Henter Izabella - Cyprus Dietetic Association

Crohn’s disease in
adolescents and
nutritional intervention
Izabella Henter RD
General secretary
Hungarian Dietetic Association

Definition of Crohn's disease
�� Chronic inflammatory disease, disease,
primarily
involving the small and large intestine, intestine,
but
which can affect other parts of the digestive
system as well. well.
�� It is named for Burrill Crohn, Crohn,
the American
gastroenterologist who first described the
disease in 1932.

HOW COMMON IS IBD?
�� It is estimated that there may be as many as one
million Americans with IBD.
�� Males and females appear to be equally affected. affected
�� Although Crohn's disease and ulcerative colitis
affect people of all ages, ages,
they are primarily
diseases of younger persons; persons;
with adolescents
and young adults between the ages of 15 and
35 being the most susceptible. susceptible
There may be at least 100,000 children under
the age of 18 in the United States who suffer
from IBD.
�� http:// http://www.ucandcrohns.org
www.ucandcrohns.org/printHtml printHtml/parents parents_guide.html guide.html

HOW COMMON IS IBD?
�� Crohn disease is most common in western
Europe and North America, America,
the age specific
incidence is 2-3/100.000 2 3/100.000 (10-19 (10 19 years old)*
�� The incidence of pediatric IBD almost doubled
in Finland from 1987 to 2003. **
�� Crohn disease occurs more often in Caucasians
(whites whites) ) and people of eastern and central
European (Ashkenazi Ashkenazi) ) Jewish descent than
among people of other ethnic backgrounds.***
backgrounds.***
*Krónikus gyullasásos bélbetegségek protokoll Csecsemő-és Csecsemő és gyermekgyógyászati szakmia
Kollégium 2006 **Turunen P et al,. Incidence of inflammatory bowel disease in Finnish
children, 1987-2003. Inflamm Bowel Dis. 2006 Aug;12(8):677-83.
***http://ghr.nlm.nih.gov/condition=crohndisease

A population-based
population based case control study of
potential risk factors for IBD N=581
�� Predictive of CD included lower likelihood of living on
a farm, of having drunk unpasteurized milk or having
eaten pork
�� On multivariate analysis, analysis,
variables significantly
associated with CD were being Jewis, Jewis,
having a first
degree relative with IBD,ever IBD, ever having smoked, smoked,
living
longer with a smoker
�� A number of significant associations with CD and UC
on univariate and multivariate analysis may support the
"hygiene hygiene hypothesis" hypothesis"
and warrant further exploration in
prospective studies. studies
Am J Gastroenterol. 2006 May;101(5):993-1002

Environmental risk factors in Crohn's disease
and ulcerative colitis
�� The role of two environmental factors has
clearly been established in IBD. Smoking is a
risk factor for Crohn's disease and a protective
factor for ulcerative colitis; colitis;
appendectomy is a
protective factor for ulcerative colitis. colitis.
Many
other environmental factors for IBD have been
investigated, investigated,
including infectious agents, agents,
diet, diet,
drugs, drugs,
stress and social status. Among them, them,
atypical Mycobacteria,
Mycobacteria,
oral contraceptives and
antibiotics could play a role in Crohn's disease. disease.
Gastroenterol Clin Biol. 2006 Jun-Jul;30(6-7):859-67

Mechanisms of disease: disease:
the hygiene
hypothesis revisited. revisited
�� The incidence of diseases caused by immune
dysregulation has risen. risen.
Epidemiologic studies
initially suggested this was connected to a
reduction in the incidence of infectious diseases; diseases;
�� Some pathogens can induce regulatory cells
to evade immune elimination,
elimination,
but regulatory
pathways are homeostatic and mainly
triggered by harmless microorganisms.
microorganisms
Nat Clin Pract Gastroenterol Hepatol. 2006 May;3(5):275-84

�� Helminths, Helminths,
saprophytic mycobacteria,
mycobacteria,
bifidobacteria and lactobacilli, lactobacilli,
which induce
immunoregulatory mechanisms in the host
�� Deficient exposure to these 'old friends' friends'
might
explain the increase in immunodysregulatory
disorders. disorders.
The use of probiotics, probiotics,
prebiotics, prebiotics,
helminths or microbe derived
immunoregulatory vaccines might, might,
therefore, therefore,
become a valuable approach to
disease prevention. prevention
Nat Clin Pract Gastroenterol Hepatol. 2006 May;3(5):275-84

Nutrition in IBD
Falk foundation 2004.

Inflammation
�� Little is known about the cause(s) cause(s)
or underlying
immunopathogenesis of CD. However, However,
several
genes are associated with CD, CD,
and mutation(s) mutation(s)
in
the CARD15/NOD2 gene seems of particular
importance. importance
Inflammatory Bowel Diseases 9(1):34–58 © 2003 Crohn’s &
Colitis Foundation of America, Inc.

IL-10 IL 10 may play a physiological role in the gut mucosa
by its ability to down-regulate
down regulate macrophage activation
induced by LPS released from gram-negative
gram negative
bacteria in the gut.
gut

Simptoms
�� Abdominal pain, pain,
diarrhea diarrhea,
, vomiting, vomiting,
fever, feve , and
weight loss are common symptoms. symptoms.
�� Crohn disease can be associated with
reddish tender skin nodules, nodules,
and inflammation
of the joints, joints,
spine, spine,
eyes, eyes,
and liver. liver.
Recommendations for Diagnosis The Porto Criteria
J Pediatr Gastroenterol Nutr, Vol. 41, No. 1, July 2005

Diagnosis
�� Crohn disease is usually diagnosed in persons
in their teens or twenties, twenties,
but can come to
therefore at any point in life. life.
It can be a
chronic, chronic,
recurrent condition or can cause
minimal symptoms with or even without
medical treatment .
Recommendations for Diagnosis The Porto Criteria
J Pediatr Gastroenterol Nutr, Vol. 41, No. 1, July 2005

Diagnosis
�� Diagnosis of CD, UC and indeterminate colitis
is based on clinical signs and symptoms, symptoms,
endoscopy and histology and radiology. radiology.
�� Every child suspected of IBD should undergo a
complete diagnostic program consisting of
colonoscopy with ileal intubation, intubation,
upper
gastrointestinal endoscopy and (in in all cases
except in definite ulcerative colitis) colitis)
radiologic
contrast imaging of the small bowel. bowel.
Multiple
biopsies from all segments of the GI tract are
needed for a complete histologic evaluation. evaluation.
Recommendations for Diagnosis The Porto Criteria
J Pediatr Gastroenterol Nutr, Vol. 41, No. 1, July 2005

54%
Results / Preparation
Results
Days on diet before colonoscopy N= 192
Hungarian Crohn and Colitis Association
and Hungarian Dietetic Association 2005.
11%
3%
2%
30%
7-day diet
3-day diet
1-day diet
without diet
N / A

35%
Results / Bowel clearing N=192
Results
Hungarian Crohn and Colitis Association and
Hungarian Dietetic Association 2005.
3% 5%
always clear
not clear 1-2 times
not clear 2 times
N / A
57%

The IBD patients need
the following complex preparation
Acceptable clearing
solution
N=192
Hungarian Crohn and Colitis Association and
Hungarian Dietetic Association 2005.
Diet without
starvation
Psychical care

How is Crohn's disease (CD)different
(CD) different
from ulcerative colitis ( UC) 1.
Localization CD UC
Oesophagus,
Oesophagus,
Stomack
+ _
Small intestine
(middle middle and distal) distal
+ _
Distal ileum ++ +
Colon ++ +++
Rectum ++ +++
Anus ++ _

How is Crohn's disease different
from ulcerative colitis 2.
Intestinal
symptoms
CD UC
Haematochesia + +++
Diarrhoea + +++
Abdominal pain +++ +
Anorexia +++ +
Vomiting ++ +

Forms of Crohn’s
�� Involvement of the large intestine (colon) only is called
Crohn colitis or granulomatous colitis, colitis,
�� Involvement of the small intestine alone is called Crohn
enteritis. enteritis
�� The most common part of the small intestine to be
affected by Crohn disease is the last portion, portion,
ileum. ileum Active
disease in this area is termed Crohn ileitis. ileitis.
�� When both the small intestine and the large intestine are
involved, involved,
the condition is called Crohn enterocolitis (or or
ileocolitis). ileocolitis).

Forms of Crohn’s
�� In mild forms, forms,
Crohn disease causes small scattered
shallow crater like areas (erosions erosions) ) called aphthous ulcers
in the inner surface of the bowel. bowel.
�� In more serious cases, cases,
deeper and larger ulcers can
develop, develop,
causing scarring and stiffness and possibly
narrowing of the bowel, bowel,
sometimes leading to
obstruction. obstruction.
�� Deep ulcers can puncture holes in the bowel wall, wall,
leading to infection in the abdominal cavity (peritonitis peritonitis) )
and in adjacent organs.
organs

Therapy
�� Therapy for inflammatory bowel disease (IBD,
ulcerative colitis, colitis,
and Crohn’s disease) disease)
is
designed for induction of remission of disease
activity, activity,
maintenance of remission, remission,
and
prevention of relapse. relapse.
�� In children, children,
normal growth and pubertal
development are additional indicators of
successful treatment or sustained remission. remission
Inflammatory Bowel Diseases 9(1):34–58 © 2003 Crohn’s & Colitis
Foundation of America, Inc

Evidence
�� In adults, adults,
enteral feeding is not as effective as
corticosteroids as primary treatment of Crohn’s
disease; disease;
however, however,
there is mounting evidence
supporting the use of enteral feeding in children, children,
especially in those with new-onset new onset Crohn’s
disease. disease.
�� With enteral feeding, feeding,
nutrition is improved, improved,
and
growth and pubertal development can be
promoted, promoted,
while avoiding the systemic toxicity
of corticosteroid therapy. therapy.
Tondeur M,Griffiths M. Enteral nutritional therapy for induction of remission in Crohn’s disease. Cohrane
Inflammatory Bowel Disease and Functional Bowel Disorders Cochrane Database of Systematic Reviews.
3.2005. EBM Reviews

�� There is insufficient evidence to prefer elemental
nutrition over polymeric feeding, feeding,
or to withhold
nutritional treatment from children with Crohn’s
colitis. colitis
�� Enteral nutrition may promote maintenance
of remission in children with Crohn’s
disease. disease.
Tondeur M,Griffiths M. Enteral nutritional therapy for induction of remission in Crohn’s
disease. Cohrane Inflammatory Bowel Disease and Functional Bowel Disorders Cochrane
Database of Systematic Reviews. 3.2005. EBM Reviews

Long-term Long term outcome of nutritional therapy in
paediatric Crohn's disease. disease
�� Of newly diagnosed patients with Crohn's disease in
whom enteral nutrition was used as the primary therapy
(44 children) children)
was analysed, analysed,
with particular reference to
time to remission, remission,
to first and subsequent relapse, relapse,
and
to first steroid usage. usage.
�� 90% of 44 patients responded to enteral nutrition, nutrition,
with
a median time to remission of 6 weeks. weeks.
25 of these 40
(62%) relapsed, relapsed,
with a median duration of remission of
54.5 weeks (range range 4-312). 312). 15 (38%) have not relapsed. relapsed.
21 of the 44 (47%) have not received steroids. steroids.
Clin Nutr. 2005 Oct;24(5):775-9.

�� This data suggests that there are long-term long term
benefits to the use of enteral nutrition to induce
remission in children with Crohn's disease
Steroids may be avoided in nearly half the cases
and, and,
in others, others,
their use postponed by 68 weeks. weeks
Clin Nutr. 2005 Oct;24(5):775-9.

Enteral nutrition as primary therapy in
childhood Crohn's disease: disease:
control of
intestinal inflammation and anabolic
response. response
�� Enteral nutrition is effective in active disease
and will induce disease remission in most cases
avoiding corticosteroid use. 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. strategy
JPEN J Parenter Enteral Nutr. 2005 Jul-Aug;29(4 Suppl)

Exclusive enteral feeding as primary therapy
for Crohn's disease in Australian children and
adolescents: adolescents:
a feasible and effective approach
�� 27children received EEN with polymeric formulae. 24
children completed the prescribed period of EEN.
Twelve of 15 (80%) newly diagnosed CD and seven of
12 (58%) with long standing disease entered remission. remission.
Children with newly diagnosed CD responding to EEN
took all feeds orally and gained an average of 4.7+/-3.5 4.7+/ 3.5
kg with mean PCDAI* decreasing from 37.1+/-10.8 37.1+/ 10.8 to
6.7+/-5.1 6.7+/ 5.1 after 8 weeks. weeks.
*PCDAI: Pediatric Crohn's Disease Activity Index
J Gastroenterol Hepatol. 2006 Oct;21(10):1609-14

�� Exclusive enteral feeds induced remission in
80% of children with newly diagnosed CD (on ( on
intention-to intention to-treat treat basis) basis)
when used as sole initial
therapy while also improving nutritional status. status.
�� Further study of the role(s) role(s)
of enteral feeds and
of longer-term longer term benefits of enteral feeding in
children with CD is now required. required
J Gastroenterol Hepatol. 2006 Oct;21(10):1609-14

Treatment includes
�� Medications that are anti-inflammatories
anti inflammatories, ,
immune suppressors or antibiotics. antibiotics.
�� Surgery can be necessary in severe cases. cases
IBD Working Group of the European Society for Paediatric Gastroenterology,
Hepatology and Nutrition (ESPGHAN)Inflammatory Bowel Disease in Children and
Adolescents:Recommendations for Diagnosis—The Porto Criteria
Journal of Pediatric Gastroenterology and Nutrition 41:1–7 _ July 2005

Aminosalicylates
�� In the treatment of pediatric IBD, fear of side
effects (nausea nausea, , dyspepsia, dyspepsia,
myalgias or arthral-
gias and headache ) and successful marketing has
caused mesalazine to be more popular than
sulfasalazine.
sulfasalazine.
Sulfasalazine,
Sulfasalazine,
however, however,
is cheaper
than mesalazine and can be administered more
easily to children as a suspension rather than a
large tablet. tablet
Inflammatory Bowel Diseases 9(1):34–58 © 2003 Crohn’s & Colitis
Foundation of America, Inc.

Corticosteroids
�� Corticosteroids are very effective in controlling
active Crohn’s disease and ulcerative colitis, colitis,
accounting for clinical remission rates of 60–91%. 60 91%.
There is, however, however,
no benefit from steroid
maintenance therapy in either disease. disease.
�� Long-term Long term side effects: effects:
Severe hypokalemia,
hypokalemia,
intracranial hypertension,
hypertension,
bone
demineralization,
demineralization,
growth retardation. retardation
�� Of the new steroid formulations,
formulations,
oral budesonide
(for for active ileocecal Crohn’s disease) disease)
has less
incidence of side effects in children receiving
short-term short term therapy.
therapy

AZATHIOPRINE OR 6- 6
MERCAPTOPURINE
�� In children with newly diagnosed Crohn’s
disease, disease,
6-MP 6 MP is effective, effective,
steroid-sparing
steroid sparing, , and
improves maintenance of remission. remission.
Based on
these data, data,
6-MP 6 MP (and ( and it s prodrug azathioprine)
azathioprine)
may be considered as part of the initial
treatment of Crohn’s disease in children. children.
�� Side effect: effect:
nausea, nausea,
Bone marrow suppression in
2–5% 5% of the patients. patients
Inflammatory Bowel Diseases 9(1):34–58 © 2003 Crohn’s &
Colitis Foundation of America, Inc.

CYCLOSPORINE
�� For closure of refractory fistulas in patients with
Crohn’s disease, disease,
intravenous cyclosporine is effective, effective,
but maintenance of this success after tapering is a prob-
lem. lem.
�� Side effects (such such as hypertrichosis and paresthesias) paresthesias)
are
frequent, frequent,
especially in high-dose high dose oral and intra-venous intra venous
treatment. treatment.
The risk of (in in some cases permanent) permanent)
renal
damage limits its use as a long-term long term drug. drug Based on the
current evidence from the many studies in children, children,
there are some reasonable approach to the use of this
immunosuppressive agent in pediatric patients.
patients

Methotrexate (MTX)
�� The anti-inflammatory
anti inflammatory drug
�� Side effects:gastrointestinal
effects gastrointestinal toxicity, toxicity,
including nausea
(in in 42%), anorexia, anorexia,
stomatitis, stomatitis,
and diarrhea (7%).
Headaches (17%), dizziness, dizziness,
fatigue (16%), and mood
alterations may also occur. occur
�� In children with CD, experience with methotrexate is
limited but encouraging. encouraging.
Until the long-term long term risks and
benefits of subcutaneous MTX are fully known, known,
methotrexate should only be considered in children and
adolescents with CD who fail to respond to
conventional drug (i.e., corticosteroids and
azathioprine/6
azathioprine/6-MP
MP) ) treat-ment treat ment or who are having
significant complications from their other therapies.
therapies

ANTI-TUMOR ANTI TUMOR NECROSIS FACTOR- FACTOR
ANTIBODY (INFLIXIMAB)
�� Infliximab, Infliximab,
anti-TNF anti TNF antibody, antibody,
is very effective
in active and fistulizing Crohn’s disease. disease
�� Further controlled, controlled,
multicenter studies focused
on dose and the role of infliximab as
maintenance treatment should be performed in
children with Crohn’s disease. disease
Inflammatory Bowel Diseases 9(1):34–58 © 2003 Crohn’s & Colitis
Foundation of America, Inc.

Review article: helminths as therapeutic
agents for inflammatory bowel disease.
�� Crohn's disease, which is associated with T
helper 1 (Th1) events it is proposed that
infection with parasitic helminths would be
beneficial: the paradigm being that of immune
deviation, where Th2 cytokines mobilized in
response to the helminth will prevent or
antagonize the disease-promoting disease promoting Th1 events in
the gut.
�� CHANGE OF ABSORPTION?
Alimentary Pharmacology & Therapeutics 2004

Frequency of nutritional disorders in
inflammatory bowel diseases
�� Source: Nutrition in inflammatory bowel diseases (Falk foundation, 2005)
Underweight
Lactose intolerance
Hypalbuminemia
Anemia
Essential fatty acid deficiency
Calcium deficiency
Magnesium deficiency
Zinc deficiency
Crohn’s disease
70 %
30-40 %
25-80%
25-85%
2-5%
20-60%
30-68%
42-92%
Ulcerative colitis
N=279 N=113
18-55 %
25-65
0-10%
22-68%
0-2%
0-46%
2-55%
12-52%

Carbohydr
ates
Reasons of nutritional disorders
in Crohn’s disease
disease Müller S.D. The informed patient 2004.
Maldigestion Abszorption
⇓
Loss Intake ⇓
+++ +
Fats +++ (+) +++ ++
Protein ++ +++ +++ ++
Ca +++ +++ +++
Mg, Zn +++ ++ ++
Folic acid +++ ++
B12 +++ ++
A,D,K vit. vit
+++ ++

Vitamin
deficiency
Complications in IBD
outside the GI tract
CD UC Tünetek
+ - Osteomalacia,
Osteomalacia,
muscle
atrophy,anaemia
atrophy anaemia, , night blindness, blindness,
hyperkeratosis
Mineral deficiency + - Anaemia, Anaemia,
osteomalacia,
osteomalacia,
immunity ⇓, ,
wound healing ⇓
Protein deficiency + - Oedema, Oedema,
transport protein
deficiences
Hyperoxaluria + + Kidney stones
Bile acid deficiency + - Gallstones
Blood loss - + Anaemia

Protein-energy
Protein energy malnutrition
�� In children with IBD, chronic malnutrition
(mainly mainly caused by reduced nutritional intake) intake)
and persistent in-flammation
in flammation are responsible for
growth failure. failure.
A decrease in height velocity is
reported even before the onset of intestinal
symptoms in almost half of pediatric Crohn’s
disease patients .
�� Weight loss is documented in approximately
85% of children with CD, and in 65% with UC
at time of diagnosis. diagnosis.
Gokhale R, Favus MJ, Karrison T, et al. Bone mineral density
assessment in children with inflammatory bowel disease. Gastro-enterology
1998;114:902–11.

Diet and nutrition is very important in
IBD management to prevent
malnutrition and extreme weight loss.

Food and drink
Intestinal brush border enzymes
Anatomy/Absorption
Anatomy/ Absorption
Pancreatic juice
Bile
Stomach
Duodenum
Jejunum
Ileum
Colon
Education
Rectum Faeces
Cl - , SO 4 -
Iron
Calcium
Magnesium
Water, sodium
Water, electrolytes
Monosaccharides, disacchari
Fat soluble vitamins
Peptides and amino acids
Monoglycerol, fatty acids an
cholesterol
Bile salts, Cl
Vitamin B 12

Dietitians’ Dietitians’
role
�� Nutritional assessment: assessment
Percentile, Percentile,
actual/ideal actual ideal body weight, weight,
BMI, BIA,
FFM
�� Dietary anamnaesis: anamnaesis
Dietary record 3-7 7 days, days,
food frequency, frequency,
food
amount
�� Calculation of energy and nutrient need

Measured versus predicted energy
expenditure in children with inactive
Crohn's disease. disease
�� The Schofield equation and (requirements
requirements for
energy for normal children) children)
EAR are unreliable
methods of predicting total energy requirements
in children with inactive CD with a significant
potential to underestimate energy needs. needs.
When
energy requirements were greater than EAR it
was due to physical activity and body habitus
rather than raised REE.
Clin Nutr. 2005 Dec;24(6):1047-55. Epub 2005 Sep 29

Dietitians’ Dietitians’
role
�� Prepare 1-3 3 week menu for the client
considering the individual aspects
�� Documentation
�� Follow up
�� Consultation with the members of health
professional team
�� Education of clients and colleagues
European Dietetic Benchmark Statement 2005 www.efad.org

Diet in IBD
�� Drink lots of fluid (8 - 10 servings daily) to keep body
hydrated and prevent constipation
�� Consideration of replaceing replaceing
of lost nutrients with
multivitamin-mineral multivitamin mineral supplement
�� Eat a high fiber diet when IBD is under control. Some
patients find cooking and steaming the vegetables more
tolerable than eating them raw. raw.
Quality of fíbre!
�� During a flare up, however, limit high fiber foods and
follow a low fiber diet or even a low residue diet to give
the bowel a rest and minimize symptoms.
Gloria Tsang R.D.
July 2005

Diet in IBD
�� Avoiding Avoiding
lactose-containing lactose containing foods such as dairy if there
are re lactose intolerance. Otherwise, it is possible to use
lactase enzymes and lactase pretreated foods.
�� It is very important to continue nourishing the body
even during a flare-up. flare up.
�� Small mall frequent meals are better tolarated
�� Eating a high protein diet with lean meats, fish and
eggs, may help relieve symptoms of IBD. / FSMP
�� „pr pre-digested digested” nutritional drinks (elemental diet) to give
a rest to the bowel and replenish lost nutrients for
repair the body

Diet in IBD
� Limit caffeine, alcohol and sorbitol (sweetener) as these
may exacerbate IBD symptoms.
� Limit gas-producing foods such as cabbage-family
vegetables (broccoli, cabbage, cauliflower and brussels
sprouts), dried peas and lentils, onions and chives,
peppers and carbonated drinks
� Reduce fat intake if part of the intestines has been
surgically removed. High fat foods usually cause
diarrhea and gas for this group of patients

Diet in IBD
�� If the ileum (part of the small intestines) has
been resected, resected,
a Vitamin B12 injection may be
required
�� Some studies found that fish oil and flax seed oil
may be helpful in managing IBD. Some also
suggested the role of prebiotics such as psyllium
in the healing process. Furthermore, probiotics
(live culture) may also be helpful in aiding
recovery of the intestines.

PARENTERAL NUTRITION
�� In adults and children, children,
parenteral nutrition is generally
reserved for patients with serious illness or preoperative
situations. situations.
Pediatric patients who are unable to tolerate
sufficient quantities of enteral supplementation because
of active inflammatory disease and diarrhea have been
shown to benefit considerably from total parenteral
alimentation (TPN). Prolonged parenteral support may
to induce remission. remission
�� In addition, addition,
TPN with or without oral feedings is of
value in improving the nutritional status of children or
adolescents with IBD as demonstrated by weight gain
or reversal of growth arrest .
Motil KJ, Grand RJ. Inflammatory Bowel Disease, In: Walker
WA, Watkins JB, eds. Nutrition in Pediatrics. 2nd ed. Hamilton,
Ontario: B.C. Decker,1997:516–33.

Role of perioperative parenteral nutrition in
severely malnourished patients with Crohn's
disease. disease
�� Perioperative parenteral nutrition possibly
ameliorates the humoral immunity, immunity,
reverses
malnutrition,
malnutrition,
and facilitates rehabilitation.
rehabilitation
World J Gastroenterol. 2005 Sep 28;11(36):5732-4

Refeeding syndrome with enteral nutrition in
children: children:
a case report, report,
literature review and
clinical guidelines. guidelines
�� Refeeding syndrome in an adolescent with newly
diagnosed Crohn's disease. disease.
This developed
within a few days of starting exclusive polymeric
enteral nutrition. nutrition A systematic literature review
revealed 27 children who developed refeeding
syndrome after oral/enteral oral enteral feeding. feeding.
Of these, these,
nine died as a direct result of complications of
this syndrome. syndrome.
We discuss the implications of
this syndrome on clinical practice and propose
evidence based guidelines for its management.
management
Clin Nutr. 2002 Dec;21(6):515-20

Depression and inflammatory bowel disease: disease:
findings from two nationally representative
Canadian surveys
�� Individuals with IBD and similar bowel
disorders experience rates of depression that are
triple those of the general population
�� Depression rates were higher among female
respondents, respondents,
those without partners, partners,
younger
respondents, respondents,
those who reported greater pain, pain,
and those who had functional limitations. limitations.
Inflamm Bowel Dis. 2006 Aug;12(8):697-707

Probiotics
�� In children, children,
two studies of probiotics have been
published. published.
In the first, first,
oral bacteriotherapy with human
Lactobacillus casei strain GG (given ( given to 14 children with
Crohn’s disease) disease)
resulted in an increase in the gut IgA
immune response.
�� A recent open-label open label pilot study of Lactobacillus GG, G,
given for 6 months to four children with mildly to
moderately active Crohn’s disease showed clinical
improvement and concomitant decrease in intes-tinal intes tinal
permeability.
Promotion of IgA immune response in patients with Crohn’s disease by oral bacte-riotherapy
with Lactobacillus GG. Ann Nutr Metab 1996;40:
. Is Lactobacillus GG helpful in children with Crohn’s disease? Results of a prelimi-nary,
open-label study. J Pediatr Gastroenterol Nutr 2000;31:

Probiotics
�� Evidence vidence has accumulated for the role of commensal
gut bacteria in the IBD. IBD.
Reduction of the enteric
bacterial concentration by antibiotics, lavage, lavage,
or surgical
bypass results in a mitigation of symptoms. symptoms
Probiotics: do they help to control intestinal inflammation? Ann N Y Acad Sci. 2006 Aug;1072:339-50.
�� There is no evidence to suggest that probiotics are
beneficial for the maintenance of remission in CD. All
of the included studies enrolled small numbers of
patients and may have lacked statistical power to show
differences should they exist. Larger trials are required
to determine if probiotics are of benefit in Crohn's
disease.
disease.
Probiotics for maintenance of remission in Crohn's disease. Cochrane Database
Syst Rev. 2006 Oct 18;(4):CD004826

Complementary and alternative medicine
�� Complementary therapies may include acupuncture or
acupressure, acupressure,
massage, massage,
music or art therapy, therapy,
guided imagery, imagery,
yoga, yoga,
tai chi, chi,
and hypnosis. hypnosis.
They can be especially effective at reducing
stress, stress,
alleviating the side effects of conventional treatments and
improving quality of life. life
�� Studies have found that more than half the people with IBD have
used some form of alternative or complementary therapy. therapy.
The
most common: common:
nutritional supplements,
supplements,
probiotics and fish oil. oil.
�� Side effects and ineffectiveness of conventional therapies are
primary reasons for seeking alternative care. care
�� Only about two-thirds two thirds report their alternative or complementary
therapy use to their doctors, doctors,
however. however.
Because even natural herbs
can have side effects and cause dangerous interactions, interactions it is
important to inform the doctor. doctor
http:// http://www.mayoclinic.com
www.mayoclinic.com/health health/crohns crohns-disease disease/DS00104/DSECTION=11
/DS00104/DSECTION=11

Prevention
Teen health prevention includes maintaining a
healthy diet, diet,
exercising regularly, regularly,
preventing
injuries and screening annually for potential
health conditions that could adversely affect
teenage health. health.
We have to support them!

Thank you for your attention!

ENTERAL NUTRITION
�� Elemental diets, diets,
originally developed to minimize bowel
actions
�� The advantages of elemental formulas: formulas:
improvement of
general condition, condition,
decreased gut motility, motility,
reduction of
antigenic load, load,
and changes in bowel flora
�� In addition, addition,
the liquid nature of the diet (and and its ease of
transport through diseased or narrowed small bowel) bowel)
may in itself be responsible for the effect . Lastly, Lastly,
in
severely painful perianal disease, disease,
elemental feeding can
minimalize fecal output while maintaining a good
nutritional status.
Korelitz BI. The role of liquid diet in the management of small
bowel Crohn’s disease. Inflamm Bowel Dis 2000;6:66–7.

PARENTERAL NUTRITION
�� These beneficial effects occurred irrespective of
whether there was an amelioration of clinical
symptoms. symptoms.
�� The greatest successes of TPN in Crohn’s
disease have been reported in children who had
no rectal bleeding and who were administered
the treatment at home (HPN).
Inflammatory Bowel Diseases 9(1):34–58 © 2003 Crohn’s & Colitis
Foundation of America, Inc.

�� Mean remission rates after enteral nutrition or steroids
are similar, similar,
approximately 85%, as described in a recent
meta-analysis
meta analysis of seven pediatric clinical trials(five trials five
randomized two unrandomized.
unrandomized.
Controlled studies of
elemental versus polymeric nutrition have not been
performed in children with active Crohn’s disease, disease,
but a
meta-analysis
meta analysis found no difference in efficacy. efficacy.
In
children with active Crohn’s disease, disease,
remission rate
after enteral nutrition was higher (86%) in children with
new-onset new onset disease as compared with those with
recurrent-relapse
recurrent relapse disease (50%) 50%) .
Heuschkel RB, Menache CC, Megerian JT, et al. Enteral nutrition
and corticosteroids in the treatment of acute Crohn’s disease in
children. J Pediatr Gastroenterol Nutr 2000;31:8–15.
1979;77:847–69.