The value of nutrition support in children with cancer

Malnutrition in paediatric patients with leukaemia and lymphoma: a retrospective cohort study

Introduction

Paediatric cancer is a potentially curable disease and its prognosis has been linked to several factors, such as nutritional status. The impact of malnutrition on these patients, either by overnutrition or undernutrition, varies and its relationship with outcomes is inconsistent. This study was conducted in order to determine the frequency of malnutrition in children with haematolymphoid malignancies at the time of diagnosis, as well as during treatment and to also investigate its relationship with the development of infections and death.

Materials and Methods

A retrospective cohort study of 191 children with a recent diagnosis of a haematolymphoid malignancy. The risks and nutritional classification were determined using anthropometry, follow-ups were conducted for up to 24 months and the presentation and frequency of infections and/or death were also recorded. Bivariate and multivariate analyses were conducted using binomial logistic regressions, for death and infection outcomes during follow-up. Survival analysis was conducted for various factors and types of cancer.

Results

83.7% of children had a sufficient nutritional classification at diagnosis, 6.8% had malnutrition by undernutrition and 9.4% by overnutrition. 83.8% had at least one infectious complication during follow-up and 47.1% had ≥ 3. This percentage increased to 69.2% when configuring it in the malnutrition by undernutrition group. 18.3% of patients died. When configuring the mortality, the percentage was greater in patients with Acute Myeloid Leukaemia (AML) (57.1%) and malnutrition by undernutrition (30.7%). The multivariate analysis for the outcome of death, only showed a statistically significant variable (AML odds ratio = 26.52; confidence interval = 1.09–643.24; p = 0.04).

Conclusion

No statistically significant relationship was found between the nutritional status of children with haematolymphoid neoplasms, and outcomes such as infections or death. The differences in the results obtained in these investigations may be related to the varied nutritional status definitions and the ways of measuring them, thus limiting comparisons between them.

A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective From Children's Oncology Group

Over the past few decades, great progress has been made in the survival rates of childhood cancer. As survival rates have improved, there has been an increased focus on supportive care. Nutrition is a supportive-care modality that has been associated with improved tolerance to chemotherapy, improved survival, increased quality of life, and decreased risk of infection in children undergoing anticancer therapy. Guidelines and assessment criteria have been proposed for the nutrition management of a child with cancer; however, there is no consistent use of criteria among institutions treating children with cancer. This review will present the current evidence and standards of practice incorporating aspects of nutrition, nursing, pharmacology, and psychosocial challenges to consider in the nutrition management of a child with cancer. Recommendations for clinical practice are presented.

Proactive enteral tube feeding in pediatric patients undergoing chemotherapy

BACKGROUND

To determine feasibility and safety of proactive enteral tube feeding (ETF) in pediatric oncology patients.

METHODS

Pediatric patients with newly diagnosed brain tumors, myeloid leukemia or high-risk solid tumors were eligible. Subjects agreeing to start ETF before cycle 2 chemotherapy were considered proactive participants (PPs). Those who declined could enroll as chart collection receiving nutritional standard of care. Nutritional status was assessed using standard anthropometric measurements. Episodes of infection and toxicity related to ETF were documented from diagnosis to end of therapy. A descriptive comparison between PPs and controls was conducted.

RESULTS

One hundred four eligible patients were identified; 69 enrolled (20 PPs and 49 controls). At diagnosis, 17% of all subjects were underweight and 26% overweight. Barriers to enrollment included physician, subject and/or family refusal, and inability to initiate ETF prior to cycle 2 of chemotherapy. Toxicity of ETF was minimal, but higher percentage of subjects in the proactive group had episodes of infection than controls. Thirty-nine percent of controls eventually started ETF and were twice as likely to receive parenteral nutrition. PPs experienced less weight loss at ETF initiation than controls receiving ETF and were the only group to demonstrate improved nutritional status at end of study.

CONCLUSIONS

Proactive ETF is feasible in children with cancer and results in improved nutritional status at end of therapy. Episodes of infection in this study are concerning; therefore, a larger randomized trial is required to further delineate infectious risks and toxicities that may be mitigated by improved nutritional status.

Children, cancer, and nutrition--A dynamic triangle in review

The overall cure rate for cancer in childhood now exceeds 70% and is projected to reach 85% by the year 2010 in industrialized countries. Therefore, major attention is being placed on reducing the side effects of therapy. However, 85% of the world's children live in developing countries, where access to adequate care often is limited and health status frequently is influenced adversely by prevalent infectious diseases and malnutrition. Despite several confounding factors (different definitions of nutritional status, the wide variety of measures used for its assessment, the selection biases by disease and stage, treatment protocols of variable dose intensity and efficacy, small sample sizes of the studies conducted in the last 20 years), it is accepted that the prevalence of malnutrition at diagnosis averages 50% in children with cancer in developing countries; whereas, in industrialized countries, it is related to the type of tumor and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukemia to 50% in patients with advanced neuroblastoma. The importance of nutritional status in children with cancer is related to its possible influence on the course of the disease and survival. Some authors have described decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, and poor clinical outcome in malnourished children. In this article, the authors review methods of nutritional assessment and the pathogenesis of nutritional morbidity in children with cancer as well as correlations of nutritional status with diagnosis, treatment, and outcome.

Basal metabolic rate in children with a solid tumour

OBJECTIVE

To study the level of and changes in basal metabolic rate (BMR) in children with a solid tumour at diagnosis and during treatment in order to provide a more accurate estimate of energy requirements for nutritional support.

DESIGN

An observational study.

SETTING

Tertiary care at the Centre for Paediatric Oncology, University Hospital Nijmegen.

SUBJECTS

Thirteen patients were recruited from a population of patients visiting the University Hospital Nijmegen for treatment. All patients asked to participate took part in and completed the study.

INTERVENTION

BMR was measured by indirect calorimetry, under stringent, standardised conditions, for 20 min and on three different occasions in all patients. Continuous breath gas analysis using a mouthpiece was performed. Weight, height and skinfold measurements were performed before each measurement.

MAIN OUTCOME MEASURES

BMR was expressed as percentage of the estimated reference value, according to the Schofield formulas based on age, weight and sex, and in kJ (kcal) per kg of fat-free mass.

RESULTS

At diagnosis, the BMR was higher than the estimated reference BMR in all patients and 44% of the patients were considered hypermetabolic. Mean BMR (as percentage of reference) was significantly increased (11.6% (s.d. 6.7%); P=0.001), but decreased during treatment in 12 of the 13 patients (mean decrease 12.7% (s.d. 3.9%); P<0.0001). Furthermore, a significant negative correlation (P=-0.67; P=0.01) was found between the change in BMR and tumour response.

CONCLUSIONS

These data suggest that the BMR of children with a solid tumour is increased at diagnosis and possibly during the first phase of oncologic treatment. This may be important when determining energy requirements for nutritional support.

Nasogastric tube feeding in children with cancer: the effect of two different formulas on weight, body composition, and serum protein concentrations

BACKGROUND

Treatment of cancer cachexia partly involves the administration of adequate amounts of energy. The aim of this study was to assess the tolerance and efficacy of two equal volumes of tube feeding, one with a standard (1 kcal/mL) and one with a high energy density (1.5 kcal/mL), during the intensive phase of treatment.

METHODS

Nutritional status was assessed weekly, in 27 children with a solid tumor, by measuring weight, height, midupper arm circumference, biceps and triceps skinfold, and serum proteins. Tolerance was assessed by recording the occurrence of vomiting and by expressing the administered volume as a percentage of the required volume.

RESULTS

Both formulas were equally well tolerated, leading to a significantly higher energy intake in the energy-enriched formula group. In both formula groups, all anthropometric variables increased significantly (range of mean increase, 5.2% to 25.5%; p < .05) during the first 4 weeks of intervention. Between 4 and 10 weeks, variables continued to increase significantly in the energy-enriched group, resulting in adequate repletion, in contrast to the standard formula group. The concentration of serum proteins, low at initiation of tube feeding, returned to the normal range within 2 to 4 weeks with no significant differences between the two groups.

CONCLUSIONS

The energy-enriched formula was more effective in improving the nutritional status of children with cancer during the intensive phase of treatment than the standard formula. Intensive, protocolized administration of an energy-enriched formula should therefore be initiated as soon as one of the criteria for initiation of tube feeding is met.

Short-term follow-up of the nutritional status of children undergoing autologous peripheral blood stem cell transplantation

A prospective longitudinal study was conducted to analyze the evolution of the nutritional status of 34 children (12 girls and 22 boys), aged 1.5-15.8 years (median age 9.06), undergoing autologous peripheral blood stem cell transplantation (PBSCT). The nutritional status was evaluated at baseline, days +1 and +7, discharge, and day +30 by dietary or parenteral intake, anthropometric and laboratory measurements, and nitrogen balance. At baseline, changes in anthropometric (53%) and biochemical measurements (83%) are frequent but mild. The mean caloric intake was normal. Children with normal values for the anthropometric parameters all had an intake > 80% (p < .01). No correlation was found between the anthropometric and biochemical parameters. During transplantation, significant changes (p < .001) were found for energy intake, albumin, transferrin, and nitrogen balance. Fibronectin, prealbumin, and retinol-binding protein showed only a few changes. All but prealbumin recovered on day +30. No correlation was found between the nutritional status and toxicity or infection in children undergoing autologus PBSCT. The changes in the nutritional status observed at the start of transplantation correlated with the nutrional intake. Anthropometric and biochemical changes are complementary. The results may be ascribable to the fact that the patients in this series had mild malnutrition.

Nutritional considerations in pediatric oncology

OBJECTIVES

To summarize the characteristics of a nutrition care plan for pediatric patients, specifically pediatric screening, assessment, and treatment protocols.

DATA SOURCES

Review articles, manuals, and textbooks.

CONCLUSIONS

Nutritional support of pediatric patients with cancer differs from adults because of their unique nutritional needs, their wide age range (infants to adolescents), and the psychosocial aspects of treating the entire family.

IMPLICATIONS FOR NURSING PRACTICE

To participate in the prevention and treatment of malnutrition in the pediatric patient with cancer, nurses require an understanding of nutrition care in this specialized population.

Nutritional status of children with solid tumors

BACKGROUND

The purposes of the study were to evaluate prospectively the nutritional status of children with solid tumors who were receiving chemotherapy, to find the most sensitive parameter of protein energy malnutrition, and to determine whether the stage of disease and aggressiveness of chemotherapy have any influence on nutritional status.

METHODS

Fifty patients were followed prospectively from the time of diagnosis throughout chemotherapy. Serum albumin, prealbumin, and weight were measured at the time of diagnosis and before each course of chemotherapy.

RESULTS

At diagnosis, only 2.7% of patients had albumin levels < 3.5 g/dL whereas 36% had prealbumin levels below the normal limit. All patients showed a weight increment of 81 g/day (P = 0.0001), an albumin increment of 0.001 U/day (P = 0.0001), and a prealbumin increment of 0.044 U/day (P = 0.0407). The change in prealbumin values was much more prominent (10-fold higher) in children age < 2 years. Changes in albumin values were not statistically significant by stage of disease but the increment of prealbumin did show statistical significance, which was most prominent in patients with Stage IV disease CCG (children's cancer group classification ) (P = 0.0003). The intensity of chemotherapy had no influence on changes in weight or albumin levels. However, it did influence changes in prealbumin levels, which were most pronounced in the group receiving high dose chemotherapy.

CONCLUSIONS

Based on the results of the current study, the authors believe prealbumin is the most powerful test overall with which to evaluate the nutritional status of children with solid tumors both at the time of diagnosis and throughout chemotherapy.

Nasogastric tube feedings in children with high-risk cancer: a pilot study

PURPOSE

To avoid the cost and complications of total parenteral nutrition (TPN), this study was initiated to determine the feasibility of administrating nasogastric tube feedings in children receiving intensive chemotherapy (CTX) or bone marrow transplantation (BMT).

PATIENTS AND METHODS

Seventeen children (aged 2 to 19 years) were entered into the study. Continuous nasogastric feedings of a glutamine-supplemented elemental diet were administered during CTX and at the time of rehospitalization for fever, neutropenia, and mucositis.

RESULTS

Fourteen children were treated with CTX and 3 with BMT. Enteral tube feedings were administered for 216 days; each patient received a mean of 12.7 days. The tubes were generally well tolerated, and there were no instances of sinusitis or epistaxis. Six children received TPN in addition to enteral feedings. The hospital charges for the enteral feedings were $25,348, compared to $112,299 for the same number of days of TPN.

CONCLUSIONS

Nasogastric tube insertion and enteral tube feedings in children receiving intensive CTX or BMT can be accomplished with minimal complications and significant cost savings when compared to TPN.

Total parenteral nutrition and home parenteral nutrition: an effective combination to sustain malnourished children with cancer

A patient with Wilms' tumor and severe failure to thrive required total parenteral nutrition (TPN) for "catch-up" growth. This case underscores how TPN might be useful in the management of a child with cancer. Cancer cachexia, chemotherapy, radiation, and infections caused by immune suppression can lead to potentially serious macro- and micronutrient deficiencies.

Psychological preparation for nasogastric feeding in children

Psychological preparation of children undergoing enteral nutrition by nasogastric tube was evaluated in a prospective study of 48 children nursed at home. They were randomly allocated to receive either standard informal preparation or detailed psychological preparation and support. The children were divided into two groups according to age: group A comprised toddlers and younger children aged 2-6 years and group B comprised older children and adolescents aged 7-16 years. Detailed questionnaires were administered to all parents and older children by dietetic colleagues who were blinded to the type of preparation received by the children. The results emphasize that detailed psychological preparation of families takes time. Passage of a nasogastric tube was seen as very distressing to both parents and children. Having a nasogastric tube was perceived as a major problem by group A. There was no statistical difference in the effects of enteral nutrition between younger children who received routine preparation and those who received detailed preparation; however, parental assessment of their child's behaviour was the sole means of determining how the younger child felt and reacted. In group B, there were marked differences: scores suggested that those who received detailed preparation had been better prepared for enteral feeding in hospital and at home and that the passage of the nasogastric tube, although unpleasant, was less distressing to them (P < 0.05). Talking to a nurse and play therapist was seen by parents as essential (P < 0.05). The authors conclude that children should be prepared for painful procedures and followed up sensitively, according to their needs.

Nutritional and treatment-related characteristics of pediatric oncology patients referred or not referred for nutritional support

Nutritional problems often result from malignancies and aggressive multimodal treatment. Early identification of reliable risk factors associated with malnutrition and need for nutritional support is necessary for development of preventative approaches. Nutritional and treatment-related characteristics were examined for 173 pediatric oncology patients referred for nutritional support and a comparison sample of 43 patients matched on treatment protocol and/or diagnosis who had never been referred for nutritional support. Abnormally low serum albumin levels, poor oral intake, mucositis, prior radiation therapy, and increased gastrointestinal toxicity were significantly more frequent among referred than non-referred patients. A discriminant function analysis indicated that poor oral intake was the single best predictor of need for nutritional support. Patients with solid tumors were more nutritionally depleted at the time of referral; all bone marrow transplant patients received nutritional support. Patients with central nervous system (CNS) tumors required nutritional support for longer time periods. We conclude that routine documentation of poor oral intake (i.e., observation of change in a child's eating patterns) is the most reliable indicator of children who eventually require nutritional support and who may benefit from interventions that could delay or prevent nutritional problems. Prophylactic interventions should be tailored to meet the specific needs of individual diagnostic groups.

The nutritional response to home enteral nutrition in childhood

The nutritional response to home enteral nutrition (HEN) was evaluated in a prospective study of 44 consecutive children (median age 48 months) who received HEN for more than 1 month (median duration 6 months). Three groups were studied: 17 children were stunted, 14 were wasted and 13 were adequately nourished but unlikely to maintain oral intake during anticipated nutritional stress. In the stunted group (median duration of HEN 15 months) there was a significant correlation between improvements in height-for-age z scores and duration of feeds (r = 0.63; p = 0.006). In the wasted group (median duration of HEN 4 months) all anthropometric indices improved significantly (p < 0.05). HEN was also successful in maintaining nutritional status in the third group. Thus, supplementary HEN is an effective method of nutritional support for a variety of indications, provided concurrent advice from a nutritional care team is available.

Nutritional support of the child with cancer

The purpose of this article is to outline how the disease, treatment, and psychological state of a child with cancer impact on the child's nutritional status. The methods of assessing nutritional status, including anthropometric measurements, laboratory indices, clinical observation, dietary assessment, and psychosocial evaluation, are summarized. After nutrition assessment, the pediatric oncology nurse and the dietitian, along with the oncologist, the family, and the child, develop a plan of care. The specific roles of the pediatric oncology nurse and dietitian in the nutrition intervention are described.

The prognostic significance of basic anthropometric data in children with advanced solid tumors

In pediatric cancer patients, malnutrition is commonly observed. This may represent the metabolic effect of the primary disease or it may be a consequence of multimodal therapy. This report evaluates the efficacy of using basic anthropometric measurements to predict morbidity during therapy. Twenty children with Wilms' tumor (Stage III, IV, and V) or neuroblastoma (Stage IV) diagnosed at Children's Hospital (Columbus, OH) between January 1983 and December 1985 were evaluated. When compared with the Wilms' tumor patients, the children with neuroblastoma had a significantly lower weight for age at diagnosis. At the completion of therapy, both weight-for-height and weight-for-age measurements were statistically lower in the neuroblastoma group (p less than 0.05). Significant differences were observed between the neuroblastoma and Wilms' tumor patients in the morbidity reported during therapy. Children with neuroblastoma had more frequent hospital admissions, spent a much greater proportion of their treatment time as hospital inpatients, experienced longer delays in therapy, and sustained many more complications. Each of the anthropometric indices was evaluated as a predictor of the complications observed during treatment. In the Wilms' tumor group, the patients with lower weight-for-height percentiles had an increased incidence of incomplete drug infusions, many more complications, more frequent hospital admissions, and an increase in the percentage of time spent as hospital inpatients. In the neuroblastoma group, the anthropometric measurements had no correlation with the subsequent development of complications. Nutritional staging based on anthropometric measurements recorded at diagnosis may be useful in predicting an increased risk of morbidity during therapy in children with Wilms' tumor.

Nutrition, infection, and morbidity in leukemia

Seven of the 25 children with acute leukemia were malnourished on admission. Of the 11 children who presented with fever, 6 had protein energy malnutrition and a bacterial infection was confirmed. They had a lower total leucocyte count. Out of 18 well-nourished children, 5 presented with a fever and the causative organism was isolated in 1 patient. There were more patients with a palpable liver in the malnourished group, and they had a high morbidity due to infections during remission induction.

Indicators of malnutrition in leukaemic children

In 24 children with acute leukaemia a low serum albumin concentration (31 g/l or less) and a median weight:height ratio of less than 0.95 on admission were indicators of severe weight loss.