Synergy Between Immunosuppressive Therapy and Enteral Nutrition in the Management of Childhood Crohn's Disease

Induction of a remission in children with Crohn's disease is increasingly successful. However this success is dependent on what measure we use to define “remission.” Achieving a clinical remission is possible in >70% of children with Crohn's disease at diagnosis, while a mucosal or even immunological remission may occur in <50%. The importance of what ‘degree of remission’ should be achieved during maintenance therapy is discussed. Does early aggressive management with immunomodulators or biological agents indeed alter the natural history of the disease, and is it possible to give a prognosis based on either a snap‐shot of endoscopic appearance, or a mucosal cytokine profile? The potential benefits of using a 6–8 week course of exclusive enteral nutrition as an induction therapy in combination with azathioprine/6‐mercaptopurine are discussed. Whole protein formulae are safe and effective at achieving a clinical remission, however they are not a long‐term maintenance strategy. Given the relative safety of these immunosuppressants and their efficacy in children treated at diagnosis, it is now more important than ever to predict which individuals will benefit from use of immunomodulators very early in the disease process. There is brief mention of enteral nutrition as maintenance therapy. Given the very limited data available, it is still not possible to recommend long‐term nutrition supplementation as a maintenance therapy in all children. However, some children may respond to repeated shorter cycles of exclusive enteral nutrition in the absence of other therapeutic options.