The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn’s and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dietary management of pediatric CD. Workshop participants ranked the exclusivity of enteral nutrition; the health care resources; and cost implications as the top three barriers to its use. Conversely, key enablers mentioned included: standardization and sharing of protocols for use of enteral nutrition; ensuring sufficient dietetic resources; and reducing the cost of EEN to the family (including advocacy for reimbursement by provincial ministries of health and private insurance companies). Herein, the authors report on the discussions during this workshop and list strategies to enhance the use of EEN as a treatment option in the treatment of pediatric CD in Canada.

Introduction: Treatment of celiac disease is a strict life-long gluten-free diet (GFD). The GFD is complex, and counseling by a dietitian is essential. The number of new referrals for GFD education has increased. We studied the feasibility of GFD teaching using distributed education. Methods: The IWK Health Center in Halifax is the only tertiary-care pediatric hospital in the 3 Maritime provinces with GFD experienced dietitians. Families travel long distances to attend teaching sessions. Families outside the Halifax area were offered to participate in the 2.5-hour education sessions held once a month via live videoconference link at their regional hospitals. All participants were surveyed with a 10-item questionnaire assessing the content and delivery and usefulness of information. Results: Over a 6-month period, 39 families attended the sessions, 21 locally and 18 at distributed sites across the Maritimes. The survey was completed by 26 participants (67%). All participants at both sites strongly agreed or agreed that their setting was good for learning and the information provided was easy to understand. There were no significant differences between the 2 groups on any individual questions in the 2 domains assessed (all P > 0.06). Conclusions: Distributed education on GFD is feasible and as effective as in person education. It affords convenience and savings to families by reducing travel costs.

Background The first line treatment for inducing remission in pediatric Crohn’s disease (CD) is Exclusive Enteral Nutrition (EEN), where a patient drinks a nutritionally complete formula exclusively for, 6 to, 12 weeks. Despite the effectiveness of EEN, some patients may experience challenges including taste fatigue, monotony, and a lack of social participation with meals. Given these challenges, patients may turn to popular or fad diets for managing their disease. These diets are often restrictive, eliminating a number of foods and exacerbating the risk of underlying nutrient deficiencies in this patient population. Methods These case studies involved a nutrient analysis of evidence-based and popular diets for CD, including Crohn’s Disease Exclusion Diet (CDED), CD-TREAT, Specific Carbohydrate Diet (SCD), IBD Anti-inflammatory Diet (IBD-AID), Autoimmune Protocol (AIP) Diet, Gut and Psychology Syndrome (GAPS) Diet, and low FODMAP. Four cases were selected with mild-moderate CD:, 11-year-old and, 16-year-old, both male and female. A nutrient analysis of sample menus of each diet was completed using Food Processor version of, 11.6.0 by ESHA Research. Results were compared to age and gender specific Dietary Reference Intakes (DRIs), population-based dietary intake data, and Health Canada Dietary Guidelines. Results Data are presented for Case, 1, 11-year-old male. Findings were comparable to other age and gender cases. As compared to Acceptable Macronutrient Distribution Ranges (AMDRs), there was a higher percentage of energy from fats and lower from carbohydrates for the SCD (% kcal, fat and carbohydrate respectively:, 59%;, 30%), IBD-AID (52%;, 37%), AIP Diet (50%;, 20%) and GAPS Diet (60%, 21%). Saturated fat intake exceeded recommendations (>10% of energy intake) for CDED (% kcal, 14%) CD Treat (17%), SCD (11%), AIP Diet (15%) and GAPS Diet (20%). Both vitamin D and/or calcium intake were below the Recommended Dietary Allowance (RDA) respectively for CDED (% RDA, vitamin D and calcium respectively:, 89%;, 86%), SCD (23%;, 53%), AIP Diet (14%;, 23%), low FODMAP Diet (4%, 96%) and GAPS Diet (calcium, 58%). Adolescent females versus males between the ages of, 14–18 years may be at greater risk of inadequate nutrient intake, given the general increase in nutrient requirements yet lower caloric needs. Conclusion Given the increase in awareness and interest in popular diets for Crohn’s disease, it is imperative that clinicians are aware of the risks of inadequate nutrient intake with restrictive diets.

Background: Treatment of celiac disease (CD) is a strict life-long gluten-free diet (GFD). The GFD is complex and counselling by an expert dietitian is essential. Number of new CD diagnoses is increasing, leading to significant impact on dietitian resources. Distributed education is a means of providing GFD teaching to groups of families off site instead of one-toone sessions. Aims: To assess the feasibility and effectiveness of GFD education using distributed teaching. Methods: The IWK Health Centre in Halifax, Nova Scotia is the only tertiary care paediatric institution in the three Maritime Provinces of Canada. It has two paediatric dietitians with expertise in GFD who provide teaching to families of children with newly diagnosed CD. Families often have to travel long distances to come to the institution, sometimes in excess of 4 hours driving. Patients outside Halifax area were offered to participate in teaching sessions via live videoconference link at their regional hospitals free of charge. All family members of the patient were encouraged to attend. Sessions were held once a month at noon and were 2-2.5 hours in duration. They were interactive, with a gastroenterologist giving a brief overview of CD, a social worker or psychologist providing information on finances/coping and dietitian providing details of GFD. All families who attended the sessions were surveyed by mail with a 10-item questionnaire to assess Content/Delivery and Usefulness of Information received on a five-point Likert scale. Results: From January to June 2017, a total of 39 families attended the GFD teaching sessions. Of these, 21 (54%) were in Halifax (local) and 18 (46%) at distributed sites including 8 at various places in Nova Scotia, 6 in New Brunswick and 4 in Prince Edward Island. Number of families at each session ranged from 3-9 with all sessions having participants from both local and distributed sites. All sessions were completed successfully. Feedback survey was completed by 26 (67%) families, 12 local and 14 from distributed sites. All participants at both sites Strongly Agreed/Agreed that the physical setting (e.g. sound, visuals) was good for learning and information provided was easy to understand. At the distributed sites 86% and at local site 92% of participants Strongly Agreed/Agreed that the learning environment was interactive. There were no significant differences in responses between the two groups to other questions asked. Three participants wished there was more time, while two felt that session was too long. Conclusions: Distributed education on gluten-free diet using videoconferencing is feasible and effective. It affords convenience for families and savings on dietitian resources. Challenges include organization of teaching sessions for multiple sites and determining their appropriate duration.

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