A new study that compared adult patients with pancreatic disease starting when they were children with pediatric patients with pancreatic disease revealed remarkable similarities in the cause of the disease and progression to chronic pancreatitis.
The report was published in the Journal of Pediatric Gastroenterology and Nutrition by a large international, multicenter team, including members from Nationwide Children’s Hospital.
The investigators compared large multicenter registries of children and adults with pancreatic disease. The results indicate that for those who develop disease in childhood, irreversible damage to the pancreas (the definition of chronic pancreatitis), occurs in the late teenage years and early adulthood. This is a time when patients are transitioning in many aspects of their lives to adulthood and the healthcare transition from pediatric to adult-care is often difficult or unsuccessful.
“What this study highlights is that when we keep pediatric research and care completely separate from adult research and care, we are doing a disservice to those with diseases that happen to hit the 17 to 24-year-old population the hardest,” says Cheryl Gariepy, MD, associate professor of Gastroenterology and director of the Pancreas Center at Nationwide Children’s Hospital and coauthor of the manuscript. “By splitting up patients based upon age, we cannot fully understand the natural history of the disease or develop intervention strategies.”
The researchers compared the demographics, risk factors, disease duration, management and outcomes of 224 children from the INternational Study group of Pediatric Pancreatitis: In search for a cuRE (INSPPIRE) patient population and 1063 adults from the North American Pancreatitis Study2 (NAPS2).
Across the groups, the median number of emergency room visits, hospitalizations, and missed days of work/school were similar. Exocrine pancreatic insufficiency, which can result in maldigestion, was also similar. Alcohol and tobacco use were strong risk factors in the adult population. Diabetes was significantly more common in adults than in children. In children, obstructive factors and genetic risk factors were more common.
A secondary analysis compared NAPS2 subjects who had childhood onset with the INSPPIRE subjects (pediatric). This revealed that these two cohorts were more similar than the whole INSPPIRE and NAPS2 cohorts. In particular, in the pediatric group or in the adult group, patients started having acute pancreatitis episodes at around 9 years of age; however, the mean age at which children were diagnosed with chronic pancreatitis was 9.9 years and the mean age at which this subset of adults was diagnosed with pancreatitis was 19.5 years. They also had a similar frequency of genetic risk factors. These findings suggest environmental factors may become greater risk factors as children transition through their teens.
“A big problem we’re having is that a lot of kids are not getting the right sort of follow up when they transition to adult care,” says Dr Gariepy.
“I am currently working closely with the pancreas experts at Ohio State University to create an organized and thoughtful transition process for young adults to make sure that they get into adult pancreatology care. This will include transition readiness assessments and education tools to be completed in the later teenage years. Then we will follow up with them to ensure that they establish a relationship with an adult-care GI doctor within 6 months. We will pilot the transition program between Nationwide Children’s Hospital and The Ohio State Wexner Medical Center and then share it with other centers around the country.”
The authors note that second-hand smoke exposure may contribute to childhood pancreatitis; however, the association has not yet been tested. Of clinical significance, children and adults reported similar levels of pain, both in frequency and severity; however, children are more likely to participate in psychological and cognitive behavioral therapies, whereas adults are often prescribed pain medication for pain management. Therefore, the authors suggest that an increased use of pain scales and protocol medication management could improve pain control and that future studies on the adequacy of pain management and outcomes in both adults and children are needed.
Schwarzenberg SJ, Uc A, Zimmerman B, et al. 2019. Chronic Pancreatitis: Pediatric and Adult Cohorts Show Similarities in Disease Progress Despite Different Risk Factors. Journal of Pediatric Gastroenterology and Nutrition. 68(4):566-573. doi:10.1097/MPG.0000000000002279