Exclusive Enteral Nutrition (EEN)

The data for the use of EEN in induction of remission for pediatric CD is so robust that it is recommended first-line in Europe (ESPGHAN) (Ruemmele FM et al, update: van Rheenan PF et al), Canada (Mack DR et al), Japan (Ishige T et al & Japanese Study Group for Pediatric Crohn's Disease) (Ueno F et al), Australia (Ho SSC and Day AS), and the US (NASPGHAN) (Critch J et al on Behalf of the NASPGHAN IBD Committee), with routine use worldwide, although it has a recognized underutilization in the US (Shaikhkhalil AK et al). Given its very high rate of remission (80%) with minimal side effects, it is a particularly attractive choice for children (Miller T and Suskind DL).  Furthermore, it has been shown to provide the additional benefits of resolving nutritional deficiencies, improving growth and weight gain, improving bone health, and inducing mucosal healing (Day AS and Lopez RN).

The recognized efficacy of EEN is the foundation for investigating the potential of therapeutic diets. If EEN can provide these benefits with liquid diet, is it possible to induce remission or to maintain it with whole foods diets? Part of the answer may lie in the proposed mechanisms for its efficacy, which include the exclusion of harmful or deleterious substances, giving the bowel rest, providing essential micronutrients that are easily absorbed, and modulating the microbiome.

Some of the underutilization of EEN in the US may be explained by the fact that there has not been an established transition from EEN to a dietary maintenance therapy. Although there is not yet an established single dietary recommendation, following EEN with a therapeutic diet may improve chances of maintaining remission, compared with PEN or a return to a liberalized diet, as a return to a liberalized diet results in rapid increases in inflammatory markers (Logan M et al) and high rates of relapse (MacLellan A et al).