Steroids are the standard of therapy when treating Crohn’s flares. Unfortunately, steroids also come with many nasty side effects. For example, bone demineralization and slow growth are just some of the side effects of steroids that are especially concerning for a growing child. Corticosteroids have also been well-known to change body fat distribution that is very difficult to reverse. They can also suppress the cortisol production in the adrenal glands, blunting an important adrenal response humans need to stay alive.
Though Crohn's is more common in young adults, it can also strike at a young age.
Though Crohn's is typically diagnosed between the ages of 15-35, there are still many children who also have the disease. Up to a quarter of Crohn's cases are under the age of 18. Treating this population of Crohn's patients with steroids is less than ideal since we want to avoid retarding their growth before they have reached their matured heights.
How can liquid nutrition play a role?
Already, some gastroenterologists have found an alternative. They use a treatment known as exclusive enteral nutrition (EEN), which is a way to provide nutrition directly through the bloodstream as a means of bypassing the gut. The treatment is pretty safe except for some mild side effects such as nausea, vomiting, and diarrhea. There are also some rare cases of life-threatening complications. Overall, it's still got a safer side-effect profile than using corticosteroids.
Exclusive enteral nutrition is already used quite frequently in Europe for the treatment of childhood Crohn's disease. It's also growing in popularity in Canada. However, despite its more common use in other countries, less than 4% of pediatric gastroenterologists in the United States are using this method of treatment for children with Crohn's.
EEN was discovered to be helpful for Crohn's by incidental observations.
Interestingly, people started to notice the power of enteral nutrition because of surgery reports. Some patients with Crohn's were awaiting surgery, and to optimize their nutritional status before their scheduled surgeries they would be placed on EEN. To everyone's surprise, some of these patients unexpectantly improved to the point of no longer needing the originally intended surgery. It was discovered then, that EEN might have some power to heal those with inflammatory bowel disease.
How EEN works is not yet clear
It’s not exactly clear how liquid nutrition helps Crohn’s disease. It’s been suggested that by giving the bowels a rest digesting food from the environment, the lining of the intestine gets a chance to heal and improve its tissue integrity. There are also other hypotheses for how EEN works, including the reduction of inflammatory signals in the tissues as well as a change in the microbial population living in the gut.
Previous research comparing EEN with steroid therapy has shown some mixed results. Some studies have found that steroids are still better than EEN in treating Crohn’s, while others found no difference between the two treatment methods. However, many of these studies did not study treatment effects specifically in children. Rather, their study populations included patients with Crohn’s of all ages, and lower quality studies were also included in the analyses.
Children may benefit more than adults
There is a suspicion that exclusive enteral nutrition actually works better in children than adults. And since it’s been a decade since the last major analysis on the subject, researchers decided to tackle the question once more.
Led by Dr. Arun Swaminath, a gastroenterologist at the Lenox Hill Hospital in New York, a team of doctors performed a meta-analysis on all the studies that compared EEN with corticosteroid treatment in children with Crohn’s. Armed with new data using biomarkers and mucosal healing to evaluate disease stage, the study team updated a new review of the present research comparing steroid therapy and EEN used for children with Crohn’s.
After analyzing studies comparing the two treatments, the researchers found that steroids were equally as effective as exclusive enteral nutrition in treating active Crohn’s in pediatric patients. It didn’t matter what stage of disease it was either. Both therapies were effective in controlling the inflammation whether it was a first-time attack or a relapse.
Advantages compared to steroids
Exclusive enteral nutrition proved to have an additional advantage. Those treated with EEN were over 4x more likely to heal the intestinal mucosa when compared to the patients treated with steroids.
Though it's not the standard recommended therapy, EEN is an acceptable therapy used to treat patients with Crohn's.
Currently, the guidelines from the North American Society for Pediatric finds it acceptable to consider enteral nutrition as a treatment for patients with Crohn’s. The European Society for Clinical Nutrition and Metabolism also recommend it to be used as a first-line therapy for both children and adolescents with Crohn’s.
We still don’t know how the liquid nutrition works to help treat Crohn’s, and we don’t know which types of patients benefit most from it. There is weak evidence suggesting EEN benefits those who have the disease in their small bowel. There is also some data suggesting that the efficacy of EEN differs between those who have just been diagnosed and those who are relapsing.
A safer alternative
Dr. Arun Swamlnath is the lead author of the study. He says that the results they found support the use of EEN as a possibly superior treatment for Crohn’s, especially for children. Not only may it possibly improve overall healing of the intestinal mucosa, but it might be able to offer a longer lasting duration of remission. Furthermore, enteral nutrition would spare the child from the growth retardation and often difficult to reverse body fat changes that happen as a side effect of steroid therapy.
Dr. Swaminath believes that their findings suggest that more research is needed to identify EEN’s benefits for children with Crohn’s. He hopes that there will be more advocacy for its use in future clinical practice. Initiating EEN will require a lot of teamwork between patients, doctors, nurses, and nutritionists. However, most people diagnosed with Crohn’s are very motivated to make any needed lifestyle changes to get control over their disease. He believes the conversation about EEN options should be discussed with newly diagnosed Crohn’s patients at the very first appointment. This is especially true for patients who are children, since EEN seems to benefit them the most.
You can read more about Dr. Swamlnath’s work published in the Journal of Alimentary Pharmacology and Therapeutics.