Nutritional Care in Children with Crohns Disease

Between 15 to 40% of children with Crohn's disease suffer from malnutrition and growth failure, puberty retardation and development of secondary sexual characteristics retardation [4]. The slowing down of height velocity has been also observed [4, 5]. What is clinically relevant is that malnutrition may affect as many as 25% of children even before the apparent onset of the disease [5]. Some factors are involved such as the catabolic state during the acute and/or persistent active phase, anorexia leading to insufficient calorie intake to cater to the subject's needs during the critical growth phase, malabsorption and protein dispersion, and deficiencies of zinc, calcium, magnesium and phosphorus. Moreover, steroid treatment plays its most detrimental role in children. A number of hormone deficiencies have been considered such as GH, thyroid hormones and cortisol. A significant correlation between height and body-weight deficits and low circulatory levels of IGF-I has been found [6], which increases with the improvement in the nutritional status induced by adequate feeding (as can be achieved artificially) [6].

Nutritional support and rehabilitation, by administering defined oral, enteral formulas or parenteral infusion of nutrients plays a major role in childhood. Several studies have shown a positive role of par-enteral nutrition in increasing weight and height, and in inducing puberty in children with Crohn's disease [7-12], with better results being obtained if the nutri tional approach begins in the prepubertal period and the disease has been in remission for some time [13, 14]. Though the growth phase covers a limited period, the earliest possible nutritional therapy is distinctly indicated in order to exploit the child's growth potential to the full. Parenteral nutrition is able to favour clinical remission of the acute phase in children [7, 8], and to trigger body growth after surgical treatment [12]. In some cases, long-term parenteral nutrition has been used [15].

A substantial number of controlled and uncontrolled trials have provided suggestions on the usefulness of both orally and enterally administered defined formulas (continuously or intermittently), depending on the indication, facilities, and patient's compliance, in inducing an increase in height or body weight and in accelerating the onset of puberty.

Elemental, semi-elemental and polymeric enteral formulas have been tested with no substantially different degrees of efficacy [16-23] and they have proved capable of facilitating remission of the acute phase [21, 24], and of having efficacy comparable (though less quickly) to prednisolone [25]. In a metaanalysis of randomised studies, EN was as effective as steroids in achieving clinical remission [26]. Though long-term nocturnal enteral protocol was able to contribute towards keeping the disease in remission [23], its long-term efficacy is not yet proven.

Re-feeding allows an improvement in the nutritional status, growth rate and height, remission of the acute phase and, in certain circumstances, reduction in relapses. The main goal in children affected by Crohn's disease is taking the patient off steroids, thereby avoiding their detrimental influence in this phase of life and hastening the onset of puberty with the development of secondary sexual characteristics. This is more conveniently achieved with EN, which plays its greatest role in children with Crohn's disease, bringing about a major change for the better in the patient's quality of life, in the sense of actual treatment and nutritional rescue and rehabilitation.

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