REFILE-Exclusive enteral nutrition for pediatric Crohn's varies significantly worldwide

Reuters Health Information: REFILE-Exclusive enteral nutrition for pediatric Crohn's varies significantly worldwide

REFILE-Exclusive enteral nutrition for pediatric Crohn's varies significantly worldwide

Last Updated: 2018-04-04

(Corrects source's name (Eytan Wine) in paras 2, 6 and 7.)

By Marilynn Larkin

NEW YORK (Reuters Health) - Variation in the use of exclusive enteral nutrition (EEN) for pediatric Crohn's disease highlights the need to improve patient education and support and reduce barriers to treatment, researchers say.

"This study was driven by the apparent variation in practice and use of EEN and in response to dietitians in our center asking for evidence to support specific practice points, such as allowing children to have gum or candy while on EEN," Dr. Eytan Wine of the University of Alberta in Canada told Reuters Health.

"EEN is an art, as it involves a multidisciplinary approach and requires intense patient cooperation and motivation," he said by email. "As a result, much energy is directed at ensuring adherence, and we each do this differently".

"Our results suggest how EEN could or should be delivered, including details on indications, treatment duration, concentration, and allowed 'cheats,' and expose how this is done differently across the globe and by different professions," he said.

"However," he added, "our study was not designed to provide direct evidence to support these specific approaches."

"One of the central points of variance is the structure of the team providing and supporting EEN care, which we believe should include dietitians and nurses," Dr. Wine said. "We hope that the results of this survey will set the bar and advocate for a standard of care in regions where such a format is not currently available."

Dr. Wine and colleagues developed a survey on EEN practices and distributed it internationally through various pediatric practice groups. As reported online in the Journal of Pediatric Gastroenterology and Nutrition, 46 participants from 26 countries completed the survey.

Sixty-five percent of participants were general pediatric gastroenterologists, not specialists in inflammatory bowel disease (IBD); 21% were IBD-focused; and 10% were dietitians. Among the findings:

- The most common indications (approx. 90% use) for EEN were for ileocecal and ileocolonic disease (Paris L1 and L3). The most common duration was eight weeks, and 66% of survey respondents preferred oral to nasogastric administration.

- Forty percent of respondents allow patients to try a few options and choose the EEN formula; 38% consider switching if the patient is not managing on the selected formula; and 18% always use the same formula with no flexibility.

- Most (63%) did not allow intake of any additional food. Practitioners in Spain (88%), other European countries (86%) as well as the UK (55%) were more likely to require EEN exclusively.

- The U.S. (74%) and Canada (57%) were more likely to allow other intake ("cheats").

- Sixty-nine percent of respondents instructed patients to continue partial enteral nutrition after completing EEN treatment.

- The main challenges to EEN programs were adherence and lack of support, and dietitians were identified as essential to EEN success.

- Regional and professional practice differences were observed in EEN indication, age, exclusivity, program structure/support, and cost coverage.

"Global variation offers opportunities for research and improving care," the authors write. "This survey establishes a framework and provides resources for collaboration and information sharing."

Dr. Satesh Bidaisee, professor of public health and preventive medicine at St. George's University in Grenada, West Indies, told Reuters Health by email, "The study is consistent with the diverse approaches doctors take when treating pediatric Crohn's disease and the varied responses that patients have to those treatments."

"Since pediatric Crohn's disease ranges in severity and in how patients tolerate different diets," he said, "it makes sense that we see variance in how EEN is administered and in its efficacy."

"From a public health perspective," he suggested, "researchers should study how socio-demographic factors impact EEN," focusing on different childhood environments.

"For example, in environments like South East Asian and African regions - where traditional breastfeeding and complex starches are common - a patient's outcome may differ from that of a child . . . exposed to limited breastfeeding and simple, processed sources of food," he said.

"Even within the same city, patients living under different socio-economic conditions are likely to have different diets - some getting better nutritional intake than others," he noted. "These factors (also) can influence the response to EEN."

"As diets become increasingly standardized over time," he added, "socio-demographic variables will be of particular interest in our understanding of pediatric Crohn's disease going forward."


J Ped Gastro Nutr 2018.

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