Although acute pancreatitis (AP) in children typically is caused by different etiologies compared to adults, it still can be associated with severe disease complications, including the risk of mortality. There is evidence in the adult medical literature that early feeding in AP is safe and beneficial; however, no similar studies have been done in children. The authors of this study (from 3 tertiary children’s hospitals in Australia and Israel) performed a randomized, controlled trial over 13 years looking at the efficacy and safety of early feeding for children with AP. AP was defined as consisting of abdominal pain consistent with AP, serum amylase and/or lipase ≥ 3 times the upper limit of normal, and abdominal imaging demonstrating AP. Patients with AP associated with organ failure or AP due to biliary obstruction, autoimmune pancreatitis, or trauma were excluded from the study. These pediatric patients were prospectively divided into 2 groups: 1) patients with AP who were fed a low-fat diet only when their abdominal pain resolved (while kept on IV fluid initially), when their amylase and/or lipase levels declined, or per the discretion of the providing physician and 2) patients with AP who were given an unrestricted diet as soon as possible (less than 24 hours after presentation). Patients in the unrestricted diet group were given nasogastric or nasojejunal tube feeds if they could not eat orally in less than 24 hours. All patients underwent chart review as well as twice daily Wong-Baker Faces Pain Rating Scale scoring. Additionally, all patients were monitored in terms of analgesic use, weight, daily caloric intake, and estimated energy requirement (EER). The primary outcome of the study was time to hospital discharge based on no pain noted on the pain scale, no analgesic use, and the patient being able to reach 75–100% of EER.
In total, 33 children between 2 and 18 years of age were recruited into the study for which 15 patients (45%) were in the initial fasting group and 18 patients (55%) were in the early feeding group. No difference existed between the two groups in regards to age, weight, serum amylase and lipase levels, and pain scores at presentation. The median time to starting feeds was significantly shorter in the early feeding group (19.3 hours) compared to the fasting group (34.7 hours). Additionally, there was an earlier ability of the early feeding group to reach at least 50% of and greater than 75% of EER although the difference was not significant. Only one patient in the early feeding group required partial use of nasogastric feeds initially and no patients in either group required long term nasogastric or nasojejunal feeds. Both groups were similar in regards to the time required before being pain free, weight throughout hospital admission, and final amylase and/or lipase levels. Of note, two patients in the initial fasting group were readmitted to the hospital for AP, and only one patient in the early feeding group was re-admitted to the hospital for diarrhea not related to AP. At follow up (median of 49 days), patients in the early feeding group had a significantly higher weight compared to the early fasting group which had a median loss of weight.
This study demonstrates that early feeding in uncomplicated pediatric AP is safe and effective and may have better long-term outcomes in regards to weight after hospital discharge. An early feeding regimen also requires less intervention and may reduce unnecessary healthcare costs.
Ledder O, Duvoisin G, Lekar M, Lopez R, Singh H, Dehlsen K, Lev-Tzion R, Orlanski-Meyer E, Shteyer E, Krisnan U, Gupta N, Lemberg D, Cohen S, Ooi C. Early feeding in acute pancreatitis in children: a randomized controlled trial. Pediatrics 2020; 146(3): e20201149.