Aggressive oral, enteral or parenteral nutrition: Prescriptive decisions in children with cancer

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.

Suplemento artesanal oral: uma proposta para recuperação nutricional de crianças e adolescentes com câncer

Objetivo Avaliar o impacto do suplemento oral artesanal na recuperação do estado nutricional de pacientes com desnutrição leve, grave e com risco nutricional. Métodos Propuseram-se oito receitas de suplementos visando ofertar entre 30,0% e 35,0% do gasto energético total. Os pacientes com desnutrição grave (grupo B) receberam o suplemento oral por duas semanas, e os demais pacientes (grupo A), por quatro semanas. Para a comparação dos resultados obtidos com o emprego do suplemento oral artesanal, foram utilizados dados referentes a um protocolo anterior, com o mesmo desenho, entretanto, com a utilização de suplemento oral industrializado. Resultados O suplemento oral artesanal fica muito aquém no que diz respeito a alguns micronutrientes, entretanto é cinco vezes mais barato do que a preparação com o suplemento oral industrializado. Os pacientes do grupo A com suplemento oral artesanal apresentaram 88,0% de resposta positiva na semana de avaliação, enquanto os com suplemento oral industrializado tiveram 84,0%. No grupo B, foram recuperados 22,0% dos pacientes com suplemento oral artesanal e 25,0% do grupo com suplemento oral industrializado, não apresentando, portanto, diferença significante. Comparando o impacto do industrializado com o do artesanal na prega cutânea tricipital e circunferência do braço, verificou-se que o suplemento oral industrializado no grupo A apresentou melhores resultados que o suplemento oral artesanal, e no grupo B, esse efeito observado na prega cutânea não foi significante (p=0,16). Os consumos de energia e de proteína, assim como a evolução nutricional, foram semelhantes entre suplemento oral industrializado e suplemento oral artesanal. Apenas a composição corpórea no grupo A com suplemento oral industrializado apresentou melhores resultados. Conclusão Os resultados apresentados neste estudo sugerem que o emprego da terapia com suplemento artesanal seja uma opção capaz de auxiliar na recuperação nutricional de pacientes oncológicos e uma opção para populações financeiramente desfavorecidas.

Suplementos orais artesanais desenvolvidos para pacientes com câncer: análise descritiva

OBJETIVO: Descrever a elaboração de oito formulações de suplementos artesanais orais desenvolvidos para aumentar o consumo de energia, proteínas e micronutrientes de pacientes com câncer, analisar seu valor nutricional e avaliar a apreciação do sabor, testando dois tipos de lipídeos. MÉTODOS: Os suplementos foram desenvolvidos com base em quatro ingredientes alimentares: leite, ovos, açúcares e óleos para recuperação nutricional. As formulações foram calculadas pelo programa de apoio à nutrição NUTWIN e seu valor nutricional foi comparado às recomendações para pacientes com câncer para macronutrientes e às Ingestões Diárias Recomendadas para micronutrientes. Por meio de degustação, os suplementos foram testados para verificação do sabor quando preparados com óleo ou margarina. RESULTADOS: A quantidade de energia por mililitro variou de 1,35 a 2,17kcal, tendo 39% a 59% de carboidrato, 11% a 13% de proteína e 30% a 49% de lipídeo, fornecendo em média 43% e 77% da recomendação de energia e proteína, respectivamente. Vitaminas C e K, ácido fólico e manganês apresentaram 15% de adequação em relação às recomendações. Com relação ao sabor, 78% dos pacientes que experimentaram com óleo e 85% dos que experimentaram com margarina relataram sabor bom, sem diferença estatística entre os tipos de suplementos. CONCLUSÃO: A avaliação do sabor demonstrou que a maioria dos pacientes considerou o suplemento com sabor bom. Essas taxas foram superiores quando testados com margarina. Os resultados sugerem que o uso de suplementos orais artesanais pode ser uma alternativa viável em situações onde não há recursos suficientes para aquisição dos industrializados.

Body composition and bone mass in survivors of childhood cancer

BACKGROUND

The number of survivors of childhood cancer has increased. Several studies in children and adults have shown relationships between lean mass (LM), fat mass (FM), and bone mineral content (BMC). The objective of the study was to examine the association between body composition and bone mass in young survivors of childhood cancer.

METHODS

Sixty-eight postpubertal participants (31 females and 37 males) aged between 15.5 and 27 years who were at least 5 years after completion of treatment for leukemia (n = 30), lymphoma (n = 28), or solid tumors (n = 10) were studied. Anthropometry was performed and dual energy X-ray absorptiometry (DXA) was used to assess BMC in the total body (T) and lumbar spine (S), FM, and LM.

RESULTS

There were no observed differences in age or time for cessation of treatment. Body mass index (BMI) was a strong determinant of bone mass in both sexes. TBMC correlated positively with LM (males r = 0.9 and females r = 0.76; P < 0.0001, respectively) and with FM (r = 0.54; P < 0.01 in males and r = 0.8; P < 0.00001 in females). SBMC correlated with LM in both sexes (in males r = 0.77 and in females r = 0.64; P < 0.0001, respectively) but only in females, SBMC also correlated positively with FM (r = 44 P = 0.03). There were no differences between patients who received radiation and those who did not.

CONCLUSIONS

The associations between bone mass and body composition differ by sex and skeletal site, however, they are similar in survivors of childhood cancer and compared to healthy individuals during growth. Further prospective research is needed in cancer survivors to determine the long-term effect of anti-cancer therapy on body composition and bone mass.

Nutritional assessment and serum zinc and copper concentration among children with acute lymphocytic leukemia: a longitudinal study

CONTEXT AND OBJECTIVE

When undergoing chemotherapy and/or radiotherapy, children with acute lymphocytic leukemia may present important nutritional disorders because of the gastrointestinal toxicity of most chemotherapy agents or the effects of radiation on the organism. These patients may also present changes in their serum concentrations of trace elements such as zinc and copper. The present study aimed to follow anthropometric parameters and serum levels of zinc and copper in a group of children under treatment for acute lymphocytic leukemia.

DESIGN AND SETTING

Longitudinal study, at the Pediatric Section of Hospital das Clínicas, Ribeirão Preto, Brazil.

METHODS

Forty-five children with acute lymphocytic leukemia were studied. Anthropometric parameters such as weight and height and the daily intakes and serum levels of copper and zinc were recorded at diagnosis and during the treatment.

RESULTS

During the initial phase of the treatment, there was an increase in energy intake accompanied by weight gain. However, during the later phases of treatment there was a reduction in energy intake with accompanying weight loss. Decreased growth rate during treatment was more pronounced in children with high-risk acute lymphocytic leukemia, probably due to radiation therapy. Serum zinc levels remained basically unaltered during the treatment, whereas copper levels decreased dramatically with the beginning of treatment.

CONCLUSIONS

The treatment given to children with acute lymphocytic leukemia has an important effect on their linear growth rate and nutritional status, and also on their serum copper levels.

Dénutrition en cancérologie pédiatrique : prévalence et dépistage

Algorithms for nutritional pediatric support have been proposed in a French national nutritional framework program. However, they are not specific for oncology. With the pediatric nutritional risk score (PNRS) all children with cancer have a high risk of malnutrition, but a systematic nutritional support is not possible for all of them.

AIM

Estimation of malnutrition prevalence and identification of predictive factors of major weight loss during treatment defined by a weight loss more than 5% within 1 month, 7.5% within 3 months, 10% within 6 months.

POPULATION AND METHODS

This historical study included children registered with a solid tumor in 2002 in an oncology pediatric unit. Data collected at diagnosis were weight, height, PNRS, the Lansky functional score, tumor type. Furthermore weight, height, and major weight loss were collected at each cure of chemotherapy and during evolution. Malnutrition at diagnosis was defined using the weight for height ratio. Relations between major weight loss and risks factors were estimated using logistic regression.

RESULTS

Seventy children were included, 16 (22.9%) were malnourished at admission. During chemotherapy, 29 (41.4%) children experienced a major weight loss. Odds ratio of those who were malnourished at diagnosis was not significantly higher in comparison to well-nourished children. Children with a high risk of malnutrition are those affected by Ewing tumor, B lymphom, head and neck localisations, osteosarcomas, metastatic cancers, or cancers treated by high dose chemotherapy with stem cell rescue. For these 29 (41.4%) children the major weight loss odds ratio was 5.9 [IC95% 2.0-16.7].

CONCLUSION

Taking into account others factors with items of PNRS allows to screen children with an higher risk of a major weight loss during treatment and to enhance nutritional care plan for them.

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.

Nutritional and metabolic aspects of gastrointestinal cancer

The profound impact of nutrition and nutritional support on the development and clinical outcome of gastrointestinal cancer is undeniable. However, scientific investigation into this area is recent, and many questions remain unanswered. While the importance of 'good nutrition' is unchallenged, details relating to which patients should receive nutritional support, when they should receive it, and what type of support they should receive are not known. Recent prospective randomized clinical trials and meta-analysis have provided conflicting results. This review summarizes the results of the published studies that have addressed these issues, and provides specifics regarding the current role of nutritional support in clinical care, and the prospects for future research.