Exclusive Enteral Nutrition and Remission in Pediatric Crohn`s Disease: How Deep is Deep Enough?

Background: Deep remission [clinical remission (CR) associated with mucosal healing (MH)] represents the treatment target in Crohn’s disease (CD). Exclusive enteral nutrition (EEN) is recommended as first-choice agent in pediatric CD, being effective in inducing deep remission (DR). However, its efficacy on transmural inflammation has been rarely investigated.

Objective: We aimed to assess the efficacy of EEN on transmural healing (TH) in CD and identify predictors for remission.

Methods: All CD patients from our tertiary centre database (2006-2017) were reviewed and included if EEN was used for induction of remission, as first-line therapy, over 6-12 weeks. All parameters were evaluated at baseline and at the end of induction period. The following definitions of remission were used: CR (wPCDAI

Results: Of the 44 newly diagnosed CD patients, 20 (mean age at diagnosis 12.32 ± 4.3 years, 67% male) met the inclusion criteria. CR was detected in 17 cases (85%), BR in 18 (90%), MH in 10 (50%) and TH in 4 (20%). Of the17 patients with CR, all achieved BR, but only 24% MH and 12% TH (p=0.05). In multivariate analysis, of all parameters, only weight loss > 5 kilograms before diagnosis was found to negatively affect MH and TH (OR=12.99; 95% CI=1.7-99.36; p=0.013).

Conclusion: CR, assessed by wPCDAI, is detected in 85% of patients; however, only half of patients achieve DR and one fifth TH. Of children in CR, TH is detected in only 12%. Therefore, we consider that deep remission should include TH; otherwise young patients could be at risk of developing progressive bowel damage, like stenosis, fistula and abscesses, with possible definitive disabilities.