Counselling advice- Yes. IBD is a life-long disease. Even if the patient is in remission phase (without symptoms), IBD medicines prescribed by the treating physician need to be continued. IBD can be managed well with specific class of medicines (including supportive treatments) and few dietary and lifestyle modifications which include low residue, low fiber diet balanced in vitamins and minerals and regularly following some stress management techniques with abstinence from smoking and alcohol.

Counselling advice- Generally there are no specific dietary restrictions for an IBD patient. Any specific trigger foods that cause IBD symptoms/flare-ups can be easily avoided by patient himself by self-monitoring his diet. In case of flare-ups a low residue, low fiber diet is advisable.

There are certain types of foods which can be avoided in case of flare-ups like-

• Caffeine in coffee, tea and other beverages, chocolates.
• Fresh fruits and fruit juices, uncooked vegetables.
• High-fiber foods (such as fiber-rich breads, cereals, nuts and leafy greens).
• High sugar foods, skins, seeds, nuts, prunes, corn, popcorn.
• High fat foods, spicy foods, raw foods.
• Beans and lentils.
• Red meat, large food portions.
• In some cases dairy products, ice-cold liquids are not tolerated well.
• Some vegetables such as cauliflower and broccoli that are gas producers and can cause abdominal distention and discomfort.

Foods that are considered safe during a ‘Flare’ are-

• Soft, low fiber breads and grains.
• Some fruits are going to be okay —the ones that are skinless and seedless.
• Choose well-cooked vegetables and fruits.
• The protein foods chosen need to be healthy and low in fat.
• Maintaining hydration is very, very important during a flare because you could have a lot of fluid loss due to persistent diarrhoea.

However, some people who follow the above guidelines may still continue to experience abdominal cramping following eating. In these cases, supportive medications may be helpful. If the normal method of eating food by the mouth is not allowing enough nutrients to be absorbed, then other methods of getting nutrients must be used. These methods include enteral nutrition (special formulas which can be easily absorbed by intestines ) and parenteral nutrition (nutrition provided through intravenous route which enters into blood directly). This type of liquid nutrition prescribed by the doctor is particularly helpful for children with IBD to ensure adequate nutrition when the appetite is poor and growth is a major concern. Certain types of enteral nutrition (through oral/ feeding tube), such as elemental formulas (simple nutrients which can be easily absorbed by inflamed intestines), can decrease inflammation in Crohn’s disease. When extra nutrie nt-rich calories are needed, supplemental nutrition may also be obtained by formulas prescribed by the doctor that contain a balance of protein, carbohydrates, fat and vitamins. Parenteral nutrition (through IV route) may be needed when a flare is too severe, medical therapy alone is not enough and bowel rest is needed. This form of nutrition may also be needed in Crohn’s disease patients who are severely malnourished or who have short bowel syndrome (short gut causing malabsorption). Do ask your doctor about enteral nutrition formulas suitable for your case.

Counselling advice- Most IBD patients experience fatigue and weakness due to recurrent diarrhea’s and loss of fluids. Malnutrition and delay in growth is a concern for children with IBD. Correction of nutritional deficiencies (by supplemental nutrition i.e vitamin B12, folic acid, Zinc,calcium and vitamin D) and a balanced diet plan can reduce inflammation in digestive tract and help in better absorption of food from the gut along with prescribed medications for IBD. This would help in early remission and prolonged flare- free period. In case of flares, apart from dietary modifications and advised medications, here are some few helpful tips to tide over fear/embarrassment due to soiling of clothes in public places-

Carry this in your purse/backpack:

• Toilet paper.
• Wet wipes.
• Powder.
• Hand sanitizer.
• Small can of air freshener.
• Disposable gloves (to handle any soiled clothes).
• Large-sized freezer bags (for the soiled clothes).
• Clean underwear, Clean shorts, pants, or leggings (anything that you can wear until you get home).

Advice to patients to manage IBD discomfort includes:

• To reduce anal irritation, use a moist toilet tissue or wipe instead of dry bathroom tissue.
• Practice good anal hygiene by showering with a hand shower or using a perianal cleansing product.
• Apply an all-purpose skin protectant at night to relieve irritation of the skin around the anus.
• For anal soreness or pain due to an anal fissure (small tear in the lining of anus) or fistula (opening in the skin near the anus that leads into a blind pouch or may connect through a tunnel with the rectum), bathe the buttocks in warm salt water (sitz bath).
• To help manage diarrhoea, anti-diarrheal OTC medications may be effective. DO NOT take any of the drugs without consulting a doctor or health care provider.
• For joint-related discomfort, recommend resting the affected joint as well as the occasional use of moist heat. Range of motion exercises, as demonstrated by a physical therapist, may also be helpful.
• To reduce the irritation of small mouth ulcers , medicinal mouth washes may be helpful along with a balanced diet and a multi-vitamin/mineral supplement.
• To help manage the symptoms of pain, acetaminophen may be the safest option for IBD patients. Consult with your health care provider about the appropriate pain management options.
• You definitely can live a normal healthy life. Remember to take care of yourself. Get plenty of sleep, eat well, and take time to recharge and reduce stress.

Counselor needs to provide enough reassurance and psychological counselling to all depressed patients. Reinforce positive behavior and ensure adherence to medications prescribed by the doctor.

General tips on treatment of IBD in children:

• Choice of formulation: Small children may have problems swallowing tablets. Do not crush tablets without consulting the treating physician or pharmacist first as some tablets get damaged this way. Some forms of medicine are also available as mixtures and some tablets can be dissolved in fluid or are available as small grains that are easier to swallow. Consult with doctor for changing the prescribed formulation/medicine.
• Taking medicine regularly: Younger children need their parents/care-givers to help them to take their medication. As the child gets older, it is important that they play an active role in managing their condition and learn to take their medicines themselves. But when things are going well, it isn’t always easy to remember to take the preventive medicine. If your child often forgets to take their medicines speak to your doctor to see if there are other treatment options available, as some medicines for IBD can be taken just once daily.
• Support with side effects: Steroids (e.g. Prednisolone) are often used for IBD flare-ups.Although these are very effective, the side effects (increased appetite, rounder face and stomach, mood swings, tendency to sweat and spots) can make them very unpopular especially with teenagers. It is therefore important to remind your child that his or her appearance will return to normal when the treatment has finished. Steroids are generally only used to manage flare-ups, but their side effects mean that they are not often used long term.
• Alternative treatments: You may want to try alternative treatments or a special diet.Always let your doctor know what alternative treatment your child is receiving as they may be able to advise you. For example, a special diet for adults with IBD patients may be unbalanced or too low in calories for a growing child.
• Vitamins and minerals: A combined daily vitamin and mineral supplement is advisable regardless of whether the disease is active or inactive. Your doctor will let you know if specific supplements are needed.
• Ensure that they are following a healthy eating plan.
• Help them during a flare-up by being supportive and maintaining a positive attitude as well as physically taking care of them.
• Ensure they are taking the right medication at the correct dose depending on whether they are in remission or a flare-up.
• Set up regular check-ups.
• Inform their school and parents of friends in case of absentees.
• Help your child to find language comfortable to them if they need to explain the condition to others.
• Ensure that adequate provisions are made during school trips/holidays.

Whether the person you are caring for is an adult or child, you can:

• Listen and lend a sympathetic ear: Be a good listener. Give them your full attention and let them express their feelings.
• Offer encouragement about how they are coping with their symptoms – this will help get them through times when they are experiencing flare-ups or feeling overwhelmed by their illness.
• Ask them what they need from you – and be prepared to give them some space if that is what they need at that time.
• Be understanding if they are feeling unwell or tired, are constantly visiting the toilet or have any other distressing symptoms or emotions associated with IBD.
• Keep a good sense of humour – it can be helpful to help them see the funny side of things and have a good laugh together.
• Get involved and be their ‘second pair of ears’ (if it is your child who has IBD, you would no doubt be doing this already).
• Help them to ask questions during medical appointments and discuss the information covered after medical appointments together.
• Offer practical help with shopping, cooking, childcare, etc when they are unwell.
• Offer to tell others about the illness so they won’t have to keep explaini ng it. However,ask your family member or friend if this is okay – they may only want a select few to know the details.
• Check out local face-to-face and online support groups that are available to help.
• Help and encourage with lifestyle changes such as:

1.   Avoid smoking when you are around someone with IBD; cigarette smoke can worsen the symptoms of IBD.

2.   Eat healthy – a diet with plenty of fresh fruit and vegetables, wholegrains and healthy fats, and avoiding processed foods, will be       good for both of you.

3.   Avoid foods that trigger symptoms – if you notice that some foods seem to make diarrhoea worse, reduce the amount of these       foods in the diet.

4.   Encourage them to limit alcohol intake, as it can exacerbate a flare-up.