Dietary Counseling Nutrition Intervention

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 . 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