Pancreatic enzyme replacement therapy (PERT) in children with persistent diarrhea: avoidance of elemental diet need, accessibility and costs.

BACKGROUND AND OBJECTIVES: Persistent diarrhea has been proven to cause pancreatic exocrine insufficiency, due to decreased stimulation to the pancreas caused by prolonged mucosal injury. Pancreatic enzyme replacement therapy (PERT) given in conjunction to regular treatment is thought to be beneficial in replacing this pancreatic enzyme deficiency, avoiding the need of elemental diet. This study aims to evaluate the benefit of PERT in chil-dren with persistent diarrhea. METHODS AND STUDY DESIGN: This is a randomized, two double-blind parallel group, placebo-controlled clinical trial to evaluate the effects of pancreatic enzyme supplementation in persistent diar-rhea. Children age 6-60 months were recruited from pediatric inpatient and outpatient units of five hospitals in Jakarta. Subjects was randomly assigned to either pancreatic enzyme 8371 USP unit of lipase or placebo, 3 times daily for 1 month, as an adjunctive therapy to standard treatment. Subjects were then reevaluated at 2 weeks and 4 weeks interval after administration of enzyme or placebo. Variables observed were length of diarrhea after the start of intervention, change in serum prealbumin, and change in FE-1 between week 0 and week 4. RESULTS: Pan-creatic enzyme supplementation shortens the length of diarrhea by 7 days in the intervention group compared to placebo (p=0.019). Serum prealbumin and FE-1 shows trend that favors the intervention group, although not sta-tistically significant (p>0.05). CONCLUSION: PERT is clinically effective in reducing the length of diarrhea, thus minimizing the need, accessibility and costs of an elemental diet.

Pancreatic exocrine insufficiency in malnourished children and those with persistent diarrhoeae.

BACKGROUND AND OBJECTIVES: Persistent diarrhoea, a serious health problem, is closely related to malnutrition. Children with severe malnutrition have a 9-fold risk of death, and children with severe stunting have a 4-fold risk of death. Prolonged mucosal injury from diarrhoea causes reduced secretin and cholecystokinin secretion, which decreases stimulation to the pancreas, and is indicated by faecal elastase-1 levels. This further aggravates persistent diarrhoea and malnutrition because of the low levels of digestive enzyme production. This study evaluated the exocrine function of the pancreas in children with persistent diarrhoea and malnutrition. METHODS AND STUDY DESIGN: This study used a cross-sectional design to compare exocrine pancreatic function among children with persistent diarrhoea, children with malnutrition, and apparently healthy children as reference Children aged 6-60 months were selected from the inpatient and outpatient units of various general hospitals in Jakarta. Faecal elastase- 1 levels were used to determine exocrine pancreatic function. RESULTS: The median values of faecal elastase- 1 in children with persistent diarrhoea, children with malnutrition, and reference children were 743 (1-1503) mcg/g, 861 (17-2909) mcg/g, and 1210 (26-3000) mcg/g, respectively. A significant difference was observed in the faecal elastase-1 levels between reference children and those with persistent diarrhoea (p<0.001). However, no differences in the faecal elastase-1 levels were noted between malnourished and reference children (p>0.05). Children with both persistent diarrhoea and malnutrition showed mean FE-1 392.3±206.9 and median 419 (125- 593). CONCLUSIONS: Exocrine pancreatic insufficiency is found in children with persistent diarrhoea. Children with combined persistent diarrhoea and malnutrition have the lowest FE-1, to which persistent diarrhea has the most significant contribution.