Pediatric Oncology Nutrition

Rebecca Schaferkotter Pediatric Nutrition 607 Dr. Hong November 2nd 2011

1.  INTRODUCTION TO CANCER 2.  CANCER TREATMENTS AND NUTRITIONAL

IMPLICATONS 3.  PATIENT ASSESSMENT 4.  SUPPLEMENTAL AND SUPPORTED NUTRITION 5.  OTHER PHYSICAL AND PSYCHOLOGICAL CONCERNS

What is Cancer?

q  Classified by: –  Uncontrolled division of abnormal

cells –  Malignant growth or tumor

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Disease caused by uncontrolled division of abnormal cells in a part of the body

q  Involves DNA mutations

q  Specific genes affected: –  Oncogenes –  Tumor Suppressor genes

q  Causes: –  90-95% = Environmental –  5-10% = Genetic

Common Childhood Cancers

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All types have multiple factors affecting nutritional status

q  Increased morbidity risk from malnutrition: –  Infants –  Adolescents

q  Increased morbidity risk: –  Obese

•  Acute lymphocytic leukemia (ALL) •  Medulloblastoma •  Acute myelogenous leukemia •  Hepatoblastoma •  Neuroblastom •  Non-Hodgkin’s lymphoma •  Sarcomas •  Wilm’s tumor

Top Concerns

q  Fourth overall leading cause of death in children under the age of 20 –  Second leading cause of death for adults

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More Children die from cancer than from any other disease in the United States

q  Thirty years ago, only 50% of children under age 15 were expected to survive cancer over 5 years

q  40-80% of children become malnourished during intensive cancer treatment

q  Today, approximately 80% have a 5-year survival rate. Reasons for improvement: –  Improved tx for ALL –  The COG –  Interdisciplinary supportive care

1.  INTRODUCTION TO CANCER

2. CANCER TREATMENTS AND NUTRITIONAL IMPLICATONS

3.  PATIENT ASSESSMENT 4.  SUPPLEMENTAL AND SUPPORTED NUTRITION 5.  OTHER PHYSICAL AND PSYCHOLOGICAL CONCERNS

Cancer Treatment - Chemotherapy

q What are the nutritional implications? –  Nausea –  Emesis –  Alterations in taste and smell –  Food aversions –  Mucositis –  Malabsorption and alteration

of gut flora

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q What does it do? –  Inhibits DNA synthesis –  Damages proliferating cells

Infusion of antineoplastic drugs

Cancer Treatment - Surgery

q What are the nutritional implications? –  Insufficient oral intake –  Chewing and Swallowing

issues –  Diarrhea –  Malabsorption of Vitamins

and Minerals –  Fluid and electrolyte

imbalances

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q What does it do? –  Surgical removal of cancerous

cells / tumor from body

Surgical removal of malignancy

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Cancer Treatment - Radiation Therapy

q What are the nutritional implications: –  Total body: diarrhea, nausea, vomiting,

mucositis, esophagitis, altered taste acuity and salivation, anorexia, delayed growth and development

– CNS: Anorexia – Head and neck: mucositis, tooth

decay, esophagitis, altered taste and smell, altered salivation, dysphagia

– Gastrointestinal system: diarrhea, steatorrhea and malabsorption, fluid and electrolyte imbalances

q What does it do? –  Destroys malignant cells as well as

rapidly replicating normal tissues –  Uses high-energy radiation

X-rays, Gamma rays, and charged particles

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Cancer Treatment - Hematopoietic Cell Transplantation

q What are the nutritional implications: –  Severe pancytopenia 2-6 weeks –  Mucositis, esophagitis, dysgeusia,

xerostomia, nausea, vomiting, anorexia, diarrhea, steatorrhea, and multiple organ dysfunction

–  Possible GVHD

q What does it do? –  Transplantation of hematopoietic stem cells

to eliminate active and residual malignant cells or a defective hematopoietic system Ø  Prepared prior to transplantation with:

Chemotherapy, possibly total body and local irradiations

Ø  May receive an intravenous infusion of stem cells from: autologous, syngeneic, allogeneic

Transplantation of healthy stem cells

Managing Common Nutritional Problems

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Mucositis Soft, pureed, or blenderized diet; nonirritating, cold, bland, moist foods

Popsicles, ice cream, frozen yogurt, slushies, custards, creamed soups, mashed potatoes

Frequent mouth rinsing to remove food and bacteria and promote healing

Xerostomia Moist Foods, add moistness/lq, drink liquids with meals, hard candies

Stews, casseroles, canned fruit, add sauce gravy, margarine, butter or broth, sugar-free candy to stimulate saliva

Encourage good oral hygiene

Viscous, thick Saliva

Beverages with Citric Acid Club soda, hot tea with lemon Encourage fluid intake and good oral hygiene

Dysgeusia Enhance food tastes, cold foods, fruit flavored drinks, tart foods

Herbs, spices, flavor extracts, oranges or lemonade

Encourage good oral hygiene

Nausea/ Vomiting

High CHO foods, small frequent meals, cold clear liquids, avoid overly sweet or high Fat foods

Crackers, toast, gelatin Encourage sipping liquids, rest after eating

Diarrhea Low-fat, low-fiber, low-lactose diet, avoid caffeine

Low fat substitutes, rice, white bread,

Encourage adequate fluids

Constipation Hot liquids, high-fiber foods Complex CHO Encourage liquids

Symptom Management Examples Recommendations

1.  INTRODUCTION TO CANCER 2.  CANCER TREATMENTS AND NUTRITIONAL

IMPLICATONS

3. PATIENT ASSESSMENT 4.  SUPPLEMENTAL AND SUPPORTED NUTRITION 5.  OTHER PHYSICAL AND PSYCHOLOGICAL CONCERNS

Baseline information provides medication dosage calculations and accesses current and growth history

ABCD - Anthropometry

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q  Initial measurement of: –  Age –  Height (<2y replace with length) –  Weight –  Head circumference (<2y) –  Arm anthropometry

q Prepubertal children –  CDC growth charts used for IBW

1.  Weight-for-height percentile

q Postpubertal children –  BMI estimation used for IBW –  ABW=actual body wt (kg) – IBW (kg) x

0.25 + IBW (kg)

q Used to determine:

2.  Plotting Growth Velocity

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ABCD - Biochemistry

q Review for detection of Nutrient deficiencies –  Renal and hepatic function –  Serum lipids –  Glucose –  Electrolytes

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Laboratory tests used for nutritional screening

q Difficulty finding reliable measures

q Hematologic parameters unreflective

q Lymphocyte counts lowered

q  Serum albumin vs. Prealbumin –  <3.2 g/dL albumin may reflect early malnutrition –  20 day half-life vs. 2 day half life –  Prealbumin is the best available marker of nutritional status

ABCD - Clinical

q  Detection of – Obesity –  Emaciation – Dehydration –  Edema – Ulceration – Cachexia – Health of Oral Cavity and

ability to chew and swallow

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Physical information gathered by examination and medical history

ABCD - Dietary

q Comprehensive diet history –  Current oral and GI symptoms –  Chewing or swallowing difficulties –  Mucositis and esophagitis –  Taste alterations –  Xerostomia –  Heartburn –  Nausea and vomiting –  Early satiety –  Changes in appetite –  Altered bowel habits

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q Stage of eating development –  Self-feeding –  Puree vs. table food –  Bottle vs. cup

q Formula or breastfeeding

q Current dietary modifications –  Special diets –  Food allergies –  Food aversions or intolerances –  Vitamins, mineral, herbal supplements

1.  INTRODUCTION TO CANCER 2.  CANCER TREATMENTS AND NUTRITIONAL

IMPLICATONS 3.  PATIENT ASSESSMENT

4. SUPPLEMENTAL AND SUPPORTED NUTRITION

5.  OTHER PHYSICAL AND PSYCHOLOGICAL CONCERNS

Nutritional Requirements

q Goals –  Provide adequate nutrition to preserve lean tissue

and promote growth and development –  Identify and prevent or correct protein-energy

malnutrition –  Prevent or correct metabolic abnormalities – Maximize quality of life

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q Energy and Protein requirements –  Factors affecting include: inactivity, bacterial sepsis, fever,

secondary complications –  BMR needs additions for growth, infection, stress:

Ø Multiplier of 1.6-1.8 for very young or malnourished children – Harris-Benedict formula can be used for children with

completed growth

Nutritional Requirements

q Recommendations based on the DRI

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Vitamins and Minerals

q  Increased needs with extensive radiation, surgical damage to GI tract, long-term antibiotic therapy

q Multivitamin/mineral supplement without iron

q Omega-3 Fatty Acids with oral medications for lowering serum triglyceride levels

q Osteopenia and fracture risks increased with ALL, non-Hodgkin’s lymphoma, or those who develop GVHD following HCT

–  Calcium and vitamin D supplementation in addition to multivitamin/mineral supplement Ø  Measure serum 25-OH vitamin D levels to evaluate for deficiency.

Nutrient Requirements

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Oral Intake

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There is less concern for suboptimal oral intake of short duration during treatment if the child was initially well nourished

q Oral Intake –  May benefit from high-density foods

Ø  Fats to soups, cereals, rice, noodles, sauces Ø  Cream with desserts, soups, egg dishes, substitute for milk, hot cocoa Ø  Sour Cream on potatoes, sauces, dressings, dips Ø  Mayonnaise to dressings, spreads, sauces Ø  Honey ( >1y) to cereal, drinks, desserts, yogurt, glazes Ø  Etc

–  Slow re-feeding process post therapy –  Focus on frequent foods enjoyed –  Supplement with nutritional shakes –  Daily food intake records provide basis for decision to move to tube feeding

Enteral Nutrition

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Primary nutrition intervention strategy for children and adolescents undergoing cancer treatment

q Enteral Nutrition –  Often central line is already in place for other treatment –  Provides safe, beneficial, physiological nutrition support

Ø  Also reduces risk for infection Ø  Cheaper than PN

–  Candidates Ø  Interval or total wt loss > 5% of pre illness body wt Ø  Wt for ht reaches ≤ 90% of ideal wt for ht (adjusted

for ht & age) Ø  BMI falls to or below 10th % Ø  Repeated attempts to meet nutrient needs orally

failed Ø  Functioning GI tract Ø  Lowest wt threshold

Parenteral Nutrition

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q Parenteral Nutrition –  Based on nutritional status, types of therapies,

expected oral and GI complications Ø  Standard for HCT patients

–  Home PN –  Close monitoring

Ø  Ensure nutrient requirements Ø  Ensure fluid requirements Ø  Correct any electrolyte alterations

–  Can result in improved treatment tolerance with fewer delays and accelerated recovery

Unusable Gastrointestinal tract and complications from therapies

q Background: –  Critically ill children differ in their energy needs from healthy children in terms of

underlying metabolic derangement, comorbidities, energy reserve, and response to illness. This study determined how many pediatric intensive care unit (PICU) patients were candidates for indirect calorimetry (IC), per American Society for Parenteral and Enteral Nutrition (AS.P.E.N.) recommendations.

q Methods: –  Admission diagnosis, demographics, type/amount of nutrition support, length of

intensive care unit/hospital stay were collected. Patients were classified as candidates for IC per A.S.P.E.N. guidelines.

q Conclusions: –  Three of four patients were candidates for IC per A.S.P.E.N. guidelines. PICU’s might

have to prioritize performing IC in patients who are less than 2 years of age, malnourished (underweight/overweight) on admission, or PICU stay of greater than 5 days. Future studies should determine the cost-benefit ratios of performing IC in PICU patients.

UG, et al. Is Indirect Calorimetry a Necessity or a Luxury in the Pediatric Intensive Care Unit? Journal of Parenteral and Enteral Nutrition. 2011, Aug.8.

Literature Search

Is Indirect Calorimetry a Necessity or a Luxury in the Pediatric Intensive Care Unit?

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Use of Integrative or Complimentary Medicine

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q Antioxidants and chemotherapeutic agents –  Argue fore the use of antioxidants: they protect healthy cells from the toxic

effects of chemo drugs while leaving the cancer cells exposed to the drugs –  Argue against the use of antioxidants: concerned that these nutrients will

interfere with or reduce the efficacy of chemo agents that use reactive oxygen species as a mechanism for cytotoxicity

q Herbal and megavitamin therapy –  May cause unexpected reactions with prescribed medications –  Plant derived preparations pose a risk of bacterial, fungal, or

parasitic infections –  May choose as the sole source of treatment

Possible harmful affects and interference with conventional treatments

q Contraindicated herbals –  Garlic and Gingko biloba –  Comfrey and Maté tea

q Abstract: –  This research sought to assess the use of complementary and alternative therapies

(CAM) amongst Turkish patients with cancer. The research sample included 94 adult patients with cancer who underwent chemotherapy at an outpatient clinic at the Adult Oncology Department of the University of Izmir between November 2006 and January 2007. Data was collected by questionnaire. Results suggest that the majority of Turkish oncology patients in the study had used herbal essences or herbal therapies. Socio-demographic factors associated with CAM use considered gender, age, education and economic status, health insurance, and whether CAM use had been recommended by friends, health care professionals or others. There appeared to be a link between CAM use, the diagnosis of cancer and where patients lived (p < 0.05). Patients reported that their primary sources of CAM information for use with their medical condition had come from friends and the media. Patients tended to use CAM therapies to reduce some of the physical symptoms of their condition and particular side effects arising from their medical treatment.

Akyol, AD, Oz, B. The use of complementary and alternative medicine by patients with cancer: In Turkey. Complementary Theraputic Clinical Practice. 2011 Nov;17(4):230-4. Epub 2011 Feb 9.

Literature Search

The use of complementary and alternative medicine by patients with cancer: In Turkey.

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q Abstract: –  Use of complementary and alternative medicine (CAM) has been reported to be more

and more frequent among cancer patients in USA. The aim of this study was to analyze among French cancer patients the prevalence of CAM use, focusing on antioxidants (AO) that could interfere with antitumor agents. Seventy-nine patients, treated by antitumor chemotherapy in oncology day care unit, participated to an interview (medium age  =  60 years old). CAM use was reported by 42% of patients: mostly AO (24%) (selenium, green tea and vitamins ACE, more specifically), but also relaxation, acupuncture, hypnosis (19%) and homeopathy (15%). Among patients using CAM, 66% of them indicated that their physicians were not aware of this use and 47% of them thought that CAM use was safe. Nevertheless, for seven patients who have taken AO, previous in vitro and preclinical studies suggested interactions with antitumor chemotherapy. Therefore, CAM use and, more specifically, AO use is common among cancer patients treated by antitumor chemotherapy in France. Nevertheless, AO could generate interactions with conventional treatment. Clinical studies are warranted to evaluate these interactions, and adequate communication with patients is needed.

Thomas-Schoemann A, et ll . [Use of antioxidant and other complementary medicine by patients treated by antitumor chemotherapy: a prospective study]. . Bull Cancer. 2011 Jun;98(6):645-53. doi: 10.1684/bdc.2011.1375.

Literature Search

[Use of antioxidant and other complementary medicine by patients treated by antitumor chemotherapy: a prospective study].

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1.  INTRODUCTION TO CANCER 2.  CANCER TREATMENTS AND NUTRITIONAL IMPLICATONS 3.  PATIENT ASSESSMENT 4.  SUPPLEMENTAL AND SUPPORTED NUTRITION

5. OTHER PHYSICAL AND PSYCHOLOGICAL CONCERNS

Diet for the Immunosuppressed

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q  Food Safety –  Providing education

Ø  Hand washing Ø  High-risk foods Ø  Proper temperatures

for storage Ø  Defrosting and

cooking

–  Main infectious concerns Ø  Salmonella Ø  E. coli Ø  Listeria

q Contraindicated –  Raw or undercooked

meat –  Raw tofu –  Lunch meats –  Smoked fish –  Non-pasteurized milk

and products –  Blue-veined and soft

cheeses –  Raw Honey –  Unpasteurized

commercial fruit

Maximize healthy food options while minimizing GI exposure to pathogenic organisms by reducing food-borne illnesses

Food Services

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q Child’s needs –  Open meal-time schedule –  Flexible food service system –  Increased oral intake encouragement

To provide a variety of foods at frequent intervals

q Promotion –  Calm, relaxing place –  Uninterrupted time –  Never forced to eat –  Toddlers and infants: secure feeding

position and variety of food textures and portions

–  Adolescents and older: group eating times, participatory preparation, knowing oral intake goals

Family-Centered Care

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q Supportive measures –  Assistance for parents to continue their roles as providers –  Educate parents and age-appropriate children on diet

essentials –  Assistance with dietary decisions for security, familiarity,

and routine –  Family-centered care –  Respect for the feeing dynamics

q Disruption of food provider role –  Parents can sense a loss of control –  Can include a loss of mealtime rituals and

routines –  Source of stress and anxiety –  Lead to a family overly focused on food

Relationship between parents and their children in the area of food and nutrition

References • Alfin-Slater, Roslyn B., and Kritchevsky, David. Cancer and Nutrition. Ed. New York, N.Y.: Plenum Press, 1991. Print.

• Altman, Arnold J. M.D. Supportive Care of Children with Cancer: Current Therapy and Guidelines from the Children’s Oncology Group 3rd ed. Ed. Baltimore, MD: The John Hopkins University Press, 2004. Print.

• Katzin, Carolyn CNS. The Cancer Nutrition Center Handbook. Los Angeles, CA: Library of Congress, 2006. Print.

• Marian, Mary., and Roberts, Susan. Clinical Nutrition for Oncology Patient. Sandbury, MA: Jones & Bartlett Publishers, 2010. Print.

• Pizzo, Philip A. M.D., and Poplack, David G. M.D. Principles and Practice of Pediatric Oncology 5th ed. Ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006. Print.

• Quillin, Patrick PhD, RD, CNS, Quillin, Noreen. Beating Cancer with Nutrition. Carlsbad, CA: Nutrition Times Press, Inc, 2005. Print.

• Samour, Patricia Queen., and Kathy King. Pediatric Nutrition. Sudbury, MA: Jones & Bartlett Learning, 2012. Print.

• Thomas-Schoemann A, et ll . [Use of antioxidant and other complementary medicine by patients treated by antitumor chemotherapy: a prospective study]. Bull Cancer. 2011 Jun;98(6):645-53. doi: 10.1684/bdc.2011.1375.

• UG, et al. Is Indirect Calorimetry a Necessity or a Luxury in the Pediatric Intensive Care Unit? Journal of Parenteral and Enteral Nutrition. 2011, Aug.8.

QUESTIONS?