| Name: | Description: | Size: | Format: | |
|---|---|---|---|---|
| 827.26 KB | Adobe PDF |
Authors
Advisor(s)
Abstract(s)
Introdução: Em idade pediátrica, o diagnóstico da Doença de Crohn (DC) pode ser um desafio, sendo a desnutrição e o atraso no crescimento complicações major associadas. Por esse motivo, a intervenção nutricional deverá ser considerada parte integrante do tratamento da DC e a restauração do estado nutricional como objetivo integrante do plano de intervenção terapêutica. A Nutrição Entérica Exclusiva (NEE) constitui atualmente a primeira linha de tratamento para a indução da remissão da DC luminal, ligeira a moderada, em idade pediátrica. Apresenta um excelente perfil de custo-benefício, com uma taxa de remissão, para os grupos a que se destina, entre 70 a 85% e benefícios adicionais no que respeita à cicatrização da mucosa, à restauração da densidade mineral óssea e à melhoria do crescimento e do estado nutricional, estando também associada à melhoria da qualidade de vida. Objetivos: O principal objetivo deste estudo é avaliar preliminarmente a contribuição da NEE na indução da remissão da apresentação inaugural da DC ligeira a moderada em crianças e adolescentes. Em simultâneo, pretende-se, ainda, caracterizar a NEE no que respeita à via de administração, composição e eventuais efeitos adversos e avaliar o impacto desta modalidade de intervenção terapêutica no estado clínico e nutricional dos doentes ao longo de quatro momentos específicos: ao diagnóstico, 2 semanas após o diagnóstico, no fim da terapêutica com NEE e 1 ano após o seguimento. De forma secundária é pretendido comparar o impacto da NEE com as modalidades terapêuticas alternativas utilizadas quando esta não foi finalizada no tempo preconizado, por ausência de adesão ou de resposta. Metodologia: Estudo observacional e retrospetivo, no qual foram recolhidos dados de 21 crianças e adolescentes com diagnóstico inaugural de DC, admitidos consecutivamente na Unidade de Gastroenterologia Pediátrica no Hospital de Santa Maria (HSM), entre Janeiro de 2014 e Junho de 2019. Foram incluídos todos os doentes tratados com NEE como terapêutica de primeira linha, não só com doença ligeira a moderada, mas também com doença grave. Nos quatro momentos foram avaliadas a evolução clínica e nutricional dos doentes, através de dados como a altura, o peso e o índice de massa corporal (IMC), e respetivos z-scores e os parâmetros laboratoriais (hemoglobina, calprotectina fecal, Proteína C Reativa - PCR e Velocidade de Sedimentação Eritrocitária - VS). Ao fim de 1 ano após a intervenção com NEE, foi também observada a ocorrência de recaídas, a duração da remissão e a necessidade de terapêuticas complementares. Resultados: Dos 21 doentes que iniciaram NEE, 2 não aderiram à terapêutica e foram excluídos, resultando uma amostra final de 19 doentes, com uma mediana de 14,2 anos (8,6- 17,9), sendo 52,6% do género masculino. A localização ileocólica foi a mais comum (47,4%) e o comportamento inflamatório destacou-se dos restantes, estando presente em 78,9% dos doentes. A maioria (52,6%) apresentou doença ligeira ao diagnóstico. Nenhum doente apresentou atraso de crescimento. A mediana de Z-score do IMC ao diagnóstico foi de -0,74 SDS (-3,18-0,88), verificando-se a presença de desnutrição em 21% dos doentes. O tempo médio desde os primeiros sintomas até ao diagnóstico foi de 154,8 ± 127,9 dias. Todos os pacientes receberam a NEE por via oral. A ingestão energética média foi de 46 ± 11 Kcal/Kg, o que correspondeu em média a, aproximadamente, 88,3% das necessidades energéticas diárias calculadas. No que respeita à ingestão de macronutrientes, verificou-se uma ingestão média de proteína de 1,7 ± 0,4 g/kg, de hidratos de carbono (HC) de 5,7 ± 1,3 g/kg e de gordura de 1,8 ± 0,4 g/kg. Apesar de a ingestão energética se situar abaixo das recomendações, não houve uma correlação significativa com o Z-score do Índice de Massa Corporal (IMC) no final do tratamento (rs=0,093, p=0,721). Dos 19 doentes que prosseguiram com a NEE, 2 não responderam à terapêutica e iniciaram terapêuticas alternativas após 2 semanas. Os restantes 17 concluíram as 6-8 semanas de tratamento, sendo que 16 (94,1%) alcançaram remissão completa e apenas 1 alcançou remissão parcial, verificando-se, neste momento, uma redução significativa da VS (p=0,001), da PCR (p=0,001) e do Pediatric Crohn’s Disease Activity Index (PCDAI) (p < 0,001) e um aumento significativo do Z-score do IMC (p=0,022). Também se verificou uma redução da calprotectina fecal, porém esta não foi significativa. Ao fim de 1 ano de tratamento, todos os parâmetros tinham melhorado significativamente com a exceção da PCR. No primeiro ano após a NEE 41,2% doentes recaíram. Discussão: Com base nos resultados preliminares do presente estudo, verificou-se que a NEE foi efetiva na indução da remissão da DC em idade pediátrica e na melhoria do estado nutricional comprometido ao diagnóstico, bem como de todos os marcadores inflamatórios, estando em concordância com a evidência pediátrica atual. Salienta-se ainda a excelente tolerância, adesão e ausência de efeitos adversos, reforçando a relevância crescente desta modalidade de intervenção na DC pediátrica.
ABSTRACT - Introduction: Diagnosis of pediatric Crohn's disease (CD) can be challenging, with malnutrition and growth retardation being major related complications. Therefore, the nutritional intervention must be considered an integral part of CD’s treatment and nutritional status restoration as an integral goal of the therapeutic intervention plan. Exclusive Enteral Nutrition (EEN) is currently the primary treatment for inducing remission in mild to moderate pediatric luminal CD. It presents an excellent cost-effective profile, with a remission rate, for the target groups, between 70 and 85%, and has additional benefits regarding mucosal healing, restoration of bone mass density, and improvement of growth and nutritional status, which is also associated with better quality of life. Objective: The primary goal of this study is to evaluate preliminarily the contribution of EEN in inducing remission of mild to moderate CD in children and adolescents. Simultaneously, it is intended to characterize the route of administration, composition, and possible side effects of EEN, as well as assess the impact of this type of therapeutic intervention on the clinical and nutritional status of patients over four specific moments: at diagnosis, two weeks after diagnosis, at the end of EEN and one year after EEN. Secondarily, it’s intended to compare the impact of EEN with other alternative therapeutic interventions used, when EEN has not been completed within the recommended time, because of the absence of adhesion or response. Methodology: Observational and retrospective study, in which were collecting data from 21 children and adolescents newly diagnosed with DC, consecutively admitted to the Paediatric Gastroenterology Unit, at Hospital de Santa Maria (HSM), between January 2014 and June 2019. Included all patients treated with EEN as first-line therapy, not only with mild to moderate disease, but also with severe disease. In the four moments were evaluated the clinical and nutritional evolution of the patients, was through data like height, weight, and body mass index (BMI), and the respective Z-scores and laboratory parameters (hemoglobin, fecal calprotectin, C-Reactive Protein – CRP, and erythrocyte sedimentation rate - ESR). One year after the intervention with EEN, was also observed the occurrence of relapse, the duration of remission, and the need for complementary therapies. Results: Of the 21 patients who started EEN, two did not adhere to therapeutic intervention and were excluded, resulting in a final sample of 19 patients, with a median age of 14,2 (8,6- 17,9), being 52,6% male. Ileocolic location was the most common (47,6%) and inflammatory behavior was highlighted from the others, being present in 78,9% of the patients. The majority (52,6%) presented mild disease at diagnosis. No patient presented growth retardation. The median BMI Z-score at diagnosis was -0,74 SDS (-3,18-0,88), showing the presence of 21% of patients malnourished. The mean time from the first symptoms until the diagnosis was 154,8 ± 127,9 days. All patients received EEN orally. Energy intake was about 46 ± 11 Kcal/Kg, which corresponds, in mean, to 88,3% of their daily energy requirements. Regarding macronutrient intake, it was observed the mean intake of protein of 1,7 ± 0,4 g/kg, carbohydrates (CH) of 5,7 ± 1,3 g/kg, and fat of 1,8 ± 0,4 g/kg. Although this number is below the recommendations, there wasn’t a correlation between energy intake and Body Mass Index (BMI) Z-score at the end of the treatment (rs=0,093, p=0,721). Of the 19 patients who proceed with EEN, 2 didn’t respond to therapeutic intervention and initiated alternative interventions after 2 weeks. The rest concluded the 6 to 8 weeks of treatment. 16 (94,1%) achieved complete remission and only 1 achieved partial remission, showing, at this moment, a significative reduction of ESR (p=0,001), CRP (p=0,001), and Paediatric Crohn’s Disease Activity Index (PCDAI) (p < 0,001) and a significative increase of BMI Z-score (p=0,022). There was also a reduction of fecal calprotectin values, although not statistically significant. One year after the treatment, all parameters have improved significatively, with exception of CRP. In the first year after EEN, 41,2% of the patients relapsed. Discussion: Based on the preliminary results of this study, was observed that EEN was effective in inducing remission of pediatric CD and in improving the compromised nutritional status at diagnosis, as well as all inflammatory markers, being in accordance with current pediatric literature. It’s important to highlight the excellent tolerance, adhesion, and absence of side effects, reinforcing the growing relevance of this intervention on pediatric CD.
ABSTRACT - Introduction: Diagnosis of pediatric Crohn's disease (CD) can be challenging, with malnutrition and growth retardation being major related complications. Therefore, the nutritional intervention must be considered an integral part of CD’s treatment and nutritional status restoration as an integral goal of the therapeutic intervention plan. Exclusive Enteral Nutrition (EEN) is currently the primary treatment for inducing remission in mild to moderate pediatric luminal CD. It presents an excellent cost-effective profile, with a remission rate, for the target groups, between 70 and 85%, and has additional benefits regarding mucosal healing, restoration of bone mass density, and improvement of growth and nutritional status, which is also associated with better quality of life. Objective: The primary goal of this study is to evaluate preliminarily the contribution of EEN in inducing remission of mild to moderate CD in children and adolescents. Simultaneously, it is intended to characterize the route of administration, composition, and possible side effects of EEN, as well as assess the impact of this type of therapeutic intervention on the clinical and nutritional status of patients over four specific moments: at diagnosis, two weeks after diagnosis, at the end of EEN and one year after EEN. Secondarily, it’s intended to compare the impact of EEN with other alternative therapeutic interventions used, when EEN has not been completed within the recommended time, because of the absence of adhesion or response. Methodology: Observational and retrospective study, in which were collecting data from 21 children and adolescents newly diagnosed with DC, consecutively admitted to the Paediatric Gastroenterology Unit, at Hospital de Santa Maria (HSM), between January 2014 and June 2019. Included all patients treated with EEN as first-line therapy, not only with mild to moderate disease, but also with severe disease. In the four moments were evaluated the clinical and nutritional evolution of the patients, was through data like height, weight, and body mass index (BMI), and the respective Z-scores and laboratory parameters (hemoglobin, fecal calprotectin, C-Reactive Protein – CRP, and erythrocyte sedimentation rate - ESR). One year after the intervention with EEN, was also observed the occurrence of relapse, the duration of remission, and the need for complementary therapies. Results: Of the 21 patients who started EEN, two did not adhere to therapeutic intervention and were excluded, resulting in a final sample of 19 patients, with a median age of 14,2 (8,6- 17,9), being 52,6% male. Ileocolic location was the most common (47,6%) and inflammatory behavior was highlighted from the others, being present in 78,9% of the patients. The majority (52,6%) presented mild disease at diagnosis. No patient presented growth retardation. The median BMI Z-score at diagnosis was -0,74 SDS (-3,18-0,88), showing the presence of 21% of patients malnourished. The mean time from the first symptoms until the diagnosis was 154,8 ± 127,9 days. All patients received EEN orally. Energy intake was about 46 ± 11 Kcal/Kg, which corresponds, in mean, to 88,3% of their daily energy requirements. Regarding macronutrient intake, it was observed the mean intake of protein of 1,7 ± 0,4 g/kg, carbohydrates (CH) of 5,7 ± 1,3 g/kg, and fat of 1,8 ± 0,4 g/kg. Although this number is below the recommendations, there wasn’t a correlation between energy intake and Body Mass Index (BMI) Z-score at the end of the treatment (rs=0,093, p=0,721). Of the 19 patients who proceed with EEN, 2 didn’t respond to therapeutic intervention and initiated alternative interventions after 2 weeks. The rest concluded the 6 to 8 weeks of treatment. 16 (94,1%) achieved complete remission and only 1 achieved partial remission, showing, at this moment, a significative reduction of ESR (p=0,001), CRP (p=0,001), and Paediatric Crohn’s Disease Activity Index (PCDAI) (p < 0,001) and a significative increase of BMI Z-score (p=0,022). There was also a reduction of fecal calprotectin values, although not statistically significant. One year after the treatment, all parameters have improved significatively, with exception of CRP. In the first year after EEN, 41,2% of the patients relapsed. Discussion: Based on the preliminary results of this study, was observed that EEN was effective in inducing remission of pediatric CD and in improving the compromised nutritional status at diagnosis, as well as all inflammatory markers, being in accordance with current pediatric literature. It’s important to highlight the excellent tolerance, adhesion, and absence of side effects, reinforcing the growing relevance of this intervention on pediatric CD.
Description
Mestrado em Nutrição Clínica
Keywords
Nutrição Doença de Crohn Nutrição entérica exclusiva Fórmula polimérica Pediatria Nutrition Crohn's disease Exclusive enteral nutrition Polymeric formula Pediatrics
Citation
Silva BF. Nutrição entérica exclusiva na indução da remissão da doença de Crohn em idade pediátrica: estudo observacional [dissertation]. Lisboa: Faculdade de Medicina da Universidade de Lisboa; Escola Superior de Tecnologia da Saúde de Lisboa/Instituto Politécnico de Lisboa; 2021.