Issue 127 crohns disease nutritional management

COVER STORY

CROHN’S DISEASE: NUTRITIONAL MANAGEMENT IN CHILDREN Rachel Wood Specialist Paediatric Dietitian in Allergy and Gastroenterology Therapy and Dietetics Rachel is Clinical Lead for Dietetic Allergy and Gastroenterology services in a tertiary centre for Paediatrics based at Central Manchester University Hospitals NHS Foundation Trust Royal Manchester Children's Hospital.

For full article references please email info@ networkhealth group.co.uk

Inflammatory bowel disease (IBD) can be defined as Crohn’s disease (CD) or Ulcerative Colitis (UC). Both conditions are of chronic inflammation and of unknown aetiology, although the causes still trigger much debate, as does whether or not the changing environment plays some part in the development of these diseases, including dietary changes, processed foods and the microbiome. However, in paediatric CD, the genetic component is much more dominant than in adults.1,2 The incidence of CD in children is on the rise worldwide, with an estimated prevalence of 58 in 100,000.3 The role of nutritional therapy as treatment is becoming even more popular.

CD can affect any part of the gastrointestinal (GI) tract; from the mouth to the bottom. Orofacial Granulomatosis (OFG) is linked to CD, as well as symptoms of frequent mouth ulcers, but the most common area to be affected by CD is the terminal ileum and right colon. CD is characterised by full thickness acute and chronic inflammation anywhere in the gastrointestinal tract; it can be patchy as well as having granulomas.2 This, as you can imagine, comes with a whole host of symptoms. In paediatric CD, symptoms can often be non-specific which can delay diagnosis. As well as the increasing prevalence, it appears that the classic ‘triad’ symptoms of abdominal pain, weight loss and diarrhoea are also changing.

DIAGNOSIS

Other symptoms can include lethargy, anaemia, poor appetite, weight loss and nausea/vomiting associated with eating; patients can become very low in mood. One of the most important factors in paediatrics is linear growth; not receiving the correct nutrition can impair this, as well as affect development if nutritional intake is not corrected.

Diagnosis is often around or during puberty, so ensuring the correct nutrition and treatment is vital to optimise growth and to ensure puberty is not delayed.

TREATMENT

Most paediatric centres are now using Exclusive Enteral Nutrition (EEN) as first line treatment in newly diagnosed Crohn’s patients.4 This comes with variation in the name as it is also known as Liquid Diet Therapy (LDT), or the Polymeric Diet (PMD).

There are three main consensus guidelines for the management of CD in Paediatrics: NICE clinical guideline for CD: management CG152, (2012), BSPGHAN guidelines produced in 2010 and the ECCO/ESPGHAN produced in 2014 all state that enteral nutrition should be used as first line treatment to induce remission.5,6,1 EEN is the complete avoidance of food for a period of six to eight weeks. The patient receives all of their nutritional requirements in the form of a ‘liquid’ diet. The aim of this is to induce remission, aid mucosal healing, reduce inflammation and provide optimum nutrition to promote growth and development.

There are many positive outcomes in using EEN as first line treatment for CD, but this does not come without its own challenges for patients and their families. We know as clinicians that

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PAEDIATRIC

Remission induced by Exclusive Enteral Nutrition (EEN) has been demonstrated in 80% of newly diagnosed children with CD and 58% in previously diagnosed children in a flare up . . .

EEN is highly effective at inducing remission; 8090% of children on EEN as seen in the systematic review by Day et al2 and in Knight et al.17 EEN also does not come with the complications of affecting bone density and delayed growth that steroids bring. However, many children just cannot adhere to EEN for the six- to eight-week period that is required, despite nasogastric tube (NGT) placement, which after the oral route would always be the next step before steroids.

Others try meticulously, but symptoms just don’t resolve, even with the combination of Azathioprine and, therefore, there is no choice than to escalate treatment.

Remission induced by EEN has been demonstrated in 80% of newly diagnosed children with CD and 58% in previously diagnosed children in a flare up and we know there are other positive factors including improved energy and mood. However, in practice this can be one of the hardest things you can ask a child or young person to do, mainly affecting their quality of life and social aspects around eating that they have missed out on for so long because of being unwell.16 A child presented at age 12 years with a variety of symptoms; loose stools up to five to seven times per day with mucous, but no blood, general lethargy with some aches and pains, low in mood and severe weight loss over a period of six months. Weight at assessment was 27.5kg, plotting just under the 2nd centile and height was 148cm plotting on the 50th centile.7 There was a reported 16% loss of body weight over a period of six months. This is significant weight loss and means that instead of tracking along the 25th centile and the 50th centile for height, which would be proportional, he dropped down across three centile lines, indicating a risk of refeeding syndrome.

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STARTING TREATMENT

EEN will be introduced slowly over a number of days, being mindful not to overfeed and daily monitoring of blood levels including phosphate, magnesium and potassium levels. This requires intense input from the dietitian and may delay how quickly the patient can reach their target volume of nutritional drinks and, hence, how quickly they can go home from the ward.

EEN commonly is done for six to eight weeks, although it is shown to have had improvements on mood and energy levels within the first seven to 10 days and inflammatory markers within 14 days, all of which continue to improve for over six to eight weeks.4 Although the initial improvements in symptoms and mood are seen within the first few weeks, it is important to inform the patients and families about the ongoing benefits of continuing with the EEN for the full six to eight weeks with the aim of complete remission. The consensus guidelines of ECCO/ESPGHAN1 advise that if a clinical response has not been induced by two weeks of EEN, then an alternative treatment should be commenced, indicating that if EEN is going to work, you will see this within two weeks.

A review half way into a patient’s treatment of EEN is a must to ensure that this is working for them and encouragement to call if no improvements are seen following discharge from the ward on their target volume. This prevents further delays to growth and development.

CHOICE OF FEED

Many years ago, Elemental Feeds (EF) were used as the EEN in treatment of CD. It was felt that the amino acid based elemental feed gave the gut good nutrition whilst resting it from the whole proteins that could aggravate

Manage

MALABSORPTION with

Cow & Gate Pepti-Junior is designed to be easy to digest and absorb for cases of malabsorption in infants. It is specially formulated to: Enhance digestion and absorption: - Extensively hydrolysed formula1 - 50% MCT2 Promote palatability: - Whey based3-5 Reduce osmotic load: - Carbohydrate as glucose polymers6 - Low osmolality (210 mOsmol/kg H2O) For further information contact our Healthcare Professional Helpline on 0800 996 1234 or visit www.eln.nutricia.co.uk References 1. Keohane PP et al. Gut 1985;26(9):907-13. 2. Bach AC, Babayan VK. Am J Clin Nutr 1982;36(5):950-62. 3. Mabin DC et al. Arch Dis Child 1995;73(3):208-10. 4. Pedrosa M et al. J Investig Allergol Clin Immunol 2006;16(6):351-6. 5. Miraglia Del Giudice M et al. Ital J Pediatr 2015;41:42.

6. Shaw V (ed). Clinical Paediatric Dietetics. 4th ed. Oxford: Wiley Blackwell, 2015.

Important notice Cow & Gate Pepti-Junior is a food for special medical purposes. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and as part of a balanced diet from 6 months.

PAEDIATRIC

Table 1: The composition of feeds available to use with CD Feed name

Emsogen (EF)

Elemental EO28 extra (EF)

Modulen (PF)

Alicalm (PF)

Ensure Plus/ Fortisip (PF)

Protein source

Amino acid

Amino acid

Whole protein

Whole protein

Whole protein

17% LCT/83% MCT

65% LCT/35% MCT

74% LCT/26% MCT

52% LCT/48% MCT

100% LCT

Fat source

the mucosal lining. Since then, it has been shown that a polymeric Feed (PF) is just as effective and more palatable which improves compliance; the mechanism we are not entirely sure of yet. A double blind randomised controlled trial comparing EF versus PF found that in 34 children who completed it, there was no difference in inducing remission of CD between the two choices of EEN, meaning that the earlier theory of avoiding certain food allergens was not correct, particularly when there had been no studies highlighting specific food as triggers.8 The Cochrane review9 also shows that there was no statistical difference found between EF and PF in any of the trials that were reviewed, which led to the ECCO/ESPGHAN guidelines stating that EEN feeds should be given orally and as whole protein feeds; unless there is a clinical reason not to use these, for example in cows’ milk protein allergy.1 14

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Modulen and Alicalm are whole protein feeds that are specifically for use in CD. They are marketed to contain the optimum amount of nutrients including lipids, with Modulen containing a natural anti-inflammatory factor.

Both these feeds come in powder forms and require making up to the required concentration, which can take time and energy. The benefits of the PF being whole protein are that they are much more palatable than the EF and you can add different flavours to the Modulen and Alicalm to add variety and improve compliance with taking the drinks. Modulen is a 1kcal/ml feed, which can mean large volumes of feeds are needed to be taken to meet full requirements compared to Alicalm (1.35kcal/ml) and Ensure Plus (1.5kcal/ml).

REQUIREMENTS

Estimated Average Requirements (EAR) should always be used for an EEN plan for a child. This

is the daily nutrient level estimated to meet the requirements of half the healthy individuals in a particular life stage and gender group.10 This is more effective than using the requirements per kilogram as you are aiming to get the individual back to a healthy weight for height and age.

Most studies fail to show that there is an increase in resting energy expenditure with active CD unless there is fever, so it is difficult to quantify increased requirements above base line level. BSPGHAN guidelines recommend EEN to meet 120% of EAR, but this is unrealistic and often unachievable.6 In clinical practice you have to be practical about the volumes of EEN you are advising a patient to drink: if on a daily basis it is too high, the child/young person is less likely to continue the treatment.

The 12-year-old boy mentioned earlier had an EAR of 2,247kcals/day.10 This equates to seven of the whole protein, ready to feed 1.5kcal/ml drinks (220mls) each day, whereas 120% of EAR would be over eight of the drinks per day.

Due to this child’s potential risk of refeeding and with all patients starting on the polymeric diet, the aim would be to reach the target volume of drinks on day three to four. Patients should be given the opportunity to take the EEN orally with the aim that the PF is much more palatable and negates the need for a NGT to meet targets. NGT placement can be distressing for the child, it also requires much more support and training and can be linked with more time off school, difficulties socialising and can affect quality of life. However, it can take the pressure off having to drink the entire target volume.11 The possibility of an NGT should always be discussed at the first review as even the unlikeliest of patients can often not tolerate the volumes expected with EEN. One study placed the NGT during endoscopy and feeds started after 12 hours, building up to target by day three, and then permitting oral intake as tolerated.12 There is much debate and no consensus on what other fluids are allowed during the period of EEN; one study reported 68% of respondents were allowed clear fluids (fizzy

drinks, ice and clear soup), 48% allowed boiled sweets, 39% allowed chewing gum and tea and coffee.4 One centre permitted 10% of intake as food, this is as suggested from Johnson’s study of partial enteral nutrition (PEE) and EEN that the anti-inflammatory effects aren’t seen if intake of food is continued and that although supplements are beneficial, it doesn’t suppress intestinal inflammation which is the key to remission.13 FOOD REINTRODUCTION AND REMISSION

Food reintroduction after EEN is another controversial area and every centre appears to introduce food slightly differently. Faiman’s retrospective cohort study in 201414 was the first to compare standard versus rapid food reintroduction with standard practice being a slow elimination diet to ensure remission is established for as long as possible. Faiman’s study was small and was unable to identify exact timings of relapse; despite this, it did show that there was no statistical significance between the five-week introduction and the three-day introduction.14 The rapid introduction means that the diet isn’t unnecessarily restricted for long periods which could be detrimental to the nutritional adequacy of the diet and hence the growth of the child.14 Following food, it is advised to continue with nutritional supplements alongside diet to aid continued remission. A retrospective study primarily focusing on Maintenance Enteral Nutrition (MEN) showed that remission rates at one year were 60% with MEN compared to 15% with no treatment. This study aimed for 25% of EEN intake per day for MEN and again found it effective compared to medications such as Azathioprine.15 This equates to one to two supplement drinks per day alongside diet.

CONCLUSION

Nutrition and enteral feeding plays a key role in the management of CD within Paediatrics, not only in inducing remission, but in maintaining remission as well, without the risks that are associated with other medications used within the disease management. The dietitian is therefore an important part of the gastroenterology multidisciplinary team. www.NHDmag.com August/September 2017 - Issue 127

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