Nutrition of children with cancer

Tolerance and efficacy of preventive gastrostomy feeding in pediatric oncology

BACKGROUND

Malnutrition in pediatric oncology remains underestimated, although having a negative impact on outcome. Enteral nutrition (EN) using percutaneous endoscopic gastrostomy (PEG) may prevent or reverse malnutrition consequences. We aimed to evaluate both efficacy and safety of early EN during tumors treatment in children.

PROCEDURES

Medical records of pediatric patients having a PEG tube inserted between 1995 and 2009 were retrospectively reviewed. We compared type and incidence of complications in Group 1, including 74 patients suffering from cancer, and control Group 2, including 57 patients with neurological impairment. Efficacy of EN was evaluated through nutritional parameters [Z-scores weight for height (W/H) and height for age (H/A)], post-operative complications and relapse rates. Statistical significance was set for P < 0.05.

RESULTS

PEG tolerance was similar in both groups, as shown by comparable complication rates (62% vs. 76%, NS). EN allowed improvement or stabilization of Z-score W/H in 76% of oncologic patients. The final height loss was lower (-0.5 vs. -1.2 SD of Z-scores H/A) when EN was started at the beginning of the oncologic treatment. In bone tumors, EN prevented weight loss during chemotherapy, and tended to lessen surgical complications, relapses and deaths.

CONCLUSIONS

Early gastrostomy feeding represents a relatively safe way to prevent malnutrition in children with cancer, and might play a role in bone tumors oncological outcome. Further prospective studies are needed to confirm these results and assess the impact of EN and PEG on quality of life.

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.

Nutritional support for children with cancer

Children with cancer are at risk of suffering from under nutrition, which can affect tolerance of therapy and may influence their overall survival. The goals of nutritional support in the cancer patient are to achieve and maintain desirable weight and to prevent or correct nutritional deficiencies. So early identification of patients at high risk for malnutrition is essential. There are different options for nutritional support. Oral feeding, when possible, is the first line. Enteral nutrition should be considered for those patients who cannot consume adequate macronutrients by mouth. Options are nasogastric tube or gastrostomy tube feeding. The advantages of enteral nutrition, when compared with parenteral nutrition, include better maintenance of the structural and functional integrity of the gastrointestinal tract, a decreased risk of bacterial translocation, greater ease and safety of administration, more physiologic and efficient use of nutrient substrates, decreased hepato-biliary complications, improved outcome and cost-effectiveness. Thus, parenteral nutrition should be considered if the gut is not functioning adequately to allow the normal absorption and digestion of nutrients or if enteral nutritional support is not sufficient to meet nutritional needs. Nutritional assessment and support should be integrated into treatment protocols for all children with neoplastic diseases.

Nutritional assessment and serum zinc and copper concentration in leukemic children

CONTEXT

Malnutrition in childhood cancer is commonly a serious problem. Changes in blood zinc and copper have also been found in malignant diseases.

OBJECTIVE

To describe the protein-energy nutritional status and serum zinc and copper of children with newly diagnosed leukemia.

DESIGN

Cross-sectional study.

SETTING

University referral center.

PARTICIPANTS

23 children with newly diagnosed acute lymphocytic leukemia (ALL) or acute non-lymphocytic leukemia (ANLL) between the ages of 1 and 10 years. The control subjects were 31 healthy school children of similar age from local schools.

MAIN MEASURES

Anthropometric measurements of height/age and weight/height, food intake and serum levels of zinc and copper.

RESULTS

Almost the entire group of children were eutrophic. Zinc and copper intake were below the recommended values. Serum zinc levels were significantly lower and serum copper levels were significantly higher in the leukemic group when compared to normal children.

CONCLUSION

At the time of diagnosis the children suffering from leukemia were not overtly malnourished but blood analysis showed alterations in concentrations of the trace elements zinc and copper.

The pathophysiology of undernutrition in the child with cancer

The physiologic consequences of malnutrition in children with cancer are reviewed. It is stressed that the child with cancer has a nutritional state that is no different from the average population from which the child comes. What little malnutrition is seen is calorie malnutrition. The physiologic consequences are those seen in any malnourished patient. Once the patient is being treated for cancer and the cancer course has progressed, the complications of chemotherapy and radiotherapy add to the difficulty in interpretation. However, the problem of decreased resistance to infection is one of the major problems that result from this malnutrition. The one nutrient found deficient in children with cancer is iron. Because transferrin is sensitive to prolonged protein malnutrition and because of the high level of ferritin in children with certain cancers, interpretation of laboratory values defining iron deficiency is difficult and iron homeostasis may well be very deranged.

Use of thyroxine-binding prealbumin in the nutritional assessment of children with cancer

The level of thyroxine-binding prealbumin was evaluated in 87 pediatric cancer patients ages 1 through 16 years whose cancer was newly diagnosed but untreated, and 39 children with benign disease or no disease. There was no difference in levels of thyroxine-binding prealbumin between the patients with either malignant or benign disease, nor was there a difference between diagnostic categories. Prealbumin values did correlate with age. When the data were compared, there was a correlation between nutritional status and prealbumin level when the total population (N = 126) was age corrected, but not within the malignant disease group by itself. This confirms data that suggest malnutrition in children with cancer is not a result of protein depletion.