Parenteral Nutrition Nutrition Intervention

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 ALL maintenance therapy explored the feasibility of a 12-month home-based nutrition and exercise intervention program, and although the study led to improvement in the frequency of physical activity p = 0.05, no difference in dietary behav- iors was observed Moyer-Mileur et al. 2009 . Due to lack of resources, effective dietary and lifestyle interventions remain a poorly studied area and emphasize the importance of ongoing education; the involvement of family, peers, schools and healthcare providers; and the need for continued care of childhood cancer survivors. The American Institute for Cancer Research www.aicr.org has published nutrition guide- lines focused on cancer prevention and are avail- able for medical providers to review with patients. Ideally, dietary counseling should be performed by a registered dietician so that strategies for behavior modifi cation may be discussed with the individual and their families. Additionally, the infl uence on dietary choices by gender, ethnicity, age and socioeconomic status should be included when discussing behavior modifi cation pro- grams. The use of lifestyle education programs has been found to be successful in promoting long-term behavior change among adult survi- vors of cancer Mosher et al. 2013 . The effec- tiveness of such programs in childhood cancer survivors is unknown. Until additional research is available, current clinical practice should incor- porate all aspects of lifestyle intervention and provide the opportunity for survivors to receive continual access to nutrition information specifi - cally designed for cancer survivors Table 12.6 .

12.5 Summary

Nutrition assessment and intervention are critical components of a pediatric oncology supportive care program, both during cancer therapy and after the completion of therapy. The inclusion of nutrition therapy promotes normal growth and development over the course of cancer therapy, may improve quality of life, and prevents therapy- related toxicities and decreased survival as has been shown in patients that are under- and over- nourished. Nutritional assessment and interven- tion should be proactive and start at diagnosis and must continue well beyond the completion of antineoplastic therapy. Although a clear evidence basis is lacking for many recommendations, there are general indications for nutritional support during cancer therapy including the use of nutri- tional supplements, appetite stimulants, enteral tube feeding and parenteral nutrition. References Antillon F, Rossi E, Molina AL et al 2013 Nutritional status of children during treatment for acute lympho- blastic leukemia in Guatemala. Pediatr Blood Cancer 60:911–915 Aquino VM, Smyrl CB, Hagg R et al 1995 Enteral nutri- tional support by gastrostomy tube in children with cancer. J Pediatr 127:58–62 Arroyave WD, Clipp EC, Miller PE et al 2008 Childhood cancer survivors’ perceived barriers to improving exercise and dietary behaviors. Oncol Nurs Forum 35:121–130 ASPEN Board of Directors and the Clinical Guidelines Task Force 2002 Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 26:1SA–138SA Bakish J, Hargrave D, Tariq N et al 2003 Evaluation of dietetic intervention in children with medulloblastoma or supratentorial primitive neuroectodermal tumors. Cancer 98:1014–1020 Barr R, Collins L, Nayiager T et al 2011 Nutritional sta- tus at diagnosis in children with cancer. 2. An assess- ment by arm anthropometry. J Pediatr Hematol Oncol 33:e101–e104 Bolze MS, Fosmire GJ, Stryker JA et al 1982 Taste acuity, plasma zinc levels, and weight loss during radiotherapy: a study of relationships. Radiology 144:163–169 Brinksma A, Huizinga G, Sulkers E et al 2012 Malnutrition in childhood cancer patients: a review on Table 12.6 Internet resources for reliable nutrition information American Institute for Cancer Research www.aicr.org National Cancer Institute www.cancer.govcancertopicspreventionenergybalance American Society for Cancer Research www.cancer.orghealthyeathealthygetactive acsguidelinesonnutritionphysicalactivityforcancerprevention acs-guidelines-on-nutrition-and-physical-activity-for-cancer-prevention- summary E.J. Ladas and P.C. Rogers