Surgical Feeding Tubes in Pediatric and Adolescent Cancer Patients: A Single-institution Retrospective Review

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Nutritional Status at Diagnosis as Predictor of Survival from Childhood Cancer: A Review of the Literature

Few studies so far have examined the impact of nutritional status on the survival of children with cancer, with the majority of them focusing on hematological malignancies. We summarized published evidence reporting the association of nutritional status at diagnosis with overall survival (OS), event-free survival (EFS), relapse, and treatment-related toxicity (TRT) in children with cancer. Published studies on children with leukemia, lymphoma, and other solid tumors have shown that both under-nourished and over-nourished children at cancer diagnosis had worse OS and EFS. Particularly, the risk of death and relapse increased by 30-50% among children with leukemia with increased body mass index at diagnosis. Likewise, the risk of TRT was higher among malnourished children with osteosarcoma and Ewing sarcoma. Nutritional status seems to play a crucial role in clinical outcomes of children with cancer, thus providing a significant modifiable prognostic tool in childhood cancer management. Future studies with adequate power and longitudinal design are needed to further evaluate the association of nutritional status with childhood cancer outcomes using a more standardized definition to measure nutritional status in this population. The use of new technologies is expected to shed further light on this understudied area and give room to person-targeted intervention strategies.

Factors Impacting Long-Term Gastrostomy Tube Dependence in Infants with Congenital Heart Disease

BACKGROUND

Infants with congenital heart disease (CHD) often experience oral feeding intolerance requiring gastrostomy (GT). Complications related to GT use are common. The study aim was to identify factors associated with continued GT use at one-year.

METHODS

A retrospective cohort study was performed at a tertiary children's hospital using the Society of Thoracic Surgeons database and patients' electronic medical record. Infants <1-year with CHD who underwent cardiac and GT surgery between January 2014-October 2019 were identified. Patient demographics, preoperative feeding, clinical variables, and GT use at one-year was evaluated. A separate cohort discharged with a nasogastric tube (NGT) was identified for longitudinal comparisons.

RESULTS

Of 137 infants who received a GT, 115 (84%) continued using their GT at one-year. Factors associated with continued GT use included lower median percent of goal oral feeding before GT placement (0% IQR 0-6.5 versus 3.7% IQR 0-31), prolonged hospitalization after GT placement (36% versus 14%, P-value = 0.048), and failure to take oral feeds at discharge (69% versus 27%, P-value <0.001). There was no difference in demographics or clinical comorbidities between groups. Clinic/emergency room visits for GT complications were common (72%). Eight infants discharged with a NGT did not require GT placement.

CONCLUSIONS

Patients with CHD tolerating minimal oral nutrition before GT placement, prolonged hospitalization after GT, and difficulty with oral feeds at discharge were more likely to use their GT at 1-year. Outpatient NGT feeding is feasible for select infants with CHD. Efforts to optimize care for this complex, device-dependent population are warranted to minimize risks and facilitate family engagement for long-term care.

Effectiveness and Complication Rate of Percutaneous Endoscopic Gastrostomy Placement in Pediatric Oncology Patients

PURPOSE

Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients.

METHODS

A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016. Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified. Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement.

RESULTS

The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre- (-1.11) to post- (-0.38) PEG placement. Improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). Site infections were seen in 12 (24%), buried bumper syndrome in five (10%), and tube dislodgement in one (2%) patient. One patient (2%) with fever was treated for possible peritonitis. There were no cases of other major complications, including gastric perforation, gastrocolic fistula, clinically significant bleeding, or PEG-related death documented.

CONCLUSION

Consistent with previous studies, our data suggests a relationship between site complications (superficial wound infection, buried bumper syndrome) and neutropenia. Additionally, PEG placement appears to be an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, larger prospective studies with appropriate controls and adjustment for potential confounders are warranted to confirm these findings.

Systematic review of gastrostomy complications and outcomes in pediatric cancer and bone marrow transplant

BACKGROUND

Nutrition support is essential in children with cancer, including those undergoing bone marrow transplant (BMT), to reduce the risk of malnutrition and associated deleterious outcomes. Enteral nutrition is more commonly provided via nasogastric than gastrostomy tubes because of safety concerns with the latter in immunocompromised children. This systematic review investigated the incidence and type of complications and outcomes in pediatric cancer patients fed by gastrostomy.

METHODS

Databases were searched for randomized and observational studies investigating the use of any gastrostomy device in children aged <18 years with any cancer diagnosis, including those undergoing BMT. Five cohort and 11 case series studies were included. Owing to clinical heterogeneity, meta-analyses were not performed.

RESULTS

Quality of evidence varied, with five studies judged at serious risk of bias and poor quality; however, the remaining 11 were considered to range from moderate to good quality. Across studies, 54.6% of children developed one or more complications, of which 76.6% were classified as minor, 23.4% major. The most frequent complications included inflammation (52% of episodes), infection (42.1%), leakage (22.3%), and granuloma (21%). Evidence regarding infection rates in cancer/BMT patients compared with other disease states was inconclusive. Gastrostomy feeding was associated with improvement or stabilization of nutrition status in 77%-92.7% of children.

CONCLUSION

Gastrostomy feeding in this population is relatively safe and effective in stabilizing or improving nutrition status throughout treatment. Complications are frequent but mostly minor. Placement requires careful consideration of the complications, benefits, nutrition risk and status at diagnosis, and quality of life.

Effects of proactive and rescue enteral tube feedings on weight change in children undergoing treatment for high-grade CNS tumors

Background

Children with high-grade CNS cancers frequently experience malnutrition during treatment. We assessed the effects of proactive enteral tube (ET) placement/enteral tube feedings (ETF) on weight in infants/children with high-grade CNS tumors treated with aggressive chemotherapy.

Methods

We conducted a retrospective study of patients age 0 to 19 years treated for new high-grade CNS tumors between 2002 and 2017 at a tertiary pediatric hospital system. Patients underwent placement of proactive ET (≤ 31 days postdiagnosis; n = 45), rescue ET (> 31 days, due to weight loss; n = 9), or no ET (n = 18). Most received surgically placed ET (98%), with percutaneous endoscopic gastrojejunostomy or gastrojejunostomy tubes favored to allow jejunal feeding. The majority of patients with ET used ETF (91%). Using mixed-effects regression models, we examined differences in mean weights between ET/ETF groups across the first year of treatment. We also evaluated observed weight changes.

Results

All infants (n = 22, median age, 1.5 years) had proactive ET placed and 21 of 22 used proactive ETF. Infants showed an initial increase in mean percentage weight change that eventually leveled off, for an estimated increase of 10.4% over the year. For the pediatric cohort (n = 50, median, 8.1 years), those receiving proactive ETF experienced weight increases (+9.9%), those with rescue ETF experienced an initial decline and eventually rebounded for no net change (0.0%), and those with no ETF demonstrated an initial decline that persisted (-11.9%; P _interaction < .001). Analysis of observed weights revealed nearly identical patterns.

Conclusions

Proactive ETF was effective at maintaining weight and/or facilitating weight gain over the first year of treatment and was acceptable to patients/families.

Nutrition & Exercise Interventions in Pediatric Patients with Brain Tumors: A Narrative Review

Brain tumors have been the most common pediatric solid tumor and leading cause of morbidity and mortality. Improved survival emphasizes the importance of adverse treatment effects especially related to nutrition and exercise. Although studies have examined nutrition and exercise outcomes, few randomized trials exist. This narrative review included a systematic literature search with analysis of controlled or single group studies examining clinical and quality-of-life impact of nutrition or exercise interventions. Seven articles were included. Three nutrition studies demonstrated improvement with proactive feeding tubes, nutritional supplementation, and nutritional status. Two exercise studies showed improvement in measures of fitness and neuroanatomy with exercise in pediatric brain tumor survivors; two cohort studies demonstrated a link between quality of life and physical activity. Preliminary studies show nutrition and exercise may improve physical well-being and quality of life, suggesting future controlled studies are warranted to inform clinical care of children with brain tumors.

Nutrition during childhood cancer treatment: current understanding and a path for future research

Proper nutritional status during cancer therapy has been recognised as being integral to a variety of health outcome measures, including overall survival, treatment tolerance, and quality of life. The prevalence of malnutrition, defined by WHO as either undernutrition or overnutrition, among children and adolescents with cancer is reported to be as high as 75%. Yet, over the past two decades there have been limited advances in elucidating the underlying pathophysiological drivers of malnutrition in this population. This effect has resulted in a paucity of research aimed at improving nutritional assessment and intervention among this group. This Review presents an in-depth discussion of the role of nutritional status in paediatric cancer care, as well as evolving avenues of investigation that might propel personalised nutrition into a viable reality. Thus, nutritional science might facilitate individualised intervention strategies, and thereby help to optimise clinical outcomes for patients and survivors of childhood cancer.

Gastrostomy tube use in children with cancer

Children with cancer are at risk of malnutrition, which can impair critical childhood processes of growth and development and contribute to poor health outcomes. Enteral nutrition can effectively ameliorate malnutrition or weight loss in children with cancer; however, published nutrition support algorithms contain minimal specific information on gastrostomy tube use, and current literature is limited. Decisions about gastrostomy tube insertion in children with cancer can be challenging. Consideration of gastrostomy tube insertion is only appropriate in children with long-term dependence on enteral nutrition, particularly when nasogastric tube insertion is predicted or proven to be problematic. Specific indications for patient selection are unclear, and referring clinicians may be unaware of important absolute and relative contraindications. Complications are predominantly minor in nature; however, reported rates are high. Morbidity must be weighed carefully against the need and anticipated duration of enteral nutrition support, and further research in this area is needed.