Nutritional considerations in pediatric oncology

146

S e m i n a r s in Oncology Nnrsing, Vol 16, No 2 (May), 2000: pp 146-151

OBJECTIVES: To summarize the characteristics of a nutrition care plan )br pediatric patients, specifically pediatric screening, assessment, and treatment protocols.

DATA SOURCES: Review articles, manuals, and textbooks.

CONCLUSIONS: Nutritional support of pediatric patients with cancer differs from adults because of their unique nutritional needs, their wide age range (infants to adolescents), and the psychosocial aspects qf treating the entire family.

IMPLICATIONS FOR NURSING PRACTICE: To participate in the prevention and treatment of malnutrition in the pediatric patient with cancer, nurses require an understanding of nutrition care in this specialized population.

From the Department qf Human, Envi7~onmental and Consumer Resources, Coordinated Program in Dietetics, Eastern Michigan University, Ypslanti, MI. Theresa Han-Markey,MS, RD:Lecturer, Department of Human, Environmental and Consumer Resources, Coordi~mted Program in Dietetics, Eastern Michigan University, Ypslantf, MI. Address reprint requests to Theresa Hau. Markey, MS. RD, Department of Human, Environmental and Consumer Reso~rces, Coordinated Program in Dietetics, Eastem, Michigan University, 206 Roosevelt Hall. Ypslanti, M148197.

Copyright ©2000 by B,:B. Saundel~ Company 0749-2081/00/1602-0004~10.00/0 doi:l O.1053/on.2000.5552

NUTRITIONAL CONSIDERATIONS IN PEDIATRIC ONCOLOGY THERESA HAN-MARKEY

M

ALNUTRITION in the pediatric oncology population has been reported to occur in 8% to 32% of patients_ 1 Malnutrition associated with cancer treatment predisposes the child to increased morbidity, decreased immune function, poorer disease outcome, and reduction in quality of life. 2,3 Compared with adults, the child's nutritional needs must include energy requirements for growth and development, in addition to those needs required to support the child during treatment of the disease. Because of their particular body composition (higher water content and decreased fat), children have decreased caloric reserves, making them susceptible to malnutrition sooner than adults. Thus, the nutritional needs of pediatric oncology patients are unique and challenging for the practitioner. Children are dependent individuals and often they are not responsible for preparing their own food. Therefore, nutrition support and counseling must involve members of the family or caregivers. Various cancer treatments can induce malnutrition_ For example, chemotherapeutic agents such as actinomycin D, methotrexate, and cisplatin may cause significant nausea and vomiting leading to decreased intake. 4 In addition, chemotherapeutic agents themselves adversely affect growth and body composition in children. 5 Despite an intact dietary intake in children with acute lymphoblastic leukemia, a decline in height occurred during the first year of chemotherapy_ Nutrition screening, assessment, and nutritional care planning should be implemented to prevent and/or proactively treat malnutrition in the pediatric oncology patient. NUTRITION SCREENING n today's health care environment, decreased length of hospital

I ,stay requires that nutrition screening be accomplished within 24 to 48 hours of admission. If a pediatrie patient with a potential

NUTRITIONAL CONSIDERATIONS IN CHILDREN

nutritional p r o b l e m is not identified early, progression to m a l n u t r i t i o n can occur. An established nutrition screening protocol is essential to identify those patients at high nutrition risk so that prompt interventions can oeeur. Several established screening protoeols appropriate for use in the pediatrie ontology population have been published5 The Joint Commission on Aeereditation of Healtheare Organizations indicated that nutritional outeomes are eritieal; as sueh, they have devoted a seetion to Standards for Nutrition Care in the 1995 Accreditation Manual tbr Hospitals. Patient screening mechanisms must be in place to fulfill this standard. 7 Figure 1 depicts a flow ehart that provides an example of a hospital's nutrition screening p r o g r a m ) By the very nature of their diagnosis, pediatric oneology patients are at high risk for malnutrition. Certain t u m o r types are assoeiated with greater risk than others. Caneer diagnoses assoeiated with high nutritional risk are listed in Table 1. 9 In addition to diagnosis, o t h e r pediatrie p a r a m eters m a y be ineluded as p a r t of the initial nutrition sereen in pediatrie patients. Simple subjeetive questions eoneerning appetite, n u m b e r of meals c o n s u m e d per day, or modified diet or s u p p l e m e n t use ean easily be asked at the time of admission. > In addition, objeetive a n t h r o p o m e t rie p a r a m e t e r s such as history of weight loss, weight for age, and weight for height percentiles are typically used to screen for malnutrition. 11

NUTRITION ASSESSMENT

p

atients identified at high nutritional risk for malnutrition require a c o m p l e t e nutrition assessment. Typically, a n t h r o p o m e t r i c , bioehemieal, elinieal, and dietary a s s e s s m e n t p a r a m e t e r s (the ABCDs) are ineluded in the a s s e s s m e n t proeess. Protein-energy malnutrition has b e e n defined as at least a 5% weight loss or weight for height less t h a n the fifth pereentile w h e n height is equal to or greater than the t e n t h pereentile for age, or s e r u m albumin less t h a n 3.2 mg/dL. 12 The A m e r i c a n A e a d e m y of Pediatries T a s k Foree published a position s t a t e m e n t regarding the timing of nutrition intervention using a m o r e conservative definition of malnutrition t h a n the one stated above, t,~ Table 2 lists the A m e r i c a n A e a d e m y of Pediatrie's r e c o m m e n d a t i o n s . Reeently, investigators have e x a m i n e d the benefit of s e r u m albumin versus p r e a l b u m i n as a m a r k e r for nutrition status. 14 In children with solid tumors, s e r u m p r e a l b u m i n correlated with weight repletion and c h e m o t h e r a p y intensity whereas s e r u m albumin did not change during these clinical events. Therefore, these authors have suggested that a shorter half-life visceral protein m a y better reflect nutrition status at the time of admission and m a y be a more sensitive marker during treatment and repletion. Dietary assessment should include 24-hour

Patient Screened 24 hours after admission

FIGURE 1. Nutrition screening process. (Reprinted with permission))

147

1

Level A High risk for malnutrition

Level B Moderate risk for malnutrition

Level C Not at risk for malnutrition

Assessment within 24 hours

Assessment within 48 hours

Basic nutrition care

Develop care plan as appropriate

Develop care plan as appropriate

1

Discharge

Rescreen at 7 days

[ Discharge

Continue basic

;

Assessment by day 14 Assign either A or B Level

148

THERESA HAN-MARKEY

in oral intake, enteral and parenteral nutrition support, or combinations of these strategies.

Oral Intake Supplementation Dietary counseling to enhance a pediatric oneology patient's oral intake requires an individualized approach and family participation. Input from a registered dietitian in developing this plan is preferable. Because of cancer treatment, several side effects impact oral intake, including loss of appetite, nausea and vomiting, and oral problems. Support should be initiated to combat these problems. 12 Food and mealtimes can become a control issue between parents, health professionals, and the child. Since everyone is focused on the child's intake, the child may be less likely to eat to exert authority over the situation. Caregivers and parents must be cognizant of these circumstances. In a hospitalized setting, therapies can also interfere with scheduled meal delivery times. One study addressed this problem by providing "room service" to pediatric oneology patients. 16 By giving patients the opportunity to call the kitchen when they were ready to eat, these patients had significant increases in calorie intake and patient satisfaction with the food service also improved. Based on a nutrition history and need, the child's calorie and protein intake may be increased using modular nutrient components and by providing nutrient-dense favorite foods at times when intake is least compromised. 12 In addition to modular nutrients, oral liquid supplements can be used to boost intake. However, children who require supplementation are often the least compliant in drinking them. Oral supplements are often

dietary recall, oral supplement usage, normal snacking pattern, and food preparation methods. Treatment schedules for cancer therapy, such as chemotherapy, radiation therapy, and pain management, must be addressed when assessing dietary intake. All these therapies may interfere with intake and should be accounted for when designing a care plan. TREATMENT PLAN nce malnutrition has been identified, nutrition support needs to be initiated. Algorithms to address the nutrition support decision-making process have been developed, is Figure 2 depicts an algorithm for nutrition support. Support is generally accomplished in three ways: voluntary increase

O

NUTRITIONAL CONSIDERATIONS IN CHILDREN

149

~ Adequately nourished 90% Ideal body weight (IBW); Albumin > 3.5; weight loss <5%

lnadequately nourished

Depleted; 81-90% IBW; albumin 3.2-3.5; weight loss 5-10%

Are > 50% caloric and protein needs being met from diet/supplements?

Severely depleted; < 80% IBW; albumin < 3.2; weight loss > 10%

Yes

I Monitor/Intervene as needed

~ P e n n d ~ t g ~

Can patient safely tolerate/absorb nutrients via the GI tract?

Yes

Yes

F I G U R E 2. Nutrition support algorithm. (Algorithm for nutritional support: Experience of the metabolic and infusion support services of St Jude Children's Research Hospital. Bowman et al. International Journal of Cancer, Copyright @ 1998. Reprinted by permission of Wiley-Liss, Inc, a subsidiary of John Wiley & Sons, Inc. is)

No

Yes

/ (

fundoplication with

Yes

I

/

(

prescribed but research of their effectiveness in the pediatric population is lacking. One study in a cystic fibrosis population determined that liquid supplements did not increase caloric intake, but rather displaced food intake. 17 New enteral formulations are palatable and, perhaps, more readily accepted. T h e y m a y be frozen into flavored ice or made into a slush for consumption, is However, oral supplements alone may not be sufficient in this population. Enteral and/or parenteral nutrition support is frequently required.

Enteral Nutrition Support For those patients who have an intact gastrointestinal tract, enteral nutritional support has been successful in reversing malnutrition and maintaining adequate nutrition status. Enteral nutrition also preserves the integrity of the intestinal mueosa. Past studies have indicated that children with cancer who are at high nutrition risk do not maintain or improve their nutritional status with intense dietary counseling. Therefore, these patients are excellent candidates for enteral nutrition support via a nasogastric or gastrostomy tube.

or nasoduodenal feedings

I

No

No I

/

The use of enteral nutrition support is not as accepted in pediatric ontology as it is in other pediatric disease states. Most pediatric patients have venous access devices in place for chemotherapy. Since this route could provide access for parenteral nutrition, parents frequently opt for this approach, indicating that they do not want their child to undergo another procedure. Moreover, other side effects of c a n c e r treatment, such as neutropenia, thrombocytopenia, and mueositis, predispose these patients to risk for bleeding with tube insertion, further discouraging enteral nutrition support. However, studies support the use of enteral nutrition in pediatric ontology patients. Ford and Pietseh 19 describe their experience with 11 h o m e pediatrie patients with c a n c e r receiving enteral feedings. Patients were fed via nasogastric or pereutaneously plaeed gastrostomies for a total of 512 days. Tolerance to feeding devices was high and complications were minimal. Other investigators also have been able to maintain or improve nutritional status in a small group of newly diagnosed cancer patients. 2° Using weight for age

150

THERESA HAN-MARKEY

as an outcome criteria, patients in the enteral group gained and/or maintained weight. Interestingly enough, patients with intakes less than 75% of the requirements in either group did not maintain their weight. Protocols and algorithms can be useful in implementing enteral nutrition support_ For example, one institution reported that after the adoption of a nutrition support algorithm, gastrostomy tube placement at the time of diagnosis for patients with head and neck carcinoma became routine. 15 Physical complications associated with enteral nutrition support include tube dislodgment, malpositioning, site infection, and local skin reactions_ Major complications such as peritonitis, gastrocolic fistula, and death are rare. A recent study reported that gastrostomy site irritation occurred with initial gastric button u s a g e . 21 However, site irritation resolved once a policy for button placement was changed. Clinical complications such as nausea, vomiting, and diarrhea may indicate enteral feeding intolerance or be the result of cancer treatment. If symptoms are the result of enteral feeding, adjusting the rate and/or strength may resolve the problem. Numerous enteral feeding formulas have been designed for the pediatric population. Nutritionally complete formulas contain intact protein, carbohydrate, and long chain fatty acids provided in low osmolarity and residue forms. Some formulas contain fiber, which may relieve constipation. For patients who are experiencing some malabsorption, chemically defined protein, nonlactose, and long and medium chain fatty acidcontaining formulations are also available.

Parenteral Nutrition S u p p o r t Parenteral nutrition support, via peripheral or central venous access, is appropriate therapy to supplement enteral intake for patient's with a nonfunctional gastrointestinal tract. The choice of c e n t r a l versus peripheral parenteral nutrition depends on the length of anticipated therapy and the extent of nutritional supplementation. Peripheral parenteral nutrition is appropriate for anticipated short-term therapy, that is, therapy which lasts fewer than 7 to 10 days. Most non fluidrestricted children can meet 100% of their estimated nutritional needs with peripheral parenteral nutrition; however, their peripheral vascular access may require frequent site changes and there is a risk of phlebitis with peripheral parenteral nutrition. Dextrose concentration is limited to 10% to 12.5% when using the peripheral

approach. Dextrose can be more concentrated when the route of administration is central. 22 Central parenteral nutrition is delivered through various types of access devices, including temporary percutaneously placed catheters, tunneled catheters, implanted ports, or peripherally inserted central catheters. The anticipated length of therapy will dictate catheter needs. Central venous access allows for the administration of concentrated sources of dextrose (limit 35%) and amino acids (limit 6%) delivered in fluid volumes to pediatric oncology patients. Care for these devices is often institution specific and protocols may vary. However, standardized protocols, regular inservicing, and use of a specialized team to maintain and troubleshoot catheter-related problems will decrease the complication rate associated with central parenteral nutrition delivery_23 Parenteral nutrition therapy requires more vigorous metabolic monitoring than does enteral nutrition. Table 3 reviews the essential parameters and suggested monitoring schedules that should be considered when delivering either therapy, s

NUTRITIONAL

CONCLUSION umerous faetors must be considered when addressing the nutritional concerns of the pediatric cancer patient. All nutritional issues must be considered within the context of the child's growth and development. The nutritional goal is the prevention, early recognition, and proaetive treatment_ This begins with eomprehensive assessments, using standardized tools at regular intervals. Development of individualized

N

CONSIDERATIONS

IN CHILDREN

151

nutrition eare plans should involve the input of the multidiseiplinary pediatrie oneology team. In addition, all treatment strategies and techniques should inelude participation of caregivers with special attention paid to food control issues. Pediatric ontology nurses should enlist the aid of trained dietary specialists, such as registered dieticians with expertise in the nutritional management of pediatric eancer patients, to assist them in ensuring that the nutritional needs of this highly specialized population are met.

REFERENCES 1. Tyc VL, Vallelunga L, Mahoney S, et al: Nutritional and treammnt-related characteristics of pediatric ontology patients referred or not referred for nutritional support. Med Pediatr Oneo125:379-388, 1995 2. Viana MB, Murao M, Ramos G, et al: Malnutrition as a prognostic factor in lymphoblastie leukaemia: A multivariate analysis. Arch Dis Child 71:304-310, 1994 3. Riekard KA, Coates TD, Grosfeld JL, et al: The value of nutrition support in children with cancer. Cancer 58:19041910, 1986 4 Betcher DL, Ablin AR: Chemotherapy induced nausea and vomiting, in Ablin AR (ed): Supportive Care of Children With Cancer: Current Therapy and Guidelines from the Children's Cancer Group. Baltimore, MD, Johns Hopkins University Press, 1993, pp 59-66 5 llalton JM, Atkinson SA, Barr RD: Growth and body composition in response to chemotherapy in ehildren with aeute lymphoblastie leukemia lnt J Cancer Suppl 11:81-84, 1998 6. Nagel MR: Nutrition screening: Identifying patients at risk for malnutrition. Nutr Clin Pratt 8:171-175, 1993 7. Joint Commission on Accreditation of ttealtheare Organizations Board of Directors: 1996 Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL, JCAHO, 1996 8. Ameriean Society for Parenteral and Enteral Nutrition Board of Directors: Goals of pediatric nutrition support and nutrition assessment. The A.S P.E.N. Nutrition Support Practice Manual. Silver Springs, MD, American Society for Parentcral and Enteral Nutrition, 1998 9. Riekard KA, Grosfeld JL, Coates TD, et al: Advances in nutrition care of children with neoplastie diseases: A review of treatment, researeh and application ,1 Am Diet Assoe 86:16661676, 1986 10. American Society for Parenteral and Enteral Nutrition Board of Directors: Standards for hospitalized pediatric patients. Nutr Clin Pratt 11:217-228, 1996 11. Hamill PV, Drizd TA, Johnson CL, et al: Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr 32:607-629, 1979

12. Alexander ttR, Richard KA, Godshall B: Nutritional supportive care, in Pizzo PA, Poplack DG (eds): Principles and Practices of Pediatric Oneology. Philadelphia, PA, LippincottRaven, 1997, pp 67-118 13. Mauer AM, Burgess JB, Donaldson SS, et al: Special nutritional needs of children with malignancies: A review. J Parenter Enteral Nutr 14:315-324, 1990 14. Elhasid R, Laor A, Lischinsky S, et al: Nutritional status of children with solid tumors. Cancer 86:119-125, 1999 15. Bowman LC, Williams R, Sanders M, et al: Algorithm for nutritional support: Experience of the metabolic and infusion support service of St Jude Children's Research IIospital. Int J Cancer 11:76-80, 1998 (suppl) 16. Williams R, Virtue K, Adkins A: Room service improves patient food intake and satisfaction with hospital food. J Pediatr Oneol Nurs 15:183-189, 1998 17. Kalnins D, Durie PR, Corey M, et al: Are oral dietary supplements effective in the nutritional management of adolescents and adults with CF? Pediatr Pulmonol 13:314, 1996 (abstr) (suppl) 18. Andrassy RJ, Chwals WJ: Nutritional support of the pediatrie oneology patient. Nutrition 14:124-129, 1998 19. Ford C, Pietseh JB: ttome enteral tube feeding in children after chemotherapy or bone marrow transplantation. Nutr Clin Pratt 14:19-22, 1999 20. Broeder ED, Lippens RJJ, van't Hof MA, et al: Effects of naso-gastrie tube feeding on the nutritional status of ehildren with cancer. Eur J Clin Nutr 52:494-500, 1998 21. Mathew P, Bowman L, Williams R, et al: Complications and effectiveness of gastrostomy feedings in pediatrie cancer patients. J Pcdiatr Itematol Oneo118:81-85, 1996 22. Kovaeevieh D, Braunsehweig C, August D, et al: The University of Michigan Medical Center Parenteral and Enteral Nutrition Manual (ed 7). Ann Arbor, MI, University of Michigan, 1994 23. Collins E, Lawson L, Lau MT, et al: Care of central venous eatheters for total parenteral nutrition. Nutr Clin Pratt 11:109-115, 1996