The optimal treatment of acute Crohn's disease in children remains controversial. In adults, steroid therapy has been shown to be superior to exclusive enteral nutrition. However, enteral nutrition is effective at inducing a remission in many children with acute Crohn's disease. Steroid usage in children has been associated with adverse side effects, particularly with delayed growth and pubertal development.
Randomized clinical trials comparing exclusive enteral nutrition with corticosteroids were identified. Two independent reviewers extracted data from selected studies. Studies were assessed for heterogeneity and relative risks for remission induction with enteral nutrition were obtained. Sensitivity analyses were performed in partially randomized studies. Estimates were made of the number of studies needed to overturn the current result. Other outcome measures were qualitatively assessed.
In five randomized clinical trials comprising 147 patients, enteral nutrition was as effective as corticosteroids at inducing a remission (RR = 0.95 [95% confidence interval 0.67, 1.34]). Addition of two further nonrandomized trials did not significantly alter the result. A minimum of 10 further studies, equal in size and outcome to the largest reported pediatric trial to date (n = 68, RR = 0.84), would be required to demonstrate a significant benefit of steroid therapy over enteral nutrition.
There is no difference in efficacy between enteral nutrition and corticosteroid therapy in the treatment of acute Crohn's disease in children. Improved growth and development, without the side effects of steroid therapy, make enteral nutrition a better choice for first-line therapy in children with active Crohn's disease.
Combined Program in Pediatric Gastroenterology and Nutrition, Children's Hospital; and
*Harvard School of Public Health, Boston, Massachusetts, U.S.A.
Received October 28, 1999; accepted December 21, 1999.
Address correspondence and reprint requests to Dr. Robert B. Heuschkel, Division of Gastroenterology, Hunnewell Building, Ground Floor, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, U.S.A.
This article accompanies an editorial. Please see Griffiths AM. Enteral nutrition: the neglected primary therapy of active Crohn's disease. J Pediatr Gastroentero Nutr 2000;31:3–5.