Enteral Tube Feeding Nutrition Intervention

Table 12.5 Food safety practices a Food shopping 1. Check expiration dates on food and do not buy or use if the food is out of date. 2. Do not purchase ready-to-eat food from bulk food bins i.e., breads, nuts, dried fruit, candies. 3. Avoid all food in cans that are swollen, dented or damaged. 4. Avoid produce that is bruised or damaged. 5. Bag fresh fruits and vegetables separately from meat, poultry and seafood products. Food storage 1. Store perishable fresh fruits and vegetables i.e. cucumbers, tomatoes in a clean refrigerator at a temperature of 40 °F or below. 2. Refrigerate all produce that is purchased pre-cut or peeled. 3. Beef should be refrigerated at 40 °F and used within two days. Beef can be frozen at 0 °F and used within 6 months of the purchase date. Food preparation 1. Wash hands with water and soap for 20 s before and after any food preparation. 2. Wash fruits or vegetables under running water even if you are going to peel them. Do not use soap, bleach or commercial produce washes to clean fruit. 3. Dry produce with a clean cloth towel or paper towel. This will reduce the spread of bacteria. Do not wash meat, poultry or eggs. 4. Defrost all meats in the refrigerator. Do not defrost at room temperature. 5. Food-preparation surfaces must be cleaned fi rst. Wash surfaces thoroughly with soap and water and thoroughly dry. As an extra precaution, you can use a solution of one tablespoon unscented, liquid chlorine bleach in one gallon of water to sanitize washed surfaces and utensils. 6. Wash cutting boards, dishes, utensils and counter tops with hot, soapy water after preparing each food item and before you go on to the next item. Cooking 1. Cook foods immediately after thawing. 2. All raw foods such as meats, poultry and entrees should be cooked until they are well-done. Beef should be cooked to 160 °F, depending on the cut. Chicken should be cooked to an internal temperature of 165 °F. Cold foods should be stored 40 °F, hot foods kept 140 °F. A home thermometer may help. Storage of cooked foods 1. Store leftovers within 2 h. By dividing leftovers into several clean, shallow containers, you’ll allow them to chill faster. Discard leftovers that were kept at room temperature for greater than 2 h. 2. Perishable foods fruits, vegetables, meat, dairy should be put into the fridge or freezer within 2 h. In the summer months, cut this time down to 1 h. 3. Do not use leftovers prior to reheating to 165 °F before serving. Baby foodinfant formula 1. Never put baby food in the refrigerator if the baby doesn’t fi nish it. Do not feed your baby directly from the jar of baby food. Instead, put a small serving of food on a clean dish and refrigerate the remaining food in the jar. If the baby needs more food, use a clean spoon to serve another portion. Throw away any food in the dish that’s not eaten. If you do feed a baby from a jar, always discard any remaining food. 2. Prepare safe water for preparing formula. Bring tap water to a roiling boil and boil it for 1 min. If you use bottled water, follow this same process. Cool the water to body temperature before mixing formula. 3. Sterilize bottles and nipples before fi rst use. After that, wash them by hand or in a dishwasher. 4. Formula can become contaminated during preparation, and bacteria can multiply quickly if formula is improperly stored. Prepare formula in smaller quantities on an as-needed basis to greatly reduce the possibility of contamination. Always follow the label instructions for mixing formula. Additional information may be found at www.foodsafety.gov. a Select recommendations from the United States Federal Drug Adminis tration’s Clean, Separate, Cook and Chill. 12 Nutrition Considerations in determining the type of for- mula, volume of feeds, and schedule should include the patient’s oral intake, sleep patterns, lifestyle, food allergiesintolerances, and GI con- ditions that affect dietary intake. Continuous feed- ing schedules are generally better tolerated than intermittent bolus feeds. Nocturnal continuous feeds allow the patient to attempt normal feeding during the day while ensuring the necessary pro- portion of nutrients are being delivered via TF. Daytime continuous feeds may be initiated on days when children are unable to consume signifi - cant oral intake. TF allows the family fl exibility with the child’s feeding schedule while continu- ing to support oromotor developmental skills and a more normal lifestyle. Continuous feeds are the preferred schedule in patients at high risk for nau- sea and vomiting, constipation, or diarrhea. If fre- quent vomiting continues to occur with continuous TF, post-pyloric feedings may help improve toler- ance Sacks et al. 2004 ; Ladas et al. 2005 . The choice of formula will depend on the clini- cal condition of the patient. In most cases, a stan- dard milk-based formula with or without fi ber may be used to initiate TF Table 12.4 . Unfl avored for- mulas have a lower osmolarity than fl avored prod- ucts, are better tolerated and should preferentially be used for TF. In patients with lactose intolerance, a soy-based or lactose- free formula should be used. Elemental formulas are ideal for patients with GI infl ammation or malabsorption. Modifi cation of the chosen formula may be necessary in patients with underlying GI problems if with intolerance to the current formula, persistent constipation or diar- rhea, or stomach pain. Continuous TF should be initiated with a full-strength formula at 1–2 mL kgh and increased by 1–2 mLkgh as tolerated until the goal rate is achieved Sacks et al. 2004 ; Ladas et al. 2005 . Elevating the head of the bed to 30° during and after TF and using prokinetic medications such as metoclopramide, erythromy- cin or cisapride not available in the United States may assist with reducing high gastric residuals caused by delayed gastric emptying and therefore promote digestion Sacks et al. 2004 . Feeding tubes should be fl ushed before and after feeds or the administration of any medication. A solution composed of a Viokase TM enzyme tablet, a 325 mg sodium bicarbonate tablet, and 5 mL of warm water can be utilized to help unclog the tube by inserting the 5 mL solution, clamping the tube for 15–30 min and then fl ushing with 20–30 mL of warm water Sacks et al. 2004 . Utilization of acidic beverages such as Coca-Cola or cranberry juice has been uti- lized but may precipitate the caseinate in formula and should not be used. Reevaluation of nutritional status and feeding methods for the individual patient should be undertaken if feeding problems persist and growth is not observed. Side effects associated with TF include diarrhea, constipation, abdominal pain and aspiration. Although empirically thought to increase the risk of infection or mucosal bleeding, feeding tube inser- tion has been shown safe during periods of mucosi- tis Deswarte-Wallace et al. 2001 . Whether TF is tolerated with severe mucositis involving much of the GI tract is unclear. Vomiting may occur but is not a contraindication to tube reinsertion; passing the tube beyond the pyloric valve into the duodenum may prevent recurrence. Diarrhea can develop sec- ondary to hyperosmolar feeds, lactose intolerance or refeeding syndrome. Refeeding syndrome can occur in the severely malnourished patient who is started on feeds at too rapid a rate and consists of diarrhea, vomiting and a variety of metabolic disturbances. Criteria for placement of a percutaneous endo- scopic gastrostomy PEG include dysphagia, risk of aspiration, intractable vomiting, esophageal strictures, cancer of the head and neck, radiation to the head, neck or chest, or anticipated long-term need for nutritional support. Adequate GI function is necessary for PEG insertion Sacks et al. 2004 ; Ladas et al. 2005 . Infection at the local insertion site can occur and careful hygiene is required.

12.3.4 Parenteral Nutrition

Parenteral nutrition PN is signifi cantly more expensive and offers no clear advantages over enteral feeding for those patients with an intact gut. PN is required when all attempts for suffi cient enteral feeding have failed or are contraindicated. Neutropenic enterocolitis, bowel obstruction and a nonfunctional GI system are indications for PN. The utility of PN has been best demonstrated in HSCT recipients who have prolonged gut damage due to the chemotherapeutic preparative regimen, graft-versus- host disease or infection Muscaritoli et al. 2002 . In many HSCT centers, PN is com- menced either during the preparative conditioning regimen or shortly thereafter as routine care with- out consideration for enteral feeds, although studies have shown that enteral feeding is safe and feasible in patients undergoing HSCT Sefcick et al. 2001 ; Garofolo 2012 . When PN is required, an effort should still be made to maintain some enteral feed- ing unless contraindicated, to help preserve gut integrity and function. PN is associated with mechanical complications such as increased risk of thrombosis or occlusion of the central venous cath- eter, infection, and GI complications including hepatic toxicity, cholestasis, and metabolic abnor- malities including fl uid and electrolyte imbalance, hyperglycemia, and metabolic acidosis Christensen et al. 1993 ; Quigley et al. 1993 ; Lenssen et al. 1998 ; Mirtallo et al. 2004 . Refeeding syndrome can also occur in the severely malnourished patient on PN. The interaction between PN and the pharmaco- kinetics and pharmacodynamics of other necessary medications remains unclear. It is important that all potential drug interactions be considered when pre- scribing PN in addition to determining which drugs can be concurrently administered in the lumen infusing PN. Short-term i.e., 2–3 week PN is rarely benefi - cial and should only be considered in those tempo- rally unable to tolerate enteral feeds. A central venous device is required for prolonged PN to avoid damage to peripheral veins by high-solute PN solu- tion. In determining PN requirements, the clinician should calculate the required fl uids, calories, pro- tein, fat, carbohydrates, vitamins and trace elements ASPEN Board of Directors and the Clinical Guidelines Task Force 2002 ; National Academy of Sciences and Institute of Medicine 2002 . The majority of institutions have strict guidelines for the prescribing and monitoring of PN, and close clinical and biochemical monitoring is necessary to prevent and anticipate complications Mirtallo et al. 2004 . PN should be altered or discontinued in patients experiencing signifi cant hepatic dysfunc- tion, cholestasis, severe hyperglycemia or other signifi cant metabolic complications. For patients on TPN, the transition back to enteral feeding requires careful weaning dependent on GI func- tion. A rapid transition may result in abdominal pain, diarrhea and sometimes hypoglycemia. Prolonged PN has been associated with sup- pressed appetite and diffi culty resuming adequate oral feeding Charuhas et al. 1997 . The decision to implement and wean PN should be undertaken with the advice from a registered dietician or a dedicated PN team. PN should not be the routine or fi rst option for nutritional intervention in pedi- atric oncology patients.

12.4 Nutrition and Survivorship

Survivors of childhood cancer are at increased risk for many nutrition-related conditions including obesity, metabolic syndrome, heart disease, osteo- peniaosteoporosis and mechanical issues such as reduced salivary function which can make eating diffi cult Hudson et al. 2003 ; Oeffi nger and Hudson 2004 ; Meacham et al. 2005 . Due to these risks, pediatric oncologists must provide nutritional counseling and promote healthy behaviors after the completion of therapy to prevent long-term compli- cations of poor nutrition and a sedentary lifestyle. Not unlike the general population, surveys of childhood cancer survivors have found that most do not meet recommended dietary guidelines for can- cer prevention or heart disease and lack a general understanding of what constitutes a healthy diet and lifestyle. How this potentially impacts the risk of secondary malignancy is unknown. In a survey of 380 childhood cancer survivors, 79 did not meet the guidelines for fruit and vegetable consumption, 84 obtained 30 of their calories from fat and only 48 were meeting exercise guidelines Demark-Wahnefried et al. 2005 . Robien et al. 2008 similarly found that childhood ALL survi- vors did not adhere to healthy dietary guidelines. Again, not unlike the general population, childhood cancer survivors reported being too tired 57 , too busy 53 , fi nding higher fat foods more visu- ally appealing 58 , and consuming high-fat foods in their social interactions 50 the primary reasons for an unhealthy diet Arroyave et al. 2008 . Practitioners must explore creative means for imparting benefi cial dietary and behavioral inter- ventions for patients beyond the intensive phases of therapy. A small, prospective study evaluating 13 children between 4 and 10 years of age during