In my opinion, the best lecture from this year’s postgraduate course was from Dr. Baldassano.  Enteral nutrition in Crohn disease: Where should this be in our treatment algorithm?  Robert N. Baldassano, MD (page 115)

Dr. Baldassono has personal experience with improving with enteral therapy after failing methotrexate/remicade.  His conclusion:

Enteral Nutritional Therapy: Where should this be in our treatment algorithm?

• Should be offered to all newly diagnosed Crohn’s patients who can tolerate Nutritional Therapy
• Special groups (especially a good idea): Malnourished patients, Younger patients, Growth failure, History of Cancer, Family history of Lymphoma, Consider when failing other therapies

This conclusion is supported by his presentation.

Should we be immunosuppressing our Patients?  Hypothesis: IBD arises from inappropriate handling of intestinal bacteria

Elements of Modern Lifestyle Lead to Changes in Gut Microbiota

1. Improved sanitation
2. Less crowded living conditions
3. Decline in parasites
4. Vaccinations
5. Increased antibiotic use
6. Caesarean section
7. Refrigeration
8. Food processing
9. Diet changes
10. Improved sanitation

Diet is associated with new onset IBD

• High dietary intakes of total fats, PUFAs, omega‐6 and meat were associated with an increased risk of CD and UC
• High fiber and fruit intakes were associated with decreased CD risk
• High vegetable intake was associated with decreased UC risk.  Reference: Hou JK et al. American Journal of Gastro 2011; 106:563-73
• The Bacteroides enterotype highly associated with animal protein and saturated fats which suggests meat consumption as in a Western diet
• The Prevotella enterotype, high values for carbohydrates and simple sugars, indicating association with a carbohydrate-based diet, more typical of agrarian societies.  References: Wu G, et al. Science. 2011 Oct 7;334(6052):105‐8

Partial or Complete Enteral Nutrition?

• 50% vs 100% of total caloric needs for induction with elemental formula (PCDAI < 10 at 6 weeks)
• 50% of total caloric needs 15% remission
• 100% of total caloric needs 42% remission
• Labs improved only in the 100% group
• Weight gain similar in the 2 groups. References: Akobeng et al Clin Nutr 2007; Ludvigsson et al Acta Paediatr 2004;Johnson et al Gut 2006;Critch et al. JPGN: 2012 

Pediatric Longitudinal Study of Semi‐Elemental Diet and Stool Microbiome (PLEASE)

Prospective cohort study of children with Crohn disease from Philadelphia (used Peptamen), Toronto (used Modulen) and Halifax (used Osmolite); (n=90)

• Enteral therapy with defined formula diet (n=38) vs. anti‐TNFα therapy (n=52)
• Similar drop in PCDAI and calprotectin in TNF group and diet group. 

Other points:

1. Insurance generally will cover nasogastric feeds
2. Disease location –not clear that this matters with Crohn’s disease
3. The reason EN works may be not what you are giving the patient but what the patient is not getting
4. Bacterial populations in pediatric IBD subjects on semi‐elemental diet (16S rDNA sequencing) develop a rapid change in gut bacterial populations upon initiating diet.
5. Partial (50%) nutrition, as noted above, helped maintain remission compared to normal diet.

Nutrition Therapy: “European” Protocol

• Induction:  Exclusive enteral nutrition with an elemental, semielemental,or polymeric formula

• Duration: 4 – 12 weeks

• Maintenance Therapy: (either)

– Nutritional therapy: Repeat 4 week cycle of exclusive enteral nutrition every 3– 4 months

OR

– Medical therapy: 6‐MP/AZA/MTX after induction with nutritional therapy

CHOP EN Experience: What if >80% of calories is from Enteral Nutrition?

• Methods: Semi‐elemental formula, 80%‐90% of patient’s caloric needs from formula, Nocturnal NG feeds (outpatient teaching program), Normal diet as tolerated during the day
• Duration:  7 days per week for 8‐12 weeks (induction), 5 days per week (maintenance) Reference: Gupta et al. Inflamm Bowel Dis. 2013:1374-8.
• Induction of remission: 65% (at 8 weeks)
• Response: 87% (at 8 weeks)
• Significant improvement in weight and linear growth
• Protocol is well tolerated:  no serious adverse events

Postgraduate Course Syllabus (posted with permission): PG Syllabus

Related blog posts:

• Practical Advice on Enteral Nutrition | gutsandgrowth -includes link to 32 minute with family-oriented video on using enteral nutrition.
• Rest easy with enteral nutrition | gutsandgrowth

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.