Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df

and intolerance. Clinical evaluation includes appropriate anthropometric and biochemical measurements Table 12.3 . Practically, weight is the measurement most frequently ascertained and followed. Assessments based on weight alone can be misleading, espe- cially in the acutely ill patient when fl uid balance may be disturbed, particularly by the presence of edema or mass disease. Additionally, weight may be maintained but lean body mass can be dimin- ished. This situation may arise in the patient who is obese at the onset of treatment. BMI calculated as weight [kg]height squared [m 2 ] is recom- mended for monitoring growth in children and adolescents and has to be interpreted relative to population reference data due to changes with age and differences between genders. BMI is consid- ered a better proxy for body fat and lean body mass compared to weight alone; however, it is not without limitations, such as in those with increased muscle mass Mosby et al. 2009 . For children 2 years of age, ideal body weight IBW should be monitored. Mid-upper-arm circumference and triceps skinfolds provide the best estimate of lean body mass and adipose tissue and should prefera- bly be undertaken by the same trained observer due to interobserver variability Barr et al. 2011 . Repeat nutrition assessment during therapy is required to detect changes in nutritional status due to treatment or complications of treatment which may necessitate nutritional interventions. Assessment of hospitalized patients is usually undertaken by the dietician or nutritionist and occurs as per institutional guidelines and ideally during each admission, especially in those at high risk for nutritional depletion Table 12.1 . The use of nutrition software to calculate protein and calories may be benefi cial to the clinician. For outpatients, the maintenance of a nutritional diary of variety and quantity of foods and supple- ments taken is a valuable aid for the dietician to ascertain if the patient is nutritionally replete. Several methods of gathering data can be uti- lized; 24-h dietary recall conducted on nonse- quential days or a 3–5-day food record is most optimal for dietary consultation. Biochemical assessments need to be interpreted carefully as some proteins can also be acute-phase reactants and give spurious values. Any condition that can alter rate of protein synthesis, degrada- tion, or excretion may alter serum protein concen- tration. Albumin and prealbumin are most frequently used as nutrition assessment tools, the latter of which is a better indicator of the acute state due to its shorter half-life. Biochemical labo- ratory assessment should include liver function, renal function, lipid panel and glucose to deter- mine if dietary modifi cation is required; the clini- cian must be cognizant that values may be altered due to cancer therapy or concurrent infection. For example, L-asparaginase inhibits liver protein syn- thesis and a very low-fat diet i.e., 10 g fatday is often required due to asparaginase side effects. Similarly, glucose levels must be followed in patients receiving high- dose steroids such as ALL induction. Dietary intervention helps in maintain- ing adequate nutrition so that chemotherapy can continue at the appropriate dose and schedule and to mitigate potential side effects. During cytotoxic therapy and with episodes of sepsis, the pediatric cancer patient undergoes a catabolic state with nutrient depletion. Decreased Table 12.3 Components of the nutritional assessment Basic anthropometrics Advanced anthropometrics Biochemical indices Weight Body composition assessment Albumin Heightlength Isotope dilution methods Prealbumin Head circumference 3 years of age Bioelectric methods Glucose Weight for heightlength Absorptiometry methods DPA and DEXA Lipid panel BMI Renal panel Height and weight Z score C-reactive protein Triceps skinfold Vitamin and trace elements Arm circumference Waist circumference BMI body mass index, DPA dual-photon absorptiometry, DEXA dual-energy X-ray absorptiometry E.J. Ladas and P.C. Rogers intake of micronutrients has been reported follow- ing chemotherapy and may be associated with therapy-related toxicity Ladas et al. 2004 . For example, reduced intake of B vitamins may be associated with the development of neuropathy; zinc, important in both immune function and mucosal integrity, has been associated with increased infection and dysgeusia altered taste; reduced antioxidant nutrients may be associated with infection and increased hospital stay; and reduced intake of vitamin D and calcium may increase bone morbidity in children with ALL Henkin et al. 1976 ; Mahajan et al. 1980 ; Bolze et al. 1982 ; Watson et al. 1983 ; Kennedy et al. 2004 ; Ozyurek et al. 2007 ; Youssef et al. 2008 ; Tylavsky et al. 2010 . Thus, a thorough analysis of dietary intake should accompany anthropometric and biochemical assessments.

12.3 Nutrition Intervention

The primary goal of nutritional therapy in the pediatric oncology population is to sustain and promote normal growth and development while the patient is receiving the necessary anticancer treatments. Nutrition interventions should be pro- active to prevent the development of malnutrition. If malnutrition develops, nutrition interventions should be implemented to reverse malnutrition and, secondarily, to prevent future protein-energy malnutrition. The most appropriate interventions must meet the nutritional needs of the child but be associated with the least risk. Nutrition counsel- ing and education should be provided to the fam- ily with awareness of cultural differences in nutritional practice. The utilization of a dietitian or nutritionist to provide and support the educa- tion of healthcare staff, patient families, and patients is a crucial component of optimal nutri- tion care in pediatric oncology Sacks et al. 2004 . Nutritional intervention should be implemented in the following situations: 1 patients who pres- ent underweight i.e., BMI 5th ile or 70 IBW; 2 patients who present overweight i.e., BMI 95th ile or IBW 120 ; 3 patients not meeting 80 of their caloric requirements through oral intake during treatment; and 4 5 weight loss from baseline body weight.

12.3.1 Dietary Counseling

Nutrition counseling should begin with strategies to enhance dietary consumption, such as through the utilization of nutrient dense foods. Oral intake may be diffi cult for many children and adoles- cents undergoing treatment due to treatment- related toxicities such as severe nausea, vomiting, stomatitis, constipation, and diarrhea but should be offered as an initial strategy before advancing to enteral or parenteral nutrition. Nutritionally fortifi ed drinks should be recommended for patients unable to consume food. Pediatric for- mulations such as Boost ® , PediaSure ® , and Ensure ® can augment oral intake, and other for- mulations may be provided to ensure adequate electrolyte balance Table 12.4 . Medium- chain triglyceride MCT oil may complement feeding strategies by increasing total calories in a readily absorbable formulation. Special diets, such as the neutropenic diet or low microbial diet, have been suggested for severely immunosuppressed patients such as those treated with hematopoietic stem cell transplant HSCT to minimize the introduction of pathogenic organisms into the gastrointestinal GI tract Moody et al. 2002 . Adherence to these diets is diffi cult and pro- vides further restraints on dietary intake. Clinical trials performed in adults and children with cancer have found that the neutropenic diet is not associ- ated with reduced risk of infection and does not offer an added benefi t over food safety guidelines alone Moody et al. 2006 ; Gardner et al. 2008 . Current standards of practice should consider the Table 12.4 Commonly used nutritional supplements Oral High-calorie oral Enteral Boost ® Boost ® Plus PediaSure ® with without fi ber Carnation ® Instant Breakfast Ensure ® Plus Jevity ® Compleat ® Pediatric PediaSure ® 1.5 Nutren ® 1.52.0 Ensure ® Resource ® 2.0 Osmolite ® PediaSure ® with without fi ber Peptamen ® Nutren Junior ® withwithout fi ber 12 Nutrition lack of evidence supporting a neutropenic diet as an augmentation to food safety guidelines Table 12.5 prior to recommending it to patients at risk for severe immunosuppression.

12.3.2 Appetite Stimulants

Appetite stimulants may augment dietary intake although consistent evidence is lacking regarding effi cacy and the side effect profi le must be consid- ered Ladas et al. 2005 . Both Orme et al. 2003 and Cuvelier et al. 2013 reported signifi cant weight gain with megestrol acetate although with common severe adrenal suppression. A study of 66 evaluated pediatric oncology patients showed modest but signifi cant weight gain with cypro- heptadine hydrochloride with the main reported side effect being drowsiness Couluris et al. 2008 . Additional agents utilized include canna- binoids such as dronabinol as well as mirtazapine, a noradrenergic and serotonergic antidepressant. Systematic studies on the benefi t of these agents and their comparative side effects are lacking.

12.3.3 Enteral Tube Feeding

Enteral tube feeding TF should be initiated when oral intake is inadequate to support growth or nutri- tional repletion in the child with cancer. Patients eligible for TF must have an intact GI tract. Enteral feeding has numerous advantages over total paren- teral nutrition TPN including maintenance of GI mucosal function, cost- effi ciency, and avoidance of TPN complications including bacterial infec- tion, thrombosis, hepatic toxicity, cholestasis, and metabolic derangements den Broeder et al. 1998 ; Nevin-Folino and Miller 1999 . TF also offers the benefi t of medication administration without oral ingestion. Despite these benefi ts, hesitation remains in the provision of TF in the medical com- munity Ladas et al. 2006 . TF is often presented as a punishment for not eating. Concerns arise from patients especially adolescents and families due to the perceived inconvenience, discomfort and poor body image associated with the placement of a nasogastric tube. To optimize acceptance, TF should be proposed as a positive intervention mea- sure that is part of a comprehensive supportive care plan to aid in overall patient well-being. Multiple studies in pediatric oncology patients have demonstrated that TF is successful in main- taining adequate nutritional status and reversing malnutrition Aquino et al. 1995 ; Mathew et al. 1996 ; den Broeder et al. 1998 ; Deswarte-Wallace et al. 2001 ; Bakish et al. 2003 ; Ladas et al. 2005 . Moreover, TF appears feasible and safe in patients with mucositis, severe neutropenia and thrombocy- topenia. DeSwarte-Wallace et al. 2001 evaluated the use of TF in a pediatric oncology population during and after intensive oncologic treatment and demonstrated that most children tolerate TF with- out signifi cant vomiting or diarrhea. The investiga- tors concluded that TF is a safe and cost-effective intervention in pediatric patients receiving dose- intensive chemotherapy. Pietsch et al. 1999 eval- uated TF in children receiving intensive chemotherapy n = 14 or HSCT n = 3 and found TF was well tolerated with minimal complications, including risk of emesis and tube dislodgment, at a substantial cost saving compared to TPN. Finally, 32 children with solid tumors were administered TF during the most intensive phase of therapy; TF was well tolerated and improved weight among the patients Den et al. 2000 . An association between TF and reduction in non- leukopenic infection was also observed p = .009 Den et al. 2000 . Taken together these small studies lend support to the benefi ts of TF on nutritional status and possibly therapy-related toxicities. Depending on the tolerability of TF and amount of oral intake, TF can commence as bolus feeds, nocturnal continuous feeds, nocturnal con- tinuous feeds with bolus feeds during the day or as continuous drip-feeds. The clinical aim of TF is to supply the required nutrient intake of both macro- and micronutrients as described in the Dietary Reference Intakes DRIs Otten et al. 2006 . The DRIs are designed to guide health professionals in determining the dietary needs of each individual patient; recommendations by age and gender are available at the United States Department of Agriculture website http:fnic. nal.usda.govdietary-guidancedietary-reference- intakesdri-tables .