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Caloric and nutrient restriction to augment chemotherapy efficacy for acute lymphoblastic leukemia: the IDEAL trial. Blood Adv 2021; 5:1853-1861. [PMID: 33792627 DOI: 10.1182/bloodadvances.2020004018] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Being overweight or obese (OW/OB) during B-cell acute lymphoblastic leukemia (B-ALL) induction is associated with chemoresistance as quantified by minimal residual disease (MRD). We hypothesized that caloric and nutrient restriction from diet/exercise could lessen gains in fat mass (FM) and reduce postinduction MRD. The Improving Diet and Exercise in ALL (IDEAL) trial enrolled patients 10 to 21 years old, newly diagnosed with B-ALL (n = 40), in comparison with a recent historical control (n = 80). Designed to achieve caloric deficits ≥20% during induction, reduce fat intake/glycemic load, and increase activity, IDEAL's end points were FM gain (primary), MRD ≥0.01%, and adherence/feasibility. Integrated biology explored biomarkers of OW/OB physiology. IDEAL intervention did not significantly reduce median FM change from baseline overall (+5.1% [interquartile range [IQR], 15.8] vs +10.7% [IQR, 16.0]; P = .13), but stratified analysis showed benefit in those OW/OB (+1.5% [IQR, 6.6] vs +9.7% [IQR, 11.1]; P = .02). After accounting for prognostic factors, IDEAL intervention significantly reduced MRD risk (odds ratio, 0.30; 95% confidence interval, 0.09-0.92; P = .02). The trial exceeded its adherence (≥75% of overall diet) and feasibility (≥80% completed visits) thresholds. Integrated biology found the IDEAL intervention increased circulating adiponectin and reduced insulin resistance. The IDEAL intervention was feasible, decreased fat gain in those OW/OB, and reduced MRD. This is the first study in any hematologic malignancy to demonstrate potential benefit from caloric restriction via diet/exercise to augment chemotherapy efficacy and improve disease response. A prospective, randomized trial is warranted for validation. These trials were registered at www.clinicaltrials.gov as #NCT02708108 (IDEAL trial) and #NCT01317940 (historical control).
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Cober MP, Gura KM. Enteral and parenteral nutrition considerations in pediatric patients. Am J Health Syst Pharm 2020; 76:1492-1510. [PMID: 31532507 DOI: 10.1093/ajhp/zxz174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed. SUMMARY The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients. CONCLUSION The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.
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Affiliation(s)
- Mary Petrea Cober
- Department of Pharmacy, Akron Children's Hospital, Akron, OH, and Northeast Ohio Medical University, Rootstown, OH
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, and Harvard Medical School, Boston, MA
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3
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Martinez EE, Ariagno KA, Stenquist N, Anderson D, Muñoz E, Mehta NM. Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit. Nutr Clin Pract 2016; 32:414-419. [PMID: 28490231 DOI: 10.1177/0884533616670623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort. METHODS We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery. RESULTS Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3. CONCLUSIONS The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.
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Affiliation(s)
- Enid E Martinez
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Harvard Medical School, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- 3 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicole Stenquist
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniela Anderson
- 4 University of São Paulo-Ribeirao Preto School of Medicine, São Paulo, Brazil
| | - Eliana Muñoz
- 5 Universidad de Chile, Hospital Dr. Luis Calvo Mackenna, Providencia, Chile
| | - Nilesh M Mehta
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Harvard Medical School, Boston, Massachusetts, USA.,3 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Shaughnessy EE, Kirkland LL. Malnutrition in Hospitalized Children: A Responsibility and Opportunity for Pediatric Hospitalists. Hosp Pediatr 2016; 6:37-41. [PMID: 26644045 DOI: 10.1542/hpeds.2015-0144] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Erin E Shaughnessy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; and
| | - Lisa L Kirkland
- Division of Hospital Medicine, Mayo Clinic, Rochester, Minnesota
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Skillman HE, Zebuhr CA. Optimal Nutrition for Acute Rehabilitation in the PICU. J Pediatr Intensive Care 2015; 4:194-203. [PMID: 31110872 DOI: 10.1055/s-0035-1563546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/12/2015] [Indexed: 01/15/2023] Open
Abstract
Achieving optimal nutrition for a child who is receiving acute rehabilitation in the pediatric intensive care unit requires an individualized approach. Nutrition screening and assessment is necessary to identify children at high risk for complications who require targeted interventions. Early enteral nutrition can improve outcomes, and is thus preferred over parenteral nutrition in the absence of gastrointestinal contraindications. Measurement of caloric requirements with indirect calorimetry is essential to accurately prescribe nutrition support, while monitoring body composition can determine efficacy of nutrition therapies employed. The complex care of critically ill children receiving acute rehabilitation is composed of treatments that compete with delivery of prescribed nutrition. Repeated feeding interruptions can lead to nutrition deficits and prolonged recovery. Nutrition bundles that incorporate evidenced-based nutrition algorithms, methods to overcome nutrition barriers, and nutrition monitoring parameters can direct and optimize nutrition care for critically ill children in need of acute rehabilitation.
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Affiliation(s)
- Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Carleen A Zebuhr
- Section of Critical Care, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, United States
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Martinez EE, Ariagno K, Arriola A, Lara K, Mehta NM. Challenges to Nutrition Therapy in the Pediatric Critically Ill Obese Patient. Nutr Clin Pract 2015; 30:432-9. [DOI: 10.1177/0884533615569887] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Enid E. Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Katelyn Ariagno
- Center for Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Aldis Arriola
- Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Kattina Lara
- Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Center for Nutrition, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Wales PW, Allen N, Worthington P, George D, Compher C, Teitelbaum D. A.S.P.E.N. clinical guidelines: support of pediatric patients with intestinal failure at risk of parenteral nutrition-associated liver disease. JPEN J Parenter Enteral Nutr 2014; 38:538-57. [PMID: 24696095 DOI: 10.1177/0148607114527772] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 02/21/2014] [Indexed: 11/07/2023]
Abstract
BACKGROUND Children with severe intestinal failure and prolonged dependence on parenteral nutrition are susceptible to the development of parenteral nutrition-associated liver disease (PNALD). The purpose of this clinical guideline is to develop recommendations for the care of children with PN-dependent intestinal failure that have the potential to prevent PNALD or improve its treatment. METHOD A systematic review of the best available evidence to answer a series of questions regarding clinical management of children with intestinal failure receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors. QUESTIONS (1) Is ethanol lock effective in preventing bloodstream infection and catheter removal in children at risk of PNALD? (2) What fat emulsion strategies can be used in pediatric patients with intestinal failure to reduce the risk of or treat PNALD? (3) Can enteral ursodeoxycholic acid improve the treatment of PNALD in pediatric patients with intestinal failure? (4) Are PNALD outcomes improved when patients are managed by a multidisciplinary intestinal rehabilitation team?
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Affiliation(s)
- Paul W Wales
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nancy Allen
- Children's Mercy Hospital, Kansas City, Missouri
| | | | | | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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Boullata JI, Gilbert K, Sacks G, Labossiere RJ, Crill C, Goday P, Kumpf VJ, Mattox TW, Plogsted S, Holcombe B. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr 2014; 38:334-77. [PMID: 24531708 DOI: 10.1177/0148607114521833] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation. METHOD A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?
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Choban P, Dickerson R, Malone A, Worthington P, Compher C. A.S.P.E.N. Clinical Guidelines. JPEN J Parenter Enteral Nutr 2013; 37:714-44. [DOI: 10.1177/0148607113499374] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Patricia Choban
- Mt Carmel Hospital, Central Ohio Surgical Associates, Columbus, OH, USA
| | | | - Ainsley Malone
- Department of Pharmacy, Mt Carmel West Hospital, Columbus, OH, USA
| | | | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Nehra D, Carlson SJ, Fallon EM, Kalish B, Potemkin AK, Gura KM, Simpser E, Compher C, Puder M. A.S.P.E.N. clinical guidelines: nutrition support of neonatal patients at risk for metabolic bone disease. JPEN J Parenter Enteral Nutr 2013; 37:570-98. [PMID: 23685349 DOI: 10.1177/0148607113487216] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Premature infants are at increased risk for metabolic bone disease, with resulting delayed bone growth, osteopenia, and rickets. METHOD A systematic review of the best available evidence to answer a series of questions regarding neonatal patients at risk of metabolic bone disease receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors. QUESTIONS (1) What maternal risk factors predispose the neonate to metabolic bone disease? (2) What is the optimal type of feeding to promote neonatal bone health? (3) When and how should vitamin D supplements be administered? (4) Does parenteral nutrition (PN) predispose a neonate to metabolic bone disease, and if so, are there PN formulation recommendations to minimize this risk?
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Affiliation(s)
- Deepika Nehra
- Department of Surgery and The Vascular Biology Program, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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Fallon EM, Nehra D, Potemkin AK, Gura KM, Simpser E, Compher C, Puder M. A.S.P.E.N. clinical guidelines: nutrition support of neonatal patients at risk for necrotizing enterocolitis. JPEN J Parenter Enteral Nutr 2012; 36:506-23. [PMID: 22753618 DOI: 10.1177/0148607112449651] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is one of the most devastating diseases in the neonatal population, with extremely low birth weight and extremely preterm infants at greatest risk. METHOD A systematic review of the best available evidence to answer a series of questions regarding nutrition support of neonates at risk of NEC was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. RESULTS/ CONCLUSIONS: (1) When and how should feeds be started in infants at high risk for NEC? We suggest that minimal enteral nutrition be initiated within the first 2 days of life and advanced by 30 mL/kg/d in infants ≥ 1, 000 g. (Weak) (2) Does the provision of mother's milk reduce the risk of developing NEC? We suggest the exclusive use of mother's milk rather than bovine-based products or formula in infants at risk for NEC. (Weak) (3) Do probiotics reduce the risk of developing NEC? There are insufficient data to recommend the use of probiotics in infants at risk for NEC. (Further research needed.) (4) Do nutrients either prevent or predispose to the development of NEC? We do not recommend glutamine supplementation for infants at risk for NEC (Strong). There is insufficient evidence to recommend arginine and/or long chain polyunsaturated fatty acid supplementation for infants at risk for NEC. (Further research needed.) (5) When should feeds be reintroduced to infants with NEC? There are insufficient data to make a recommendation regarding time to reintroduce feedings to infants after NEC. (Further research needed.).
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Affiliation(s)
- Erica M Fallon
- Department of Surgery and The Vascular Biology Program, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C. A.S.P.E.N. clinical guidelines: nutrition support of adult patients with hyperglycemia. JPEN J Parenter Enteral Nutr 2012; 37:23-36. [PMID: 22753619 DOI: 10.1177/0148607112452001] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hyperglycemia is a frequent occurrence in adult hospitalized patients who receive nutrition support. Both hyperglycemia and hypoglycemia (resulting from attempts to correct hyperglycemia) are associated with adverse outcomes in diabetic as well as nondiabetic patients. This American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline summarizes the most current evidence and provides guidelines for the desired blood glucose goal range in hospitalized patients receiving nutrition support, the definition of hypoglycemia, and the rationale for use of diabetes-specific enteral formulas in hospitalized patients. METHOD A systematic review of the best available evidence to answer a series of questions regarding glucose control in adults receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. RESULTS/CONCLUSIONS 1. What is the desired blood glucose goal range in adult hospitalized patients receiving nutrition support? We recommend a target blood glucose goal range of 140-180 mg/dL (7.8-10 mmol/L). (Strong) 2. How is hypoglycemia defined in adult hospitalized patients receiving nutrition support? We recommend that hypoglycemia be defined as a blood glucose concentration of <70 mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes-specific enteral formulas be used for adult hospitalized patients with hyperglycemia? We cannot make a recommendation at this time.
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Affiliation(s)
- M Molly McMahon
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Pediatric obesity is a major public health threat. Obese children and adolescents are at increased risk for many medical and surgical conditions. These conditions may affect their quality of life and life expectancy. The rapidly progressive nature of type 2 diabetes mellitus within the first 5 years of obesity diagnosis is particularly concerning. Because health risk increases with degree of obesity, adolescents who may be eligible for more aggressive obesity treatment should be identified and counseled.
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