Systematic Review and Network Meta-Analysis Compares Enteral Nutrition and Medications in Pediatric Crohn's Disease
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Key Takeaway
Consider enteral nutrition for induction in pediatric Crohn's disease; evidence shows superiority over corticosteroids.
This systematic review and network meta-analysis synthesized data from 1,182 patients with pediatric Crohn's disease to compare enteral nutrition strategies against immunomodulators and corticosteroids. The authors evaluated clinical remission induction, mucosal healing, and maintenance outcomes across various nutritional and pharmacological interventions within the pediatric population.
Regarding induction, exclusive enteral nutrition was significantly superior to corticosteroids for clinical remission with an odds ratio of 1.72 (95% CI 1.18–2.52). For mucosal healing, exclusive enteral nutrition demonstrated marked superiority versus corticosteroids with an odds ratio of 7.55 (95% CI 3.59-15.88). SUCRA rankings placed CDED plus PEN at 0.80 and exclusive enteral nutrition at 0.78 for remission induction, while corticosteroids ranked lowest at 0.31.
Safety data indicated serious adverse events ranged from 0%–3.1% for enteral nutrition therapies compared to 15.1% for corticosteroids and 11.8% for azathioprine or 6-mercaptopurine. Notably, these safety profiles differ between nutritional and pharmacological approaches. For maintenance, azathioprine or 6-mercaptopurine was superior to placebo with an odds ratio of 12.50 (95% CI 2.47–63.14).
The authors note that these findings support enteral nutrition as first-line induction therapy in pediatric Crohn's disease. However, the review does not report follow-up duration or absolute numbers for all outcomes. Clinicians should interpret these pooled estimates within the context of available evidence and individual patient factors carefully.
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View Original Abstract ↓
BackgroundEnteral nutrition (EN) and immunomodulators are established therapies for pediatric Crohn's disease (CD), yet comparative effectiveness data remain limited.ObjectiveWe conducted a network meta-analysis (NMA) to compare the efficacy and safety of EN therapies vs. immunomodulators and corticosteroids for remission induction and maintenance in pediatric CD.MethodsWe systematically searched PubMed, Embase, Cochrane CENTRAL, and Web of Science from inception through October 2024. Randomized controlled trials (RCTs) and comparative observational studies evaluating exclusive enteral nutrition (EEN), partial enteral nutrition (PEN), Crohn's Disease Exclusion Diet plus PEN (CDED + PEN), supplemental enteral nutrition (SEN), corticosteroids (CS), azathioprine/6-mercaptopurine (AZA/6-MP), or methotrexate (MTX) were included. Primary outcomes were clinical remission and mucosal healing. Frequentist NMA was performed using random-effects models. Surface under the cumulative ranking curve (SUCRA) values determined treatment rankings.ResultsTwenty studies (7 RCTs, 13 observational) comprising 1,182 patients were included. For clinical remission induction, EEN was significantly superior to CS [odds ratio [OR] 1.72; 95% confidence interval [CI] 1.18–2.52; 7 studies; I2 = 0%]. EEN demonstrated marked superiority for mucosal healing vs. CS (OR 7.55; 95% CI 3.59-15.88). SUCRA rankings for remission induction were: CDED + PEN (0.80), EEN (0.78), MTX (0.55), AZA/6-MP (0.47), CS (0.31), and PEN (0.08). For maintenance, AZA/6-MP was superior to placebo (OR 12.50; 95% CI 2.47–63.14). EN therapies exhibited favorable safety profiles with serious adverse event rates of 0%–3.1% compared with 15.1% for CS and 11.8% for AZA/6-MP.ConclusionsEEN and CDED + PEN are the most effective treatments for inducing clinical and endoscopic remission in pediatric CD, with superior safety profiles compared to pharmacological therapies. Immunomodulators remain essential for maintenance therapy. These findings support EN as first-line induction therapy in pediatric CD.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261345561, PROSPERO CRD420261345561.
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