evidence from the paediatric literature and high-quality data from the adult IBD literature, together with the clinical expertise and multidisciplinary experience of paediatric IBD experts.

Impact of disease activity on resting energy expenditure in children with inflammatory bowel disease

BACKGROUND AND AIMS Exclusive enteral nutrition is used as primary therapy in Crohns disease. Nutrition support is frequently required in children with both Crohns disease and Ulcerative Colitis when acutely unwell and during periods of recovery. There is considerable controversy about nutritional needs during phases of active and inactive disease. It is, for example, often assumed that in acute illness a child requires increased nutritional support however the precise relationship between illness severity and energy expenditure is uncertain. This study explores the relationship between disease activity and resting energy expenditure (REE) in children with inflammatory bowel disease. METHODS Patients were recruited from the regional paediatric gastroenterology unit at Southampton University Hospitals NHS Trust. Disease activity was assessed using standard scoring systems (Paediatric Crohns Disease Activity Index; Simple Colitis Activity Index) and biochemical markers of inflammation (C-Reactive Protein, CRP). Fat free mass was estimated from skinfold thickness and Bioelectrical Impedance Analysis. Resting energy expenditure was measured by indirect calorimetry. A logarithmic correction and a linear regression model were used for analysis of REE corrected for body size. RESULTS 55 children were studied; 37 (67%) with Crohns disease and 18 (33%) with Ulcerative Colitis. Median PCDAI was 10 (range 0-60), 22 (59%) had PCDAI > or =10 (active disease). Median SCAI was 1.5 (range 0-12). Within disease groups there were strong correlations between REE/KgFFM(0.52) and disease activity; PCDAI (r -0.386, p 0.018) in Crohns disease and SCAI (r -0.456, p 0.057) in Ulcerative Colitis. In the cohort as a whole there was no increase in REE/KgFFM(0.52) with increasing CRP (r 0.129, p 0.361). Using the regression model each mg/l increase in CRP was associated with a reduction in REE of nearly 1.5 kCal/day. CONCLUSIONS We were unable to demonstrate a significant relationship between REE and disease activity in children with inflammatory bowel disease.

Nutrition issues in pediatric Crohn's disease

Twenty-five percent of inflammatory bowel disease (IBD) diagnoses present in childhood, with Crohns disease (CD) being the most common type. Many children have poor nutrition status at presentation of the disease, which may worsen during the clinical course, with a significant number of children having impaired linear growth. The cause of this poor nutrition status is complex, and contributing factors include inadequate intake, malabsorption, altered energy demands, and losses through stool, particularly in colitis. The principal aim of medical management is to induce disease remission, with minimal side effects, thereby enabling normal growth and development. This must include active consideration of the nutrition needs of such children and how they may be best met. However, our understanding of the manner in which the disease process affects the energy demands of children with CD or how poor nutrition, in turn, may affect the disease course is limited. This may constrain the efficacy and effectiveness of standard therapeutic approaches to care. This review explores the many factors of relevance in the delivery of nutrition support to children with inflammatory bowel disease, and explores the role of exclusive enteral nutrition as a corticosteroid-sparing strategy to induce remission in children with active Crohns disease.

Ultrasound scanning may reduce the need for barium radiology in the assessment of small-bowel Crohn's disease.

Aim: Bowel wall thickening on transabdominal ultrasound scanning (USS) correlates well with Crohns disease (CD) activity. However, the role of USS in the assessment of CD has not been fully defined. This study compared USS and barium follow‐through (BaFT) in the assessment of CD. Methods: A retrospective case series was undertaken of 24 children with CD who underwent USS and BaFT during the same period of clinical disease activity. Results: For terminal ileum abnormality, all 13 cases with abnormal USS had abnormality on BaFT. USS did not detect five cases with affected terminal ileum and two cases with isolated proximal small‐bowel CD.

Energy expenditure, nutrition and growth

Fundamental to appropriate nutritional prescription is an understanding of the conditions necessary for growth that include the requirements for energy in health and illness. Energy requirements need to be met by the dietary intake to prevent weight loss. A positive energy balance will result in weight gain. Energy requirement includes several components; the largest is the basal metabolic rate, although physical activity level and the energy needs of growth are important components. All aspects of energy metabolism are likely to be influenced by illness and impact on energy balance. Changes in dietary intake and physical activity are observed clinically but poorly described in most childhood illnesses. Changes in metabolic rate are poorly described in part owing to methodological problems. This review explores changes in energy expenditure associated with health and disease, highlights the lack of evidence underpinning this aspect of practical nutritional support and provides the clinician with a guide to the factors involved in estimating energy requirements, emphasising the importance of measuring the childs response to nutritional support.

Outcome of childhood ulcerative colitis at 2 years

Aim: Ulcerative Colitis (UC) has an incidence of 1.4 per 100 000 in childhood. There is a paucity of data regarding outcome particularly with the increased use of early immunosuppression. This study reviews outcome at 2 years in a cohort with UC referred to a single centre.

Essential fatty acid status in paediatric Crohn's disease: relationship with disease activity and nutritional status

Background:  Active paediatric Crohns disease is associated with nutritional deficiencies and altered nutrient intake. The availability of essential fatty acids (linoleic and α‐linolenic acids) or their derivatives (arachidonic and eicosapentaenoic acids) may alter in plasma and cell membrane phospholipid in protein‐energy malnutrition in children and in Crohns disease in adults.

Current therapy of ulcerative colitis in children.

Ulcerative colitis presents in childhood in 10% of those affected, usually with pancolitis. Important features in management include growth, development and avoidance of treatment toxicity. This review addresses the current treatment options including both the paediatric evidence-based experience and areas where paediatric practice is informed by adult studies. Standard treatments include sulfasalazine or 5-aminosalicylates, corticosteroids, purine derivatives (azathioprine or 6-mercaptopurine) and surgery. Other immunosuppressant therapies and the emerging roles for biological therapies and probiotics are discussed.

Enteral nutrition as primary therapy in childhood Crohn's disease: control of intestinal inflammation and anabolic response.

Crohns disease in childhood is a chronic relapsing and remitting condition that can significantly impact normal growth and development. This influences choice of both initial and ongoing management. The goal of therapy is to induce and maintain remission with minimal side effects. Enteral nutrition is effective in active disease and will induce disease remission in most cases avoiding corticosteroid use. The high frequency of relapse means additional immunosuppressive therapies are usually required but nutrition remains a key priority as part of the subsequent management strategy.

Parental knowledge of coeliac disease

Aim: Little information exists regarding parental knowledge of CD at diagnosis. We aimed for assessment of parental information at disease diagnosis to help us develop a tailored coeliac information package. Methods: Children and teenagers referred for endoscopy and duodenal biopsy, with the sole indication for the diagnosis of CD, were prospectively recruited to the study. Parents were asked information and concerns regarding use of GFD. Results: Sixty-three children (median 6.9 yrs (IQR 3.71–10.94)) and families were prospectively recruited in the study. The parents were very knowledgeable with an impressive 98% of the parents understanding that GFD is the treatment of CD; 95% knowing that this treatment is for life. However, specific dietary information was lacking with one-third correctly identifying all the Gluten containing foods. Internet (70.6%) was the most common source of information. Knowing someone with CD (p = 0.038), particularly in the same household in the family (p = 0.013) and researching about the disease (p = 0.001) rather than level of parental education (p = ns) was predictive of better parental knowledge. Conclusion: Internet is a major influence to parental knowledge in today’s age but there is a continued need for hospitals regarding provision of accurate information and alleviating anxieties regarding use of GFD.