Exclusion Diet in Pediatric Crohn’s Tied to Clinical Remission in Small Study

SAN FRANCISCO — The pediatric Crohn’s disease exclusion diet was associated with clinical remission for children with good adherence, but this was a significant challenge for most participants, results from a small, single-center retrospective study suggested.

Among all 24 patients who started the diet, corticosteroid-free clinical remission occurred in 58% of patients at 6 weeks, 46% of patients at 12 weeks, and 33% of patients at 24 weeks, reported Joseph Runde, DO, of the Ann & Robert H. Lurie Children’s Hospital of Chicago, during the Crohn’s & Colitis Congress.

For the participants who maintained the diet — 75% were continuing it at 6 weeks, which fell to 50% at 12 weeks and 42% at 24 weeks — corticosteroid-free clinical remission occurred in 78% at 6 weeks, 92% at 12 weeks, and 80% at 24 weeks.

“Expert consensus increasingly recommends application of dietary therapy, and interest for patients and families remains high even in the face of a growing arsenal of advanced therapies,” Runde said. “It will be imperative in the years to come for all dietary therapies to offer customizability, respecting cultural and community traditions, if uptake is to be improved, and dietitian education and support will be critical in this effort.”

Andrew Grossman, MD, co-director of the Center for Pediatric Inflammatory Bowel Disease at Children’s Hospital of Philadelphia, told MedPage Today that this diet is an important component in the treatment of pediatric Crohn’s disease and should be offered to appropriate patients. However, feasibility of adherence will be key, he added.

“It is very hard to always adhere to a specific diet, particularly for children, and what this showed was that they did have some who, over time, struggled with adherence,” he said. “But for those who were able to adhere to the diet, for whom it worked, there were good results. They were able to achieve remission. We even saw some endoscopic evidence of this, and we need to be pursuing this further.”

A dietitian who is very familiar with the diet can be very helpful given its potential monotony for children, Grossman noted. “There are additional options or variations that a creative and well-versed registered dietitian can offer in pediatrics specifically,” he said, adding that both parents and children need to be engaged and motivated in trying the diet.

The Crohn’s disease exclusion diet consists of three phases that each last 6 weeks, with the option of continuing it for maintenance. The first phase includes mandatory foods and 50% formula, followed by mandatory foods and 25% formula in the second phase, and concluding with 25% formula and no mandatory foods in the third phase.

The diet limits patients to one yogurt per day for all dairy, two slices of bread per day, and one portion of seafood and lean steak per week. The diet excludes processed meat, seeds, artificial sweeteners, processed foods/preservatives/artificial additives, and emulsifiers.

Among the 419 patients with Crohn’s disease at Lurie Children’s Hospital, 32 met with the dietitian to discuss the diet and 24 children started it. Mean age at diagnosis was 11 years, 75% were boys, and 83% were white. The time from diagnosis to start of the diet was a median 2.4 months, and median follow-up was 23.6 months.

There was no family history available for most of the participants (58%), but 38% had a family history of Crohn’s. Most children (88%) had no history of Crohn’s-related surgery. Nearly all participants (96%) had non-stricturing, non-penetrating Crohn’s. Disease location was ileocolonic for 54%, and ileocolonic and upper gastrointestinal for 21%.

Nearly half of the participants had not received any prior medications for Crohn’s. Over half received a steroid with diet induction: 46% with prednisone and 13% with budesonide. A quarter had concomitant therapy with the diet, including methotrexate (13%), ustekinumab (Stelara; 13%), and adalimumab (Humira; 4%).

Calprotectin levels fell from 3,982 μg/g at week 0 to 504 μg/g at week 24 (P<0.01), with no changes in albumin, hemoglobin, erythrocyte sedimentation rate, or C-reactive protein levels. Six of the patients underwent a colonoscopy, four of whom had an endoscopic response, and two of whom were in endoscopic remission.

Adverse events included abdominal discomfort in 17% of participants, diarrhea in 13%, and weight loss in 8%. The weight loss ranged from 5-10% of total body weight and was transient, stabilizing by week 6, Runde said.

Study limitations included the retrospective design, the small sample size at a single institution, and the inability to strictly monitor dietary intake. Another limitation was its generalizability since the study population included “a group of highly motivated patients and families with the resources needed to procure the dietary staples of the Crohn’s disease exclusion diet,” Runde said.

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