Nasogastric tube feeding in children with cancer: the effect of two different formulas on weight, body composition, and serum protein concentrations

The importance of enteral nutrition to prevent or treat undernutrition in children undergoing treatment for cancer

Nutrition therapy is a therapeutic approach to treating medical conditions and symptoms via diet, which can be done by oral, enteral or parenteral routes. It is desirable to include nutritional interventions as a standard of care in pediatric cancer units (PCUs) at all levels of care. The interventions are dependent on available resources and personnel across all clinical settings. Enteral nutrition is easy, inexpensive, uses the gastrointestinal tract, maintains gut mucosal integrity, and allows for individualized nutritional strategies. This narrative review describes enteral nutritional interventions for children undergoing cancer treatment and is aimed at PCUs of all levels of care located in a low- and middle-income country.

Nutritional support in children and young people with cancer undergoing chemotherapy

BACKGROUND

It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known.

OBJECTIVES

To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review.

SEARCH METHODS

We searched the following databases for the initial review: CENTRAL (The Cochrane Library, Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information.

MAIN RESULTS

The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD -27.00, 95% CI -43.32 to -10.68) and energy intake (MD -15.00, 95% CI -26.81 to -3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD -0.34 z-scores, 95% CI -0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference -0.12, 95% CI -0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74).

AUTHORS' CONCLUSIONS

There is limited evidence from individual trials to suggest that PN is more effective than EN in well-nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential.

Proactive enteral tube feeding in pediatric patients undergoing chemotherapy

BACKGROUND

To determine feasibility and safety of proactive enteral tube feeding (ETF) in pediatric oncology patients.

METHODS

Pediatric patients with newly diagnosed brain tumors, myeloid leukemia or high-risk solid tumors were eligible. Subjects agreeing to start ETF before cycle 2 chemotherapy were considered proactive participants (PPs). Those who declined could enroll as chart collection receiving nutritional standard of care. Nutritional status was assessed using standard anthropometric measurements. Episodes of infection and toxicity related to ETF were documented from diagnosis to end of therapy. A descriptive comparison between PPs and controls was conducted.

RESULTS

One hundred four eligible patients were identified; 69 enrolled (20 PPs and 49 controls). At diagnosis, 17% of all subjects were underweight and 26% overweight. Barriers to enrollment included physician, subject and/or family refusal, and inability to initiate ETF prior to cycle 2 of chemotherapy. Toxicity of ETF was minimal, but higher percentage of subjects in the proactive group had episodes of infection than controls. Thirty-nine percent of controls eventually started ETF and were twice as likely to receive parenteral nutrition. PPs experienced less weight loss at ETF initiation than controls receiving ETF and were the only group to demonstrate improved nutritional status at end of study.

CONCLUSIONS

Proactive ETF is feasible in children with cancer and results in improved nutritional status at end of therapy. Episodes of infection in this study are concerning; therefore, a larger randomized trial is required to further delineate infectious risks and toxicities that may be mitigated by improved nutritional status.

Enteral nutrition during bone marrow transplantation in patients with pediatric cancer: a prospective cohort study

CONTEXT AND OBJECTIVE

Cancer patients undergoing bone marrow transplantation (BMT) often require nutritional therapy due to treatment toxicities. The aim here was to evaluate the use of tube feeding and its applicability, indications, contraindications and complications in these patients.

DESIGN AND SETTING

Prospective observational study conducted at a public university in São Paulo between January 2002 and August 2007.

METHODS

The patients were followed up daily in the BMT unit by a research dietitian. Tube feeding was indicated when oral supplementation proved to be insufficient, when the patient had severe malnutrition or there was an impediment to use of oral feeding. It was contraindicated in the presence of gastrointestinal toxicity of grade 3 and 4 or other conditions that implied a risk or hindered its use or placement. Complications of tube feeding were divided into minor and major, according to whether they had life-threatening implications.

RESULTS

Forty-two (47.2%) patients had indications for tube feeding: the main reasons were transplantation inadequate food and supplement intake, insufficient intake with malnutrition or weight loss, severe malnutrition or need for oral fasting. Thirty-one (73.8%) received tube feeding: 11 autologous and 20 allogenic patients (P = 0.04). The main contraindications were severe gastrointestinal toxicities and sinusitis. Minor complications from tube feeding were more prevalent in patients with allogenic BMT, but no major complications were observed.

CONCLUSION

Enteral nutrition is a feasible procedure in patients undergoing BMT and should be encouraged. The main difficulty in BMT patients, in relation to tube feeding, is gastrointestinal toxicities.

Resultados da implantação de um algoritmo para terapia nutricional enteral em crianças e adolescentes com câncer

Objetivo Descrever o algoritmo e os resultados globais após sua implantação. Métodos Ensaio clínico randomizado realizado com pacientes com câncer e desnutrição. O acompanhamento foi guiado por algoritmo, e desnutridos leves eram randomizados para suplementação oral industrializada ou artesanal, reavaliados após três, oito e doze semanas. Dependendo da resposta no grupo suplementação oral indus-trializada, indicava-se suplemento industrializado por sonda, mantinha-se suplementação oral industrializada ou ela era suspensa. O grupo suplementação oral artesanal com resposta positiva permaneceu com a mesma orientação; se negativa iniciou com suplementação oral industrializada. Nos desnutridos graves, resposta negativa indicou suplemento industrializado por sonda, positiva manteve suplementação oral industrializada ou ela era suspensa no caso de eutrofia. A avaliação das respostas foi realizada por meio do escore-Z de peso para estatura, índice de massa corpórea, prega cutânea triciptal e circunferências. Resultados Cento e dezessete de 141 pacientes completaram três semanas iniciais; 58 desnutridos grave e 59 leve. Evolução nutricional positiva ocorreu em 41% dos graves, em 97% dos leves com suplementação oral industrializada e em 77% dos desnutridos leves com suplementação oral artesanal. Dos 117, 42 tiveram indicação de suplemento industrializado por sonda; 23 usaram e 19 recusaram, mantendo suplementação oral industrializada. Pacientes que usaram suplemento industrializado por sonda apresentaram consumo de suplemento superior aos demais; o consumo de suplemento industrializado por sonda também foi superior quando comparado ao período anterior com suplementação oral industrializada nos mesmos pacientes. O uso de suplemento industrializado por sonda demonstrou melhorar o estado nutricional, com associação positiva entre sua duração e evolução nutricional. Conclusão Suplementação oral industrializada reduziu o deficit nutricional, principalmente em desnutridos leves. Os resultados sugerem que a suplemento industrializado por sonda favoreceu a recuperação nutricional, principalmente com o uso mais prolongado.

Nutritional support in children and young people with cancer undergoing chemotherapy

BACKGROUND

Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are unclear.

OBJECTIVES

To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support in children and young people with cancer undergoing chemotherapy.

SEARCH STRATEGY

We searched the following databases: CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). We scrutinised reference lists of articles to identify additional trials. We also contacted experts in the field for information on relevant trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials. Three authors independently assessed quality and extracted data. We contacted trialists for missing information.

MAIN RESULTS

We included eight trials which randomised 159 participants (< 21 years) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12; 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70; 95% CI 0.14 to 1.26), calorie intake (MD 22.00; 95% CI 5.12 to 38.88) and protein intake (MD 0.80; 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD -27.00; 95% CI -43.32 to -10.68) and energy intakes (MD -15.00; 95% CI -26.81 to -3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group(MD 0.47; 95% CI 0.13 to 0.81, P = 0.008).

AUTHORS' CONCLUSIONS

There is limited evidence from individual trials to suggest that parenteral nutrition is more effective than enteral nutrition in well-nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. No studies were identified comparing the nutritional content in the PN or EN groups of studies. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential.

Short-term nutritional implications of total gastrectomy for malignancy, and the impact of parenteral nutritional support

AIMS

To report on peri-operative nutritional status in gastric cancer patients undergoing total gastrectomy, and to examine the role of post-operative parenteral nutrition.

METHODS

Retrospective study of prospectively collected data on 90 consecutive patients who underwent total gastrectomy for malignancy.

RESULTS

At diagnosis 46% of patients reported clinically severe weight loss, and dietary intake was inadequate in 72% of patients. Post-operatively 42% were given total parenteral nutrition (TPN) and 53% were given intravenous fluids (IVF) alone. TPN patients spent a mean of 13.6 days on nutrition support versus IVF patients who spent a mean of 9.2 days without any form of nutrition. IVF patients lost significantly more weight in hospital than TPN patients (5.2 kg versus 3.1 kg, p=0.008). 69% of IVF patients lost severe amount of weight versus 34% in the TPN group (p=0.01). Post-discharge, IVF patients continued to lose significantly more weight than those given TPN post-operatively (7.5 kg versus 2.9 kg, p=0.01) corresponding to 10.5% of their body weight from discharge to follow up versus 4.9% for TPN group (p=0.014). From pre-illness to follow up, patients lost an average of 15.5 kg--IVF patients lost 17.8 kg versus 9.6 kg in TPN (p<0.01). There was no difference in post-operative complications between the groups; however, patients with >10% weight loss had a significantly higher rate of complications and a significantly higher mortality rate than patients who lost <10% body weight (26.2% versus 51.9%, p=0.036 and 11.1% versus 0%, p=0.027, respectively). On multivariate logistic regression analysis >10% weight loss at diagnosis was the only predictive factor of post-operative complications OR 3.1 (95% CI 1.0-9.6), p=0.04).

CONCLUSIONS

There is a high prevalence of malnutrition in gastric cancer patients undergoing surgery. Total gastrectomy is associated with dramatic weight loss, which continues beyond the surgeon's view post-discharge, with patients losing an average of 15.5 kg by 3-month follow up. Provision of nutrition support in the form of TPN post-operatively significantly reduces in-hospital weight loss and also helps to attenuate further weight loss post-discharge.

Common gastrointestinal symptoms in pediatric palliative care: nausea, vomiting, constipation, anorexia, cachexia

Gastrointestinal symptoms are suffered commonly by children at the end of life. Diagnosis and management of these common symptoms include careful history and physical examination to assess for possible causes; treatment - pharmacologic and nonpharmacologic; and a discussion with patients and families of care goals. Aggressive management of these symptoms is essential to improving the quality of life for these children.

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.

Diretrizes para terapia nutricional em crianças com câncer em situação crítica

Este trabalho é constituído de uma revisão de conceitos fundamentais e atualizados relacionados à terapia nutricional de crianças com câncer criticamente doentes. O objetivo principal desta revisão é discutir alterações nutricionais e metabólicas decorrentes dessa condição, bem como as indicações, recomendações, contra-indicações e complicações da terapia nutricional (nutrição enteral e parenteral) em pacientes com câncer. Este artigo aborda, de forma objetiva, a aplicação prática de alguns conceitos baseados em evidências científicas, e propõe algumas diretrizes para auxiliar na decisão da terapia nutricional no âmbito da vivência clínica. Conclui-se que há necessidade de maior incentivo ao desenvolvimento da ciência da terapia de suporte, como o tratamento das infecções, a terapia intensiva e a terapia metabólico-nutricional, para que se ampliem as possibilidades de cura de crianças e adolescentes com câncer.

Nutritional support strategies for malnourished cancer patients

A large body of evidence exists, which demonstrates the importance of nutritional support in cancer. The nutritional needs of patients with cancer may differ from those of the healthy population due to hypermetabolism, impaired organ function, increased nutrient losses and therapy-related malnutrition. Patients with cancer often have increased requirements for both macro- and micronutrients due to long periods of undernutrition prior to diagnosis. The aim of nutritional support should be the prevention or reversal of malnutrition, and this should be initiated as early as possible to improve outcomes. Oral supplementation is a simple, non-invasive method of increasing the nutrient intake of those patients who are unable to meet nutritional requirements, despite dietary counselling. Enteral tube feeding is indicated for patients who are unable to meet their nutritional needs by oral intake alone, and has been shown to improve clinical outcomes. Novel approaches in oral supplementation include the use of eicosapentaenoic acid (EPA), a compound under investigation for its role in preventing and treating cancer-associated malnutrition. Individual studies suggest that EPA attenuates cancer-associated wasting and improves immune function. In addition, it has been shown to have anti-tumour effects and improve clinical outcomes. However, results are not consistent for all patient groups and further research is required.

Cancer-associated malnutrition

Malnutrition is a common problem among patients with cancer, affecting up to 85% of patients with certain cancers (e.g. pancreas). In severe cases, malnutrition can progress to cachexia, a specific form of malnutrition characterised by loss of lean body mass, muscle wasting, and impaired immune, physical and mental function. Cancer cachexia is also associated with poor response to therapy, increased susceptibility to treatment-related adverse events, as well as poor outcome and quality of life. Cancer cachexia is a complex, multifactorial syndrome, which is thought to result from the actions of both host- and tumour-derived factors, including cytokines involved in a systemic inflammatory response to the tumour. Early intervention with nutritional supplementation has been shown to halt malnutrition, and may improve outcome in some patients. However, increasing nutritional intake is insufficient to prevent the development of cachexia, reflecting the complex pathogenesis of this condition. Nutritional supplements containing anti-inflammatory agents, for example the polyunsaturated fatty acid (PUFA) eicosapentanoic acid (EPA), have been shown to be more beneficial to malnourished patients than nutritional supplementation alone. EPA has been shown to interfere with multiple mechanisms implicated in the pathogenesis of cancer cachexia, and in clinical studies, has been associated with reversal of cachexia and improved survival.

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.