Nutrition

Pediatric IBD can interrupt your child’s digestion, affecting his or her nutritional health. Good nutrition is especially important for children with Pedi IBD to help them grow and develop at a healthy rate.

• What is healthy digestion?
• How can Pedi IBD affect my child’s digestive system?
• What are nutritional deficiencies and how are they caused?
• Vitamin and mineral supplementation
• Nutritional and dietary recommendations for children with
  Pedi IBD
• Complementary nutritional therapies

What is healthy digestion?

Healthy digestion is the process our bodies use to break down and absorb calories and nutrients from the foods that we eat.

Once digestive enzymes have broken down the food, a healthy digestive system absorbs the nutrients it needs to give the body energy and keep it healthy. Any unused waste is removed from the body in a bowel movement.

A healthy digestive system in children uses the calories and nutrients from food to help the body grow and develop at a normal rate.

How can Pedi IBD affect my child's digestive system?

Pedi IBD can interrupt the healthy digestion of foods by causing

• inflammation of different parts of the intestine

Crohn’s disease can affect any part of a child’s intestine from the mouth to rectum, most often affecting the lining of the small intestine, and can cause problems such as

• poor appetite
• inability to absorb nutrients or vitamins and minerals from food
• diarrhea

Ulcerative colitis involves the lining of a child’s large intestine and can cause

• diarrhea

What are nutritional deficiencies and how are they caused?

• calories
• vitamins
• minerals

from the foods he or she is eating for them to grow and develop at a normal and healthy rate.

If nutritional deficiencies are not corrected, they can become a serious complication and can cause your child to have

• delayed growth and development

Many nutritional deficiencies can be avoided or reversed with supplements prescribed by your child’s

• physician or gastroenterologist
• dietician
• nutritionist

Causes of nutritional deficiencies

Some of the causes of nutritional deficiencies can include

• poor food intake (not eating enough)
• reduced absorption and digestion
• diarrhea
• medication use

Poor food intake

• poor food intake

When symptoms of Pedi IBD are active, many children do not eat enough food or take in as many calories a day as their bodies need to grow and thrive.

If your child’s Pedi IBD is active, he or she can experience

• nausea
• vomiting
• abdominal pain
• a feeling of bloating
• diarrhea

These symptoms can limit the amount of food that your child can or wants to eat at one time. 

Children with Pedi IBD may not be able to eat when feeling nauseous, bloated or vomiting. Sometimes, children with Pedi IBD can choose not to eat if eating causes diarrhea or stomach pain or when they are afraid that they may have an accident. This can happen especially when they are at school or somewhere that a bathroom may not be close by. 

Reduced absorption or digestion

Children with Crohn's disease are more affected by this problem than children with ulcerative colitis.

If your child's Crohn's disease affects many areas of the small intestine, the intestine may not be able to take in enough

• proteins
• fats
• carbohydrates
• minerals (calcium and iron)
• vitamins

If your child’s Crohn’s disease affects the terminal ileum where the small intestine joins the large intestine, the digestive system may not be able to take in enough

• vitamin B12

Children who have had surgery to remove part of their small intestine can also have these nutritional deficiencies.

Diarrhea

Diarrhea is a major cause of loss of nutrients, calories, vitamins and minerals as food moves through a child’s body before the intestine has a chance to absorb what it needs to grow and thrive. Children with both Crohn’s disease and ulcerative colitis can frequently struggle with diarrhea.

Children with active disease or inflammation can have more

• protein loss in stool or hypo-albuminemia (low levels of protein in blood)

• blood loss in diarrhea or iron deficiency that can become anemia
• dehydration or low fluid and electrolyte levels

It is always important when your child is experiencing a bout of diarrhea to make sure that he or she is drinking enough fluids, especially drinks with electrolytes.

Medication use

Some medications used to treat Crohn’s disease and ulcerative colitis can

• interfere with or stop some of the absorption of minerals/vitamins

Examples of medications that can interfere with the way your child’s body absorbs or takes in an important vitamin like folate (folic acid) are

• sulfasalazine
• methotrexate

Nutritional and dietary recommendations for children with Pedi IBD

What your child eats or is able to eat can depend greatly on whether their Pedi IBD is

• in remission and they are experiencing few symptoms 
• or active and causing increased inflammation of the digestive tract

When your child’s disease is in remission or not active, the goal is to
maintain a well balanced diet of a wide variety of foods including

• protein — meats, fish, poultry, dairy products, beans, legumes
• carbohydrates — cereals, breads, vegetables, fruit
• fats — oils, butter, margarine

A well balanced diet can help to make sure that your child gets enough

• calories
• proteins
• vitamins/minerals

to help them grow and develop at a healthy rate.

When your child's Pedi IBD is active and they are experiencing more symptoms, your healthcare provider may suggest special nutritional recommendations that may be helpful during this time.

Special Nutritional Recommendations in Pedi IBD

When your child’s disease is active or they are experiencing symptoms, the goal is to make sure your child is taking in enough calories and nutrients.

To help with this, your child’s healthcare provider may recommend a

• modified or special diet

Modified diets are developed especially for your child usually with input of a dietician or nutritionist and can depend on

• age of your child
• area of the intestine affected by the disease

Modified diets can include

• low fiber, low residue diet
• lactose-free diet
• high calorie diet

Low fiber, low residue diet

When your child has active Pedi IBD, the ability of their intestine to digest and absorb or take in foods is not as good as it should be.

Fiber is a part food that is not digested in the human intestine and is usually eliminated from the body in a bowel movement.
Eating foods high in fiber when your child’s disease is active can

• increase diarrhea
• increase pain and discomfort with bowel movements
• increase bleeding

Avoiding foods with high fiber content such as

• fresh vegetables and fruit
• whole grains, cereals, nuts and popcorn

can help to decrease stools and help to ‘rest’ the intestines.

When Pedi IBD is active, changes to your child’s diet are recommended mainly to help with any discomfort or unpleasant symptoms your child may have.

A low fiber low residue diet may also be recommended in children who have a narrowing or a stricture in the intestine from Crohn’s disease, or when surgery is performed to remove part of the intestine due to complications from Pedi IBD.

If your child’s doctor does recommend a low fiber low residue diet, they may also recommend a multivitamin or vitamin supplements in order to add nutrients normally found in fruits and vegetables. Remember to always check with your child’s healthcare provider before beginning a new diet.

Lactose free diet

Lactose is the carbohydrate portion of milk. It can be difficult to tell the difference between lactose intolerance and a milk allergy. A lactose breath test can be performed to diagnose lactose intolerance, and your child’s healthcare provider may order this test before making any changes to your child’s diet.

Children with lactose intolerance, especially with disease in the small intestine, sometimes benefit from a lactose-free diet.
Symptoms of lactose intolerance include

• nausea
• bloating
• increased burping
• increased gas
• stomach pain
• diarrhea

These symptoms can decrease or go away completely when milk and dairy products including

• cheese, ice cream and yogurt

are removed from the diet.

Because milk and dairy products are very important sources of nutrition for a growing child, your healthcare provider may suggest switching to

• lactose-free milk
• or recommend your child take a lactase supplement when eating milk products

Before taking dairy products out of your child’s diet, talk with your healthcare provider about ways to do this a little at a time.
A dietician or nutritionist can also make suggestions that will help to lessen symptoms and keep up the amount of calcium and vitamin D in your child’s diet.

In children who are allergic to milk proteins or have

• milk allergies

fortified soy milk or fortified rice milk can be used instead of regular milk.

Vitamin and Mineral Supplementation

Calcium

Children’s bones continue to grow throughout childhood and into early adulthood. For this reason, it is especially important to make sure children get enough calcium in their diet during the childhood years and puberty.

Too little calcium in the diet, or calcium deficiency

• can cause poor bone mineralization and bone growth
• may increase risk of osteoporosis or brittle bones
• lead to fractures

Including milk and dairy products in your child’s diet is a good way to give them the calcium and vitamin D they need for strong bones.

Your child’s healthcare provider may recommend a calcium supplement if your child is unable to take in enough calcium from the foods they eat.

Vitamin D

Vitamin D supplements are not often recommended and usually only if your child has a history of low vitamin D levels. In most cases, a well balanced diet including dairy products and regular exposure to sunlight is enough to maintain good vitamin D levels.

Regular physical exercise also helps to make healthy bones and can be encouraged if your child is able.

Iron deficiency

Many children with IBD have iron deficiency or not enough iron in their blood. Iron deficiency can happen because of

• poor food intake
• poor absorption
• loss of iron because of blood in the stool

Iron deficiency can lead to anemia. Anemia can make your child unusually tired and can make it difficult for them to participate in everyday activities.  Eating foods rich in iron may help to correct this, such as

• red meats, beans, spinach and milk

Iron levels can be measured with a blood test and children with low iron levels may be prescribed iron supplements by their healthcare provider.

Vitamin B12

Vitamin B12 deficiency can happen in children with Crohn’s disease in the terminal ileum where the small intestine connects with the large intestine.

Children who have had surgery to remove this part of the intestine can also develop a B12 deficiency, as vitamin B12 is absorbed in the terminal ileum.

Levels of vitamin B12 can be measured by a blood test, and children with low levels may be prescribed be vitamin B12 supplement or injections by their healthcare provider.

Micronutrients

Deficiencies or lack of other micronutrients like

• magnesium and phosphorus

and develop in children who have

• extensive disease in the small intestine
• large surgical resection

Nutritional Supplementation

Nutritional supplementation may be prescribed when a child’s Pedi IBD is very active. Supplementation may help manage symptoms such as

• weight loss
• slow growth or lack of growth
• delay in puberty
• effects on bone health
• malnutrition
• increased infections

In some cases, children with severe symptoms may benefit from

• semi-elemental, elemental or polymeric formulas

that can be used to increase calories and taken as a drink.

The taste of these can be a problem for some children. If a child cannot drink the supplements they can be given through a

• nasogastric (NG) tube
• gastrostomy tube

The NG tube can be placed on a nightly basis and removed during the day to maintain normal activities. The gastrostomy tube leads directly into the stomach and is placed by a pediatric surgeon.

The goal of nutritional supplementation is to make sure that the child is getting 100-150% of the calories recommended daily for their age.
There are a number of research studies that show nutritional therapy to be effective in

• bringing about disease remission
• reversing growth failure

Nutrition can also be given through a tube in a vein. This is known as 

• peripheral hyperalimentation

This kind of supplementation is given through a special intravenous line (PICC line, central line) and is usually used only with children who have had surgery or are hospitalized for long periods.

Complementary nutritional therapies

Complementary therapies sometimes used by children with Pedi IBD include

• probiotics
• Omega-3 fatty acids

Probiotics

Probiotics are dietary supplements that contain bacteria that may be beneficial. The commonly used probiotics are

• Culturelle® (Lactobacillus GG)
• VSL#3®

Probiotics may help to reduce intestinal inflammation by reducing the overgrowth of harmful bacteria.

Probiotics may help to improve

• infectious diarrhea
• pouchitis

(a condition that sometimes happens after surgery in patients in with ulcerative colitis)

Probiotics may help to reduce food allergies and eczema. Some children can complain of mild bloating and increased gas. Probiotics are generally easy to take and are considered safe for children.

Probiotics in smaller amounts can be found in foods like

• yogurt, fermented milk and buttermilk, or
• juices that are specially enriched with active probiotics microorganisms

It is not clear yet if the amounts of live bacteria in these foods are enough to give any real benefit.

Omega-3 Fatty Acids

Omega-3 fatty acids have anti-inflammatory properties that may help to reduce some symptoms of Pedi IBD. Omega-3 fatty acids are found in

• plant oils (flax seeds)
• fish oils (sardines, herring, mackerel, bluefin tuna, salmon)

and can also be taken as a supplement in pill or liquid form.

It is important to remember that there are no conclusive studies that show a clear benefit in taking Omega-3 fatty acids, but they are considered safe with no side effects.

At the present time the data currently available does not prove benefit of complementary therapies in reducing the disease activity of Pedi IBD.