Our study demonstrated that early EN and IVF had a good impact on the outcomes of pediatric SAP patients. EN combined with IVF treatment in these patients may reduce abdominal pain duration, time for recovery of food intake and LOS better than with NPO + IVF and NPO + no IVF. Our study found that EN and IVF could play important roles and should be recommended in the management of children with SAP.
There are several important studies suggesting that early EN in adults with SAP can lead to better outcomes [9–11], and this has been confirmed by a meta-analysis including five randomized controlled trials with 202 patients showing a reduced risk of infectious complications, pancreatic infections and mortality [12]. Similarly, another meta-analysis that included eight trials with 348 participants also found that EN was superior to parenteral nutrition in terms of complications and mortality [13]. EN may support the gut-mucosal barrier and reduce bacterial translocation, and thereby reduce the risk of infected peripancreatic necrosis and other serious acute pancreatitis outcomes [1]. Daily caloric requirements can be calculated on the basis of the patient’s weight and severity of illness, with the goal of improving serum nutritional parameters including prealbumin and albumin levels [1]. Although our study demonstrated the decrease in abdominal pain duration, time for recovery of food intake, and LOS of patients in the EN + IVF group compared with patients in the NPO + IVF group, we did not find any difference in complication rate and case fatality rate. The main reason might have been the limited number of cases in our study. Further studies should include more cases to determine the influence of early EN on complications and mortality.
Early resuscitation is also recommended in adult SAP patients considering that they could develop hypovolemia and have hypotension secondary to a systemic inflammatory response. Various fluid preparations are available for resuscitation such as lactated Ringer’s solution or hydroxyethyl starch solution. In adult patients with SAP, several trials have evaluated the influence of these two solutions on outcomes [11, 14, 15], but not all trials have drawn the same conclusion. Although the different types of fluid do not seem to affect the outcome and prognosis in adult patients with SAP, the consensus guidelines from the International Association of Pancreatology and American Pancreatic Association recommend lactated Ringer’s solution as the first choice for initial phase of resuscitation [16]. However, a consensus is still lacking for pediatric patients with SAP. Our study successfully demonstrated that early fluid resuscitation is better in decreasing abdominal pain duration, time for recovery of food intake, and LOS compared with no IVF. But future studies are also needed to explore which fluid type is more suitable for children with SAP. Moreover, in adult SAP patients, goal-directed IVF therapy with 5–10 ml/kg/h should be used initially until resuscitation goals are reached, but the dose of fluid resuscitation in pediatric patients with SAP is still unclear and needs to be standardized.
Our study has several strengths. Only a few studies have reported an association between early EN as well as IVF and outcome or prognosis in pediatric patients with acute pancreatitis [8]. To the best of our knowledge, there has been no pediatric study focusing on the role of EN and IVF in the outcome and prognosis of SAP. Our study is the first one to explore the influence of EN and IVF on the outcome and prognosis of children with SAP. In addition, we used several response variables including abdominal pain duration, time for recovery of food intake, and LOS to evaluate the outcomes, which are more objective and comprehensive.
Despite the clear strengths of our study, some limitations should be acknowledged. First, our study was a retrospective study. Besides the limitation from the retrospective nature of the analysis, we only retrieved the patients’ information in our HIS. The lack of follow-up could have lost sight of long-term complications. Secondly, because the complete HIS of our hospital has been developed since 2012, it is hard for us to get the full information regarding the demographic characteristics and treatment details of patients before 2012. Therefore, our study only included 40 children patients with SAP after January 1, 2012. The limited number of patients may underestimate the benefit of EN and IVF. In the future, we will collect more SAP cases and perform a prospective cohort study to evaluate the influence of EN and IVF on outcomes in pediatric patients with SAP.