Early Feeding in Acute Pancreatitis in Children: A Randomized Controlled Trial

Pancreatitis in cystic fibrosis: Presentation, medical and surgical management, and the impact of modulator therapies

Patients with Cystic Fibrosis (CF) are at increased risk of acute (AP) and chronic (CP) pancreatitis, and their complications. The extent of remaining healthy pancreatic parenchyma determines the risk of developing future episodes of pancreatitis, as well as pancreatic exocrine or endocrine insufficiency. Pancreatitis may be the presenting symptom of CF, and genetic testing is especially important in pediatrics. AP and recurrent AP are managed with intravenous fluid hydration and pain control, in addition to early refeeding and treatment of complications. With the use of modulator therapy in CF, pancreatic function may be restored to some extent. CP related pain is managed with analgesics and neuromodulators, with surgery if indicated in specific situations including TPIAT as a possible type of surgical intervention. Long-term sequelae of CP in patients with CF include exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy, fat-soluble vitamin deficiencies and associated metabolic complications such as bone disease/osteoporosis, pancreatogenic diabetes, and less commonly, pancreatic cancer. We review the presentation and etiologies of pancreatitis in CF patients as well as the management of AP and CP primarily in children.

Very early and early nutrition in children with pancreatitis-A randomised trial

OBJECTIVES

The aim of our study was to assess the impact of the very early introduction of refeeding on the course of acute pancreatitis (AP) in children. Additionally, we evaluated the effect of nutrition on inflammatory markers, including cytokines.

METHODS

This prospective randomised study was conducted in three university hospitals in Poland. Patients, aged 1-18 years with AP, were randomised into two groups: A-refeeding within 24 h of hospital admission (very early), and B-refeeding at least 24 h after admission (early nutrition). The severity of AP was assessed after 48 h. The serum concentrations of four cytokines (tumour necrosis factor α [TNFα], interleukin-1β [IL-1β], interleukin-6 [IL-6] and interleukin-8 [IL-8]) and C-reactive protein, as well as the activity of amylase, lipase and aminotransferases, were measured during the first 3 days of hospitalisation.

RESULTS

A total of 94 children were recruited to participate in the study. The statistical analysis included 75 patients with mild pancreatitis: 42-group A and 33-group B. The two groups did not differ in the length of hospitalisation (p = 0.22), AP symptoms or results of laboratory tests. Analysis of cytokine levels was conducted for 64 children: 38-group A and 26-group B. We did not find a difference in concentrations of the measured cytokines, except for IL-1β on the third day of hospitalisation (p = 0.01).

CONCLUSIONS

The time of initiation of oral nutrition within 24 h (very early) or after 24 h (early) from the beginning of hospitalisation had no impact on the length of hospitalisation, concentrations of TNF-α, IL-1β, IL-6 and IL-8, activity of amylase and lipase or occurrence of symptoms in children with mild AP.

Faster discharge with lactated ringers than normal saline in first 72 h of acute pancreatitis: A multicenter randomized trial

OBJECTIVES

Data driven strategies for acute pancreatitis (AP) in pediatrics are limited; adult data suggests lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes, but has not been studied in pediatrics. Our objective was to evaluate the efficacy of LR during the first 48 h of an AP episode compared with NS.

STUDY DESIGN

A multisite randomized controlled clinical trial, from 2015 to 2020 (Clinical Trials.gov NCT03242473). Patients were randomized to exclusively LR or NS for the first 48 h. Primary outcomes were serial C-reactive protein (CRP) values. Secondary outcomes included other lab values, time to feeds, length of stay (LOS), systemic inflammatory response syndrome (SIRS) development, and progression to severe AP (SAP).

RESULTS

We studied 76 patients (38 LR, 38 NS). CRP at 24 and 48 h were not significantly different between LR or NS group. Additionally, there were no differences in trends of BUN, amylase, lipase, SIRS status, or SAP development between the LR and NS group at 24 and 48 h. A higher proportion of LR patients (32%, 12/38) were discharged before 48 h compared to NS (13%, 5/38). The LR group had a significantly higher rate of discharge within the first 72 h compared to the NS group (p = 0.02).

CONCLUSION

The use of LR was associated with a faster rate of discharge during the intervention period and in the first 72 h, but no other differences compared to NS. This reduction in length of hospitalization has significant implications for patients and healthcare costs.

Acute pancreatitis in children: risk factors, management, and outcomes

PURPOSE OF REVIEW

Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis.

RECENT FINDINGS

Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis.

SUMMARY

The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.

The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents

Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

Nutrition management and pancreatitis in children: new insights

RECENT FINDINGS

Early initiation of feeds is safe and possible in mild to moderate pediatric acute pancreatitis (AP) and is not associated with increased pain or increased serum lipase level. Enteral nutrition within 48 h of admission compared to no feeds within 48 h (NPO) is associated with a significant reduction in length of stay, reduced progression to severe acute pancreatitis, decreased ICU transfers, and increased weight gain at follow-up. Early standard fat meals did not worsen pain or serum lipase levels in children with mild to moderate AP.

PURPOSE OF REVIEW

Nutrition is essential in the management of AP in children. Diet before, during, and after an attack of AP can affect outcomes. Here, we highlight recent advances that have been made in the last decade on nutritional interventions in pediatric acute pancreatitis and provide future directions for research.

SUMMARY

Early enteral nutrition is safe and feasible in pediatric mild to moderate AP and is associated with improved outcomes. There are only a handful of studies on nutritional interventions in pediatric mild to moderate AP. Further studies are needed to understand the effects of early enteral nutrition in pediatric severe AP.

Early Enteral Nutrition in Paediatric Acute Pancreatitis-A Review of Published Studies

Nowadays, nutrition is said to be an integral aspect of acute pancreatitis (AP) treatment. Early enteral nutrition (EEN) is safe and beneficial for patients. This was confirmed by clinical experience and can be found in guidelines on managing adults with AP. Furthermore, paediatric recommendations encourage EEN use in AP. However, paediatric guidelines are based exclusively on studies in adults. Therefore, we present a review of published studies on the time of nutritional interventions in children with AP. A search was independently conducted in April 2022 by two of the authors. Only full-text papers published in English involving children between 0-21 were considered. Only four papers met our inclusion criteria: one randomised-control trial (RCT), one prospective study with retrospective chart review, and two retrospective chart reviews. All studies supported EEN and there was no recommendation of any delay in its initiation. The results of all four papers suggested EEN with a regular, normal-fat diet. EEN is safe in children with mild or moderately severe AP and may decrease the length of hospitalisation. Unfortunately, all the conclusions are based on a small amount of heterogeneous data that are mostly retrospective. Future prospective RCTs are needed.

Nasogastric or nasojejunal feeding in pediatric acute pancreatitis: a randomized controlled trial

BACKGROUND

The aim of this study was to compare nasogastric (NG) feeding with nasojejunal (NJ) feeding when treating pediatric patients with acute pancreatitis (AP).

METHODS

We performed a single-center, prospective, randomized, active-controlled trial involving 77 pediatric patients with AP from April 2014 to December 2017. The patients were randomized into two groups: the NG tube feeding group (34 patients) and the NJ tube feeding group (33 patients). The primary outcome measures included the enteral nutrition intolerance, the length of tube feeding time, the recurrent pain of pancreatitis and complications.

RESULTS

A total of 62 patients with AP (31 patients for each group) came into the final analysis. No differences were found in baseline characteristics, pediatric AP score and computed tomography severity score between the two groups. Three (9.7%) patients in the NG group and one (3.2%) patient in the NJ group developed intolerance (relative risk = 3.00, 95% confidence interval 0.33-27.29, P = 0.612). The tube feeding time and length of hospital stay of the NG group were significantly shorter than those of the NJ group (P = 0.016 and 0.027, respectively). No patient died in the trial. No significant differences were found in recurrent pain, complications, nutrition delivery efficacy, and side effects between the two groups.

CONCLUSIONS

NG tube feeding appears to be effective and safe for acute pediatric pancreatitis compared with NJ tube feeding. In addition, high qualified, large sample sized, randomized controlled trials in pediatric population are needed.

Metabolism and energy prescription in critically III children

Optimal nutrition therapy can positively influence clinical outcomes in critically ill children. Accurate assessment of nutritional status, metabolic state, macronutrient requirements and substrate utilization allows accurate prescription of nutrition in this population. In response to stress and injury, the body undergoes adaptive physiologic changes leading to dysregulation of the inflammatory response and hyperactivation of the inflammatory cascade. This results in a global catabolic state with modification in oxygen consumption and macronutrient metabolism. A comprehensive understanding of the metabolic response is essential when prescribing nutritional interventions aimed to offset the burden of this adaptive stress response in the critically ill. In this narrative review we aim to provide a comprehensive review of the physiologic basis, recent literature and some emerging concepts related to energy expenditure and the practical aspects of energy delivery in the critically ill child. Based on the unique metabolic characteristics of the critically ill child, we aim to provide a pragmatic approach to providing nutrition therapy.

Nutrition and Acute Pancreatitis

Acute pancreatitis (AP) is an acute inflammatory process of the pancreas that is characterized by severe abdominal pain, elevated pancreatic enzymes, and pancreatic changes on abdominal imaging. AP is, by nature, an inflammatory process that leads to protein catabolism and an increased metabolic rate, highlighting the strong need for early nutritional support in the initial management of the disease process. The goal of nutritional support in acute pancreatitis is to correct the negative nitrogen balance to reduce inflammation and improve outcomes. Many trials and multiple systemic reviews and meta-analyses have examined the best modality, timing, and composition of nutritional support for acute pancreatitis. Early enteral nutrition has emerged as an important aspect of the clinical management of AP. This narrative review aimed to provide an overview of the clinical management of nutrition in acute pancreatitis based on the currently available data.