Nutritional support of children with neoplastic diseases

Poor Diet Quality in Children with Cancer During Treatment

Background: With improved long-term health outcomes and survivorship, the long-term nutritional management of childhood cancer survivors, from diagnosis to long-term follow-up, has become a priority. The aim of this study was to examine the diet quality of children receiving treatment for cancer. Methods: Participants were parents of children with cancer who were receiving active treatment and not receiving supplementary nutrition. A 24-h dietary recall assessed food and nutrient intake. Serves of food group intakes and classification of core and discretionary items were made according to the Australian Dietary Guidelines and compared with age and sex recommendations. Results: Sixty-four parents participated (75% female). Most children were not consuming adequate intake of vegetables (94% of patients), fruit (77%), and milk/alternatives (75%). Of the vegetables that were consumed, half were classified as discretionary foods (e.g., chips/fries). Nearly half (49%) of children exceeded recommendations for total sugar intake and 65% of patients had an excessive sodium intake. Discussion: Children receiving cancer treatment are consuming diets of reasonable quantity, but poor quality. Information provided during treatment should focus on educating parents on a healthy diet for their child, the importance of establishing healthy eating habits for life, and strategies to overcome barriers to intake during treatment.

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.

Neuroblastoma, body mass index, and survival: a retrospective analysis

Extremes of body mass index (BMI) at diagnosis of childhood cancers have been associated with poorer prognosis. The aims of this retrospective review were to examine the growth and BMI status of children diagnosed with neuroblastoma (NB) and determine if BMI status at diagnosis affected survival. Between 1985 and 2005, 154 children were diagnosed with NB at Sydney Children's Hospitals Network (Westmead), Australia, of which 129 had both length/height and weight recorded in the medical records at diagnosis. BMI was calculated and children were classified as underweight (BMI <15th percentile), normal weight, and overweight (BMI >85th percentile). Disease stage was classified according to the International NB Staging System. At diagnosis, 24.0% of the children were classified as underweight and 11.6% were overweight. Six months after diagnosis all children except those with stage 4s disease had a decrease in BMI z-score; difference in estimated marginal mean -0.73, P < .001. After 12 months an increase in BMI z-score was observed and by 2 years BMI z-score was significantly higher than BMI z-score at baseline; difference in estimated marginal mean 0.81, P = .007. At the last follow-up (median 5.6 years [range 3-7] after diagnosis) the proportion of children who were classified as underweight decreased to 8.7% and the proportion of children who were classified as overweight increased to 27.5%. The overall survival rate was 61.2%; however, BMI status did not predict survival. In multivariable Cox regression modeling, stage at diagnosis was the only predictor of survival; children diagnosed with stage 4 were less likely to survive (hazard ratio [HR] [95%CI]: 7.02 [1.7-29.0], P = .007). Almost a quarter of children with NB were underweight at diagnosis. However, we did not demonstrate a prognostic association between BMI status and survival. The high proportion of children who were classified as overweight at follow-up indicates a need for nutritional interventions to prevent potential late effects.

Nutritional status and dietary intake of children with acute leukaemia during induction or consolidation chemotherapy

BACKGROUND

The assessment of nutritional status among paediatric patients is important for the planning and execution of nutritional strategies that strive to optimise the quality of life and growth among sick children. The present study aimed to evaluate the nutritional status and dietary intake among children with acute leukaemia.

METHODS

This cross-sectional study included 53 paediatric patients aged 3-12 years old, who were diagnosed with either acute lymphoblastic leukaemia or acute myelogenous leukaemia and were undergoing chemotherapy treatments (induction or consolidation phase). Patients were matched for sex, age (±6 months) and ethnicity with healthy children as controls. Weight, height, body mass index, waist circumference, mid-upper arm circumference, triceps skinfold thickness, mid-upper arm muscle area and fat area were determined. Dietary intake was assessed using 3-day food records.

RESULTS

Anthropometric variables were generally higher among patients compared to controls, although the differences were not statistically significant (P > 0.05). The prevalence of overnutrition among patients according to body mass index-for-age, waist circumference-for-age, mid-upper arm circumference-for-age and triceps skinfold-for-age were 24.5%, 29.1%, 17.0% and 30.2%, respectively. Mean energy [5732 ± 1958 kJ (1370 ± 468 kcal) versus 6945 ± 1970 kJ (1660 ± 471 kcal), P < 0.01], protein (50.0 ± 19.7 g versus 62.3 ± 22.3 g, P < 0.01) and fat (43.6 ± 18.9 g versus 58.3 ± 16.7, P < 0.001) intakes of patients were significantly lower than controls.

CONCLUSIONS

The prevalence of being overweight and obesity in children with acute leukaemia was higher despite lower energy intake compared to controls. Studies assessing physical activity, the complex interaction and the effects of treatment drugs are warranted to better manage malnutrition among paediatric patients.

Important aspects of nutrition in children with cancer

Adequate nutrition during cancer plays a decisive role in several clinical outcome measures, such as treatment response, quality of life, and cost of care. However, the importance of nutrition in children and young adults with malignancies is still an underestimated topic within pediatric oncology. The importance of our work is to reinforce and indicate that malnutrition in children with cancer should not be accepted at any stage of the disease or tolerated as an inevitable process. Unique to our manuscript is the close collaboration, the exchange of knowledge and expertise between pediatric oncologists and a nutritional specialist, as well as the comprehension of the mechanisms during cancer cachexia and malnutrition. We provide a critical review of the current state of research and new knowledge related to nutritional management in childhood cancer.

Nutritional problems in children treated for medulloblastoma: implications for enteral nutrition support

BACKGROUND

The aim of this study was to identify the nature and severity of nutritional problems associated with the current treatment of medulloblastoma and to identify any risk factors for nutritional morbidity during treatment.

PROCEDURE

A multicentre retrospective audit of medical and dietetic notes of 41 children treated for medulloblastoma in three UK paediatric oncology centres was undertaken. Data on nutritional status, nutritional support, mutism, swallowing and common toxicity criteria (CTC) scores for vomiting, constipation and mobility were collected at defined points in treatment from diagnosis until 12 months post-treatment.

RESULTS

Significant problems including weight loss, vomiting and constipation were highlighted early on in treatment. The majority of patients were well nourished at diagnosis with a mean percentage weight: height of 99.8%, however nutritional status started to decline early in treatment during radiotherapy, coinciding with 49% of patients having grade 1 or above CTC score for vomiting and constipation. The decline in nutritional status continued, peaking by course 2 of chemotherapy with a mean weight loss of 8.2% since diagnosis. Proactive supplementary feeding early in treatment by one of the three centres demonstrated a superior nutritional outcome when compared statistically to the two centres that fed only as a response to nutritional decline.

CONCLUSION

The study highlighted significant morbidity associated with the current treatment of medulloblastoma. Findings suggest the need to consider earlier proactive nutritional intervention to prevent nutritional decline during treatment. These early nutritional problems may be related to toxicities of radiotherapy and concomitant vincristine.

The effect of cyproheptadine hydrochloride (periactin) and megestrol acetate (megace) on weight in children with cancer/treatment-related cachexia

BACKGROUND

Children with cancer frequently have associated cachexia and malnutrition. Failure to thrive affects nearly 40% of oncology patients with advanced or progressive disease. Malnutrition can erode quality of life and adversely impact disease prognosis. Appetite stimulation and increased food intake is 1 approach to combat cancer-related cachexia.

MATERIALS AND METHODS

Cyproheptadine hydrochloride (CH), an appetite stimulant, was administered to children with cancer-associated cachexia to prevent further weight loss. All participants started CH and were evaluated for response after 4 weeks. Efficacy of megestrol acetate (MA) was evaluated in patients who did not respond to CH. Medical evaluation, weight measurements, prealbumin, and serum leptin levels were preformed at follow-up visits.

RESULTS

Seventy patients were enrolled. Of the 66 evaluable patients, 50 demonstrated a response to CH (average weight gain 2.6 kg and mean weight-for-age z-score change of 0.35, P=0.001). Seven of the 16 nonresponders received MA. Six patients completed 4 weeks of MA, 5 responded (average weight gain of 2.5 kg). The most commonly reported side effect of CH was drowsiness. One patient on MA developed low cortisol levels and hyperlipidemia.

CONCLUSIONS

This study demonstrates that CH is a safe and effective way to promote weight gain in children with cancer/treatment-related cachexia.

Validation of percent body fat indicators in pediatric oncology nutrition assessment

BACKGROUND

Given the high prevalence of malnutrition and potential impact nutritional status can have on a child undergoing treatment for cancer, it is vital that oncology centers regularly assess nutritional status. It is important that simple noninvasive anthropometric nutrition assessment measures correlate to more accurate body composition measures.

OBJECTIVES

The aim of this study was to determine the relationship between anthropometric measures and percent body fat determined via air displacement plethysmography in the children being treated in a pediatric oncology and hematology department.

DESIGN

This cross-sectional study measured height, weight, percent ideal body weight (%IBW), mid arm circumference, triceps skinfolds, and mid upper arm fat area in 23 children. These anthropometric variables were compared against the reference measure of percent body fat via air displacement plethysmography.

RESULTS

Correlational analysis and general linear models showed that there was a significant statistical relationship between percent body fat and body mass index Z score, %IBW, mid arm circumference, triceps skinfolds, and arm fat area.

CONCLUSIONS

Simple anthropometric measurements of %IBW and triceps skinfolds are good indicators of percent body fat and should be incorporated into regular nutrition assessment of the pediatric oncology patient.

Standards of nutritional care in pediatric oncology: results from a nationwide survey on the standards of practice in pediatric oncology. A Children's Oncology Group study

BACKGROUND

The prevalence of malnutrition in children with cancer ranges between 8% and 60%. Malnutrition is strongly associated with the nature of treatment and increases an individual's risk of infection. Clinical studies have suggested that nutrition intervention may decrease toxicity and improve survival in the oncology population. In order to identify the standards of practice in the nutritional management of a child with cancer, we conducted an international survey in institutions that are part of the Children's Oncology Group (COG) consortium.

PROCEDURE

Surveys were submitted to 233 participating COG institutions. We requested one member in three disciplines complete the survey: physician, registered dietitian, and nurse or nurse practitioner. The survey was returned to the nutrition sub-committee of COG.

RESULTS

Fifty-four percent of institutions responded to the survey. We found no consistency in the provision of nutrition services. Assessment of nutritional status does not routinely occur and different indices are employed to indicate the nutrition status of a patient. Institutions rely upon different guidelines when categorizing malnutrition. When nutrition intervention is clinically indicated, a variety of approaches are employed.

CONCLUSIONS

This survey did not find standardized nutrition protocols being employed in the pediatric oncology population. The effect of varied nutrition practices on the quality of life, toxicity, and outcome in children with cancer is unknown. Prior to the initiation of clinical trials, uniform guidelines need to be developed and validated. Future clinical trials need to investigate the most efficacious method of nutrition assessment and intervention and its effect on quality of life, toxicity, and survival in children with cancer.

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.

Association between the change in nutritional status in response to tube feeding and the occurrence of infections in children with a solid tumor

In 32 children with a solid tumor, the association between the change in weight for height, in response to 4 weeks of tube feeding during the intensive phase of treatment, and the occurrence of leukopenia, leukopenic infections, and nonleukopenic infections in a period thereafter (4-10 weeks) was studied. Factors possibly influencing the change in weight for height during the first 4 weeks of tube feeding were also assessed. A statistically significant negative correlation (rho = -0.59; p < .001) was found between the change in z-score of weight for height in response to the first 4 weeks of tube feeding, and the occurrence of nonleukopenic infections between 4 and 10 weeks. A reduced occurrence of nonleukopenic infections resulted in a significant reduction of the number of days of infection-related hospital admission (rho = .45; p = .009), which, besides providing advantages for the patient, also had economical benefits. The change in weight for height in response to tube feeding was mainly influenced by the incidence of therapy-induced vomiting (r = -.45; p = .02) and by the amount of energy provided by tube feeding (r = .47; p = .007). Based on these findings, it is recommended that naso-gastric tube feeding be used in children with a solid tumor during the early intensive phase of treatment, and that one should aim for a considerable increase in weight for height during the first 4 weeks of administration, since this has been shown to reduce the number of nonleukopenic infections in a subsequent period. The increase in weight for height may be improved by providing an optimal antiemetic protocol, which will increase energy uptake, and an energy-enriched formula, which will increase energy intake.

Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients

BACKGROUND

The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population.

PROCEDURE

Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period.

RESULTS

Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months.

CONCLUSIONS

We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.

Nutrition, morbidity, and survival in South African children with Wilms' tumor

Fifty-nine children with Wilms' tumor (WT) were divided into a normal or poorly nourished group according to anthropometric parameters. The 2 groups were compared for morbidity and survival. There was no difference in the median age or stage of disease in the 38 well nourished and 21 poorly nourished children. There was no difference in the number of children in the normal or poorly nourished group who developed a raised urea or creatinine level, febrile episodes, severe stomatitis, varicella, or upper or lower respiratory infections, or who needed intravenous antibiotics, parenteral nutrition, or red cell and platelet transfusions. Projected survival rate was 56 and 74% for normal and poorly nourished children, respectively (p = .3). Poor nutrition at diagnosis, as determined by anthropometry, had no effect on the morbidity of treatment or survival in children with WT. Based on these results, selective dietary supplementation instead of routine intensive parenteral nutritional support for all children with WT is recommended in countries with limited resources.

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.

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.

Enteral nutritional support by gastrostomy tube in children with cancer

We examined the use of gastrostomy tubes in malnourished children with cancer as part of our ongoing efforts to improve their supportive care. Patients were examined on the basis of percentage of weight loss and percentage of desirable body weight. Twenty-five patients underwent gastrostomy tube placement followed by aggressive enteral nutritional support. Gastrostomy tubes were placed at a mean of 3.5 months (range, 0.3 to 8 months) after diagnosis; mean weight loss had been 10.1% (range, to 21%) of desirable body weight. There were no immediate postoperative complications. Gastrostomy tube feedings were well tolerated by all patients. All children gained or maintained weight, and 60% of the severely malnourished children returned to a desirable body weight after an average of 4.9 months (range, 1 to 13 months). Weight gain averaged 12.9% (range, to 45.4%) of desirable body weight. The most common complications were 38 episodes of inflammation at the gastrostomy tube site during periods of severe neutropenia, which were treated successfully with topically or orally administered antibiotics, and 13 episodes of cellulitis, which required intravenously administered antibiotics. The infection rate was 1.58 episodes per 1000 days of use compared with a rate of 5.0 per 1000 days previously reported with total parenteral nutrition. The monthly costs of gastrostomy tube nutrition support were 9% of those associated with use of total parenteral nutrition. Gastrostomy tube use in children with cancer is a safe, effective, and cost-effective method of reversing malnutrition. Further investigation with larger numbers of patients is warranted.

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.