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Abstract
This study aims to examine the changing practices of exclusive enteral nutrition (EEN) in paediatric Crohn’s disease (CD) including the influence of the 2021 ECCO-ESPGHAN guidelines and the COVID-19 pandemic.
We analysed a prospectively identified cohort of newly diagnosed CD patients in two paediatric regional centres between 01/01/15 and 30/06/22. Data were retrospectively collected from electronic medical records. CD patients who received EEN were divided into biannual epochs for analysis. Continuous outcome measures were analysed using Mann-Whitney U or Chi-squared tests, and linear regression modelling for longitudinal comparison.
Of 503 patients (62.2% male; median age 13.0 years, IQR: 10.9 – 14.8), primary EEN was used in 383 (76.1%) with a median course length of 8 weeks (IQR: 7.2 – 8.3). An increasing incidence of CD diagnosis and total EEN courses were observed (p=.01, figure 1). Remission/response rates, nasogastric tube (NG) usage and completion rates were examined; there were no changes in these parameters over time (p=.153, p=.913, p=.601, p=.337 respectively). Weight z-scores increased (pre-EEN -0.11 vs post-EEN 0.33, p≤.001). An increased rate of EEN as induction therapy was observed (first 12-months 66.7% vs last 87.7% - p=.004), with dual induction (EEN combined with biologics) an emerging strategy over time (first 12-months 2.6% vs last 18.7% - p=.018). (Figure 2).
During the COVID-19 pandemic, primary EEN was less frequently used (63/96, 65.6% vs 320/407,78.6% - p=.007), completion rates were lower (41/68, 60.3% vs 236/315, 74.9% - p=.015) but remission rates were comparable (37/67, 53.7% vs 181/315, 57.3% - p=.59).
Repeat courses of EEN occurred in 47/503 (9.3%) with no difference in remission rates (2nd course 23/47, 46.7% vs 1st course 217/383, 56.7% - p=.463).
This large real-world cohort demonstrates EEN usage has increased together with CD incidence despite an increase in biologic use. The use of dual induction therapy with biologics is an emerging trend; further research is required to ascertain the clinical benefit above dose-optimised biologic induction and its cost-effectiveness.
Line graph showing the total number of new CD diagnosis and total new first EEN courses
Line graph showing percentage of all newly diagnosed CD patients receiving EEN at induction and those EEN as their sole induction therapy. The difference between the two respresenting those receiving dual induction with biologics