What Is Known
- Acute pancreatitis is increasing in incidence in pediatrics.
- Management is extrapolated from adult guidelines.
- Data are lacking on nutrition management in pediatric acute pancreatitis.
What Is New
- Early feeds are feasible in acute pancreatitis in pediatrics.
- Early feeds were not associated with increase pain or longer hospital course in patients with acute pancreatitis.
- Early feeds did not cause further elevation of the serum lipase.
Pediatric acute pancreatitis (AP) is reported to be increasing in frequency in the last 2 decades (1,2). Management of pancreatitis in children is mainly extrapolated from adult studies, given the lack of data in pediatrics (3). Nutrition as an integral part of pancreatitis management is not adequately studied in children. The role of nutrition in the maintenance of gut barrier function, and enhancing the body's ability to lower the systemic inflammatory response and bacterial translocation is likely the mechanism by which it affects patients’ outcomes during episodes of pancreatitis (4,5). Adult studies have shown that early enteral feeding via oral, nasogastric (NG), or nasojejunal (NJ) routes are safe in patients with mild, moderate, and severe pancreatitis (5–8). Studies advocate for early nutrition typically within 24 to 48 hours to reduce complications, length of hospital stay, and mortality (4,6,9,10). Such comparative studies are not available in pediatrics. Data are scarce on the type of diet that is beneficial for AP management, although a low-fat diet is most widely implemented (11,12).
At our institution, management of nutrition is variable between providers given the lack of guidelines (12). The goal of the present study was to evaluate the effect of oral nutrition and fat content in the diet on the length of stay (LOS), pain severity, and the clinical course of the patients.
This is a retrospective chart review of our prospectively collected nutrition database on AP admissions to Cincinnati Children's Hospital Medical Center between May 1, 2014 and December 1, 2014. The study was approved by the institutional review board.
The inclusion criteria were AP was diagnosed in a patient younger than 20 years of age, who met at least 2 of 3 Atlanta criteria (14–17). Mild AP cases admitted to the gastroenterology or hospitalist service were included, as defined by lack of systemic complications, systemic inflammatory response syndrome (SIRS), multiorgan failure, or local pancreatic complications (hemorrhage, necrosis, pseudocyst) (16).
The exclusion criteria included severe AP on admission (16). There was 1 patient who was originally in the database as having mild AP on admission, but the patient developed vital signs instability requiring an intensive care unit admission and was excluded from the analysis.
Nutrition Database at Cincinnati Children's Hospital Medical Center
Patients’ intake was recorded as oral, enteral, or tube feed. None of the 38 admissions were associated with NG or NJ feeds. Data on patients’ overall calorie intake and calculated amount of fat in grams consumed daily were recorded. For data analysis we compared the fat intake based on fat per kilogram in 3 ranges (0–0.5 g · kg−1 · day−1; low, 0.5–1 g · kg−1 · day−1; normal, and >1 g · kg−1 · day−1; high).
During their hospitalization, patients’ pain levels were documented as mild-to-severe based on the patient and parent assessment and reported to the nursing staff every 4 hours. The highest pain level of the day was used for data analysis. Pain was evaluated using numeric scales ratings of pain: 0, none; 1 to 3, mild; 4 to 6, moderate; and 7 to 10, severe. Those ratings of pain were translated into 0—none, 1—mild, 2—moderate, and 3—severe for data analysis purposes.
To evaluate the relation between feeds and fat intake to pain, a generalized estimation equation method was applied, to account for within patient correlation, to model the ordinal pain severity scores (0–3 scale) in a logistic regression model, with proportional odds.
A linear regression model was applied to study the fat intake effect on (log-transformed) LOS. A 2-sample t test was applied to log LOS to study the effect of feeding versus nil per os (NPO) status on LOS. To study the effect of nutrition on lipase, a linear regression model with repeated measure was applied to study relation between lipase level and daily fat intake. Lipase was natural log-transformed. The results were considered statistically significant if adjusted P < 0.05.
There were 38 admissions that met the inclusion criteria of having mild AP during the study time period, with 33 unique patients. Data for total length of their hospital stay included 193 total patient days. Patients had enteral fat intake of under 0.5 g · kg−1 · day−1 for 128 days, enteral fat of 0.5 to 1 g · kg−1 · day−1 for 20 days, >1 g · kg−1 · day−1 enteral fat intake for 8 days. Patients were NPO for 24 days. There were 13 days with missing fat intake information. Patients’ demographic data are presented in Table 1. Etiologies for AP were systemic, viral, post-ERCP, genetic, trauma, and idiopathic as presented in Table 2, which shows the clinical comparisons between the early PO and the NPO groups.
Pain in Relation to the Feeds
An important aim of our study was to evaluate the pain severity between patients kept NPO and patients allowed to feed. Patients who received enteral feeds of any kind (clears, low fat, or regular diet) had similar pain severity scores compared with patients kept NPO (P = 0.21). Sex did not have a significant effect on pain severity scores (P = 0.18). Older age patients appeared to have a significantly higher pain severity scores (P < 0.001).
Pain Severity and Fat Content in the Diet
We aimed to study the association of daily fat intake (grams per kilogram) on the pain severity (none, mild, moderate, severe). A higher fat intake grams per kilogram per day was associated with significantly lower daily pain severity scores (P < 0.001). Pain severity scores in relation to fat content are shown in (Fig. 1).
Length of Stay
The average fat intake did not significantly affect the duration of LOS from regression analysis (P = 0.63). We further evaluated the association of being NPO during the first 24 hours with LOS, compared with patients who were allowed to eat on admission. Patients kept NPO within 24 hours of admission had a median LOS of 94.7 hours compared with patients that were allowed to eat within 24 hours of admission had a median LOS of 81.7 hours (P = 0.57).
Higher fat intake was not associated with higher lipase levels (P = 0.004) (Fig. 2). Days since admission had a significant association with lipase level. The longer the stay, the lower the lipase levels (P < 0.001) (Fig. 3). After adjusting for the day effect, there was no significant effect of fat intake on lipase (P = 0.117).
Although nutrition has an important role in the management of AP through maintenance of the gut barrier function and lowering the systemic inflammatory response (4,18), the gaps in knowledge remain when it pertains to the best practice in nutrition management in children with AP. The present study was designed to address some of these gaps, mainly the effect of early nutrition and fat content in the diet on pain and LOS in AP in pediatrics. Adult studies evaluating the effect of diet in AP on the LOS and pain severity have shown promising results (6).
Our study represents a unique attempt to evaluate the relation of nutrition with pain and LOS in pediatric AP. Pain is one of the main symptoms of pancreatitis, and tends to affect the providers’ decisions on allowing the patients to receive their daily nutrition (12). We evaluated the relation of feeds on the pain severity compared with patients that were kept NPO, and found no difference in the reported scores in pain severity between the groups that received feeds of any kind (low-fat, regular diet) compared with the group that was kept NPO. This is contrary to the school of thought that NPO, to avoid stimulating the pancreas, is the appropriate therapy for the management of AP. Another important observation from the present study is that the higher fat contents were associated with lower pain scores.
Our study aimed to answer questions about mild pancreatitis and did not include severe pancreatitis patients, as an initial attempt to study the role of nutrition in managing AP. Severe pancreatitis may affect the providers’ decision on the mode of nutrition, of NG/NJ, which is beyond the scope of the present study. There is a potential fear of feeding patients with severe pancreatitis, and demonstrating that it is safe in the mild group is one big step to change the culture from fasting or “resting the gut” for patients with pancreatitis toward offering feeds to patients who may actually feel ready to get feeds, but are not allowed because the managing practitioners may not be comfortable with feeding them. Along that line of evidence, Eckerwall et al (4) showed that LOS was shorter in patients with predicted mild AP when patients received feeds compared with the “conventional therapy with fasting” in a cohort of adult patients (4). Feeds did not affect pain severity. In our cohort, the mean LOS was shorter in patients on feeds compared with patients that were kept NPO on the first day of admission. This did not reach statistical significance, and the small sample size could be 1 factor contributing to these results. Another factor that could have impacted the small difference in LOS in our patients is that most patients (35 of the 38) were receiving feeds by hospital day number 2 (in the first 48 hours of the hospitalization) which is considered an early feeding regimen (18).
In regards to the serum lipase values we aimed to study if the fat intake in the diet has any effect on the lipase values. We showed that higher fat intake did not result in higher lipase values as someone may postulate it would. We also found that lipase trended down each day into the hospitalization, so the longer the days of admission as part of the recovery from an AP attack, the lower the lipase levels. Finally, from our analysis although higher fat intake appeared to be associated with lower lipase level, that effect is probably due to days (after admission) effect. Therefore, the association is not significant.
Our study is limited by the small sample size, and the retrospective nature. It, however, examines a novel concept (early feeds in pediatric AP), and sets a reasonable foundation to start feeds on pediatric patients with mild pancreatitis, and following their outcomes prospectively. At this point there is not enough evidence that low fat diet is needed for AP management, a question that remains important for future studies.
Nutrition as an integral part of AP management is understudied in pediatrics. Our data showed that feeds can be started orally, on admission, without increasing the pain severity and LOS. The fat content in the feeds did not seem to be associated with increased pain levels or the LOS in our cohort. Future prospective multicenter studies are needed to fill the knowledge gap in nutrition management for pediatric pancreatitis and mainly to answer the following: timing of the feeds, mode of nutrition, content of the feeds, necessity of the low-fat diet, and finally the outcomes of those interventions on AP management in pediatrics.
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