| ESPEN 2017 [34] |
A multi-disciplinary guideline based on extensive systematic review of the literature, with expert opinion input, producing 64 recommendations.
Diets with a high fruit and vegetable content, rich in n-3 fatty acids, and relatively deplete of n-6 fatty acids are associated with a lower risk of developing CD. While protein requirements are elevated in active IBD (therefore necessitating increased intake relative to the general population), protein needs in remission are more commonly normal. Iron supplementation is advised in all IBD patients with iron deficiency anaemia, with oral iron recommended as the first-line treatment in patients with mild anaemia and clinically inactive disease while intravenous iron is advised in patients with clinically active IBD, with haemoglobin below 100 g/L, and in those requiring erythropoiesis-stimulating agents. In CD patients with both intestinal strictures (or stenosis) and obstructive symptoms, a diet with adapted texture, or post-stenosis enteral nutrition is advised. In patients with active disease and those who are steroid-treated, serum calcium and vitamin D levels should be monitored and supplemented as necessary to maintain bone mineral density. Exclusion diets are not recommended to achieve remission in active CD, even if the patient suffers from individual intolerances. Probiotics should not be used for treatment of active CD. ONSs are advised as a first line dietary treatment when artificial nutrition is indicated, albeit a minor supportive strategy in addition to normal food. If oral feeding is insufficient then tube feeding should be considered using formulae or liquids, as a preference over parenteral feeding. In children and adolescents with acute active CD, EEN is recommended as first line treatment to induce remission. Probiotic therapy should not be used for maintenance of remission in CD. All IBD patients in remission should undergo counselling by a dietician as part of the multidisciplinary approach to enhance nutritional therapy and avoid malnutrition and secondary disorders. In patients who are pregnant, iron status and folate levels should be monitored regularly with deficiencies of iron/folic acid/vitamin B9 treated with supplementation accordingly.
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| Cochrane Systematic Review 2019 [119] |
A retrospective systematic review, including of 18 randomized controlled trials with 1878 patients, assessing the impacts of different dietary strategies on both active and inactive CD.
At four weeks, 100% of patients in the high fibre and low refined carbohydrates diet group experienced clinical remission of active CD compared to 0% in the control group. 50% of participants in the symptoms-guided diet group achieved clinical remission of active CD while 0% of the control group participants achieved remission. There is insufficient evidence to support the role of exclusion diets in clinical remission rates of active CD. There is insufficient evidence to support the role of exclusion diets in reducing clinical relapse rates for inactive CD. More thorough evaluation of the benefits and harms of specific compositions of dietary interventions is required through further randomized controlled trials.
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| European Crohn’s and Colitis Organisation (ECCO)/European Society for Paediatric Gastroenterology Hepatology and Nutrition(ESPGHAN) 2014 [120] |
A set of evidenced based and consensus driven guidelines for paediatric-onset CD formulated by an expert panel of 33 IBD specialists to optimise treatment of children and adolescents with CD, with bespoke management plans based on benefit-risk analyses according to different clinical contexts.
EEN is recommended as a first line therapy to induce remission in children with active luminal CD. PEN should not be used for induction of remission. The use of EEN as induction therapy usually runs for 6–8 weeks, with an absence of clinical response after two weeks considered to warrant consideration for alternative treatment. EEN is more ideally implicated for children with poor growth, a low BMI and those with a catabolic state (e.g., hypoalbuminemia). In cases where oral EEN is not tolerated, a nasogastric tube may be considered. However, the psychological and monetary impact of this option requires cautious consideration in regard to alternative strategies, such as a limited course of steroids treatment.
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| Croatian Guidelines 2010 [121] |
A set of guidelines governing the use of enteral nutrition in CD, developed by an interdisciplinary expert group of IBD-related clinicians based on relevant evidence-based literature and experience.
Enteral nutritional therapy is an effective first-line treatment for paediatric patients with active CD. There is no difference in the efficacy of elemental, oligomeric and polymeric enteral formulae. Therefore, polymeric formulae are advised on account of its more acceptable palatability, and relatively lower cost. There is evidence of beneficial effects supporting the use of novel nutritional therapeutically-enriched feeds, such as TGF β2 enteral feeding.
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| North American Guidelines 2012 [122] |
An ‘aid’ review of the use of enteral nutrition as paediatric CD therapy by the Enteral Nutrition Working Group, composed of six clinicians with expertise and/or experience in exclusive enteral nutrition.
EEN provides an alternative to corticosteroids in the induction of clinical remission in paediatric CD and should be used as a first-line treatment, irrespective of active disease location. A treatment course of at least eight weeks of EEN is advised for induction, although benefits may be yielded for up to 12 weeks in some cases. In children with stunted growth or pubertal delay, continued PEN, alongside additional treatment interventions may yield clinical improvement. Polymeric formulae are cheaper, more palatable, and are associated with better weight gain when compared with an elemental diet. They are thus more conducive to oral administration in the paediatric population. Multidisciplinary coordination between nursing staff, medical clinicians, and dietetic services are more likely to enhance the impact of an EEN programme, with evidence also supporting the roles of social workers and psychology support staff where appropriate.
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| Japanese Guidelines 2005–2006 [56,123] |
Japanese guidelines on the management of CD recommend nutritional therapy as both a first-line treatment for remission and as a maintenance therapy thereafter. Japanese patients with CD have a proven lower mortality rate because of this, in comparison to those who do not receive enteral feeding. For home-based tube enteral feeding, administration of nutrition overnight is advised. Excessive amounts of long-chained fatty acids in the composition of feed can hamper the beneficial effects of enteral nutrition. This adversity can be bypassed through the use of medium-chained triglycerides.
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