1. Advances in Inflammatory Bowel Diseases 2014 Millie Boettcher, MSN, PPCNP Children’s Hospital of Philadelphia Division of Gastroenterology, Hepatology and Nutrition

2. Pediatric case DS presented at 8 months of age with decreased oral intake and bloody diarrhea Associated with introduction of solids Milk and diary was eliminated from the diet with improvement

3. Pediatric case At 15 months after immunization – he presented with dark red stools and weight gain slowed and had dropped to <5 th %ile on WHO curve He was having 5 to 7 stools per day, with blood and mucous His diet was basically vegetarian with soy milk

4. Pediatric case He underwent a colonoscopy and the histology revealed – focal active ileitis with granuloma, chronic active colitis with architecture changes and granuloma Family history is significant for father with papillary thyroid carcinoma and removed at age 25 and mother with Hashimoto’s disease

5. Pediatric case What are the current options for treatment for induction of remission? steroids mesalamine antibiotics

6. Pediatric Case Parents opted for balsalazide 250mg 2 times per day and metronidazole 15mg/kg day was added TMPT was drawn and normal at 32.6 EU He continued to have bloody stools and abdominal pain and poor intake

7. Pediatric case Azathiaprine 25 mg daily initiated 6TG 315 was therapeutic 6MMP level persistently undetectable Prednisone started due to blood persisting and was tapered off over 6 weeks

8. Pediatric case Admitted due to persistent symptoms – ESR 65, CRP 6, Hgb 8.6 and azathiaprine at this time was at 3.5mg/kg and was on steroid taper He was having 4 to 6 stools with intermittent blood and his intake was poor IV steroids were initiated

9. Pediatric Case What are the treatment options, for this now 3 year old? Do the risks outweigh the benefits? What are the goals of treatment?

10. Pediatric Case Biologics versus enteral nutrition Family history of cancer Goals not only remission, include weight gain and growth He began NG tube feedings for supplementation and Remicade was initiated

11. Pediatric Case After 3 induction doses of inflximab he had no circulating infliximab and no improvement in his symptoms Parents opted for 100% exclusive enteral nutrition via a NG tube at night He began Soy formula and steroids were tapered over 6 weeks and stools improved

12. Pediatric Case Weight gain improved and up to 34% ile Growth improved up to 2%ile then 4%ile Stools decreased to 2 to 3 per day and his energy level improved

13. Enteral Nutrition in IBD A therapy that has been used for 4 decades Involves the use of a specific enteral formula as nutrition therapy Formula is most often delivered via an NG tube Exclusive, 100% of calories, for a defined period of time Partial 80-90% of calorie, with the remainder from normal food Whitten et al Journal of Digestive Diseases 2012

14. Enteral Nutrition in IBD Clinical relevance of diet and IBD -CCFA receives more than 14,000 inquiries per year, of which approximately 65% are for dietary advice. -Patients desire therapies which do not suppress the immune system

15. Enteral Nutrition in IBD Diet is associated with new onset IBD – High dietary intake of total fats, PUFAs, omega-6 and meat were associated with an increased risk of CD and UC – High fiber and fruit intake were associated wit decreased CD risk – High vegetable intake was associated with decreased UC risk

16. Enteral Nutrition in IBD CHOP Protocol Semi-elemental formula 80-90% of total caloric needs from formula Nocturnal NG feed via pump Unrestricted diet during the day Duration – 7 days per week for 8-12 weeks for induction and 5 days per week for maintenance

17. Retrospective review of CHOP ENT protocol 43 patients with CD treated from 1998-2010 87% response rate and 65% remission rate Decreases in ESR and CRP, increase in albumin Increases in weight and height

18. Enteral Nutritional Therapy for Crohn Disease Induction of remission Yes Maintenance of remission Yes Prevent Post-op recurrence Yes Mucosal healing Yes

19. Enteral Nutritional Therapy Why does it work? –Change in gut microbiota ? –Decrease in antigenic load ? –Effect of certain nutrients ?

20. Enteral Nutritional Therapy Reduction in luminal antigens Modulation in the gut microbiota - proteobacteria were more abundant and bacteroidetes were less abundant There is some evidence that an increased in fecal short chain fatty acids

21. Enteral Nutrition Therapy A study by Leach and colleagues evaluated the abundance of 5 key groups of bacteria in the stool of patients with CD treated with EN and healthy patients on a regular diet The CD pts treated with EN had a significant decrease in the bacterial diversity which was sustained for several months following completion of therapy.

22. Safety of EN therapy for Crohn’s Disease No immunosuppression and beneficial effects on microbiota Generally well tolerated Most common side effects: Nausea, flatulence, abdominal pain, diarrhea Akonberg AK. JPGN. 2010. Afzal NA et al. Clin Nutr. 2002.

23. Enteral Nutrition in IBD CHOP Experience 36 complaints by 22 patients Morning emesis Liquid stools Difficulty placing the NG tube Abdominal pain/bloating Loss of appetite Throat irritation Gupta K et al In Press

24. Enteral Nutritional Therapy: Where should this be in our treatment algorithm? Should be offered to all newly diagnosed patients with CD who can tolerate nutritional therapy –Special groups Malnourished patients Younger patients Growth failure History of cancer Family history of lymphoma? Consider when failing other therapies

25. Enteral Nutrition IBD Special groups – Malnourished patients – Younger patients – Growth failure – History of cancer – Family history of lymphoma – Patients that are failing other therapies or have had significant side effects

26. Enteral Nutrition in IBD Induction of remission Maintenance of remission Prevent post-op recurrence Mucosal healing Tolerability Serious side effects Immunosuppressant yes no

27. Enteral Nutrition in IBD Potential disadvantage monotony of the diet social implications compliance support for patients and families financial and insurance issues

28. Thank You Special thanks to Dr. Lindsey Albenberg for her assistance in preparing this talk.