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
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
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))
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
Rescreen at 7 days
Assessment by day 14 Assign either A or B Level
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
NUTRITIONAL CONSIDERATIONS IN CHILDREN
~ Adequately nourished 90% Ideal body weight (IBW); Albumin > 3.5; weight loss <5%
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%
I Monitor/Intervene as needed
~ P e n n d ~ t g ~
Can patient safely tolerate/absorb nutrients via the GI tract?
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)
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
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
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
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
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.
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