Pancreatic Enzyme Replacement Therapy Dosing for a 20 kg Child
For a 20 kg child with pancreatic insufficiency, start with 500 units of lipase per gram of dietary fat consumed, not exceeding a maximum daily dose of 10,000 units of lipase per kilogram of body weight (200,000 units lipase/day for this child). 1
Weight-Based Dosing Algorithm
Initial dosing strategy:
- Start at 500 units of lipase per gram of dietary fat consumed at each meal 1
- Alternative starting approach: 2,000-4,000 units of lipase per 120 mL of formula or per estimated breast milk intake for infants, and approximately 2,000 units of lipase per gram of dietary fat in solid foods 2
- For this 20 kg child, the absolute maximum daily dose is 200,000 units of lipase (10,000 units/kg/day) 2, 1
Practical Dosing Examples
For typical meals in a 20 kg child:
- If consuming a meal with 10 grams of fat: give 5,000-10,000 units of lipase 1
- If consuming a snack with 5 grams of fat: give 2,500-5,000 units of lipase 1
- Distribute enzymes throughout the meal if using multiple capsules 3
Administration Technique
Critical timing and method:
- Administer enzymes during the meal, not before or after, to maximize mixing with food 3, 4
- For young children unable to swallow capsules: open capsule and mix enteric-coated microspheres with small amount of acidic food (applesauce) or expressed breast milk 2
- Never add enzymes directly to the child's bottle or feeding tube formula 5
- Enteric-coated microspheres are preferred over tablets for better efficacy and parent acceptance 2
Monitoring and Dose Titration
Assess treatment adequacy by:
- Monitoring growth parameters (weight, height) at every clinic visit 5
- Evaluating stool frequency, consistency, and presence of steatorrhea 4
- Checking for abdominal pain, bloating, and flatulence 4
- Measuring fat-soluble vitamin levels (A, D, E, K) regularly 4
If symptoms persist despite adequate dosing:
- Consider adding a proton pump inhibitor to improve enzyme effectiveness rather than simply increasing enzyme dose 2
- Verify compliance with taking enzymes during (not before/after) meals 3, 4
- Rule out other causes of malabsorption 4
Critical Safety Considerations
Absolute contraindication:
- Never exceed 10,000 units of lipase/kg/day (200,000 units/day for 20 kg child) due to risk of fibrosing colonopathy, a serious complication particularly in young children 2, 1
Common Pitfalls to Avoid
Frequent errors in pediatric PERT:
- Using over-the-counter enzyme supplements instead of FDA-approved prescription PERT formulations, which lack standardized dosing and verified enzymatic activity 3, 4
- Taking enzymes at wrong time (before or after meals instead of during) reduces effectiveness 3, 4
- Crushing or chewing enteric-coated microspheres, which destroys acid protection 5
- Inadequate dosing for high-fat meals leads to persistent symptoms 3
- Failing to adjust dose based on actual fat content of meals 4