Columbus, OH — February 2018
Historically, patients with acute pancreatitis would be kept without food by mouth (nil per os or NPO) until their physician team deemed them ready to eat again, usually based on blood tests or the reported level of pain. But a recent study from clinician-scientists at Nationwide Children’s Hospital reveals that pediatric patients both eat and go home sooner when they make the call on when to reintroduce food, rather than relying on the physician’s decision.
“Our most important finding was that pediatric patients with mild to moderate pancreatitis do not need to be kept NPO when they are hungry,” says Cheryl Gariepy, MD, director of the Pancreas Center at Nationwide Children’s and a member of the hospital’s division of Gastroenterology. She is also senior author on the recent study, which appeared in The Journal of Pediatrics. “Allowing children with pancreatitis to eat soon after admission to the hospital is a big change from the way most of us were trained.”
Food in the stomach stimulates the pancreas to produce digestive enzymes, so patients with pancreatitis historically were kept NPO to allow the pancreas to rest. About 15 years ago, however, studies in adults with severe pancreatitis revealed that patients receiving nutrition via a feeding tube recovered better than those who were not fed. This led to formal recommendations to allow oral feedings for adults with mild pancreatitis once nausea, vomiting and pain resolve.
Most pediatric pancreatitis is mild to moderate, and management has been guided by historical practice and studies done on adults; the dominant management approach is for the treatment team to decide when the patient is ready to eat.
“In my time caring for pancreatitis patients, it became clear to me that children were being kept from eating based on blood work or an ultrasound finding, when they really felt ready to eat,” says Dr. Gariepy, who is also an associate professor of Pediatrics at The Ohio State University College of Medicine. “Since studies had found nutrition into the gut was safe and resulted in a decreased length of stay among adults with severe pancreatitis, I became interested in finding out whether we could safely get our pediatric patients eating sooner.”
The clinical team recruited 30 patients for the prospective study and allowed them to decide when to eat, starting at the point of admission for a mild or moderate pancreatitis diagnosis. This patient-directed nutrition group was compared with retrospective cases of treatment team-directed nutrition for length of stay, duration of NPO, and development of complications within 30 days of hospital discharge.
The patient-directed nutrition group had a median length of stay of 48.5 hours, compared with 93 hours in the treatment team directed nutrition group. In addition, patients in the patient-directed nutrition group were NPO for a median of 14 hours, compared with 34 hours in the treatment team-directed nutrition group. No one in the patient-directed nutrition group developed complications within 30 days of discharge.
The team presented their findings in a symposium on pancreas disease last November at the annual meeting for the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). They have also used their findings to develop and promote the use of a new set of admission order instructions at Nationwide Children’s, allowing mild and moderate acute pancreatitis patients to eat from the point of diagnosis upon admission.
“The decision to feed a child who has pancreatitis should not be based on blood work,” Dr. Gariepy advises. “I don’t recommend using the historical standard of repeat blood tests to determine clinical care.”
Dr. Gariepy is a founding member of INSPPIRE, the International Study Group of Pediatric Pancreatitis: In Search for a Cure. She and her colleagues at the Nationwide Children’s Pancreas Center, along with the consortium’s other member institutions, are now helping to collect clinical data and blood samples for future studies in the field of pediatric acute pancreatitis.
Ellery KM, Kumar S, Crandall W, Gariepy C. “The benefits of early oral nutrition in mild acute pancreatitis.” The Journal of Pediatrics. 2017; 191:164-9.