Nutritional management guidelines for pancreatitis—a commentary

The recent ESPEN practical guideline on clinical nutrition in acute pancreatitis (AP) and chronic pancreatitis (CP) is a very useful resource for directing clinical management of AP and CP (1). Screening for nutritional risks and proactive management of different nutritional aspects is an integral step in the care of patients with pancreatitis. Given the catabolic state, inflammatory state, the effect of diet on pain, the exocrine and endocrine derangements that accompany pancreatitis cases; studying evidence based nutritional modalities becomes essential. These guidelines included all the recommendations of the ESPEN guideline on clinical nutrition for pancreatitis that were published in 2020 (2), but also included summaries, flowcharts and diagrams of the recommendations. A total of 48 statements are included in the guidelines, with level of evidence and the grade assessment.

Although these guidelines are detailed, they are tailored more for the adult population, where more literature exists. It is worthy to note that the awareness of pediatric pancreatitis has increased over the past two decades (3). The incidence of pediatric AP and CP were 12.3/100,000 persons and 1.9/100,000 persons in 2014 respectively (4). Given the importance of the maintenance of optimal nutrition in the management of both AP and CP in children; the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Pancreas Committee have jointly released a position paper on nutritional considerations in pediatric pancreatitis (5).

Both pediatric and adult studies have shown improvement in AP outcomes with allowance of oral intake when feasible, or initiation of early enteral feeds. Therefore, we agree with nutritional screening and initiation of enteral feeds as quickly as possible in AP regardless of the lipase levels. However, so far in children, we have not recommended a low-fat diet in AP or CP, due to lack of evidence for need of a low-fat diet. In adult pancreatitis, the low-fat diet recommendation is also mostly applied in biliary causes or gallstone induced pancreatitis, or when exocrine dysfunction exists to limit the symptoms of maldigestion. There remains a low to no evidence that low fat diet is more helpful for pancreatitis compared to a general (well balanced and healthy diet). Single center studies have shown that interpretation of low-fat diet differs by dietitians and a lower fat dietary intake during mild AP attacks does not improve pain scores, length of hospitalization or lipase levels (6,7). Given this data, it is time to revisit the regular diet for age in pancreatitis cases, unless there is a clinical indication beyond pancreatitis for low fat diet, such as in cases of hyperlipidemia. The other knowledge gap is best practices in moderately severe and severe AP in children (8). Further, most of the recommendations do not have any available pediatric literature to support them and some of these include avoidance of a high fiber diet in children with CP, consumption of small frequent meals of up to 5–6 meals a day in patients with CP and use of a central venous access for short term parenteral nutrition.

In summary, current guidelines are helpful in nutritional management of pancreatitis. There is a lack of evidence to recommend a low-fat diet over a regular diet (well-balanced healthy) in adult related and in pediatric pancreatitis. Pediatric studies in nutritional management of both AP and CP are limited and are direly needed.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

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