Nutritional perspectives of children with Crohn's disease: a single-centre cohort observation of disease activity, energy expenditure and dietary intake.

BACKGROUND/OBJECTIVES: Children with Crohn's disease often demonstrate nutritional recovery during primary therapy at diagnosis, but long-term nutritional support is sometimes necessary. Evidence to inform best nutritional practice including energy and micronutrient requirements is limited. The principal objective of this study was to determine how energy expenditure and physical activity vary with disease activity over the first year following diagnosis. SUBJECTS/METHODS: Twenty children were studied at diagnosis with Crohn's disease and were followed up over 1 year while receiving treatment according to national guidelines. The majority of children (13) were treated with exclusive enteral nutrition. At study visits, height, weight, bioelectrical impedance, resting energy expenditure by indirect calorimetry, tri-axial accelerometer and blood investigations were performed alongside clinical assessment. RESULTS: There was no significant effect of disease activity on resting energy expenditure (REE). Physical activity was greater after primary therapy (Z=3.31, P<0.01). Median wPCDAI fell from 58 at diagnosis to 7.5 after primary therapy and was 7.5 at 1 year. Weight s.d.s increased from -1.67 to -0.86 and lean index s.d.s increased from -2.93 to -1.64, although the increase was mostly in the first 2 months. Median height s.d.s was unchanged throughout this study. There was a significant association between dietary intake and weight gain (r=0.8 P<0.01) but not height gain. Persistent micronutrient deficits beyond diagnosis were seen for both iron and vitamin D. CONCLUSIONS: This study has demonstrated that REE does not change significantly through different phases of disease activity, but physical activity is low at diagnosis. Children with Crohn's disease should be screened for deficiencies of iron and vitamin D.

Rising incidence of paediatric inflammatory bowel disease (PIBD) in Wessex, Southern England.

BACKGROUND: There has been a significant increase in the incidence of paediatric inflammatory bowel disease (PIBD) over the last 25 years although there is no recent data from England. We aimed to analyse changes in incidence within a defined English population over the last decade and compare this to recent and historical incidence data from comparable studies. METHODS: The new diagnosis incidence of PIBD (age less than or equal to 16 years) was recorded from a prospective database for a geographically defined area within Southern England (2002-2012). Data were analysed for two separate time periods (cohort 1:2002-2006 and cohort 2:2008-2012) and compared to data from the British Paediatric Surveillance Unit (BPSU) survey in 1998/1999. Data were analysed by age, sex and disease type. RESULTS: There has been an increase in incidence of PIBD from 6.39/100,000/year during cohort 1 to 9.37/100,000/year during cohort 2 (p=0.0002). This compares with the BPSU incidence data in England (1998-1999) of 5.2/100,000/year. There was no statistically significant difference in median age of diagnosis between cohorts (p=0.46). The incidence of Crohn's disease (CD) was 3.8/100,000/year in cohort 1 rising to 5.85/100,000/year in cohort 2 (p=0.001). The incidence of ulcerative colitis (UC) was 2.01/100,000/year in cohort 1 rising to 2.62/100,000/year in cohort 2 (p=0.1458). Overall PIBD incidence is higher in males in cohort 1 (male-to-female ratio 1.35:1) and cohort 2 (male-to-female ratio 1.5:1). CONCLUSIONS: The incidence of PIBD continues to increase with a rise of almost 50% in the last decade in Southern England. The reasons for this increase remain unclear.

Surgery for children with Crohn's disease: indications, complications and outcome.

BACKGROUND: Outcome data for surgery in paediatric Crohn's disease are limited. We report 10 years' experience at a regional paediatric gastroenterology centre. METHODS: Children undergoing surgery for Crohn's disease (January 2002-December 2012) were identified from an onsite patient register. Patients were followed until transition to adult services. Data were obtained from medical records and are expressed as median (range). RESULTS: Sixty-nine children, aged 13.8 years (6.3-17.0) at diagnosis, were included. 42 were male (61%). Follow-up was 1.8 years (27 days-6 years). Surgery followed diagnosis by 9 months (0 days-7 years). 52 children (75%) received thiopurines and 5 (7%) anti-TNF (tumour necrosis factor) therapy preoperatively. 58 (84%) underwent intra-abdominal surgery (40 right hemicolectomy, 8 stoma formation, 2 subtotal colectomy, 2 small bowel resection, 6 other) and 10 (14%) underwent surgery for perianal disease. The commonest indications for intra-abdominal surgery were stricturing disease 35 (60%) and unresponsive luminal disease 13 (22%). There were 13 (22%) early, and 5 (8.6%) late, complications following intra-abdominal surgery. Nine children had disease relapse, five required further surgery. Height SD scores (SDS) did not increase between diagnosis; -0.5 (-3.4-2.1) and most recent follow up; -0.4 (-3.0-1.1). Body Mass Index (BMI) SDS increased from -1.0 (-6.3-1.5) to -0.3 (-3.3-2.0) (p<0.05). CONCLUSIONS: Surgery was associated with a 22% early complication rate and a 15% risk of relapse. 21% of patients required a second unplanned intra-abdominal procedure. Surgical intervention was associated with an increase in BMI SDS, but not in height SDS.

Paediatric nutrition risk scores in clinical practice: children with inflammatory bowel disease.

BACKGROUND: There has been increasing interest in the use of nutrition risk assessment tools in paediatrics to identify those who need nutrition support. Four non-disease specific screening tools have been developed, although there is a paucity of data on their application in clinical practice and the degree of inter-tool agreement. METHODS: The concurrent validity of four nutrition screening tools [Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP), Screening Tool for Risk On Nutritional status and Growth (STRONGkids), Paediatric Yorkhill Malnutrition Score (PYMS) and Simple Paediatric Nutrition Risk Score (PNRS)] was examined in 46 children with inflammatory bowel disease. Degree of malnutrition was determined by anthropometry alone using World Health Organization International Classification of Diseases (ICD-10) criteria. RESULTS: There was good agreement between STAMP, STRONGkids and PNRS (kappa > 0.6) but there was only modest agreement between PYMS and the other scores (kappa = 0.3). No children scored low risk with STAMP, STRONGkids or PNRS; however, 23 children scored low risk with PYMS. There was no agreement between the risk tools and the degree of malnutrition based on anthropometric data (kappa < 0.1). Three children had anthropometry consistent with malnutrition and these were all scored high risk. Four children had body mass index SD scores < -2, one of which was scored at low nutrition risk. CONCLUSIONS: The relevance of nutrition screening tools for children with chronic disease is unclear. In addition, there is the potential to under recognise nutritional impairment (and therefore nutritional risk) in children with inflammatory bowel disease.

Energy expenditure, nutrition and growth.

Fundamental to appropriate nutritional prescription is an understanding of the conditions necessary for growth that include the requirements for energy in health and illness. Energy requirements need to be met by the dietary intake to prevent weight loss. A positive energy balance will result in weight gain. Energy requirement includes several components; the largest is the basal metabolic rate, although physical activity level and the energy needs of growth are important components. All aspects of energy metabolism are likely to be influenced by illness and impact on energy balance. Changes in dietary intake and physical activity are observed clinically but poorly described in most childhood illnesses. Changes in metabolic rate are poorly described in part owing to methodological problems. This review explores changes in energy expenditure associated with health and disease, highlights the lack of evidence underpinning this aspect of practical nutritional support and provides the clinician with a guide to the factors involved in estimating energy requirements, emphasising the importance of measuring the child's response to nutritional support.

Outcome of childhood ulcerative colitis at 2 years.

AIM: Ulcerative Colitis (UC) has an incidence of 1.4 per 100,000 in childhood. There is a paucity of data regarding outcome particularly with the increased use of early immunosuppression. This study reviews outcome at 2 years in a cohort with UC referred to a single centre. METHOD: Patients were recruited on the basis of a diagnosis made between 2000 and 2003 as a consecutive cohort. All had UC according to standard clinicopathological criteria. Children with indeterminate colitis were excluded. Follow-up data was collected at 2 years by case notes review. RESULTS: Thirty-two children are reported. The median age at diagnosis was 11 years (range 2-16). All were treated with corticosteroids and 5-ASA derivatives at diagnosis. The majority of patients (94%, 30/32) received more than one course of steroids. By 2 years azathioprine use was high with 75% (24/32) of patients on treatment for steroid-dependent disease. There were 6 extra-intestinal manifestations and 8 disease related complications occurring in 12 patients (38%). The colectomy rate was 9% (3/32) for unresponsive disease. CONCLUSION: There is a high need for Azathioprine in childhood UC. Colectomy rate at 2 years was around 10%. Extra-intestinal manifestations and disease related complications are common.