Summary
Background : Crohn's disease is a chronic debilitating disorder affecting a child's physical and emotional well‐being. Recent emphasis on ‘quality of life’ (QOL) has led to re‐evaluation of available medical treatments.
Aim : To assess prospectively change in QOL, clinical disease activity and intestinal mucosal inflammation in active paediatric Crohn's disease after treatment with exclusive enteral nutrition. In addition, we evaluated whether change in QOL could predict changes in paediatric Crohn's disease activity index (PCDAI) and mucosal inflammation (endoscopic and histologic).
Methods : The IMPACT II questionnaire was used prospectively and longitudinally in 26 consecutively recruited children [16 males (67%), median 14 years, s.d. = 1.7 years] with active Crohn's disease (PCDAI > 20). They were treated with a new polymeric enteral feed (ACD004, Nestle) for a period of 8 weeks. All had PCDAI, QOL and endoscopic assessment at the time of diagnosis and after 8 weeks of treatment.
Results : Twenty‐three of 26 children achieved a clinical remission at 8 weeks, with improvement in the QOL scores (P < 0.05). The change in QOL score after treatment was predictive of achieving a clinical remission, but not of histological improvement.
Conclusions : Although children may find dietary restrictions difficult, this study confirms a clear improvement in QOL after treatment with exclusive enteral nutrition. However, improvement in QOL scores is not reflected by improvement in mucosal inflammation. Whilst improving QOL remains a core principal in patient management, the long‐term consequences of ongoing mucosal inflammation must be better understood before relying only on short‐term QOL measures to dictate treatment choices.
Although a ubiquitous pathogen, cytomegalovirus (CMV) is very rarely thought to be the cause of significant gastrointestinal infection in the immunocompetent child. We report the case of a 2-month-old infant who presented with bloody diarrhoea and severe dehydration, which was subsequently diagnosed as CMV enterocolitis and resolved spontaneously without antiviral treatment.
Enteral feeding, in particular with formula feeds, is associated with necrotizing enterocolitis (NEC). In this study, we have examined, in the systemic and mucosal immune compartments, for evidence of bovine milk antigen sensitization in infants with NEC. Eleven newborns with Bell’s staging 2–3 NEC [median post‐conceptional age 31 wk (range 27–41 wk)], 21 neonatal controls [33 (28–40) wk] and 15 infants undergoing intestinal resection or mucosal biopsy for non‐inflammatory conditions [39 (34–42) wk] were studied. Spontaneous and antigen or mitogen elicited interferon‐γ (IFN‐γ) [T‐helper type I (Th1)], interleukin (IL)‐4 and IL‐5 [T‐helper type II (Th2)] responses were enumerated using single‐cell enzyme‐linked immunospot (ELISPOT) assay in peripheral blood (PBMC) or lamina propria mononuclear cells. NEC infants, compared with controls, showed a significant elevation in baseline PBMC cytokine secreting cells, vigorous mitogen responses (20‐ to 120‐fold increase) for IFN‐γ, IL‐4 and IL‐5 (p < 0.001), strong responses to beta‐lactoglobulin (βlg) (IFN‐γ > IL‐4/IL‐5, p ≤ 0.001), and somewhat smaller casein responses. Similarly, in the lamina propria, a small but significant increase in spontaneous cytokine‐secreting cells was detected in NEC infants (p < 0.01), with an IFN‐γ/IL‐4 predominant phytohemagglutinin (PHA)/concanavalin‐A (ConA) response. Three of nine NEC infants (but no controls) also showed a positive ELISPOT response to βlg (IFN‐γ only) but none to casein. We have thus demonstrated significant cow’s milk protein (CMP) sensitization in NEC, at least in the systemic compartment (mixed Th1/Th2), with minimal mucosal activation in some cases. These novel findings provide a potential mechanism for a direct contributory role of CMP in the pathogenesis of NEC.
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