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MASCC/ISOO clinical practice guidelines for the management of mucositis: sub-analysis of current interventions for the management of oral mucositis in pediatric cancer patients. Support Care Cancer 2020; 29:3539-3562. [PMID: 33156403 DOI: 10.1007/s00520-020-05803-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this sub-analysis was to highlight the MASCC/ISOO clinical practice guidelines for the management of oral mucositis (OM) in pediatric patients and to present unique considerations in this patient population. METHODS This sub-analysis of the pediatric patient population is based on the systematic review conducted by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISSO) published in 2019/2020. Studies were scored and assigned a level of evidence based on previously published criteria. Data regarding adverse effects and compliance was collected from the original publications. RESULTS A total of 45 papers were included and assessed in this sub-analysis, including 21 randomized controlled trials (RCTs). Chewing gum was demonstrated to be not effective in preventing OM in pediatric cancer patients in 2 RCTs. The efficacy of all other interventions could not be determined based on the available literature. CONCLUSION There is limited or conflicting evidence about interventions for the management of OM in pediatric cancer patients, except for chewing gum which was ineffective for prevention. Therefore, currently, data from adult studies may need to be extrapolated for the management of pediatric patients. Honey and photobiomodulation therapy in this patient population had encouraging potential. Implementation of a basic oral care protocol is advised amid lack of high level of evidence studies.
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Retrospective Evaluation Of Children After Stem Cell Transplantation: Single Center Experience. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.605404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Yarom N, Hovan A, Bossi P, Ariyawardana A, Jensen SB, Gobbo M, Saca-Hazboun H, Kandwal A, Majorana A, Ottaviani G, Pentenero M, Nasr NM, Rouleau T, Lucas AS, Treister NS, Zur E, Ranna V, Vaddi A, Cheng KKF, Barasch A, Lalla RV, Elad S. Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements. Support Care Cancer 2019; 27:3997-4010. [PMID: 31286229 DOI: 10.1007/s00520-019-04887-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 05/22/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To update the clinical practice guidelines for the use of natural and miscellaneous agents for the prevention and/or treatment of oral mucositis (OM). METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer / International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible. RESULTS A total of 78 papers were identified within the scope of this section, out of which 29 were included in this part, and were analyzed with 27 previously reviewed studies. A new Suggestion was made for oral glutamine for the prevention of OM in head and neck (H&N) cancer patients receiving radiotherapy with concomitant chemotherapy. The previous Recommendation against the use of parenteral glutamine for the prevention of OM in hematopoietic stem cell transplantation (HSCT) patients was re-established. A previous Suggestion for zinc to prevent OM in H&N cancer patients treated with radiotherapy or chemo-radiotherapy was reversed to No Guideline Possible. No guideline was possible for other interventions. CONCLUSIONS Of the vitamins, minerals, and nutritional supplements studied for the management of OM, the evidence supports a Recommendation against parenteral glutamine in HSCT patients and a Suggestion in favor of oral glutamine in H&N cancer patients for the management of OM.
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Affiliation(s)
- Noam Yarom
- Oral Medicine Unit, Sheba Medical Center, Tel Hashomer, Israel. .,School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Allan Hovan
- British Columbia Cancer - Vancouver Centre, Vancouver, Canada
| | - Paolo Bossi
- Medical Oncology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
| | - Anura Ariyawardana
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia.,Metro South Oral Health, Queensland Health, Brisbane, Australia
| | - Siri Beier Jensen
- Department of Dentistry and Oral Health, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Margherita Gobbo
- Division of Oral Medicine and Pathology, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Abhishek Kandwal
- Cancer Research Institute, Himalayan Institute of Medical Sciences, Swami Rama Himayalan University, Dehradun, Uttarakhand, India
| | - Alessandra Majorana
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, Dental School University of Brescia, Brescia, Italy
| | - Giulia Ottaviani
- Division of Oral Medicine and Pathology, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Monica Pentenero
- Department of Oncology, Oral Medicine and Oral Oncology Unit, University of Turin, Turin, Italy
| | - Narmin Mohammed Nasr
- Special Needs Dentistry, Dental Services, Directorate General of Health Services-Muscat Governorate, Ministry of Health, Muscat, Oman
| | - Tanya Rouleau
- Dental Oncology Program, Health Sciences North, North East Cancer Center, Sudbury, ON, Canada
| | - Anna Skripnik Lucas
- Medical Oncology Service, Department of Medicine, NYU Langone Perlmutter Cancer Center, New York, NY, USA
| | - Nathaniel Simon Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Eyal Zur
- Compounding Solutions, Tel-Mond, Israel
| | - Vinisha Ranna
- Department of Oral and Maxillofacial Surgery, The Mount Sinai Hospital, New York, NY, 10029, USA
| | - Anusha Vaddi
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Karis Kin Fong Cheng
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrei Barasch
- Division of Oncology, Weill Cornell Medical College, New York, NY, USA
| | - Rajesh V Lalla
- Section of Oral Medicine, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Sharon Elad
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
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Cho YK, Hong SY, Jeon SJ, Namgung HW, Lee E, Lee E, Bang SM. Efficacy of parenteral glutamine supplementation in adult hematopoietic stem cell transplantation patients. Blood Res 2019; 54:23-30. [PMID: 30956960 PMCID: PMC6439295 DOI: 10.5045/br.2019.54.1.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) patients need parenteral nutrition because of nausea, vomiting, and mucositis caused by conditioning regimens. The demand for glutamine increases during the HSCT period. We evaluated the effects of glutamine-containing parenteral nutrition on the clinical outcomes of HSCT patients. METHODS In this retrospective analysis, we reviewed HSCT patients from Seoul National University from August 2013 to July 2017. Depending on their glutamine supplementation status, 91 patients were divided into 2 groups: glutamine group (N=44) and non-glutamine group (N=47). We analyzed the rate of weight change, infection (clinically/microbiologically documented), complications (duration of mucositis and neutropenia, acute graft versus host disease), and 100-days mortality in each group. RESULTS Regarding the clinical characteristics of the patients, there were no significant differences between the 2 groups except that there was a larger proportion of myeloablative conditioning regimen in the glutamine group (P=0.005). In the glutamine group, the average number of days of glutamine use, parenteral nutrition, and mucositis was 7.6±1.4, 14.6±9.9, and 13.3±9.5, respectively. Furthermore, multivariate analysis revealed odds ratios of 0.37 (95% CI, 0.14-0.96; P=0.042) and 0.08 (95% CI, 0.01-0.98; P=0.048) for clinically documented infection and 100-days mortality, respectively, in the glutamine group. CONCLUSION Results showed that the glutamine group had less clinically documented infection and 100-days mortality than the non-glutamine group, but the other outcomes did not show significant differences. The extended duration of glutamine supplementation according to the period of total parenteral nutrition and mucositis should be considered.
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Affiliation(s)
- Yun Kyung Cho
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - So Yeon Hong
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Su Jeoung Jeon
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung Wook Namgung
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Euni Lee
- College of Pharmacy, Seoul National University, Seoul, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Chang YH, Yu MS, Wu KH, Hsu MC, Chiou YH, Wu HP, Peng CT, Chao YH. Effectiveness of Parenteral Glutamine on Methotrexate-induced Oral Mucositis in Children with Acute Lymphoblastic Leukemia. Nutr Cancer 2017; 69:746-751. [DOI: 10.1080/01635581.2017.1324995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Yu-Hsiang Chang
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Nursing, Tajen University, Pingtung, Taiwan
| | - Ming-Sun Yu
- Haematology-Oncology Section, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kang-Hsi Wu
- Division of Pediatric Hematology and Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
- School of Post-baccalaureate Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Mao-Chou Hsu
- Department of Recreation Sports Management, Tajen University, Pintung, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Tien Peng
- Division of Pediatric Hematology and Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Yu-Hua Chao
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Integrative Therapy Use for Management of Side Effects and Toxicities Experienced by Pediatric Oncology Patients. CHILDREN-BASEL 2014; 1:424-40. [PMID: 27417488 PMCID: PMC4928739 DOI: 10.3390/children1030424] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/11/2014] [Accepted: 10/29/2014] [Indexed: 01/29/2023]
Abstract
Integrative Therapies (IT), otherwise known as Complementary and Alternative Medicine, are widely used among pediatric oncology patients, despite a paucity of available evidence. This review summarizes surveys that describe the prevalence of IT use by pediatric oncology patients, both during therapy and in survivorship, as well as the modalities being used. Additionally, the evidence that exists for specific treatments that appear to be efficacious in controlling specific symptoms is described. Finally, there are recommendations for practitioners on how to best counsel patients about IT use.
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Parenteral glutamine supplementation has no effect on chemotherapy-induced toxicity in children with non-Hodgkin lymphoma. J Pediatr Hematol Oncol 2013; 35:371-6. [PMID: 23426005 DOI: 10.1097/mph.0b013e318282daf4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE Protecting patients from the acute and/or chronic toxicity of antineoplastic therapy has become a major concern of oncology centers around the world. Glutamine has been used as a multisystemic protective agent to minimize the side effects arising from the treatment of childhood cancers. In this study, the effect of intravenous glutamine supplementation was investigated in children receiving chemotherapy for non-Hodgkin lymphoma. METHODS Twelve children, of 48 to 120 months of age, and who had non-Hodgkin lymphoma were enrolled in the study. Thirty chemotherapy courses were given in combination with glutamine, and 31 chemotherapy courses were given without glutamine. Glutamine was given intravenously for 7 days, at a dose of 0.4 g/kg/d. Patients were evaluated in each course with regard to gastrointestinal, mucosal, and hematological toxicities. RESULTS There were no significant differences in the hematological parameters between the 2 groups. The requirements for red blood cells and platelets during the chemotherapy courses were similar in both groups (P=0.64 and 0.40, respectively). Patients supplemented with glutamine developed mucositis in 21 of 30 courses (70%) and patients without glutamine supplements developed mucositis in 23 of 31 courses (74%). The mean duration of mucositis and the mean mucositis score in each course were similar between the 2 groups. In addition, gastrointestinal system and hepatic toxicity did not differ between groups. The mean duration of febrile neutropenia and the length of hospitalization were also similar in both groups (P=0.09 and 0.13, respectively). CONCLUSIONS Parenteral glutamine supplementation has no effect on mucositis, fever and febrile neutropenia, length of hospitalization, red blood cell, and platelet requirements, and hematological, gastrointestinal, and hepatic toxicities in children receiving severe chemotherapy.
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Yarom N, Ariyawardana A, Hovan A, Barasch A, Jarvis V, Jensen SB, Zadik Y, Elad S, Bowen J, Lalla RV. Systematic review of natural agents for the management of oral mucositis in cancer patients. Support Care Cancer 2013; 21:3209-21. [PMID: 23764678 DOI: 10.1007/s00520-013-1869-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 05/21/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to review the available literature and define clinical practice guidelines for the use of natural agents for the prevention and treatment of oral mucositis. METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology. The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guideline possible. RESULTS A total of 49 papers across 15 interventions were examined. A new suggestion was developed in favor of systemic zinc supplements administered orally in the prevention of oral mucositis in oral cancer patients receiving radiation therapy or chemoradiation (Level III evidence). A recommendation was made against the use of intravenous glutamine for the prevention of oral mucositis in patients receiving high-dose chemotherapy prior to hematopoietic stem cell transplant (Level II evidence). No guideline was possible for any other agent, due to inadequate and/or conflicting evidence. CONCLUSIONS Of the various natural agents reviewed here, the available evidence supported a guideline only for two agents: a suggestion in favor of zinc and a recommendation against glutamine, in the treatment settings listed above. Well-designed studies of other natural agents are warranted.
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Affiliation(s)
- Noam Yarom
- Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel-Hashomer, Israel,
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Hébuterne X, Bensadoun RJ. Nutrition chez le patient adulte atteint de cancer : place de la pharmaconutrition en cancérologie. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mok E, Hankard R. Glutamine supplementation in sick children: is it beneficial? J Nutr Metab 2011; 2011:617597. [PMID: 22175008 PMCID: PMC3228321 DOI: 10.1155/2011/617597] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/28/2011] [Indexed: 12/14/2022] Open
Abstract
The purpose of this review is to provide a critical appraisal of the literature on Glutamine (Gln) supplementation in various conditions or illnesses that affect children, from neonates to adolescents. First, a general overview of the proposed mechanisms for the beneficial effects of Gln is provided, and subsequently clinical studies are discussed. Despite safety, studies are conflicting, partly due to different effects of enteral and parenteral Gln supplementation. Further insufficient evidence is available on the benefits of Gln supplementation in pediatric patients. This includes premature infants, infants with gastrointestinal disease, children with Crohn's disease, short bowel syndrome, malnutrition/diarrhea, cancer, severe burns/trauma, Duchenne muscular dystrophy, sickle cell anemia, cystic fibrosis, and type 1 diabetes. Moreover, methodological issues have been noted in some studies. Further mechanistic data is needed along with large randomized controlled trials in select populations of sick children, who may eventually benefit from supplemental Gln.
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Affiliation(s)
- Elise Mok
- INSERM Centre D'Investigation Clinique 802, Centre Hospitalier Universitaire de Poitiers, 86021 Poitiers Cedex, France
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Saha P, Arthur S, Kekuda R, Sundaram U. Na-glutamine co-transporters B(0)AT1 in villus and SN2 in crypts are differentially altered in chronically inflamed rabbit intestine. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2011; 1818:434-42. [PMID: 22100603 DOI: 10.1016/j.bbamem.2011.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 10/05/2011] [Accepted: 11/02/2011] [Indexed: 02/06/2023]
Abstract
Glutamine is a major nutrient utilized by the intestinal epithelium and is primarily assimilated via Na-glutamine co-transport (NGcT) on the brush border membrane (BBM) of enterocytes. Recently we reported that B(0)AT1 (SLC6A19) mediates glutamine absorption in villus while SN2 (SLC38A5) does the same in crypt cells. However, how B(0)AT1 and SN2 are affected during intestinal inflammation is unknown. In the present study it was shown that during chronic enteritis NGcT was inhibited in villus cells, however, it was stimulated in crypt cells. Our studies also demonstrated that the mechanism of inhibition of NGcT during chronic enteritis was secondary to a reduction in the number of B(0)AT1 co-transporters in the villus cell BBM without a change in the affinity of the co-transporter. In contrast, stimulation of NGcT in crypt cells was secondary to an increase in the affinity of SN2 for glutamine without an alteration in the number of co-transporters. Thus, glutamine assimilation which occurs via distinct transporters in crypt and villus cells is altered in the chronically inflamed intestine.
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Affiliation(s)
- Prosenjit Saha
- West Virginia University Health Science Centre, Morgantown, WV, USA
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Akbulut G. New perspective for nutritional support of cancer patients: Enteral/parenteral nutrition. Exp Ther Med 2011; 2:675-684. [PMID: 22977559 DOI: 10.3892/etm.2011.247] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/24/2011] [Indexed: 12/15/2022] Open
Abstract
Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of quality of life (QoL). Cancer-related malnutrition may evolve into cancer cachexia due to complex interactions between pro-inflammatory cytokines and the host metabolism. Depending on the type of cancer treatment (either curative or palliative), the clinical condition of the patient and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counseling, oral supplementation, enteral or total parenteral nutrition). Nutritional support has been widely advocated as adjunctive therapy for a variety of underlying illnesses, including surgery and medical oncotherapy (radiation or chemotherapy for cancer). Glutamine, n-3 fatty acids and probiotics/prebiotics are therapeutic factors that potentially modulate gastrointestinal toxicity related to cancer treatments. Enteral and parenteral nutrition may help improve patient survival, functional status and QoL, yet the benefits appear to be primarily limited to patients with good functional status and with gastrointestinal disease affecting nutritional intake. Parenteral nutrition offers the possibility of increased or maintenance of the nutrient intake in patients for whom normal food intake is inadequate and for whom enteral nutrition is not feasible, is contraindicated or is not accepted by the patient. This article reviews evidence on issues relevant to enteral and parenteral nutrition in patients with cancer.
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Affiliation(s)
- Gamze Akbulut
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Gazi University, Besevler, Ankara, Turkey
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Slicker J, Vermilyea S. Pediatric parenteral nutrition: putting the microscope on macronutrients and micronutrients. Nutr Clin Pract 2009; 24:481-6. [PMID: 19605802 DOI: 10.1177/0884533609339073] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Parenteral nutrition can be a life-saving therapy, but its benefits need to be balanced with a unique set of risks and complications. Methods of practice vary because there is a dearth of research in the area of pediatric parenteral nutrition. This article reviews the available literature on parenteral nutrition in children and provides suggestions on prevention and management of parenteral nutrition-associated liver disease. Some of the issues discussed in this article include glucose infusion rates, cycling of parenteral nutrition, copper and manganese toxicity, and the provision of glutamine, selenium, and carnitine.
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Affiliation(s)
- Julie Slicker
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53201-1997, USA.
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