There Is No Iron in Human Milk.

in children. Only 41% of the cohort were on daily preoperative narcotics, so this cohort had less opioid dependence than is seen in adolescent and adults (6). Despite this relatively low rate of daily narcotic use preoperatively, patients required a median of 2 months to wean off of narcotics. At our center, we have had similar experience that younger children, with shorter duration of disease, often wean off of narcotics more quickly and recover from their chronic pain more easily. Regardless of opioid dependence, all of these children suffer from chronic pain before TP-IAT. Chronic pancreatitis significantly impairs quality of life in pediatric patients and in their parents (6). In our experience, psychiatric issues including anxiety, depression, and conversion disorder are common in older children and teenagers experiencing chronic pancreatitis; whether early intervention might alleviate or even prevent these serious morbidities is not known. Close collaboration with pediatric pain specialists is crucial for postoperative pharmacologic and nonpharmacologic pain management, and coping skills. The long-term psychological impact of severe chronic pain, missed school days, disruption of family life has not been systematically studied but should be in the future for these children. Adult studies have shown significant improvements in quality of life after TP-IAT that are independent of insulin dependence; this balance will be important to investigate in children (7). Despite the severity of these children’s pancreatitis, they had excellent islet yields—with almost all exceeding the 5000 islet equivalents per kilogram body mass that has been associated with high prevalence of insulin independence in previous reports (8). The relatively short duration of disease and Minnesota’s decades of experience with islet isolation are both key components of these islet yields. Following with the high islet yields, insulin independence rates were high—and seemed to be sustained over the reported follow-up period. Reported postsurgical follow-up time was relatively short, with most less than 5 years. Longer-term follow-up of this and other pediatric TP-IAT cohorts will be crucial, particularly in evaluating the sustainability of islets and insulin independence. Even over the relatively short follow-up period, it appears that 3 of the 14 patients that attained temporary insulin independence had to resume insulin. Two of 7 patients that had more than 3 years of follow-up had to restart insulin, and 1 of those 7 never came off of insulin (1). Continued monitoring of glucose tolerance, even in those off of insulin, is key for children who undergo TP-IAT. In Bellin et al’s cohort, hemoglobin A1c was elevated in 2 patients and borderline elevated in 75% of the cohort. Given their early onset of severe disease, these children would likely have progressed to insulindependent diabetes eventually without the TP-IAT. And even their insulin-dependent patients had some islet function, indicated by their C-peptide, which likely gave them some protection from the brittle diabetes that inexorably follows pancreatectomy without IAT. But careful monitoring for hyperglycemia and its consequences—whether or not it reaches the threshold for insulin dependence—will be important for optimizing the long-term health of these children.