Pediatric Nutrition in Practice

240 Mouzaki  Griffiths

Treatment of Active Crohn Disease

Evidence of Efficacy
Most data concerning the efficacy of EEN in treat-
ing active Crohn disease relate to clinical end-
points. Response to EEN has been associated with
endoscopic healing in uncontrolled studies. In a
recent controlled trial among 35 children treated
for active Crohn disease, clinical response was as-
sociated with endoscopic improvement in 77%
with EEN, but in only 33% with steroids [7].

Patient Selection
Roughly 50–60% of Crohn disease patients treated
with EEN achieve clinical remission [3]. The re-
sponse depends on the patient population. Recent-
onset disease may be more responsive [3] , perhaps
contributing to the superior response rates report-
ed in small trials conducted exclusively among
children and summarized in a meta-analysis of
outcomes in paediatric trials [8]. Although contro-
versial, predominantly small intestinal inflamma-
tion is considered more likely to respond to EEN,
compared with isolated Crohn colitis [6, 9]. This
may be a reflection of the fact that Crohn colitis is
particularly difficult to control. European and
American guidelines advocate in favour of EEN
use, irrespective of disease location [5, 10]. EEN is
not used to treat ulcerative colitis.

Therapeutic Regimens
Exclusive versus Supplementary
Enteral Nutrition
To be successful, EEN should be the sole source
of nutrition. Allowance of regular food during
treatment of active disease compromises its effi-
cacy [11] and may induce satiety and intolerance
of the amounts of prescribed formula.
Screening for micronutrient deficiencies (e.g.
vitamin D) should guide the need for supplemen-
tation. The micronutrient content of the formula,
as well as its mucosal healing effects, is also ex-
pected to assist in the correction of nutritional
imbalances [1 2].

Mode of Administration

Liquid diets may be sipped orally or administered

via a silastic nasogastric feeding tube (NG tube;

size: 6 or 8 Fr). Most children learn to insert the

NG tube and administer the formula overnight.

The tube is removed each morning to facilitate

daytime activities. When use over a period of

months is contemplated, an indwelling gastros-

tomy tube may be inserted.

Target Volume and Calories

EEN should provide 100% of the patient’s esti-

mated caloric and protein requirements. These

are calculated using normal predictive equations

(e.g. Schofield, WHO equation, etc.; summarized

in the clinical guidelines by the NASPGHAN

Committee on Inflammatory Bowel Disease) [5].

In the setting of malnutrition, ideal body weight

(the weight for the patient’s age that corresponds

to the same percentile on the growth chart as their

height percentile) should be used instead of ac-

tual weight to prevent underfeeding. An activity

factor should be added for the estimation of total

energy requirements. Maintenance fluid volumes

do not have to be provided exclusively via EEN as

consumption of clear fluids is also allowed.

When using NG feeding, infusion rates should

be increased in a stepwise manner considering tol-

erance. The duration of infusion is gradually de-

creased. A sample protocol for the gradual increase

to full feeds is given in table 1. Most young patients

aim to complete the infusion over 10–14 h.

Choice of Formula

Polymeric, peptide-based and amino acid-based

formulae have all been used to treat active Crohn

disease [3]. There is general agreement that the

protein content of liquid diets does not influence

their efficacy [3]. Dietary lipids, however, can

modulate inflammation by a variety of mecha-

nisms which influence cellular production of

cytokines and eicosanoids [3, 13]. While the

amount and type of fat may modulate inflamma-

tory pathways, the therapeutic success achieved

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 239–243

DOI: 10.1159/000360345