Inflammatory bowel diseases (IBD) may be accompanied by undernutrition due to reduced absorption in the intestines and decreased food intake. This can lead to weight loss, deficiency in vitamins and minerals, and more. Part of the absorption problem is not caused by damage to the gut lining but rather by the inflammation itself, which releases substances that impair absorption (e.g., in the case of iron deficiency). Nutrition is even more critical in children, as their growth and development depend on a regular and balanced supply of all food components. Nutritional deficiencies are common in children with inflammatory bowel diseases. Therefore, in the framework of treating these diseases, emphasis is placed on periodic blood tests to assess levels of vitamins, minerals, protein, and meticulous growth monitoring.
Reduced food intake is due to loss of appetite, nausea, fear of diarrhea, and abdominal pain, especially in children. Malnutrition can lead to a decline in the immune system function and overall daily function. In the context of nutritional monitoring, there is a focus on increasing calories and protein intake, balancing and supplementing vitamins and minerals.
Nutrition plays a significant role in the healing process of Crohn's disease, especially when it affects the small intestine. In addition to regular nutritional follow-up and supplementation of deficiencies, in certain cases, Crohn's disease can be treated solely through nutrition (Exclusive Enteral Nutrition). Studies have found that continuous nutrition therapy for 7-10 weeks, providing only a formula (such as Elecare, Modulen, Pediasure, Osmonut, Neocate, and Ensure) without any other food supplements, is as effective as administering steroids. Furthermore, nutritional therapy can heal inflammation of the intestinal lining in most cases, while such healing with steroid treatment occurs only in about a third of cases (even if there is a clinical improvement). For unknown reasons, this treatment is more effective in children than in adults and is particularly recommended for those with small intestine involvement rather than the large intestine. While this treatment is not easy for children, it is highly recommended when there is poor growth and nutritional deficiencies. The assistance of a multidisciplinary team, including specialists in pediatric inflammatory bowel diseases, nurses, and dedicated dietitians for the disease, is essential for the success of the treatment and support for the family during the process. This is the only treatment for inflammatory bowel diseases that has been found to be highly effective and free of side effects.
During active disease with frequent diarrhea, a low-residue diet is recommended. This treatment is temporary and aims to ease the burden of feeding during the active phase. In the period of remission, it is advisable to gradually return to a regular diet. A low-residue diet involves reducing the amount of dietary fiber (cellulose), and in some cases (depending on the nature of the disease) also reducing the amount of fat, fried food, and lactose. Reducing dietary fiber is intended to prevent mechanical irritation of the affected intestinal lining and avoid excessive intestinal movements. Reducing lactose is intended to prevent worsening of diarrhea, as during this period, there may be a temporary decrease in the function of the enzyme lactase that breaks down lactose. Reducing fat is intended to prevent fatty stools and reduce the production of inflammatory stimulants. However, it is essential not to completely avoid fat to provide essential fatty acids.
Dietary fiber: What are they?
These are fibers that resist digestion by human digestive enzymes. Fibers are divided into soluble and insoluble fibers. Soluble fibers slow down the rate of intestinal emptying and can be consumed in the presence of inflammatory bowel diseases. Foods rich in soluble fibers include apples, bananas, pears, cucumbers, carrots, figs, hummus, lentils, dry beans, dried apricots, raisins, and oats. Insoluble fibers are outstanding in absorbing fluids and increasing stool volume, thereby increasing bowel movements. Due to these properties, insoluble fibers are not desirable in patients with Crohn's disease and colitis with active disease or in patients with intestinal obstruction. Foods rich in insoluble fibers include grains (whole wheat, brown rice, rye, barley), vegetables (cabbage, broccoli, celery, cauliflower, and vegetable peels), nuts, almonds, and kernels.
It is essential to remember that limiting food in children can lead to reduced food intake, so it is important to return to a regular diet as quickly as possible while considering the clinical improvement (except in cases of permanent partial blockages in the intestines, where non-digestible fibers should be avoided). In cases of undernutrition, it is recommended to use food supplements such as Pediasure and Modulen, which also help maintain inflammatory remission in Crohn's disease of the small intestine.
Even during remission, it is advisable to limit the consumption of fatty and fried foods and simple sugars (white sugar). It is recommended to consume fish twice a week due to the potential benefits of omega-3 in reducing inflammation. However, this should be taken with caution as there is no conclusive evidence supporting the effect of omega-3 intake on improving the inflammatory condition in the intestines. Moreover, there are no studies supporting specific diets (despite many popular, diverse, and unique diets...). Sometimes, a certain food may cause discomfort in a specific child, and then it should be avoided. Every patient learns to recognize the foods that agree or disagree with them. Since this is a chronic disease, one should be cautious not to follow extreme diets based on unfounded beliefs. It could reduce the quality of life and, in children, even limit the amount of food and calories that are essential for them.
In conclusion, nutrition plays a crucial role in the treatment of inflammatory bowel diseases, especially in children. Intensive nutritional follow-up, checking for nutritional deficiencies, and supplementing them, along with regular counseling within a multidisciplinary team at pediatric inflammatory bowel disease centers, such as the Shaare Zedek Medical Center, are the best way to prevent complications and expedite the healing process.
Attached:
Stages of Exclusive Enteral Nutrition Therapy in Children with Crohn's Disease of the Small Intestine
Shaare Zedek Medical Center for Pediatric Inflammatory Bowel Diseases
These stages were developed to bring the disease to a state of calmness, and in 75% of cases, even to the healing of inflammation in the intestines (Mucosal Healing). It is important to emphasize that this is not a complete and permanent cure. With the return to regular nutrition, the inflammation will return as well. Therefore, maintenance treatment should be started concurrently with nutritional therapy.
Stage A (6-9 weeks)
Exclusive liquid formula (such as Modulen, Neocate, Pediasure, and Ensure). The minimal required quantity is calculated based on various variables, including weight, height, and nutritional status. Drinking water is allowed freely.
Stage B (1-3 weeks)
• Cooked vegetables without peels (avoid small seeds such as eggplant, hummus, lentils, and beans).
• Fruits: Apple without peel + banana.
• Non-seasoned chicken.
• Abundant drinking, preferably with calorie-rich supplements.
The food should be in a soft texture. Eat small meals frequently. At this stage, it is advisable to avoid dairy and its products, fatty foods, and wheat. However, the recommendation is not extreme or rigid.
Stage C (Lifestyle)
Gradually reintroduce a rich, diverse, and complete diet based on individual capacity and tolerance.
Dairy products: It is advisable to start with yogurt and then gradually add other products.
If there is a known stricture in the intestines, it is essential to completely avoid foods that may cause blockages, such as eggplant, celery, pomegranate, guava, figs, grapes, fruits with seeds, corn, and kernels. Please pay attention to the additional notes regarding regular nutrition in the above text.
In any case, it is important to consult with gastroenterologists and dietitians who specialize in inflammatory bowel diseases. You are welcome to contact the Pediatric Inflammatory Bowel Disease Center at Shaare Zedek at 02-6555307/634 for any questions related to inflammatory bowel diseases in children.