David Suskind, MD, on Pediatric Crohn Disease
Since there is currently no cure for Crohn disease (CD), controlling inflammation and achieving and maintaining remission are key components of treating pediatric patients with the condition.1
Currently, a number of treatment options for CD exist, including medications like antibiotics, steroids, and biologics, and even surgery. However, according to David Suskind, MD, professor of pediatrics at the University of Washington and director of clinical gastroenterology at Seattle Children’s Hospital in Washington, nutrition is often the best treatment option for pediatric patients with CD.
Dr Suskind recently presented “Advances in the use of nutrition for therapy in pediatric Crohn disease” at Advances in Inflammatory Bowel Diseases (AIBD) 2017, which took place from November 9 to 11, 2017 in Orlando, Florida.2 Consultant360 spoke with Dr Suskind about his presentation, as well as the critical importance of diet in treating pediatric inflammatory bowel diseases (IBDs) like CD.
Consultant360: How is CD different in children vs adults?
David Suskind: Approximately 25% of new diagnoses of IBD occur in children, and while some studies suggest that the incidence of IBD has plateaued in the adult population, it continues to rise in the pediatric population. Not only is the incidence rising in school-aged children, but also in the very young (those who we consider very early onset IBD [VEO-IBD]). The severity of the disease in children has increased as well. For example, pediatric patients are more likely to have more extensive disease and pancolitis in ulcerative colitis (UC) vs adults.
Medication therapies for CD are similar in adult and pediatric patients, with similar efficacy seen in both groups. Pediatric gastroenterologists are more likely to prescribe nutritional therapy in the form of exclusive enteral nutrition (EEN), due to higher compliance rates in children than in adults. There are currently 2 adult studies demonstrating the efficacy of EEN in adults with the use of nasogastric tubes.3, 4
C360: How important is nutrition in treating pediatric patients, and how does it compare with medication and/or surgery in these patients?
DS: With the growing knowledge of the impact of the fecal microbiome in IBD, as well as the knowledge that the fecal microbiome is strongly affected by diet, nutrition is central in the treatment of IBD. For more than 50 years, nutrition has been used as a primary therapy in pediatric IBD. EEN—a dietary therapy that solely uses formula for a patient’s diet—has been shown to work equally as well as steroids in helping patients achieve remission but heals the gut mucosa better than steroids. The North American Society of Pediatric Gastroenterology and Hepatology (NASPGHAN) has recommended EEN as first-line therapy for CD.5
The impact of a whole-foods diet, such as the Specific Carbohydrate Diet (SCD), is currently being studied. Preliminary studies of this diet have demonstrated clinical efficacy, as well as improvements/normalization of inflammatory markers in patients with IBD. In a prospective study of the SCD in patients with IBD, 8 out of 10 patients able to maintain the diet achieved clinical remission with improvement and normalization of inflammatory markers. This study showed a significant shift in the fecal microbiome with dietary change.6
In addition, 2 large multicenter studies are currently underway to better understand the impact of dietary intervention. With that being said, there are convincing animal models demonstrating a negative effect of high-sugar, high-fat diet, as well as some food additives such as emulsifiers (maltodextran, CMC, and P80).
C360: How has nutrition therapy advanced in recent years for children with CD?
DS: We have known for many years that formula-based diets are effective for the treatment of CD. In fact, formula-based diets work equally as well as steroids but have shown better mucosal healing. Our research now indicates that a focused elimination diet such as the SCD can have a positive impact on disease symptoms and inflammation itself.
The impact of diet appears to be multifocal, with diet having a major impact on the fecal microbiome, as well as the immune system itself. Our research and the research of others have shown that diet can shift the constituents of the fecal microbiome significantly. It is the fecal microbiome that is felt to be the trigger of the immune system in CD. In addition, diet has been shown to affect the mucosal barrier between the microbiome and the immune cells. A high-fat, high-sugar diet as well as food emulsifiers break down the mucus layer in the gut and increase permeability in the gut.
C360: What do you hope practitioners will take away from your session?
DS: I hope practitioners who attended my session understand that diet matters for all patients with IBD. Physicians and patients who are interested in our dietary protocol for IBD can visit Nutrition in Immune Balance (NiMBAL).
—Christina Vogt
References:
1. Crohn’s Treatments. Crohn’s & Colitis. https://www.crohnsandcolitis.com/crohns/disease-treatment. Accessed on November 20, 2017.
2. Suskind DL. Advances in the use of nutrition for therapy in pediatric Crohn's disease. Presented at: Advances in Inflammatory Bowel Diseases (AIBD) 2017; November 9 to 11, 2017; Orlando, FL.
3. Okada M, Yao T, Yamamoti T, et al. Controlled trial comparing an elemental diet with prednisolone in the treatment of active Crohn's disease. Hepatogastroenterology. 1990;37(1):72-80. https://www.ncbi.nlm.nih.gov/pubmed/?term=Okada+M.++Hepatogastroenterology+1990.
4. O'Moráin C, Segal AW, Levi AJ. Elemental diet as primary treatment of acute Crohn's disease: a controlled trial. Br Med J (Clin Res Ed). 1984;288(6434):1859-1862. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1441790/.
5. Critch J, Day AS, Otley A, King-Moore C, Teitelbaum JE, Shashidhar H; NASPGHAN IBD Committee. Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease. J Pediatr Gastroenterol Nutr. 2012;54(4):573. doi:https://www.ncbi.nlm.nih.gov/pubmed/22002478.
6. Suskind DL, Cohen SA, Brittnacher MJ, et al. Clinical and fecal microbial changes with diet therapy in active inflammatory bowel disease [Published online December 27, 2016]. J Clin Gastroenterol. doi:10.1097/MCG.0000000000000772.