Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal (GI) tract and an umbrella term for Crohn’s disease and ulcerative colitis. In Crohn’s disease, several parts of the GI tract can be affected, whereas in ulcerative colitis, the inflammation is confined to the large bowel. In some cases, IBD can be unclassified (IBD-U).

Approximately 25% of patients are diagnosed during childhood or adolescence, and the prevalence is rising.[1,2] IBD is a relapsing disease that can lead to symptoms that often affect growth and development in children, increasing the risk of
malnutrition.

The role of the dietitian in a multi-disciplinary team is vital to support nutritional status and in nutritional treatments, such as exclusive enteral nutrition (EEN).

The increased risk of malnutrition in children with IBD is multifactorial. Symptoms such as nausea and vomiting, abdominal pain, fatigue, diarrhoea or constipation, can have a direct effect on appetite and dietary intake. Children with IBD may also have increased gastrointestinal losses and impaired absorption of nutrients, increasing the risk of nutritional deficiencies.[1,3]

As childhood is a time of rapid growth and development, those with poorly controlled disease are at a higher risk of impaired growth and weight loss, reduced bone mineral density and delayed puberty. In children with Crohn’s disease, growth failure has been reported in up to one third. If inflammation and nutritional status are not managed optimally, there can be long-term health and quality of life consequences.[1,4]

Micronutrient deficiencies are also common in children with IBD and can occur due to poor dietary intake, gastrointestinal losses or bleeding and inflammation. Those often seen in clinical practice include vitamin D deficiency, vitamin B12 deficiency and iron deficiency. Correction and monitoring of these deficiencies are [ED1.1]an important aspect of managing these patients.[4,5]

A comprehensive dietetic assessment should be completed at diagnosis and reviewed regularly throughout the course of treatment. The aim is to identify those at risk of malnutrition, or those malnourished, optimise growth, treat micronutrient deficiencies and formulate a nutritional care plan.[1,5]

Anthropometric measurements of weight, height, BMI and growth trajectory should be considered and plotted on appropriate growth charts to identify weight loss and faltering growth.[1]

Biochemical markers such as vitamin D, vitamin B12, folate, zinc, iron studies, ferritin, full blood count and inflammatory markers can help guide dietetic intervention in terms of identifying and treating micronutrient deficiencies.[3,5] Gastrointestinal symptoms and disease severity, as previously highlighted, are also important to consider.

Dietitians should complete a detailed diet history and consider current dietary patterns and usual intake, appetite and any food avoidances. Families may restrict certain foods before diagnosis while trying to improve symptoms, so it is important to understand whether this has been guided by a health professional and to address any misconceptions.[5]

Psychosocial factors such as attendance at school, social life and emotional well-being should also be considered, as it may affect a child’s ability to follow a nutritional care plan.

Exclusive enteral nutrition (EEN) involves a child taking exclusively nutritionally complete liquid formula as a treatment. Duration may vary from centre to centre, but is generally between six and eight weeks. Polymeric formulas are recommended as first line, as they are more palatable and nutritionally complete.1 Most children manage the volume required orally, but some may need a nasogastric feeding tube.[4] Elemental formulas may be considered for some children with food allergies or who do not tolerate whole proteins.

EEN is the recommended first-line therapy for induction of remission in children with Crohn’s disease.[3] Studies support the efficacy as comparable to corticosteroids, while also improving nutritional status and growth and supporting mucosal healing.[1] Inducing remission with EEN allows children to avoid some of the potential effects of steroids, such as impaired bone health.[1]

Dietitians calculate energy, protein and fluid requirements and provide a ‘target’ for EEN to ensure the child is meeting their nutritional needs for adequate growth. It is important to ensure the formula is suitable for the child in terms of their age and religious beliefs, and flavour preferences are considered. Dietitians provide practical advice on formula administration, social and school situations and hydration.[5]

Adherence to the diet can be challenging, often due to social exclusion, taste fatigue and poor motivation, particularly in older children. Regular dietetic support and advice have been shown to improve treatment adherence and may contribute to higher remission rates.[5] Weight and growth should be reviewed regularly throughout treatment, and EEN adapted appropriately.

The dietitian plays a key role in gradual re-introduction of food following completion of exclusive enteral nutrition. Currently there is no universally accepted food re-introduction protocol, so centres often have their own individualised plan according to current evidence.[1]

Partial enteral nutrition (PEN) involves some nutritionally complete formula alongside normal diet. It is not recommended as treatment to induce remission; however, some studies suggest it may have a role in maintaining remission and supporting growth and nutritional status in children with inflammatory bowel disease.[5]

The Crohn’s disease exclusion diet (CDED) is an emerging dietary treatment option to induce remission in children with mild to moderate Crohn’s disease. CDED allows children to have a selection of whole foods such as chicken, potatoes, bananas and carrots, alongside partial enteral nutrition. Evidence suggests treatment adherence is better than for EEN for some patients.[6] The diet is structured in three phases that gradually increase food variety. Foods included are those thought to promote a healthier intestinal microbiome and epithelial barrier function. Foods excluded are thought to negatively affect the gut microbiome, such as processed meats and sugary drinks.

Dietitians play an important role in implementing CDED by educating children and families on foods allowed, eating out, meal planning and shopping. A comprehensive dietetic assessment should be completed to identify if the child is appropriate for the diet and any nutritional concerns. Individual energy, protein and fluid requirements should be calculated, as enteral formula prescription changes throughout the course of the diet.[3] Ongoing dietetic support is vital through the course of treatment. Monitoring should include growth and weight, dietary intake, biochemistry and gastrointestinal symptoms.

Although early evidence supporting CDED is promising, longer-term studies are still required to establish its place within routine clinical practice. CDED should be delivered by experienced multidisciplinary teams with dietetic support.[1,6]

There is much emerging evidence and interest in other dietary approaches for children with IBD, in either maintaining remission or improving symptoms. Some approaches have shown encouraging results in small studies, but more high-quality evidence is needed before they can be recommended as treatments.[1,3]

Mediterranean diet: The evidence for the Mediterranean diet in children with IBD is still emerging; however, it is considered a nutritionally balanced diet that may support overall health during remission.[1]

Specific carbohydrate diet (SCD): SCD has shown promising improvements in symptoms in small paediatric studies, but is not recommended as routine therapy, especially due to the limited dietary variety.[1]

Low FODMAP diet: The low FODMAP diet should only be recommended in children with a diagnosis of irritable bowel syndrome or functional gastrointestinal symptoms, and not as a treatment for inflammation in Crohn’s disease.[3]

With the ever-growing nutritional information available online, dietitians play an important role in interpreting current research and supporting families to make informed decisions, so unnecessary dietary restrictions are avoided.

When children with IBD are in a ‘flare’, they have an increased risk of malnutrition, due to factors such as reduced oral intake, malabsorption and gastrointestinal symptoms. Nutritional care should be individualised, dependent on severity of disease, nutritional status and tolerance of oral intake. Dietitians should encourage a varied, balanced diet where possible. Temporary avoidance of foods that exacerbate symptoms may be recommended during periods of active disease.[3] Small frequent meals and snacks may help maintain nutritional intake.

For children who are unable to meet their nutritional requirements through diet alone, oral nutritional supplements may be required to provide additional energy and protein. Enteral nutrition should be considered in those where oral intake is inadequate, especially in children with significant weight loss or faltering growth. If enteral nutrition is not possible or the gastrointestinal tract cannot be used, parenteral nutrition is occasionally indicated.[1,5] Examples include bowel obstruction, high-output stomas and intestinal failure.

Paediatric dietitians have a vital role in supporting children from diagnosis and throughout their disease journey, to optimise nutritional status and growth and deliver evidence-based nutritional treatments. As research continues to grow, dietitians remain central to deliver individualised and evidence-based care, and can help improve clinical outcomes and quality of life in children with IBD.