Enteral nutrition

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Enteral nutrition

  1. 1. Role of Enteral Nutrition in Pediatric Crohn’s Disease Joanna Yeh Peds GI Case Conference May 2012
  2. 2. Objectives • Understand the role of enteral therapy in treating Crohn’s disease • Understand the differences in practice internationally • Understand the pros and cons of enteral therapy
  3. 3. History • First case reports in 1970s • 1984: first controlled study to show elemental diet induced remission • 2006: Europe and Japan independently published guidelines recommending enteral nutrition as first line induction therapy in children • 2010: Similar conclusions by British society • So why not in U.S.?
  4. 4. Pros • Can induce remission • Can maintain remission • Reduced steroid dosage over long term (growth retardation, osteopenia) • No major side effects Cons • Unpalatability • Slower to get results • Compliance concerns • Costs/insurance • Resource demands (nutritionist, nurse) • QOL, psychosocial
  5. 5. International Variance 4% 36% 62%
  6. 6. Why does enteral therapy work? • Unknown • Hypotheses: – Overall nutritional repletion – Altered gut microflora – Correction of intestinal permeability – Decreased synthesis of inflammatory mediators via reduction in dietary fat – Elimination of dietary antigen uptake
  7. 7. Steroid concerns • Growth • Bone mineral density • Lack of mucosal healing • Infections • Psychosocial (depression, anxiety, loss of concentration, irritability, sleep disturbance) “A stunted, cushingoid child without GI sx is not a success story”
  8. 8. Growth • Positive effect of enteral therapy compared to steroids occurs within 10 week to 6 months
  9. 9. Mucosal healing • New standard to aim for? • Improved endoscopic and histologic scores with decreased mucosal inflammatory cytokines • Documented in enteral therapy
  10. 10. Induction Therapy • CHOP – Semi elemental formula – 90% of caloric needs from formula – Nocturnal NG feeds (outpatient teaching program) – Normal diet during day – 7 days per week for 8-12 weeks
  11. 11. Induction therapy • Cochrane 2007 meta analysis of 6 trials • Steroids vs. enteral therapy • Favored steroid therapy • Adults and pediatrics but more adults • 3 pediatric meta analysis • Benefits of enteral therapy differ in children from adults?
  12. 12. Pediatric Meta Analysis
  13. 13. 0 20 40 60 80 100 Healing of GI tract Enteral nutrition Corticosteroids 0 20 40 60 80 100 Clinical improvement Borrelli O, et al. Clin. Gastroenterol. Hepatol.; 2006 % % n=19 n=18 P<0.05 Polymeric Diet Alone vs. Steroids for Active Pediatric CD (Induction Therapy)
  14. 14. Duration of therapy • Majority of centers use 6-8 weeks • Inflammatory markers improve in as little as 1 week • Time to remission 11 days to 2.5 weeks • NASPGHAN group suggests a period of 3-4 weeks to see if therapy is effective
  15. 15. Remission Rates • Induction – Range: up to 85% (53-80%) – CHOP 75% at 12 weeks – Steroid remission rates = 70-80% • Maintenance – 32% at 1 year – Old studies (1988, 1996) from Canada • At 12 month, 43% of enteral group relapsed vs. 79% in non enteral group – No recent studies
  16. 16. Maintenance Therapy • By itself or with medical therapy • Options: – Overnight NG feeds with normal daytime eating 5 days per week (CHOP) – Short bursts of NG feeds every few months (“European”) • i.e. 4 week cycles of exclusive enteral nutrition q3-4 months – Oral supplements +/- medical therapy
  17. 17. Partial enteral therapy • Lack of published data • UK study of 50 children (Johnson, Gut, 2006) • 100% of caloric needs seems better than 50% (15% vs. 42% remission) • CHOP, unpublished data, allows 10% of energy intake as regular diet
  18. 18. Formula composition • Comparisons between elemental, semi elemental, and polymeric (whole protein) show no significant differences • ? Fat composition remains unclear, non significant trend favoring very low fat and low long chain triglyceride (larger trials needed)
  19. 19. Disease location • Some evidence that enteral therapy works better in small bowel disease rather than in colonic disease but overall unclear • Afzal (2005) – 11/12 with ileal disease achieved remission – 32/39 with ileocolonic – 7/14 with isolated colonic • Buchanan (2009) – 10/13 with isolated small bowel – 15/19 with isolated colonic
  20. 20. Reasons Preventing Widespread use of Enteral Therapy In U.S. • Side effects: emesis, nausea, diarrhea, NG tube problems • Compliance • Psychosocial (food as an important social event) • Lack of financial support • Poor access to dietician/nursing support • Lack of experience • Lack of understanding of mechanisms of actions • Lack of confidence in efficacy
  21. 21. Medical Therapies for Crohn’s Disease • Induction: Steroids, anti TNF • Maintenance: 6MP/AZA, MTX, anti TNF • Mucosal healing: anti TNF > 6MP/AZA/MTX • Improved growth: anti TNF > 6MP/AZA/MTX Where does enteral therapy fit in?
  22. 22. Enteral Therapy in Crohn’s Disease • Induction: Yes • Maintenance: Yes • Mucosal healing : Yes • Improved growth : Yes • Serious adverse events : No
  23. 23. Unanswered Questions • Phenotype (SB vs. colonic) • Induction protocol (100% vs. 90%) • Maintenance protocol • Induction Maintenance – Nutritional -> 6MP/AZA/MTX/anti TNF – Steroid -> 6MP/AZA/MTX/anti TNF Does induction with enteral therapy result in better long term outcomes? (height, bone density, mucosal healing, remission rate, etc.?)
  24. 24. Summary • Enteral therapy is an effective induction therapy in newly diagnosed Crohn’s (grade A) • Enteral therapy has an improved adverse effect profile over steroids (grade A) • Enteral therapy improves mucosal healing, linear growth (grade A) • Enteral therapy can be considered in the motivated, compliant patient
  25. 25. References • Critch, et al, “Use of Enteral Nutrition for the Control of Intestinal Inflammation in Pediatric Crohn Disease,” JPGN, Feb 2012. • Levine, et al, “Consensus and Controversy in the Management of Pediatric Crohn Disease: An International Survey,” JPGN, April 2003. • Stewart, et al, “Physician Attitudes and Practices of Enteral Nutrition as Primary Treatment of Pediatric Crohn Disease in North America,” JPGN, Jan 2011. • Heuschkel, et al, “Enteral Nutrition and Corticosteroids in the Treatment of Acute Crohn’s Disease in Children,” JPGN, July 2000. • Zachos, et al, “Enteral Nutritional Therapy for Induction of Remission in Crohn’s Disease,” Cochrane Review, 2007. • Borrelli, et al, “Polymeric Diet Alone Versus Corticosteroids in the Treatment of Active Pediatric Crohn’s Disease: A Randomized Controlled Open-Label Trial,” Clinical Gastroenterology and Hepatology, May 2006.

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