What is the initial treatment for a child diagnosed with Crohn's disease?

Initial Treatment for Children with Crohn's Disease

Exclusive Enteral Nutrition (EEN) is recommended as the first-line therapy to induce remission in children with newly diagnosed active luminal Crohn's disease. 1

Assessment of Disease Severity

Before initiating treatment, disease severity should be evaluated using:

• Weighted Pediatric Crohn's Disease Activity Index (wPCDAI)
• Serum inflammatory markers (CRP)
• Fecal calprotectin
• Endoscopic and radiographic evaluation
• Growth parameters

First-Line Treatment Algorithm

For Most Children with Active Luminal Crohn's Disease:

1. Exclusive Enteral Nutrition (EEN)

   • Duration: 6-8 weeks
   • Formulation: Polymeric formula (whole protein) is preferred over elemental formula
   • Administration: Oral intake is preferred; nasogastric tube only if adequate oral intake cannot be achieved
   • Target: Approximately 120% of daily caloric needs 1

2. Monitoring Response

   • If no clinical response within 2 weeks, consider alternative treatment
   • After completion of EEN, gradually reintroduce normal food over 2-3 weeks with concomitant decrease of formula volume 1

For Children Unable to Tolerate EEN:

Corticosteroids are recommended as alternative first-line therapy:

• Oral prednisone/prednisolone: 1 mg/kg once daily (maximum 40 mg/day)
• For mild-moderate ileocecal disease: Budesonide 9 mg daily (up to 12 mg for first 4 weeks)
• Taper over approximately 10 weeks 1

Special Considerations

High-Risk Patients

For patients with severe disease or poor prognostic factors:

• Perianal disease
• Severe growth retardation
• Deep ulcers on endoscopy
• Extensive disease (including upper GI and proximal small bowel)
• Need for corticosteroids at diagnosis

Consider early escalation to anti-TNF therapy (e.g., infliximab) 1, 2

Disease Location Considerations

• EEN is effective for all disease locations, including isolated colonic disease 1
• Budesonide is particularly effective for ileocecal disease 1

Maintenance Therapy After Induction

After successful induction of remission:

1. For most patients (moderate-severe risk): Initiate immunomodulators

   • Thiopurines (azathioprine 2-2.5 mg/kg/day or 6-mercaptopurine 1-1.5 mg/kg/day)
   • Or methotrexate (15 mg/m² once weekly, maximum 25 mg) if thiopurines are contraindicated 1

2. For high-risk patients: Consider anti-TNF therapy (infliximab) 1, 2

Common Pitfalls to Avoid

1. Inappropriate use of 5-ASA compounds: The use of 5-ASA in Crohn's disease is controversial and generally not recommended, especially for moderate disease 1

2. Prolonged or repeated corticosteroid use: Steroid dependency should not be tolerated; steroids should never be used for maintenance therapy 1

3. Delayed recognition of treatment failure: If EEN does not induce clinical response within 2 weeks, alternative treatment should be considered 1

4. Inadequate monitoring: Regular assessment of disease activity using clinical indices, inflammatory markers, and growth parameters is essential 1

5. Overlooking growth parameters: Growth retardation is a critical outcome measure unique to pediatric Crohn's disease 1

The evidence strongly supports EEN as first-line therapy for pediatric Crohn's disease, with clinical remission rates of approximately 80% in large cohort studies 1. EEN has the additional benefits of promoting mucosal healing, improving nutritional status, and avoiding corticosteroid-related adverse effects, which is particularly important for growing children.