PORTLAND, ORE. – Fecal transplants are proving useful for pediatric ulcerative colitis, and enteral feedings are already well established in Europe to help kids with Crohn’s disease; together, the findings suggest that gut flora is more important to pediatric gastrointestinal health than previously thought, according to Dr. Linda Muir.
In both cases, "they think a lot of [the effect] has to do with modification of bowel flora. I think we are all starting to realize that the bacteria we carry around in our bodies drive and determine a lot of our health and illness. A lot of autoimmune disorders may be related to [imbalances in our] gut microbiome," said Dr. Muir, chief of pediatric gastroenterology at the Oregon Health and Science University in Portland.
Dr. Linda Muir
Although it’s unclear at the moment if donor stool is best delivered by nasogastric tube, colonoscope, or enema, it’s easy to understand how fecal transplants might correct such an imbalance. They’ve proven remarkably effective for Clostridium difficile infections, and now "good studies are being published for [their] application in [inflammatory bowel disease]. They’re very promising" for pediatric ulcerative colitis (UC), she said at a conference sponsored by the North Pacific Pediatric Society.
In one study from Michigan State and Emory universities, 10 children (aged 7-21 years) with mild to moderate UC received fecal enemas, 165 mL on average, for 5 days. Seven of nine (78%) – the 10th couldn’t retain the enema – showed a significant clinical response within a week, including three remissions. Six (67%) maintained their response at 1 month. There were no serious adverse events (J. Pediatr. Gastroenterol. Nutr. 2013;56:597-601).
If other studies have results like that, "I think [fecal transplants] may become more common in our practice. [Perhaps] we can turn around kids who are not responding to medication," Dr. Muir said.
It’s less clear how enteral feedings might rebalance the gut flora in Crohn’s kids. Typically, a child gets 100% of his or her nutrition for a period of time from milk-based products such as Ensure, Boost, or Nutren delivered by nasogastric tube at home; older children often learn to place the tube themselves. Dr. Muir favors products that pack the most calories in the least volume so kids don’t have to get up in the middle of the night to urinate; she uses enteral therapy as a supplement to the more usual Crohn’s approaches.
"Why does this make them better? We don’t know. Is it because of the nutrients? Are you removing food protein antigens? It may tie together with what we are seeing with fecal transplant, somehow modifying the fecal flora to allow mucosal healing. [Kids] obviously have much improved growth and they actually get true mucosal healing" on enteral feeding, unlike with steroids, Dr. Muir said.
Whatever the reason, pediatric gastroenterologists in Europe have been using the technique for years and touting its benefits. "They don’t use nearly the steroids U.S. physicians use," she said. In 2012, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition noted that enteral feeding offers "an alternative to corticosteroids to induce remission in pediatric CD [Crohn’s disease] and should be supported as a first-line induction therapy in pediatric CD" (J. Pediatr. Gastroenterol. Nutr. 2012;54:298-305). And it just might be the case that CD kids don’t need to get all their calories through a tube. Researchers at the Children’s Hospital of Philadelphia recently reviewed the charts of 23 kids who got 80%-90% of their calories by enteral feedings and found that 20 (87%) had a clinical response, and 15 (65%) went into remission after a mean of 2 months (Inflamm. Bowel Dis. 2013;19:1374-8).
Even though they were on the tube at home, they could pull it out in the morning and have lunch with their friends at school just like any other kid, Dr. Muir said.
She said she had no relevant financial disclosures.