NHD Paediatric Hub

EVIDENCE FOR US OF EEN IN CD

EEN is a nutritional therapy used for inducing remission in CD and is now widely recognised as the first-line treatment for active CD2 (3) - for the induction of remission at diagnosis and for periods of flare. EEN has many clear benefits and has been shown to improve nutritional complications, improve weight loss and inflammatory markers and promote mucosal healing. It was demonstrated to be as effective at inducing remission as corticosteroids.(4,5) EEN also has the added benefit of minimal side effects. 

EEN usually consists of six to eight weeks of exclusive liquid diet as a sole source of nutrition. Full nutritional requirements are provided by the liquid formulation and, therefore, patients should not feel hungry once tolerating full volumes. The majority of patients are able to tolerate EEN orally.(2,3,6) EEN can be based on a polymeric feed (whole protein) or an elemental feed (which should only be used in cases of pre-existing milk allergy).

The efficacy of EEN is not fully understood but there is ongoing research to try to establish how and why it works. It is believed to enhance changes to the gut microbiota, reduce intestinal permeability, enhance the protection of the intestinal barrier and lessen the impact of pro-inflammatory cytokines – this in turn leads to gut healing and symptom improvement in paediatric CD patients.(5)

Although current guidelines recommend EEN as being the first-line treatment for achieving remission for children with CD, there is growing interest regarding other strategies that may help achieve remission whilst improving quality of life.

CROHN'S DISEASE EXCLUSION DIET

Crohn’s disease exclusion diet (CDED) is a whole food diet coupled with partial enteral nutrition. The diet limits animal fat, certain types of meat, gluten, maltodextrin, emulsifiers, sulphites and certain monosaccharides.(9) Research showed that PEN provided 50% of calculated energy requirements alongside CDED diet for a period of six weeks, followed by a step-down period where PEN provided 25% of nutritional requirements alongside CDED. Clinical remission was achieved in 80% of patients following both PEN and CDED.(9) There is questionability over the need for PEN alongside CDED diet to sustain remission rates. However, it is well recognised that PEN contributes to calorie intake, as well as calcium intake which is essential in improving nutritional benefit whilst on this dietary treatment. The diet is complicated, avoiding a large number of foods, which may make achieving it with families outside of the supportive research environment difficult.

CD TREATMENT  WITH EATING DIET (CD-TREAT)

CD-TREAT is a solid food-based diet that recreates the composition of EEN (Modulen IBDTM, Nestle). The diet excludes dietary components like gluten and lactose and matches other nutrient profiles such as carbohydrates and proteins.(10) CD-TREAT aims to mimic EEN's effect on the gut microbiome, metabolome, inflammation and clinical outcomes.

In an RCT by Svolos et al from 2019 (10), CD-TREAT was used as an induction therapy in five paediatric patients who had active CD. The patients were provided with CD-TREAT meals and snacks, which they selected from a menu. They followed the CD-TREAT diet for a period of eight weeks.  80% (4/5) children had a clinical response with 3/5 achieving remission with a significant decrease in faecal calprotectin. This research also analysed the impact of CD-TREAT on healthy adults and rat models. The researchers reported that CD-TREAT was more acceptable to adults than EEN and reported positive changes in stooling microbiome and metabolome.

Whilst the evidence suggests the CD-TREAT diet has good outcomes by replicating EEN changes in the microbiome and decreasing gut inflammation, the diet may be difficult to follow out with research protocols when families have to plan and make their own meals.