Pain management in pediatric acute pancreatitis: An area of need

Pediatric pancreatology is an expanding field with a rise in publications and interest mirroring the rising incidence.1 Many have studied and reported the natural history of acute, recurrent acute, and chronic pancreatitis with a focus on etiology, genetic underpinnings, treatment modalities, and society impacts. The formation of the INSPPIRE Consortium2 has greatly advanced our understanding of both ARP and CP, yet the management of acute pancreatitis (AP) remains based on a combination of North American Society for Pediatric, Gastroenterology, Hepatology, and Nutrition guidelines,3 European Pancreatic Club (EPC)/Hungarian Pancreatic Study Group guidelines,4 expert consensus opinions, adult practices, and institutional care pathways. The mainstays of therapy have always relied on appropriate fluid resuscitation, early enteral nutrition, and, most importantly, appropriate pain management. Unfortunately, with all the progress made in understanding this complex disease in children, there has been a dearth of literature focusing on one of the most debilitating symptoms—PAIN. The adult literature has an abundance of reports and trials examining various modalities for analgesia in the acute and chronic setting. More recently a comprehensive meta-analysis by Cai et al. concluded that nonsteroidal anti-inflammatory drugs and opioids are equally effective in decreasing the need for rescue analgesia in adult patients with mild AP and that there continues to be a paucity of high-quality, prospective data looking at pain strategies in patients with severe AP.5 Unfortunately, there is still no current international consensus on the optimal analgesic approach for pain management in AP. Older guidelines suggest that the “use of intravenous patient-controlled analgesia (PCA) is advantageous”6-8 as it allows the patient to self-administer opioids and strike a balance between analgesia and side effects. This requires cognitive maturity to understand how to use PCA and poses challenges for younger children, particularly infants and toddlers, as well as pediatric patients with developmental delays. It is particularly concerning that, in the past, greater than 94% of surveyed pediatric practitioners would use morphine or related opioids as a first-line therapy in children with AP9 especially when there had been no studies examining the benefits/risks of opioid versus nonopioid analgesics or opioid-sparing therapies in pediatric AP. Sadly, not much has changed in the past decade. The lack of literature examining appropriate pain management in children with AP demonstrates a large gap in the understanding and management of this disease. While opioid therapies have remained the mainstay, especially in adult practice, we must be reminded of the societal implications. There is a growing and concerning national epidemic of opioid addiction and the current opioid crisis is just as prevalent in the pediatric population.10-12 To date, there are only three published studies focused on pain management in AP in children, none of which are prospective in nature. Each with its own shortcomings. In this issue of JPGN, Lucocq et al. review and report on the current literature and reaffirm the lack of data in this field. Following PRISMA guidelines for scoping reviews, the authors identified a total of three full-text articles describing pain management in 658 pediatric patients with AP. All studies were carried out in North America, retrospective in nature without any long-term follow-up and included patients both admitted to an inpatient service and/or were seen in the emergency room. While analgesia was used in up to 80% of patients with AP, rates of opioid usage varied from 44% to 71%. No clear association was reported between opioid administration and age, sex, ethnicity, or etiology of AP. Interestingly, the authors were able to abstract data suggesting that there has been a trend toward less opioid usage over time. A promising conclusion. Unfortunately, none of these studies report on opioid usage at the time of discharge nor comment on post pancreatitis complications. The authors have successfully highlighted and affirmed that the area of pain management in pediatric AP is grossly lacking. They astutely address this as well as the lack of long-term follow-up and metrics in these patients. The present article has done an excellent job at identifying significant gaps that exist currently and proposing areas for future targeted studies, that is, alternative modalities such as epidural anesthesia or nonmedical treatments, or examination of disparities in care to underserved populations. While this study brings to light the gaps that exist in this space, it unfortunately, does not provide enough compelling data to change current practice, something that is desperately needed. More prospective clinical trials examining optimal pain management in children and adolescents with AP are needed. The EPC has recently set up a working group on pain in pancreatitis and pediatrics features prominently. Challenges in completing these studies focus on proper recruitment and study design. It is hard to convince a parent whose child is actively in pain that they should be given an alternative therapy that may or may not control their symptoms. The authors are to be acknowledged for highlighting the importance of this topic. It will hopefully serve as an eye-opening reminder of where we are lacking and how much more we have to do to help treat our children with pancreatitis-associated pain. The authors declare no conflict of interest.