TABLE 2.

Summary of recommendations

Category	Recommendation	Grade
Nutrition and endocrine	1. Patients with CP are at risk for macro- and micronutrient deficiencies. Patients should be monitored for growth and pubertal delay, dietary intake, and fat-soluble vitamin deficiencies. Growth and intake should be reviewed at every clinic visit, a minimum of every 6 to 12 months. Fat-soluble vitamin laboratory analysis should occur every 12 to 18 months or as clinically indicated	1B
	2. A multidisciplinary approach that includes a clinical pediatric dietitian is needed to adequately monitor nutritional status, evaluate nutrient intake and provide education and recommendations to help prevent both malnutrition and obesity	1C
	3. There is a clear role for PERT in children with CP who have EPI with steatorrhea, poor growth and/or nutritional deficiencies. PERT dosing for CP-associated EPI is similar to that used in patients with CF	1B
	4. Children with CP should be screened yearly for pancreatogenic DM with a fasting glucose and HbA1c level	1C
	5. Consider OGTT if pre-diabetes is present based on abnormal fasting glucose (100–125mg/dL) and/or HbA1c level (5.7%–6.4%). OGTT should be performed annually once a patient is considered to have pre-diabetes	1C
	6. Chronic pancreatitis patients with diabetes should be referred to a pediatric endocrinologist to optimize glucose management and determine if evaluation for other forms of DM should be considered	1B
	7. It is important to address clinical symptoms of malabsorption and PERT in children with CP and DM to improve glycemic control	1C
	8. Insufficient data exists to recommend the use of antioxidants as a treatment to prevent EPI or other disease progression in children with CP	2C
Pain management	9. Treatment of pain in pediatric CP requires a multidisciplinary approach, ideally involving a pediatric pain physician, pediatric gastroenterologist, psychologist, nurse, and physical therapist	1B
	10. Cognitive behavioral Therapy (CBT) should be considered in management of pediatric CP pain	1B
	11. Physical therapy may be considered as an adjunct therapy for pain management in children with CP	2B
	12. There is insufficient data to recommend PERT as therapy for pain in children without EPI	1B
	13. There is insufficient data to recommend antioxidants, steroids, leukotriene antagonists, or somatostatins in the management of pain for children with CP	2C
	14. Analgesic pain management in CP should follow an “analgesic ladder” that incorporates the layering of non-opioid and opioid medications. Ideally this should be directed by a pain specialist working in partnership with a pancreatologist or gastroenterologist	1B
	15. Neuromodulators may be effective in treating pain in children with CP as part of a multidisciplinary approach	1C
	16. Celiac plexus block for pain has not been shown to be effective in children with CP and cannot be recommended	1C
	17. Children with CP suffering from pain refractory to standard medical management should be evaluated at a center with pediatric experience in pain management	1C
Lifestyle modifications	18. On the basis of long-term adult data, providers should caution patients about the acute and chronic negative effects of alcohol abuse on pancreatic health	1B
	19. Health-care providers should caution patients about the dose-dependent response of tobacco smoking on the development and progression of CP among adult patients and should advise against smoking	1A
	20. Data are limited regarding the impact of weight and BMI on CP outcomes, as such, providers should counsel patients and parents about a balanced healthy diet and lifestyle	1C
	21. Administering a survey tool to assess QOL and/or functional assessment among pediatric patients to assess degree of impairment and drive targeted interventions indicated	2C
Sequelae of disease	22. The majority of pancreatic fluid collections will resolve spontaneously with supportive care. Intervention is reserved for complications from mass-effect, infection/necrosis or if spontaneous regression of the collection is thought to be unlikely	1B
	23. Children with CP that continue to exhibit abdominal pain, bloating or other GI concerns deserve an appropriate GI workup to evaluate for other etiologies that may explain their symptoms	1C

CP = chronic pancreatitis; DM = diabetes mellitus; EPI = exocrine pancreatic insufficiency; GI = gastrointestinal, OGTT = oral glucose tolerance test; PERT = pancreatic enzyme replacement therapy; QOL = quality of life.