Can FMT be a Successful Pediatric IBD Treatment?

While adults with inflammatory bowel disease (IBD) have been treated with fecal microbial transplant (FMT), the jury is still out on whether experts can perform the procedure safely in children.

Researchers from Ontario, Canada examined the existing adult and pediatric literature regarding FMT in IBD treatment to provide a comprehensive overview of FMT and its role in pediatric IBD. The researchers added that because FMT is often a successful treatment for recurrent Clostridium difficile (C. difficile) infection, the process has lately been applied to other diseases.

The study authors reported that only 45 pediatric patients have been treated for recurrent C. difficile infection and only 27 patients with IBD. The investigators also explored the features of the microbiome that could be linked to host response in FMT and potential challenges and opportunities for FMT in pediatric IBD.

The pediatric microbiome and pediatric IBD, are unique, especially because IBD could conflict and overlap with growth periods, bone accretion, and psychological development.

In four published case studies for the treatment of pediatric ulcerative colitis (UC) and Crohn’s disease (CD) using FMT, all three main routes of administration were used: serial enemas, serial enemas with supplementary colonoscopic administration, and nasogastric tube.

The first study showed that 6 of 9 patients maintained clinical response after a one-month follow-up period. In the second publication, comprised of 2 parts, 7 of 9 patients reached remission after 2 weeks, while 5 of those 9 patients maintained remission at week 6 and week 12. The ulcerative colitis patients involved in that study did not produce a clinical response. In the third study, with 3 patients, all reached remission by week 2. Those patients maintained remission by week 4.

“These studies suggest that serial treatment may be required to achieve an appreciable response in IBD patients, in contrast to single, or short-course FMT administrations in the treatment of recurrent C. difficile infection,” the study authors wrote. “This may reflect the chronic nature of IBD, vs. the acute changes that characterize secondary, infectious illnesses like C. difficile colitis.”

The researchers found that there are currently 12 pediatric studies registered on Clinicaltrials.gov; 3 of those trials are randomized, placebo controlled investigations. Canada’s first pediatric FMT trial is underway at McMaster Children’s Hospital, where their randomized controlled trial is using non-household anonymous donors.

In a 2016 meta-analysis of adult and pediatric FMT treatments for ulcerative colitis, about half of the 231 patients maintained favorable changes for more than 2 months. The researchers speculated that FMT success in IBD treatment might be linked to the recipient microbiome diversity, though this diversity can be manipulated through antibiotics and other similar IBD treatments.

The long-term side effects of FMT are unknown; however, one case report from 2014 discussed a patient who developed obesity after their daughter acted as the FMT donor. This finding was the first among human FMT scenarios in a clinical setting, though obesity is a known side effect among animal models of FMT. Other side effects described in recurrent C. difficile treatments of FMT included cramping, diarrhea, or nausea throughout a follow up period of 13 weeks.

“The existing literature on IBD therapeutics has disproportionately focused on medication therapies,” the study authors concluded. “As patients increasingly embrace ‘natural’ therapies, it is time we dedicate the funding and resources that have traditionally gone towards multi-center randomized controlled trials on immune modulators and explore microbial therapeutics for IBD care.”

The paper, “Fecal microbial transplant for the treatment of pediatric inflammatory bowel disease” was published in the World Journal of Gastroenterology.

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