Enteral Nutrition as Primary Treatment for Pediatric Inflammatory Bowel Diseases (IBD)

1. Enteral Nutrition as Primary Treatment for Pediatric Inflammatory Bowel Diseases (IBD) Authors: Kristin Madden, MSN, APRN-PNP Children’s Hospital & Medical Center Omaha, NE Lois Siegle, MSN, RN Cincinnati Children’s Hospital Medical Center Cincinnati, OH Reviewed by the Crohn’s & colitis foundation Nurse & Advanced Practice Committee

2. Instructions To begin, please enter into “Presentation mode” to enable full interactivity of case and questions. (Click “slide show” tab)When you see words or phrases that are underlined click on the underlined word and this will take you to the next screen. To continue the presentation make sure you click back in the bottom left corner.

3. Disclosures • Authors have nothing to disclose

4. Objectives • After completing this activity, the advanced practice providerwill demonstrate the ability to: • Obtain basic knowledge for initiation of enteral feeds as a treatment option for Crohn’s disease • List patient resources for enteral feeds • Identify goals of enteral nutrition

5. Introduction of Case • 8 year old female presents to clinic with: • Weight loss • Pyoderma Gangrenosum • Hypoalbuminemia • Anemia • Abdominal pain • Change in stool pattern from baseline

6. Which of the following are red flags for IBD diagnosis? • Red painful eyes • Recurrent fever (low grade) • Oral aphthous ulcers • Chronic otitis media • Recurrent streptococcal pharyngitis • Chronic recurrent abdominal pain ‘since birth’ • Painful sores on lower extremities

7. What would be ordered for workup (consider each one, next slide shows the answer) • Labs: true vs false • CT Enteroscopy (CTE): true vs false • Esophagogastroduodenoscopy: true vs false • Colonoscopy: true vs false • Pill Cam: true vs false • Lactose Breath Test: true vs false • Stool Studies: true vs false • pH probe: true vs false

8. What would be ordered for workup • Labs: true vs false • CT Enteroscopy (CTE): true vs false • Esophagogastroduodenoscopy (EGD) true vs false • Colonoscopy: true vs false • Pill Cam: true vs false • Lactose Breath Test: true vs false • Stool Studies: true vs false • pH probe: true vs false

9. Results of Workup

10. Laboratory Results

11. Laboratory Results (cont.) • Pathology results from EGD/Colonoscopy: Non-uniform colitis with granuloma and chronic ileitis strongly suggest Crohn disease • Stool testing negative for infections (culture & clostridium difficile) and parasites (ova & parasite screening for giardia and cryptosporidium)

12. Diagnosis – Biochemical Evaluation & Histology • Inflammatory Markers: ESR (sed rate) elevated at 68, CRP elevated at 7.31 • Chemistry Profile with normal liver enzymes and hypoalbuminemia (albumin 2.8) • CBC with hypochromic, microcytic anemia and elevated platelets supporting inflammation • Endoscopy evaluation with skip lesion ulcerations, granuloma and chronic active inflammation

13. Determining Phenotype and Extent of Disease • Improve Care Now (ICN) uses a pediatric modification of the Montreal Classification for Inflammatory Bowel Disease – The Paris Classification

14. Determining Phenotype and Extent of Disease

15. Paris Classification How is this helpful • Macroscopic (visual appearance during endoscopy) appearance of mucosal ulceration or gross radiographic abnormalities regardless of histologic findings • Classified as the worst extent of disease the patient has ever had • Phenotype can only progress, never go backwards: once stricturing always stricturing, once perianal always perianal • Determines IBD behavior/phenotype: inflammatory, stricturing, penetrating or stricturing and penetrating & perianal modifier • Helps to understand how the disease may respond to medications and progress over time

16. Treatment Options • Biologic Therapy • Pros – safety and efficacy is highly researched, 80% achieve remission within 1 year of starting treatment, no significant dietary restrictions • Cons – black box warning for infection and malignancy, requires IV infusion or injection, requires time away from home or school, risk of allergic reaction or lack of response, increased risk of infections • Enteral Nutrition (EN) • Pros – steroid sparing, improve nutrition, improve growth, lack of serious side effects, effect form of treatment for Crohn’s disease with mucosal bowel healing • Cons – not effective in treatment for Ulcerative Colitis, difficulty with adherence, may require nasogastric tube • Prednisone • Pros – quick acting and effective • Cons – multiple unappealing side effects (infection, bone mineralization, blood sugar changes, suicidal ideation, weight gain, etc.), can not be used long term, not involved in mucosal healing

17. Now What? Initiation of Enteral Nutrition (EN) • Traditional Protocol • Induction • 100% of calories from formula – exception of clear liquids and hard candies (allowed only in moderation) • Duration – 4-12 weeks • Oral vs Nasogastric (NG) tube • Maintenance • Repeated 4 week cycles of exclusive enteral nutrition (EEN) every 3-4 months OR • Transition to medical therapy with immunomodulator or biologic medication • Use of EN allowed for sparing of steroid use and side effects

18. Now What? Initiation of Enteral Nutrition (EN) • Partial Enteral Nutrition Protocol • Induction • 8-12 weeks • 80-90% of estimated caloric needs come from formula • 10-20% of caloric needs from food (but food is restricted) • NG tube vs oral vs combination • Maintenance • Time frame is rolling – unknown end date • Simultaneously lower % calories from formula and increase calories from food – monitor closely for relapse

19. Initiation of EEN

20. Goal of EN • Steroid sparing • Decreased serious side effects • Safety of EN is established and has been used for 50 years • Involves the use of a specified formula as nutritional therapy – replacing all or the majority of daily calories with formula and excluding or limiting other food sources

21. Barriers to EN • Barriers can be related to patients, families, and medical provider/team • Adherence to the plan: holidays, school, socialization, nasogastric tube • Limited resources (registered dietitian) • Unclear on how to manage EEN • Cost of EEN and letters of medical necessity

22. Back to the Case • Shared Decision • Family concerned about side effects of steroids and biologic medications • Option of EEN favorable to family • Patient did require use of steroids to control disease in addition to initiation of EEN • Follow up – 8 weeks • Normalization of lab values • Weight gain – 25 lbs. • Energy increased & normal physical exam • Prednisone fully weaned • Follow up – 10 months • Diet liberalized – continued to avoid processed foods, choosing organic options • Lost to follow up • 10 months after diagnosis re-presented with weight loss, anemia, hypoalbuminemia & perianal disease. Required hospital admission with NG feeds and initiation of biologic medication

23. Thoughts… • Improved compliance may have shown better outcome and prevention of need to start biologic medication

24. Thank you! We hope you enjoyed this case. Check back next month for a new case! Please complete a brief evaluation to provide us with feedback on this program: https://www.surveymonkey.com/s/ibdnurse