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Acute Pancreatitis in Childhood
21
mortality compared to parenteral nutrition; these benefits were lost if enteral
nutrition was commenced 48 hours after admission [73]. It has been suggested
that enteral nutrition may better maintain integrity and function of intestinal
mucosa and reduce gut-origin sepsis [74].
Mode of delivery of enteral nutrition has been previously assessed in
adults with AP. Historically, nasojejunal feeds were felt to be safer than oral or
nasogastric (NG) feeds in the setting of acute pancreatitis by avoiding the
cephalic and gastric phases of pancreatic stimulation. However, nasojejunal
feeding requires tube insertion under radiographic or endoscopic guidance,
which exposes the child to radiation or general anaesthesia respectively.
Furthermore, recent studies in adult acute pancreatitis suggest that oral or NG
feeding with a low fat diet was safe and well-tolerated compared to
nasojejunal feeding [75-78].
A group in Cincinnati, US [79] reported, in a retrospective study of 38
admissions with mild pancreatitis, that children may start feeds on admission,
without increasing pain or the length of stay. The same group [69] reviewed
201 admissions before and after the implementation of adult-based
recommendations. Their data suggest that early enteral nutrition may improve
the outcome of paediatric acute pancreatitis (length of stay, rate of severe
acute pancreatitis, and rate of transfer to intensive care unit). The group
receiving enteral nutrition had a shorter length of stay, a reduced rate of severe
acute pancreatitis and a reduced transfer rate to intensive care unit.
Randomized controlled trials are needed to assess the administration of enteral
feeding in children.
A summary of these concepts is presented in Figure 1.
6.4. Other
The management of acute pancreatitis should include pain control,
treatment of the underlying condition and management of complications. Due
to the sparse paediatric data on the treatment of specific aetiology and
complications in paediatric acute pancreatitis, the management has been
inferred from adult recommendations.
In addition, in the recent review by Husain et al. [33], treatment
recommendations regarding hyperlipidemia, hypercalemia, chronic renal
failure, smoking exposure and medications were discussed. For biliary acute
pancreatitis, in a case series examining the timing of cholecystectomy, Lin et
Gilles Duvoisin and Chee Yee Ooi
22
al. [80] reported that early performance of cholecystectomy is safe. However,
larger, prospective and controlled studies are required.
Figure 1. Early enteral feeding and early aggressive intravenous fluid resuscitation,
illustrated concept.
Acute Pancreatitis in Childhood
23
CONCLUSION
Acute pancreatitis in children is a challenging clinical entity which
incidence is approaching adult acute pancreatitis. In addition, as children are
not “small adults,” this chapter tried to underline the specificity of this disease:
clinical presentation, variety of aetiology, management. One of the most
challenging aspects in studying this disease has been the relatively small
number of affected children in each centre, necessitating the establishment of
multicentre prospective studies to enhance our current understanding, in
general.
The search continues for a specific and effective treatment for acute
pancreatitis. Novel therapies have been used in animal experiments, such as
anti-secretory agents, protease inhibitors, probiotics, anti-inflammatory agents,
anti-oxidants, and anti-TNF-α agents. Recently, in predicted severe acute
pancreatitis in adults, pentoxifylline, a competitive nonselective
phosphodiesterase inhibitor and reported modulator of TNF-α activity, was
investigated in a randomized controlled double-blind trial [81].
There are many unanswered questions regarding the nutritional
management of paediatric acute pancreatitis also, including “Which patients
will benefit most from enteral feeding?”, “When can early enteral feeding
start?”, and “Which enteral route is the optimal route?”.
The knowledge of patients with genetic susceptibilities to pancreatitis is
increasing and novel genetic mutations are expected to be discovered.
However, for the majority of genetic cause of pancreatitis, this has not
translated to specific therapies based on the underlying genetic mutation to
date.
Nonetheless, there is optimism that this will change in the future. For
instance, alipogene tiparvovec [82, 83], the first gene therapy to be approved
anywhere in the world, is an adeno-associated virus serotype 1-based gene
therapy for adult patients with familial lipoprotein lipase (LPL) deficiency
(LPLD) who suffer from severe or multiple attacks of acute pancreatitis
(despite dietary interventions). The majority of LPLD cases are only
diagnosed in adulthood. Additionally, therapies that specifically target the
basic defect in the CFTR protein are also now available. Small molecules that
either increase the number or the opening time (‘open probability’) of CFTR
channels on the cell surface have now been identified and successfully trialled
in patients with cystic fibrosis [84, 85]. The effects of these therapies on
CFTR-related pancreatitis is unknown, including whether they increase or
decrease the risks of developing acute pancreatitis [86, 87].
Gilles Duvoisin and Chee Yee Ooi
24
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BIOGRAPHICAL SKETCHES
Name: (Keith) Chee Y. Ooi
Affiliation: Discipline of Paediatrics, School of Women’s and Children’s
Health, Faculty of Medicine, University of New South Wales, and Department
of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, Australia