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Nutritional support of pediatric patients with cancer consuming an enteral formula with fructooligosaccharides
Nutrition Research 26 (2006) 154 – 162 www.elsevier.com/locate/nutres
Nutritional support of pediatric patients with cancer consuming an enteral formula with fructooligosaccharides Shan Zhenga, Philippe Steenhoutb, Dong Kuirana, Wang Qihonga, Wang Weipinga, Corinne Hagerc, Ferdinand Haschkeb, Roger A. Clemensd,4 a
Fundan University, Children’s Hospital, Department of Surgery, 183 Fenglin Road, Shanghai 200032, China b Nestle Nutrition, Nestec Ltd., 32 Av Reller, Vevey 1800, Switzerland c Nestle Research Centre, Nestec Ltd., Lausanne 1000, Switzerland d USC School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90089-9121, USA Received 25 October 2005; revised 25 March 2006; accepted 10 April 2006
Abstract The objective of this study was to determine the tolerance and effects of a fructooligosaccharide (FOS)-containing enteral formula on fecal microbiota, nutritional status, biologic and immunologic outcomes of pediatric patients with cancer. A prospective, randomized, double-blinded, controlled trial was conducted at Children’s Hospital, Shanghai Medical University. Sixty-seven hospitalized patients (1-12 years old) diagnosed with cancer (stage 1-3) and undergoing chemotherapy met study inclusion criteria. Patients received at least 400 mL of an assigned formula for 13 to 30 days. The control group received enteral formula without FOS (control); the study group received the same formula with FOS (+FOS; 2 g/L). Stool samples on days 0, 3, 13, and 30 were analyzed for bifidobacteria, lactobacilli, and other microbiota. Biochemical markers of nutritional and hematologic status and anthropometrics were also assessed. The mean energy intake provided by the formulas was similar. At day 30 but not day 13, stool lactobacilli counts were significantly ( P b .02) higher in the +FOS group. A similar trend was seen for bifidobacteria. There were no clinically significant differences between groups for nutritional or hematologic status. There were no differences in immunologic parameters assessed except for significantly higher a1-acid glycoprotein in the control at day 13 ( P b .01). The prognostic inflammatory and nutritional index of +FOS at day 30 significantly decreased compared with control ( P = .016). These data suggest that an enteral formula containing dietary FOS produced a mild prebiotic effect at day 30 without any gastrointestinal discomfort in pediatric patients with cancer. Both enteral formulas were welltolerated and accepted. D 2006 Elsevier Inc. All rights reserved. Keywords:
Tolerance; Bifidobacteria; Fructooligosaccharides; Cancer
1. Introduction Patients with cancer often need to receive nutritional support to treat their malnutrition status before surgery or during chemotherapy and radiotherapy [1-4]. Parenteral nutrition has been extensively used to give this nutritional support, but some investigators report that its value is 4 Corresponding author. Tel.: +1 323 442 2124; fax: +1 323 442 1499. E-mail address: [email protected] (R.A. Clemens). 0271-5317/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2006.04.001
unclear and, until further clarified, suggest this approach to nutrition support should not be applied routinely [5]. Synergism between nutrition, infection, and immunity is now well known [6]. Schattner [7] demonstrated the importance of enteral feeds in patients with cancer to stave off malnutrition and to enhance the immune function to decrease risk of infections and complications. Gianotti et al [8] and Georgieff and Tugtekin [9] indicated the use of enteral feeding provided a positive bimmunonutritionQ effect by enhancing the host defense mechanism. Scioscia
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et al [10] reported that enteral nutrition may decrease the complications due to chemotherapy for gastrointestinal malignancies in patients with weight loss. These investigators demonstrated that serum amino acid levels, which are correlated with nutritional status, may provide prognostic information before treatment of head and neck cancer. Ideally, enteral nutrition should induce the same gut physiology as a complete and well-balanced oral food diet. Therefore, subjects requiring long-term enteral nutrition could benefit from dietary fiber delivered in an oral feed [11,12]. Some fermentable dietary fibers are known to improve host health by stimulating the growth and activity of select strains of bifidobacteria and other lactic acid microbiota and subsequently increase the production of short-chain fatty acids [13-15]. These fatty acids are fuel for the gut cells and are consequently possible candidates for the treatment of gut injury [16]. In addition, some of these fibers, such as dietary oligosaccharides and inulin, may inhibit the growth of certain types of tumors [17] and may potentiate the effects of some chemotherapeutic agents without any patient risk [18]. Several mechanisms have been proposed to elucidate the possible role of these fermentable fibers in improving health. Some possibilities are that these fibers have a positive effect on the host defense mechanism, including immunologic status changes [19], the production of shortchain fatty acids, by altering intestinal microbiota and subsequent modulation of hepatic fatty acid synthesis [20], the diminution of intestinal pH, decreased activity of selected intestinal enzymes associated with increased risk for some tumorigenesis [21], the reduction of some bacterial metabolites that may promote tumor cell development or proliferation [18], and the induction of tumor cell apoptosis [22,23]. Nevertheless, the relationship among nutrition, immunology, and cancer is a subject with complex interactions not yet well understood [24]. Although the daily value (DV) for dietary fiber is 25 g, the healthy US population consumes, on average, slightly less than 50% of this DV. This may be due in part to the potential side effects of gastric discomfort. Fermentable fiber, when consumed in excessively large quantities, can also induce gastrointestinal intolerance, such as flatulence and frequency and consistency of stools. The possibility of intolerance in vulnerable populations is an important consideration when deciding appropriate amounts and types of fermentable fibers to feed such patients. There are limited data on the effects of chemotherapeutic agents on the intestinal microbiota, and even less is known about the beneficial effect of these bifidobacteria and lactic acid flora in patients with cancer. This study was designed to investigate whether specific fermentable dietary fibers, fructooligosaccharides (FOS), also known as prebiotics, when delivered in an enteral formula, are tolerated and can maintain or stimulate the development of bifidobacteria and lactic acid microbiota when consumed by pediatric patients under chemotherapy.
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2. Methods and materials 2.1. Subjects Pediatric patients diagnosed with neuroblastoma, Wilms’ tumor, malignant teratoma, hepatoblastoma, and/or rhabdomyosarcoma were recruited from the Children’s Hospital, Shanghai Medical University. Inclusion criteria included 1 to 12 year-old patients diagnosed with cancer in stages 1 to 3, receiving chemotherapy as part of their standardized regimen, and receiving oral and/or enteral tube feedings. Patients with depressed neurologic status, terminal medical status, and severe malnutrition, under the use of regimens influencing immunologic response or the use of lactulose within the week before study entry, or those consuming any investigational drug within 30 days before the start of the study were excluded from enrollment. The Shanghai Medical University Institutional Review Board approved the study protocol, and the study was conducted in accordance with good clinical practice. All subjects participated after informed consent was obtained from a parent or legal guardian. Sixty-seven pediatric patients who met the above criteria were enrolled and randomized into 2 study groups between July 1999 and February 2001. 2.2. Treatment In a double-blind, randomized prospective study, 35 patients received 400 mL (1674 kJ) of a commercial enteral feed (Nutren Junior 1.0, Nestle´, Konolfingen, Switzerland) without FOS (control) for at least 13 days (30 days maximum) while hospitalized. Continuation of the study from day 14 to day 30 was optional. The second study group of 32 hospitalized children received the same enteral feed containing 2 g/L of FOS (+FOS; Nestle´) for the same period. All products were delivered orally or with a nasogastric or gastrostomy tube on gravity administration. Both products contained proteins, carbohydrates, and fats with vitamins and minerals in amounts intended for full nutritional support of pediatric patients and differed only in the addition of FOS to the study product (Table 1). The FOS contained 70:30 Raftilose/Raftiline from Orafti (Brussels, Belgium). Table 1 Nutritional composition of the enteral formulas Macronutrients per 1674 kJ (400 mL)
Control
+FOS
Energy density (kJ/mL) Protein (50:50 whey/casein) (g) Fat (g) MCT (%) MUFA (%) PUFA (%) n6/n3 Carbohydrate (g) FOS (g)
4.186 12 15.8 20 50 20 6 53 –
4.186 12 15.8 20 50 20 6 53 0.8
MCT indicates primarily caprylic and capric acids; MUFA, primarily oleic acid; PUFA, n6 a-linoleic acid; n3 linoleic acid.
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All patients were allowed an oral mixed diet of their choice ad libitum. Patients continued all chemotherapeutic medications and antibiotics as needed for treatment of their clinical condition throughout the study period. 2.3. Outcomes Baseline values were assessed at day 0 before beginning study feeds. The primary clinical outcome of the study was the effect of FOS on stool microbiota. This effect was determined by the presence and quantification of enterobacteria, bifidobacteria, lactobacillus, and Clostridium perfringens in stool cultures from patients on days 0, 3, 13, and 30. At each specified time point, stools were collected by the subject/caretaker on a plastic plate placed in the toilet. A sterile spoon and cup were used to collect and store approximately 5 to 10 g of stool in anaerobic conditions within 30 minutes of emission. The collection container (with proper identifiers) holding the stool sample was placed in an aluminum bag with the lid of the container left slightly ajar to allow air exchange. An opened packet of AnaeroGen (Oxoid Limited, Hampshire, UK) was placed inside the aluminum bag in an upright position and the bag was closed tightly. The stool sample was then refrigerated at 48C, transferred on ice to the laboratory, and analyzed within a maximum of 10 hours. Stool samples were prepared and analyzed on-site at the Shanghai Sixth People’s Hospital microbiology laboratory. For quantification of lactobacilli colony-forming units (CFU), fecal samples were cultured on MRS medium with antibiotics. For quantification of bifidobacteria CFU, fecal samples were cultured on Eugon Tomato medium [25]. Differentiation of the bacteria was made by a check of each type of colony by microscopic observation. Secondary clinical outcomes included assessment of immunologic and nutritional status. Blood samples were obtained by venipuncture from a peripheral vein and drawn by the investigator or study nurse. Immunologic parameters were assessed by using plasma samples collected at baseline (day 0) before beginning study feeds and on day 13 and/or day 30. These parameters included tumor necrosis factor a (TNF a) (Beijing East Asia Immunology Technology Institute, Beijing, China), a1-acid glycoprotein (AGP) (Orion Diagnostica, Espoo, Finland), cytokines interleukin (IL)-2 and IL-6 (R&D Systems, Minneapolis, MN), and CD4 and CD8 (BD Diagnostics, Franklin Lakes, NJ) cell populations. The nutritional status of all patients was assessed. In addition, routine physical examination (height, weight, blood pressure, heart rate, body temperature, respiratory rate), 24-hour dietary records, tolerance measures by a standardized questionnaire (recorded daily from days 0-13 and then from days 28-30; flatulence, nausea, rectal discomfort, abdominal pain, abdominal distention, diarrhea, stool frequency and consistency), the Prognostic Inflammatory and Nutritional Index (PINI), and standard hematologic and biochemical parameters were also assessed. PINI is a tool to predict morbidity or mortality in hospitalized patients and was calculated as:
PINI ¼
a1 Acid glycoproteinðg=L Þ C Q reactive proteinðmg=LÞ Albumin ðg=L Þ Prealbumin ðg=LÞ
Healthy children typically have a PINI value less than 1, whereas sick patients are characterized by a progressive rise greater than 1 as condition worsens [26]. Biochemical parameters assessed in this study at baseline, day 13, and day 30 included total bilirubin, alanine aminotransferase, alkaline phosphatase, blood urea nitrogen, creatinine, glucose, sodium, potassium, total protein, albumin, prealbumin, calcium, phosphate, and C-reactive protein (CRP) levels. The limit of detection of CRP with the method used was 1 mg/L. In addition, the hematologic parameters of hemoglobin level, red blood cell counts, hematocrit level, leukocyte, neutrophil, monocyte, lymphocyte, and platelet counts, and erythrocyte sedimentation rate were evaluated at baseline, day 13, and day 30. 2.4. Adverse events All adverse events were reported and recorded whether or not they were considered to be serious or related to the treatment. Adverse events were defined as illnesses, signs, or symptoms occurring or worsening during the course of the study. 2.5. Statistical analysis All available data were analyzed on an intention-to-treat (ITT) model. No statistical procedures were performed to compensate for missing data. Per protocol (PP) analysis was defined as completion of study up to day 13, whereas data from subjects who discontinued before day 13 were excluded from analysis. Data are expressed as mean F SD. It was hypothesized that subjects receiving the +FOS formula would have an increased level of bifidobacteria in their stool compared with those receiving the control. It was assumed that 95% of the pediatric population studied would have bifidobacteria present in their stool, and the goal was to show a significant increase of 0.5log10 CFU of bifidobacteria per gram of stool. Given this, a sample size of 30 per group to complete the study was calculated based on a conservative value of P = .75, which allows for a type I error (a error) of .05 and a type II error (b error) of .2. For fecal bacterial counts, because all subjects did not start chemotherapy at day 0, and the chemotherapy did not last all 13 days of enteral feed intake, the incremental change in log10 bifidobacteria was modeled with the covariables of treatment group, sex, age, the number of days between the start of chemotherapy and day 0, and the number of days between the end of chemotherapy and day 13 as covariables. If the chemotherapy ended after day 13, then the number of days between the end of chemotherapy and day 13 was set to 0. Pearson correlation coefficients were determined for secondary outcomes. For immunologic, hematologic, and biochemical parameters that are normally distributed or normally distributed after a log transformation, an analysis
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of covariance model with baseline value as covariable was applied to the corresponding measurements on respective days. Growth was assessed by weight and height measurements and plotted against National Center for Health Statistics references [27]. To normalize the data, z-scores were determined for weight-for-age and height-for- age. Change in weight-for-height z-scores was also calculated. All statistical analyses using parametric and nonparametric estimators were performed using SAS software (v 8.0, SAS Institute, Inc., Cary, NC). The rejection level in statistical tests was equal to 5%. 3. Results The only difference between ITT and PP analysis was one male subject in the +FOS group who was noncompliant with the protocol and withdrew from the study at day 3. The ITT analysis was not considered necessary because the values for missing data were not replaced, which means that ITT and PP analyses would be the same at day 13. Sixty-seven pediatric patients were enrolled in the study: 35 in the control group and 32 in the +FOS group. All enrolled patients were of Asian ethnicity. None of the patients had a history of allergies or major surgery. Patients’ profiles at baseline are summarized in Table 2. The patient profile and anthropometrics between the 2 study groups were statistically similar with some clinically irrelevant differences. The proportion of girls and the proportion of subjects with stage 3 cancers was slightly higher in the control than in the +FOS group, but did not differ statistically. On average, pediatric patients in +FOS were older than the controls (7.5 F 2.9 vs 5.0 F 3.1 years). The subjects in each group were shorter than the American reference for healthy children (negative height for age z-scores), and they weighed less for their age (negative weight for age z-scores). Most pediatric subjects did not start chemotherapy at day 0. Subjects typically initiated chemotherapy 2.8 F 8.1 days before starting the study formulas. Thirty-nine subjects started chemotherapy before day 0, 10 subjects began Table 2 Patient parameters in ITT analysis (percentages or mean F SD) Profile parameter
Control (n = 35)
+FOS group (n = 32)
Sex (% of females) Age (y) Height-for-age z-scores Weight-for-age z-scores Weight-for-height z-scores Stage of cancer = 1, 2, 3 Carcinoma Neuroblastomal (%) Wilms’ tumor (%) Malignant teratoma (%) Hepatoblastoma (%) Rhabdomyosarcoma (%)
43
34
5.0 F 3.1 1.59 F 1.90 0.62 F 1.10 0.70 F 1.69 20%, 43%, 37%
7.5 F 2.9 1.38 F 2.02 0.74 F 1.11 0.42 F 2.46 34%, 38%, 28%
31 29 11 6 23
12 16 19 12 41
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therapy exactly at day 0, and the remaining 17 subjects started chemotherapy 1 to 11 days after initiating the study. Some subjects had already finished the chemotherapy before the start of enteral feed intake. A total of 66 subjects, 34 individuals in the control group and 32 in the +FOS group, were considered in the PP analysis. All of these subjects consumed a minimum of 400 mL/d (1674 kJ/d) of the assigned enteral product during the first 13 days. Subjects consumed an average of 30.1 F 11.4 mL/kg body weight. In the +FOS group, therefore, the average amount of FOS consumed from the study product was 60 F 20 mg FOS/kg body weight. The total energy from regular diet and study product combined as well as the study product alone for the control and +FOS groups (regular diet + study product: 4655 F 1005 vs 4931 F 1168 kJ/d; study product alone: 2592 F 578 vs 2554 F 494 kJ/d) and quantity of study formula intake (619 F 138 vs 610 F 118 mL/d) were comparable between the 2 treatment groups. Using these volumes, FOS intake from the study formula in the +FOS group was 1.22 F 0.24 g/d. Six patients in the control group and 3 patients in the +FOS group voluntarily discontinued the study enteral product between days 13 and 30, the optional phase of the study. 3.1. Bifidobacteria in stools The bifidobacteria counts were measured at day 0, day 3, day 13, and day 30. The detection limit of bifidobacteria in stools was 100 CFU/g. None of the covariables was significant (treatment [ P = .97], sex [ P = .26], age [ P = .66], start of chemotherapy [ P = .91], and end of chemotherapy [ P = .87]). The incremental change of log10 bifidobacteria levels from day 0 to day 13 was positive for both study groups (Fig. 1). At day 0, the 2 treatment groups had a similar number of bifidobacteria. During the initial 13 days, there was a tendency toward an increase of bifidobacteria in the +FOS group, whereas the bifidobacteria level was unchanged relative to baseline in the control group. No statistical difference between the 2 treatment groups was detected (95% confidence interval [CI], 1.62, 1.69). The incremental change of bifidobacteria at 30 days of treatment was not significantly different between the 2 study groups ( P = .24). None of the covariables was significant. The incremental change between the control group and +FOS group was equal to 0.99 (95% CI, 2.65, 0.68). However, on day 30, there was a trend toward an increase in number of bifidobacteria CFU/g in the +FOS group as compared with the control ( P = .08; Fig. 1). 3.2. Selected microbiota in stools Stool samples were also cultured for the presence of enterobacteria, C. perfringens, and lactobacilli. The lower detection limit for these bacteria was also 100 CFU/g. The longitudinal bacterial quantification of these bacteria is shown in Fig. 1.
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Fig. 1. Concentration of selected organisms in stools at the different visits and by group, control vs treatment (mean F SEM, log10 CFU/g). There were no significant differences in incremental change of bifidobacteria. On day 30, there was a trend toward an increase in number of bifidobacteria in the +FOS group as compared with control ( P = .08). For the period from day 0 to 30, there was a significantly greater change in the +FOS group of Lactobacilli in stools ( P = .007). In addition, at day 30, there was a significantly higher number of Lactobacilli in the stools of the +FOS group than in the control group ( P = .02). There were no significant differences in concentration of Bifidobacteria, Enterobacteria, or C. perfringens in stools.
0.44) for lactobacillus. At day 30, the increment for C. perfringens ( P = .78) and enterobacteria ( P = .24) were not significantly different between treatments.
Dietary FOS had no significant effect on enterobacteria or C. perfringens at any time point tested. In the case of lactobacilli, there was not any difference between the 2 treatment groups during the first 13 days. However, at day 30, the number of lactobacilli was significantly ( P = .02) higher in the +FOS group than in the control group. For the period from day 0 to 30, the incremental change of lactobacilli was significantly higher in the +FOS group ( P = .007). The change in the increment between the control group and +FOS group was equal to 1.36 (95%CI, 2.33, 0.38]). Regression coefficients of age, sex, and start and end of chemotherapy were not significant except age for C. perfringens where the regression coefficient was estimated at 0.18 ( P = .01). In a multiple regression model with treatment and sex as effects, and age, start of chemotherapy and end of chemotherapy defined as covariables, increments from day 0 to day 13 were not significantly different between the 2 treatment groups ( P = .43 for C. perfringens, P = .66 for enterobacteria, and P = .26 for lactobacillus). The difference between the control group and +FOS group was equal to 0.38 (95% CI, 0.58, 1.33) for C. perfringens, 0.21 (95% CI, 0.75, 1.17) for enterobacteria and 0.58 (95% CI, 1.60,
3.3. Immune status The assessed immunologic parameters are shown in Table 3. These values were normal in each study group throughout the study period and did not differ significantly between these groups except for AGP at day 13 ( P = .01). At day 0, there was a higher number of patients with an AGP value higher than 1.4 g/L in the control group than in the +FOS group. The proportion of patients whose AGP increased to a level greater than 1.4 g/L after 13 days in the control group was 20% vs 4% in the +FOS group. This proportion was not significantly different ( P = .12). AGP level was not related to cancer stage. 3.4. Prognostic Inflammatory and Nutritional Index The PINI values of both +FOS and control groups declined during the 30-day study period. However, the PINI value of +FOS at day 30 decreased more than in the control group, the median values being 0.28 and 0.82, respectively. The difference between both groups was statistically
Table 3 Immunologic parameters (mean F SD) by treatment group at different days Day 0
Day 13
Control TNF-a (ng/mL) AGP (g/L)4 IL-6 (ng/mL) IL-2 (ng/mL) ln(CD4/CD8)
1.40 1.38 84.9 172.8 0.10
F F F F F
0.97 0.77 56.7 67.6 0.52
+FOS
Control
1.44 F 0.77 1.17 F 0.94 91.0 F 54.4 183.9 F 105 0.05 F 0.49
1.14 1.324 84.8 176.9 0.05
TNF-a indicates tumor necrosis factor a. 4 P = .01 between control and +FOS at day 13 (ANCOVA).
F F F F F
Day 30 +FOS 0.86 0.60 62.9 83.5 0.44
1.16 0.964 93.0 153.4 0.03
Control F F F F F
0.67 0.56 61.1 81.5 0.39
1.11 1.28 87.4 161.3 0.10
F F F F F
+FOS 0.75 0.65 69.4 74.0 0.40
1.08 0.99 92.8 150.3 0.05
F F F F F
0.91 0.62 64.8 77.1 0.41
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counts were within normal limits and did not differ statistically with the exception of the following parameters from day 0 to day 13: +FOS group had a significantly higher hemoglobin level (100 F 17 vs 112 F 13g/L; P = .009) and hematocrit (30.0 F 5.1 vs 33.3 F 3.9%; P = .04) and a significantly lower sedimentation rate (12.6 F 3.9 vs 9.8 F 3.6mm/hr; P = .03). The sedimentation rate was not obtained on all patients, and should therefore be interpreted with caution. None of these differences was clinically significant. 3.7. Tolerance
Fig. 2. PINI index.
significant ( P = .016). Fig. 2 shows the changes in PINI values over the entire study period. PINI for all 66 subjects declined remarkably after nutrition supplement at day 30. The median value was 1.22 on day 0, 0.52 on day 13, and 0.43 on day 30, showing statistical significance (day 0 vs day 30, P b .001). 3.5. Biochemical parameters From day 0 to day 13, there were no significant differences between the treatment groups for any of the parameters tested. Glucose and CRP levels had a skewed distribution, so the statistical tests were performed on logtransformed data. At day 30, glucose after log transformation was significantly higher in the +FOS group ( P = .02). Total bilirubin level after log transformation was significantly higher in the control group at day 30 ( P = .01). Neither of these differences was clinically significant. With the exception of CRP, all values were within normal limits. CRP levels were elevated in both groups (30 days: control, 6.6 F 4.5; +FOS 5.2 F 5.4 mg/L), which were assumed to be related to the pathology of these subjects. 3.6. Hematology All of the hematologic values for red blood cell, leukocyte, neutrophil, monocyte, lymphocyte, and platelet
No patient presented any abdominal distention on any of the recorded days. One patient in the +FOS group reported rectal discomfort at day 4. Three patients in this group reported mild flatulence at baseline and on one other occasion before day 10. Two of the 3 patients with mild flatulence also reported 2 occasions of abdominal pain. One patient reported mild diarrhea at day 5. Twelve patients in the control group and 11 in the +FOS group reported at least one episode of nausea during the study. The color of the stools was quite similar in both treatment groups. Considering both groups, approximately 70% of the stools were brown, whereas the remaining 30% were yellow. The control group reported red stool at 0.5% during the first 13 days of the study period. Subsequently, none of the control or treatment groups reported any red stool from day 28 to day 30. Stools from the +FOS group were more frequently formed than in the control group, although stool consistency did not differ statistically between the 2 study groups. 3.8. Growth Increased weight for age and weight for height was observed in both treatment groups during the study period. These pediatric patients with cancer maintained, if not improved, their weight. The z-scores for this population of ill children were low and often with negative values in both groups and at both time points. Changes in z-scores of weight, weight-for-age, and weight-for-height were generally all positive in the +FOS and control groups at days 13 and 30 (Table 4).
Table 4 Change in growth z- scores (mean F SD) for control and treatment group for days 0 to 13, 13 to 30, and 0 to 30 Day 0-13
Height-forage Weight-forage Weight-forheight
Day 13-30
Day 0-30
Control
+FOS
Control
+FOS
N
Mean F SD
N
Mean F SD
N
Mean F SD
N
Mean F SD
Control N
Mean F SD
+FOS N
Mean F SD
33
0.04 F 0.17
30
b 0.1 F 0.09
34
0.04 F 0.09
32
0.12 F 0.62
33
b 0.1 F 0.16
30
0.13 F 0.63
34
0.27 F 0.33
31
0.11 F 0.19
34
0.28 F 0.32
32
0.26 F 0.18
34
0.55 F 0.45
31
0.37 F 0.26
30
0.35 F 0.42
30
0.19 F 0.30
30
0.44 F 0.40
29
0.31 F 0.45
30
0.80 F 0.51
29
0.50 F 0.52
160
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3.9. Adverse events One adverse event was documented throughout the entire study. One 6-year-old boy with stage 2 cancer with neuroblastoma in the +FOS group presented diarrhea with mild epiumbilical discomfort and unformed, soft yellow stools. These stools were negative for occult blood. Medical review indicated these symptoms were unlikely related to the assigned enteral feed. It was his parents’ decision to discontinue his participation in the study at day 3. This subject did not comply with the study protocol and was excluded from the PP analysis.
4. Discussion Patients with cancer undergoing chemotherapy and/or radiotherapy frequently require nutritional support to obviate risks associated with malnutrition and gastrointestinal complications [5]. Taber and Roberfroid [18] suggested the introduction of dietary oligosaccharides may improve the outcomes of chemotherapy and possibly potentiate the effects of these cytotoxic medications in a rodent model. They further noted the administration of oligosaccharides may complement classical protocols of human cancer treatment without any additional risk for the patients [28]. Although the anticipated increase in bifidobacteria in the +FOS group was not seen, there was a trend ( P = .08) for an increase in bifidobacteria in those consuming FOS. The significant increase in lactobacilli is of interest as it illustrates the potential interrelationship between commensal organisms. Demonstration of a significant bifidogenic effect may require a larger sample size and evaluation of timing and dose of prebiotic administration in relation to chemotherapy. It is entirely possible that the dosage of FOS subjects were exposed to in this study (1.22 F 0.24 g/d; 0.06 F 0.02 g FOS/kg body weight) was not enough to induce a bifidogenic effect. A study by Buddington and colleagues [21] has shown that ingestion of 4 g of FOS/d by healthy adults was sufficient to alter the fecal flora, although lower dosages were not examined in this study. The amount of prebiotics needed to induce a bifidogenic effect in pediatric patients with cancer has not been established. FOS in the nutrition supplement studied here had a significant lactogenic effect and a tendency to increase the bifidobacteria by the end of the study period in pediatric patients treated by chemotherapy. Emerging evidence suggests that FOS and the associated increase in lactic acid bacteria may function as immunomodulators by stimulating IgA synthesis, promoting mucin production, modulating inflammatory cytokines, binding mucosal receptors, and decreasing antigen absorption [28,29]. Patients with cancer present various degrees of immunocompetence, which is influenced by different types of pathologies and nutritional status. This is the first study to evaluate the potential of FOS as part of an enteral feeding on immunocompetency of young patients with cancer. Dietary
FOS significantly decreased AGP ( P = .01), an acute-phase reactant protein, relative to controls, which suggests oligosaccharides may decrease the inflammatory process and impact the immunomodulation cascade even in patients with cancer. However, the difference was no longer significant on day 30, which may be due to the short-term immunologic benefits of the formula. None of the other assessed immunologic parameters differed. AGP elevation is typically observed in tumor-bearing patients and is an acute phase response in other disorders requiring pharmacologic intervention. Because AGP may bind or trap many basic vs acidic drugs, each of these presentations necessitates an adjustment of a dosing regimen; thus, modulation of AGP via dietary components may lead to more consistent chemotherapy. PINI is a sensitive, universal tool where lower scores indicate less risk for morbidity or mortality among hospitalized patients. As suggested by several investigators [26,30,31], PINI may be a rapid and useful clinical tool to assess both inflammatory and nutrition status among pediatric, critically ill patients. It is noteworthy that the PINI score, which includes CRP, AGP, albumin, and prealbumin (as indicators of inflammation and nutrition status), was significantly reduced in the +FOS group. The authors suggest the effect of dietary FOS on this inflammatory index may be due to modulation of AGP levels. Over the course of advancing disease and throughout the therapeutic period, PINI should be considered in future research on nutritional status and prediction of prognosis in advanced cancer especially as dietary intervention and nutrition support improves [32]. Walsh et al [33] recently noted elevated IL-6 levels correlated with high PINI and CRP values in patients with advanced cancer. CRP is virtually absent in the normal healthy individual. On the other hand, CRP increases during inflammatory processes, such as cancer, arthritis and cardiovascular disease, and throughout the normal course of pregnancy. Although IL-6 did not differ in this study, a study by Guigoz and colleagues [34] demonstrated a significantly decreased expression of IL-6 mRNA in peripheral blood monocytes of elderly people consuming 8 g FOS/d for a period of 3 weeks. Despite the anti-inflammatory effect of FOS shown in this study with the PINI and AGP data, IL-6 and CRP levels did not differ between the groups, but may be an area of interest for future research. The plethora of biochemical and hematologic data indicated no clinically significant changes during the study period. None of the 14 biochemical parameters or any of the 9 hematologic outcomes indicated any clinical impact by an average intake of 1.22 F 0.24 g/d in the +FOS group at days 13 or 30 relative to baseline data assessed at day 0. It is reassuring that the dietary intervention did not alter these parameters in this ill population, and that the values remained within reference ranges for children. Tolerance of FOS without significant changes in perceived gastrointestinal status in healthy children has been documented [35]. The children with cancer in this study also
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tolerated the addition of FOS to an established enteral feed. In another study of a vulnerable population, Barshop and colleagues [36] demonstrated that FOS was tolerated even among individuals with diagnosed hereditary fructose intolerance. The subjects in the Barshop et al study tolerated approximately 0.22 F 0.13 g FOS/kg body weight during a short-term period. The exposure in the study reported here approximated 0.06 F 0.02 g FOS/kg body weight and provides additional information to support the tolerance and safety of FOS in high-risk individuals. This safety assessment is reinforced by the unremarkable presentations of the biochemical and hematologic data obtained throughout the study. As in other studies, some subjects in the FOS group reported symptoms of intolerance, possibly during a period of adaptation. However, in this study, these symptoms were not considered to be of clinical detriment and did not affect the overall ability of subjects to continue their treatment. The positive change in z-scores even during the relatively short course of this study show the value of nutritional support during cancer treatment and the safety of FOS in this population. In the present study, 29 children diagnosed with cancer were fed an FOS-containing enteral product for a period up to 30 days, resulting in a significant increase in some lactic acid bacteria. Inflammatory status was reduced in the FOSsupplemented group. Physical growth as assessed by z scores was positive in each study group, indicating the nutritional status was not compromised by FOS. The study supports the growing clinical evidence that certain populations, including children with cancer, could benefit from a nutritionally appropriate, prebiotic-containing enteral formula. Further research is required to enhance our understanding of optimal effective prebiotic doses and immunomodulatory mechanisms. Acknowledgment The contributors to this article are grateful for the excellent administrative coordination, editorial support, and critical review provided by Laura Czerkies and the sponsorship of Nestle´ SA (Vevey, Switzerland). References [1] Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer 1998;34:503 - 9. [2] ReyFerro M, Castano R, Orozco O, Serna A, Moreno A. Nutritional and immunologic evaluation of patients with gastric cancer before and after surgery. Nutrition 1997;13:878 - 81. [3] Hochwald SN, Harrison LE, Heslin MJ, Burt ME, Brennan MF. Early postoperative enteral feeding improves whole body protein kinetics in upper gastrointestinal cancer patients. Am J Surg 1997; 174:5325 - 30. [4] Bachmann P, Gordiani B, Ranchere J-Y, Lallemand Y, Combret D, Latour J-F, et al. E´valuation de l’indication et de la qualite´ de la prise en chage nutritionnelle en cance´rologie me´dicale. Nutr Clin Me´tab 1998;12:3 - 11.
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[5] Sikora S, Ribeiro U, Kane JM, Landreneau RJ, Lembersky B, Posner M. Role of nutrition support during induction chemoradiation therapy in esophageal cancer. J Parenter Enteral Nutr 1997;282:18 - 21. [6] Scrimshaw NS, San Giovanni JP. Synergism of nutrition, infection, and immunity: an overview. Am J Clin Nutr 1997;66:S464 - 77. [7] Schattner M. Enteral nutrition support of the patient with cancer: route and role. J Clin Gastroenterol 2003;36:297 - 302. [8] Gianotti L, Braga M, Vignali A, Balzano G, Zerbi A, Bisagni P, et al. Effect of route of delivery and formulation of postoperative nutritional support in patients undergoing major operations for malignant neoplasms. Arch Surg 1997;132:1222 - 30. [9] Georgieff M, Tugtekin IF. Positive role of immune nutrition on metabolism in sepsis and multi-organ failure. Kidney Int 1998;53: S80 - 3. [10] Scioscia KA, Snyderman CH, Wagner R. Altered serum amino acid profiles in head and neck cancer. Nutr Cancer 1998;30:144 - 7. [11] Shankardass K, Chuchmach S, Chelswick K, Stefanovich C, Spurr S, Brooks J, et al. Bowel function of long-term tube-fed patients consuming formulae with and without dietary fiber. J Parenter Enteral Nutr 1990;14:508 - 12. [12] Liebl BH, Fischer MH, Van Calcar SC, Marlett JA. Dietary fiber and long-term large bowel response in enterally nourished nonambulatory profoundly retarded youth. J Parenter Enteral Nutr 1990; 14:371 - 5. [13] Hartemink R, VanLaere KM, Rombouts FM. Growth of enterobacteria on fructo-oligosaccharides. J Appl Microbiol 1997;83:367 - 74. [14] Alles MS, Katan MB, Salemans JM, VanLaere KM, Gerichhausen MJ, et al. Bacterial fermentation of fructooligosaccharides and resistant starch in patients with an ileal pouch-anal anastomosis. Am J Clin Nutr 1997;66:1286 - 92. [15] Roberfroid MB. Dietary fiber, inulin, and oligofructose: a review comparing their physiological effects. Crit Rev Food Sci Nutr 1993; 33:103 - 48. [16] Jiang T, Savaiano DA. Modification of colonic fermentation by bifidobacteria and pH in vitro: impact on lactose metabolism, short-chain fatty acid, and lactate production. Dig Dis Sci 1997;42: 2370 - 7. [17] Taber HS, Roberfroid M. Influence of inulin and oligofructose on breast cancer and tumor growth. J Nutr 1999;129:1488S - 91S. [18] Taber HS, Roberfroid MB. Nontoxic potentiation of cancer chemotherapy by dietary oligofructose or inulin. Nutr Cancer 2001;38:1 - 5. [19] Axford J. Glycobiology and medicine: an introduction. J R Soc Med 1997;90:260 - 4. [20] Kok N, Roberfroid M, Robert A, Delzenne N. Involvement of lipogenesis in the lower VLDL secretion induced by oligofructose in rats. Br J Nutr 1996;76:881 - 90. [21] Buddington RK, Williams CH, Chen SC, Witherly SA. Dietary supplement of neosugar alters the fecal flora and decreases activities of some reductive enzymes in human subjects. Am J Clin Nutr 1996; 63:709 - 16. [22] Hague A, Diaz GD, Hicks DJ, Krajweski S, Reed JC, Paraskeva C. bcl-2 and bak may play a pivotal role in sodium butyrate–induced apoptosis in colonic epithelial cells; however, overexpression of bcl-2 does not protect against bak-medicated apoptosis. Int J Cancer 1997; 72:898 - 905. [23] Hughes R, Rowland IR. Stimulation of apoptosis by two prebiotic chicory fructans in the rat colon. Carcinogenesis 2001;22:43 - 7. [24] Sanders BG, Kline K. Nutrition, immunology and cancer: an overview. In: Longenecker JB, Kritchevsky D, Drezner MK, editors. Nutrition and biotechnology in heart disease and cancer. New York7 Springer-Verlag; 1995. p. 185 - 94. [25] Guigoz Y, Rochat F, Perrisseau-Carrier G, Rochat I, Schiffrin EJ. Effects of oligosaccharide on fecal flora and non-specific immune system in elderly people. Nutr Res 2002;22:13 - 25. [26] Pressac M, Vignoli L, Aymard P, Ingenbleek Y. Usefulness of a prognostic inflammatory and nutritional index in pediatric clinical practice. Clin Chim Acta 1990;188:129 - 36.
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[27] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. CDC Growth Charts7 United States. Adv Data 2000;314:1-28. [28] Taber HS, Roberfroid MB. Inulin/oligofructose and anticancer therapy. Br J Nutr 2002;87:S283. [29] Naidu AS, Bidlack WR, Clemens RA. Probiotic spectra of lactic acid bacteria (LAB). Crit Rev Food Sci Nutr 1999;39:13 - 126. [30] Kudlackova M, Andel M, Hajkova H, Novakova J. Follow-up of burn injuries using the PINI index. Rozhl Chir 1989;68:595 - 9. [31] Bartolome LML, Garcia VC, Ruiz-Echarri ZMP, Calvo Ruata ML, Baldellou VA. Evaluation of the nutritional state in patients with congenital cardiopathy. An Esp Pediatr 1991;35:185 - 8. [32] Ingenbleek Y, Carpentier YA. A prognostic inflammatory and nutritional index scoring critically ill patients. Int J Vitam Nutr Res 1985;55:91 - 101.
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Nutritional support of pediatric patients with cancer consuming an enteral formula with fructooligosaccharides Shan Zhenga, Philippe Steenhoutb, Dong Kuirana, Wang Qihonga, Wang Weipinga, Corinne Hagerc, Ferdinand Haschkeb, Roger A. Clemensd,4 a
Fundan University, Children’s Hospital, Department of Surgery, 183 Fenglin Road, Shanghai 200032, China b Nestle Nutrition, Nestec Ltd., 32 Av Reller, Vevey 1800, Switzerland c Nestle Research Centre, Nestec Ltd., Lausanne 1000, Switzerland d USC School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90089-9121, USA Received 25 October 2005; revised 25 March 2006; accepted 10 April 2006
Abstract The objective of this study was to determine the tolerance and effects of a fructooligosaccharide (FOS)-containing enteral formula on fecal microbiota, nutritional status, biologic and immunologic outcomes of pediatric patients with cancer. A prospective, randomized, double-blinded, controlled trial was conducted at Children’s Hospital, Shanghai Medical University. Sixty-seven hospitalized patients (1-12 years old) diagnosed with cancer (stage 1-3) and undergoing chemotherapy met study inclusion criteria. Patients received at least 400 mL of an assigned formula for 13 to 30 days. The control group received enteral formula without FOS (control); the study group received the same formula with FOS (+FOS; 2 g/L). Stool samples on days 0, 3, 13, and 30 were analyzed for bifidobacteria, lactobacilli, and other microbiota. Biochemical markers of nutritional and hematologic status and anthropometrics were also assessed. The mean energy intake provided by the formulas was similar. At day 30 but not day 13, stool lactobacilli counts were significantly ( P b .02) higher in the +FOS group. A similar trend was seen for bifidobacteria. There were no clinically significant differences between groups for nutritional or hematologic status. There were no differences in immunologic parameters assessed except for significantly higher a1-acid glycoprotein in the control at day 13 ( P b .01). The prognostic inflammatory and nutritional index of +FOS at day 30 significantly decreased compared with control ( P = .016). These data suggest that an enteral formula containing dietary FOS produced a mild prebiotic effect at day 30 without any gastrointestinal discomfort in pediatric patients with cancer. Both enteral formulas were welltolerated and accepted. D 2006 Elsevier Inc. All rights reserved. Keywords:
Tolerance; Bifidobacteria; Fructooligosaccharides; Cancer
1. Introduction Patients with cancer often need to receive nutritional support to treat their malnutrition status before surgery or during chemotherapy and radiotherapy [1-4]. Parenteral nutrition has been extensively used to give this nutritional support, but some investigators report that its value is 4 Corresponding author. Tel.: +1 323 442 2124; fax: +1 323 442 1499. E-mail address: [email protected] (R.A. Clemens). 0271-5317/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2006.04.001
unclear and, until further clarified, suggest this approach to nutrition support should not be applied routinely [5]. Synergism between nutrition, infection, and immunity is now well known [6]. Schattner [7] demonstrated the importance of enteral feeds in patients with cancer to stave off malnutrition and to enhance the immune function to decrease risk of infections and complications. Gianotti et al [8] and Georgieff and Tugtekin [9] indicated the use of enteral feeding provided a positive bimmunonutritionQ effect by enhancing the host defense mechanism. Scioscia
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et al [10] reported that enteral nutrition may decrease the complications due to chemotherapy for gastrointestinal malignancies in patients with weight loss. These investigators demonstrated that serum amino acid levels, which are correlated with nutritional status, may provide prognostic information before treatment of head and neck cancer. Ideally, enteral nutrition should induce the same gut physiology as a complete and well-balanced oral food diet. Therefore, subjects requiring long-term enteral nutrition could benefit from dietary fiber delivered in an oral feed [11,12]. Some fermentable dietary fibers are known to improve host health by stimulating the growth and activity of select strains of bifidobacteria and other lactic acid microbiota and subsequently increase the production of short-chain fatty acids [13-15]. These fatty acids are fuel for the gut cells and are consequently possible candidates for the treatment of gut injury [16]. In addition, some of these fibers, such as dietary oligosaccharides and inulin, may inhibit the growth of certain types of tumors [17] and may potentiate the effects of some chemotherapeutic agents without any patient risk [18]. Several mechanisms have been proposed to elucidate the possible role of these fermentable fibers in improving health. Some possibilities are that these fibers have a positive effect on the host defense mechanism, including immunologic status changes [19], the production of shortchain fatty acids, by altering intestinal microbiota and subsequent modulation of hepatic fatty acid synthesis [20], the diminution of intestinal pH, decreased activity of selected intestinal enzymes associated with increased risk for some tumorigenesis [21], the reduction of some bacterial metabolites that may promote tumor cell development or proliferation [18], and the induction of tumor cell apoptosis [22,23]. Nevertheless, the relationship among nutrition, immunology, and cancer is a subject with complex interactions not yet well understood [24]. Although the daily value (DV) for dietary fiber is 25 g, the healthy US population consumes, on average, slightly less than 50% of this DV. This may be due in part to the potential side effects of gastric discomfort. Fermentable fiber, when consumed in excessively large quantities, can also induce gastrointestinal intolerance, such as flatulence and frequency and consistency of stools. The possibility of intolerance in vulnerable populations is an important consideration when deciding appropriate amounts and types of fermentable fibers to feed such patients. There are limited data on the effects of chemotherapeutic agents on the intestinal microbiota, and even less is known about the beneficial effect of these bifidobacteria and lactic acid flora in patients with cancer. This study was designed to investigate whether specific fermentable dietary fibers, fructooligosaccharides (FOS), also known as prebiotics, when delivered in an enteral formula, are tolerated and can maintain or stimulate the development of bifidobacteria and lactic acid microbiota when consumed by pediatric patients under chemotherapy.
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2. Methods and materials 2.1. Subjects Pediatric patients diagnosed with neuroblastoma, Wilms’ tumor, malignant teratoma, hepatoblastoma, and/or rhabdomyosarcoma were recruited from the Children’s Hospital, Shanghai Medical University. Inclusion criteria included 1 to 12 year-old patients diagnosed with cancer in stages 1 to 3, receiving chemotherapy as part of their standardized regimen, and receiving oral and/or enteral tube feedings. Patients with depressed neurologic status, terminal medical status, and severe malnutrition, under the use of regimens influencing immunologic response or the use of lactulose within the week before study entry, or those consuming any investigational drug within 30 days before the start of the study were excluded from enrollment. The Shanghai Medical University Institutional Review Board approved the study protocol, and the study was conducted in accordance with good clinical practice. All subjects participated after informed consent was obtained from a parent or legal guardian. Sixty-seven pediatric patients who met the above criteria were enrolled and randomized into 2 study groups between July 1999 and February 2001. 2.2. Treatment In a double-blind, randomized prospective study, 35 patients received 400 mL (1674 kJ) of a commercial enteral feed (Nutren Junior 1.0, Nestle´, Konolfingen, Switzerland) without FOS (control) for at least 13 days (30 days maximum) while hospitalized. Continuation of the study from day 14 to day 30 was optional. The second study group of 32 hospitalized children received the same enteral feed containing 2 g/L of FOS (+FOS; Nestle´) for the same period. All products were delivered orally or with a nasogastric or gastrostomy tube on gravity administration. Both products contained proteins, carbohydrates, and fats with vitamins and minerals in amounts intended for full nutritional support of pediatric patients and differed only in the addition of FOS to the study product (Table 1). The FOS contained 70:30 Raftilose/Raftiline from Orafti (Brussels, Belgium). Table 1 Nutritional composition of the enteral formulas Macronutrients per 1674 kJ (400 mL)
Control
+FOS
Energy density (kJ/mL) Protein (50:50 whey/casein) (g) Fat (g) MCT (%) MUFA (%) PUFA (%) n6/n3 Carbohydrate (g) FOS (g)
4.186 12 15.8 20 50 20 6 53 –
4.186 12 15.8 20 50 20 6 53 0.8
MCT indicates primarily caprylic and capric acids; MUFA, primarily oleic acid; PUFA, n6 a-linoleic acid; n3 linoleic acid.
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All patients were allowed an oral mixed diet of their choice ad libitum. Patients continued all chemotherapeutic medications and antibiotics as needed for treatment of their clinical condition throughout the study period. 2.3. Outcomes Baseline values were assessed at day 0 before beginning study feeds. The primary clinical outcome of the study was the effect of FOS on stool microbiota. This effect was determined by the presence and quantification of enterobacteria, bifidobacteria, lactobacillus, and Clostridium perfringens in stool cultures from patients on days 0, 3, 13, and 30. At each specified time point, stools were collected by the subject/caretaker on a plastic plate placed in the toilet. A sterile spoon and cup were used to collect and store approximately 5 to 10 g of stool in anaerobic conditions within 30 minutes of emission. The collection container (with proper identifiers) holding the stool sample was placed in an aluminum bag with the lid of the container left slightly ajar to allow air exchange. An opened packet of AnaeroGen (Oxoid Limited, Hampshire, UK) was placed inside the aluminum bag in an upright position and the bag was closed tightly. The stool sample was then refrigerated at 48C, transferred on ice to the laboratory, and analyzed within a maximum of 10 hours. Stool samples were prepared and analyzed on-site at the Shanghai Sixth People’s Hospital microbiology laboratory. For quantification of lactobacilli colony-forming units (CFU), fecal samples were cultured on MRS medium with antibiotics. For quantification of bifidobacteria CFU, fecal samples were cultured on Eugon Tomato medium [25]. Differentiation of the bacteria was made by a check of each type of colony by microscopic observation. Secondary clinical outcomes included assessment of immunologic and nutritional status. Blood samples were obtained by venipuncture from a peripheral vein and drawn by the investigator or study nurse. Immunologic parameters were assessed by using plasma samples collected at baseline (day 0) before beginning study feeds and on day 13 and/or day 30. These parameters included tumor necrosis factor a (TNF a) (Beijing East Asia Immunology Technology Institute, Beijing, China), a1-acid glycoprotein (AGP) (Orion Diagnostica, Espoo, Finland), cytokines interleukin (IL)-2 and IL-6 (R&D Systems, Minneapolis, MN), and CD4 and CD8 (BD Diagnostics, Franklin Lakes, NJ) cell populations. The nutritional status of all patients was assessed. In addition, routine physical examination (height, weight, blood pressure, heart rate, body temperature, respiratory rate), 24-hour dietary records, tolerance measures by a standardized questionnaire (recorded daily from days 0-13 and then from days 28-30; flatulence, nausea, rectal discomfort, abdominal pain, abdominal distention, diarrhea, stool frequency and consistency), the Prognostic Inflammatory and Nutritional Index (PINI), and standard hematologic and biochemical parameters were also assessed. PINI is a tool to predict morbidity or mortality in hospitalized patients and was calculated as:
PINI ¼
a1 Acid glycoproteinðg=L Þ C Q reactive proteinðmg=LÞ Albumin ðg=L Þ Prealbumin ðg=LÞ
Healthy children typically have a PINI value less than 1, whereas sick patients are characterized by a progressive rise greater than 1 as condition worsens [26]. Biochemical parameters assessed in this study at baseline, day 13, and day 30 included total bilirubin, alanine aminotransferase, alkaline phosphatase, blood urea nitrogen, creatinine, glucose, sodium, potassium, total protein, albumin, prealbumin, calcium, phosphate, and C-reactive protein (CRP) levels. The limit of detection of CRP with the method used was 1 mg/L. In addition, the hematologic parameters of hemoglobin level, red blood cell counts, hematocrit level, leukocyte, neutrophil, monocyte, lymphocyte, and platelet counts, and erythrocyte sedimentation rate were evaluated at baseline, day 13, and day 30. 2.4. Adverse events All adverse events were reported and recorded whether or not they were considered to be serious or related to the treatment. Adverse events were defined as illnesses, signs, or symptoms occurring or worsening during the course of the study. 2.5. Statistical analysis All available data were analyzed on an intention-to-treat (ITT) model. No statistical procedures were performed to compensate for missing data. Per protocol (PP) analysis was defined as completion of study up to day 13, whereas data from subjects who discontinued before day 13 were excluded from analysis. Data are expressed as mean F SD. It was hypothesized that subjects receiving the +FOS formula would have an increased level of bifidobacteria in their stool compared with those receiving the control. It was assumed that 95% of the pediatric population studied would have bifidobacteria present in their stool, and the goal was to show a significant increase of 0.5log10 CFU of bifidobacteria per gram of stool. Given this, a sample size of 30 per group to complete the study was calculated based on a conservative value of P = .75, which allows for a type I error (a error) of .05 and a type II error (b error) of .2. For fecal bacterial counts, because all subjects did not start chemotherapy at day 0, and the chemotherapy did not last all 13 days of enteral feed intake, the incremental change in log10 bifidobacteria was modeled with the covariables of treatment group, sex, age, the number of days between the start of chemotherapy and day 0, and the number of days between the end of chemotherapy and day 13 as covariables. If the chemotherapy ended after day 13, then the number of days between the end of chemotherapy and day 13 was set to 0. Pearson correlation coefficients were determined for secondary outcomes. For immunologic, hematologic, and biochemical parameters that are normally distributed or normally distributed after a log transformation, an analysis
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of covariance model with baseline value as covariable was applied to the corresponding measurements on respective days. Growth was assessed by weight and height measurements and plotted against National Center for Health Statistics references [27]. To normalize the data, z-scores were determined for weight-for-age and height-for- age. Change in weight-for-height z-scores was also calculated. All statistical analyses using parametric and nonparametric estimators were performed using SAS software (v 8.0, SAS Institute, Inc., Cary, NC). The rejection level in statistical tests was equal to 5%. 3. Results The only difference between ITT and PP analysis was one male subject in the +FOS group who was noncompliant with the protocol and withdrew from the study at day 3. The ITT analysis was not considered necessary because the values for missing data were not replaced, which means that ITT and PP analyses would be the same at day 13. Sixty-seven pediatric patients were enrolled in the study: 35 in the control group and 32 in the +FOS group. All enrolled patients were of Asian ethnicity. None of the patients had a history of allergies or major surgery. Patients’ profiles at baseline are summarized in Table 2. The patient profile and anthropometrics between the 2 study groups were statistically similar with some clinically irrelevant differences. The proportion of girls and the proportion of subjects with stage 3 cancers was slightly higher in the control than in the +FOS group, but did not differ statistically. On average, pediatric patients in +FOS were older than the controls (7.5 F 2.9 vs 5.0 F 3.1 years). The subjects in each group were shorter than the American reference for healthy children (negative height for age z-scores), and they weighed less for their age (negative weight for age z-scores). Most pediatric subjects did not start chemotherapy at day 0. Subjects typically initiated chemotherapy 2.8 F 8.1 days before starting the study formulas. Thirty-nine subjects started chemotherapy before day 0, 10 subjects began Table 2 Patient parameters in ITT analysis (percentages or mean F SD) Profile parameter
Control (n = 35)
+FOS group (n = 32)
Sex (% of females) Age (y) Height-for-age z-scores Weight-for-age z-scores Weight-for-height z-scores Stage of cancer = 1, 2, 3 Carcinoma Neuroblastomal (%) Wilms’ tumor (%) Malignant teratoma (%) Hepatoblastoma (%) Rhabdomyosarcoma (%)
43
34
5.0 F 3.1 1.59 F 1.90 0.62 F 1.10 0.70 F 1.69 20%, 43%, 37%
7.5 F 2.9 1.38 F 2.02 0.74 F 1.11 0.42 F 2.46 34%, 38%, 28%
31 29 11 6 23
12 16 19 12 41
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therapy exactly at day 0, and the remaining 17 subjects started chemotherapy 1 to 11 days after initiating the study. Some subjects had already finished the chemotherapy before the start of enteral feed intake. A total of 66 subjects, 34 individuals in the control group and 32 in the +FOS group, were considered in the PP analysis. All of these subjects consumed a minimum of 400 mL/d (1674 kJ/d) of the assigned enteral product during the first 13 days. Subjects consumed an average of 30.1 F 11.4 mL/kg body weight. In the +FOS group, therefore, the average amount of FOS consumed from the study product was 60 F 20 mg FOS/kg body weight. The total energy from regular diet and study product combined as well as the study product alone for the control and +FOS groups (regular diet + study product: 4655 F 1005 vs 4931 F 1168 kJ/d; study product alone: 2592 F 578 vs 2554 F 494 kJ/d) and quantity of study formula intake (619 F 138 vs 610 F 118 mL/d) were comparable between the 2 treatment groups. Using these volumes, FOS intake from the study formula in the +FOS group was 1.22 F 0.24 g/d. Six patients in the control group and 3 patients in the +FOS group voluntarily discontinued the study enteral product between days 13 and 30, the optional phase of the study. 3.1. Bifidobacteria in stools The bifidobacteria counts were measured at day 0, day 3, day 13, and day 30. The detection limit of bifidobacteria in stools was 100 CFU/g. None of the covariables was significant (treatment [ P = .97], sex [ P = .26], age [ P = .66], start of chemotherapy [ P = .91], and end of chemotherapy [ P = .87]). The incremental change of log10 bifidobacteria levels from day 0 to day 13 was positive for both study groups (Fig. 1). At day 0, the 2 treatment groups had a similar number of bifidobacteria. During the initial 13 days, there was a tendency toward an increase of bifidobacteria in the +FOS group, whereas the bifidobacteria level was unchanged relative to baseline in the control group. No statistical difference between the 2 treatment groups was detected (95% confidence interval [CI], 1.62, 1.69). The incremental change of bifidobacteria at 30 days of treatment was not significantly different between the 2 study groups ( P = .24). None of the covariables was significant. The incremental change between the control group and +FOS group was equal to 0.99 (95% CI, 2.65, 0.68). However, on day 30, there was a trend toward an increase in number of bifidobacteria CFU/g in the +FOS group as compared with the control ( P = .08; Fig. 1). 3.2. Selected microbiota in stools Stool samples were also cultured for the presence of enterobacteria, C. perfringens, and lactobacilli. The lower detection limit for these bacteria was also 100 CFU/g. The longitudinal bacterial quantification of these bacteria is shown in Fig. 1.
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Fig. 1. Concentration of selected organisms in stools at the different visits and by group, control vs treatment (mean F SEM, log10 CFU/g). There were no significant differences in incremental change of bifidobacteria. On day 30, there was a trend toward an increase in number of bifidobacteria in the +FOS group as compared with control ( P = .08). For the period from day 0 to 30, there was a significantly greater change in the +FOS group of Lactobacilli in stools ( P = .007). In addition, at day 30, there was a significantly higher number of Lactobacilli in the stools of the +FOS group than in the control group ( P = .02). There were no significant differences in concentration of Bifidobacteria, Enterobacteria, or C. perfringens in stools.
0.44) for lactobacillus. At day 30, the increment for C. perfringens ( P = .78) and enterobacteria ( P = .24) were not significantly different between treatments.
Dietary FOS had no significant effect on enterobacteria or C. perfringens at any time point tested. In the case of lactobacilli, there was not any difference between the 2 treatment groups during the first 13 days. However, at day 30, the number of lactobacilli was significantly ( P = .02) higher in the +FOS group than in the control group. For the period from day 0 to 30, the incremental change of lactobacilli was significantly higher in the +FOS group ( P = .007). The change in the increment between the control group and +FOS group was equal to 1.36 (95%CI, 2.33, 0.38]). Regression coefficients of age, sex, and start and end of chemotherapy were not significant except age for C. perfringens where the regression coefficient was estimated at 0.18 ( P = .01). In a multiple regression model with treatment and sex as effects, and age, start of chemotherapy and end of chemotherapy defined as covariables, increments from day 0 to day 13 were not significantly different between the 2 treatment groups ( P = .43 for C. perfringens, P = .66 for enterobacteria, and P = .26 for lactobacillus). The difference between the control group and +FOS group was equal to 0.38 (95% CI, 0.58, 1.33) for C. perfringens, 0.21 (95% CI, 0.75, 1.17) for enterobacteria and 0.58 (95% CI, 1.60,
3.3. Immune status The assessed immunologic parameters are shown in Table 3. These values were normal in each study group throughout the study period and did not differ significantly between these groups except for AGP at day 13 ( P = .01). At day 0, there was a higher number of patients with an AGP value higher than 1.4 g/L in the control group than in the +FOS group. The proportion of patients whose AGP increased to a level greater than 1.4 g/L after 13 days in the control group was 20% vs 4% in the +FOS group. This proportion was not significantly different ( P = .12). AGP level was not related to cancer stage. 3.4. Prognostic Inflammatory and Nutritional Index The PINI values of both +FOS and control groups declined during the 30-day study period. However, the PINI value of +FOS at day 30 decreased more than in the control group, the median values being 0.28 and 0.82, respectively. The difference between both groups was statistically
Table 3 Immunologic parameters (mean F SD) by treatment group at different days Day 0
Day 13
Control TNF-a (ng/mL) AGP (g/L)4 IL-6 (ng/mL) IL-2 (ng/mL) ln(CD4/CD8)
1.40 1.38 84.9 172.8 0.10
F F F F F
0.97 0.77 56.7 67.6 0.52
+FOS
Control
1.44 F 0.77 1.17 F 0.94 91.0 F 54.4 183.9 F 105 0.05 F 0.49
1.14 1.324 84.8 176.9 0.05
TNF-a indicates tumor necrosis factor a. 4 P = .01 between control and +FOS at day 13 (ANCOVA).
F F F F F
Day 30 +FOS 0.86 0.60 62.9 83.5 0.44
1.16 0.964 93.0 153.4 0.03
Control F F F F F
0.67 0.56 61.1 81.5 0.39
1.11 1.28 87.4 161.3 0.10
F F F F F
+FOS 0.75 0.65 69.4 74.0 0.40
1.08 0.99 92.8 150.3 0.05
F F F F F
0.91 0.62 64.8 77.1 0.41
S. Zheng et al. / Nutrition Research 26 (2006) 154 – 162
159
counts were within normal limits and did not differ statistically with the exception of the following parameters from day 0 to day 13: +FOS group had a significantly higher hemoglobin level (100 F 17 vs 112 F 13g/L; P = .009) and hematocrit (30.0 F 5.1 vs 33.3 F 3.9%; P = .04) and a significantly lower sedimentation rate (12.6 F 3.9 vs 9.8 F 3.6mm/hr; P = .03). The sedimentation rate was not obtained on all patients, and should therefore be interpreted with caution. None of these differences was clinically significant. 3.7. Tolerance
Fig. 2. PINI index.
significant ( P = .016). Fig. 2 shows the changes in PINI values over the entire study period. PINI for all 66 subjects declined remarkably after nutrition supplement at day 30. The median value was 1.22 on day 0, 0.52 on day 13, and 0.43 on day 30, showing statistical significance (day 0 vs day 30, P b .001). 3.5. Biochemical parameters From day 0 to day 13, there were no significant differences between the treatment groups for any of the parameters tested. Glucose and CRP levels had a skewed distribution, so the statistical tests were performed on logtransformed data. At day 30, glucose after log transformation was significantly higher in the +FOS group ( P = .02). Total bilirubin level after log transformation was significantly higher in the control group at day 30 ( P = .01). Neither of these differences was clinically significant. With the exception of CRP, all values were within normal limits. CRP levels were elevated in both groups (30 days: control, 6.6 F 4.5; +FOS 5.2 F 5.4 mg/L), which were assumed to be related to the pathology of these subjects. 3.6. Hematology All of the hematologic values for red blood cell, leukocyte, neutrophil, monocyte, lymphocyte, and platelet
No patient presented any abdominal distention on any of the recorded days. One patient in the +FOS group reported rectal discomfort at day 4. Three patients in this group reported mild flatulence at baseline and on one other occasion before day 10. Two of the 3 patients with mild flatulence also reported 2 occasions of abdominal pain. One patient reported mild diarrhea at day 5. Twelve patients in the control group and 11 in the +FOS group reported at least one episode of nausea during the study. The color of the stools was quite similar in both treatment groups. Considering both groups, approximately 70% of the stools were brown, whereas the remaining 30% were yellow. The control group reported red stool at 0.5% during the first 13 days of the study period. Subsequently, none of the control or treatment groups reported any red stool from day 28 to day 30. Stools from the +FOS group were more frequently formed than in the control group, although stool consistency did not differ statistically between the 2 study groups. 3.8. Growth Increased weight for age and weight for height was observed in both treatment groups during the study period. These pediatric patients with cancer maintained, if not improved, their weight. The z-scores for this population of ill children were low and often with negative values in both groups and at both time points. Changes in z-scores of weight, weight-for-age, and weight-for-height were generally all positive in the +FOS and control groups at days 13 and 30 (Table 4).
Table 4 Change in growth z- scores (mean F SD) for control and treatment group for days 0 to 13, 13 to 30, and 0 to 30 Day 0-13
Height-forage Weight-forage Weight-forheight
Day 13-30
Day 0-30
Control
+FOS
Control
+FOS
N
Mean F SD
N
Mean F SD
N
Mean F SD
N
Mean F SD
Control N
Mean F SD
+FOS N
Mean F SD
33
0.04 F 0.17
30
b 0.1 F 0.09
34
0.04 F 0.09
32
0.12 F 0.62
33
b 0.1 F 0.16
30
0.13 F 0.63
34
0.27 F 0.33
31
0.11 F 0.19
34
0.28 F 0.32
32
0.26 F 0.18
34
0.55 F 0.45
31
0.37 F 0.26
30
0.35 F 0.42
30
0.19 F 0.30
30
0.44 F 0.40
29
0.31 F 0.45
30
0.80 F 0.51
29
0.50 F 0.52
160
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3.9. Adverse events One adverse event was documented throughout the entire study. One 6-year-old boy with stage 2 cancer with neuroblastoma in the +FOS group presented diarrhea with mild epiumbilical discomfort and unformed, soft yellow stools. These stools were negative for occult blood. Medical review indicated these symptoms were unlikely related to the assigned enteral feed. It was his parents’ decision to discontinue his participation in the study at day 3. This subject did not comply with the study protocol and was excluded from the PP analysis.
4. Discussion Patients with cancer undergoing chemotherapy and/or radiotherapy frequently require nutritional support to obviate risks associated with malnutrition and gastrointestinal complications [5]. Taber and Roberfroid [18] suggested the introduction of dietary oligosaccharides may improve the outcomes of chemotherapy and possibly potentiate the effects of these cytotoxic medications in a rodent model. They further noted the administration of oligosaccharides may complement classical protocols of human cancer treatment without any additional risk for the patients [28]. Although the anticipated increase in bifidobacteria in the +FOS group was not seen, there was a trend ( P = .08) for an increase in bifidobacteria in those consuming FOS. The significant increase in lactobacilli is of interest as it illustrates the potential interrelationship between commensal organisms. Demonstration of a significant bifidogenic effect may require a larger sample size and evaluation of timing and dose of prebiotic administration in relation to chemotherapy. It is entirely possible that the dosage of FOS subjects were exposed to in this study (1.22 F 0.24 g/d; 0.06 F 0.02 g FOS/kg body weight) was not enough to induce a bifidogenic effect. A study by Buddington and colleagues [21] has shown that ingestion of 4 g of FOS/d by healthy adults was sufficient to alter the fecal flora, although lower dosages were not examined in this study. The amount of prebiotics needed to induce a bifidogenic effect in pediatric patients with cancer has not been established. FOS in the nutrition supplement studied here had a significant lactogenic effect and a tendency to increase the bifidobacteria by the end of the study period in pediatric patients treated by chemotherapy. Emerging evidence suggests that FOS and the associated increase in lactic acid bacteria may function as immunomodulators by stimulating IgA synthesis, promoting mucin production, modulating inflammatory cytokines, binding mucosal receptors, and decreasing antigen absorption [28,29]. Patients with cancer present various degrees of immunocompetence, which is influenced by different types of pathologies and nutritional status. This is the first study to evaluate the potential of FOS as part of an enteral feeding on immunocompetency of young patients with cancer. Dietary
FOS significantly decreased AGP ( P = .01), an acute-phase reactant protein, relative to controls, which suggests oligosaccharides may decrease the inflammatory process and impact the immunomodulation cascade even in patients with cancer. However, the difference was no longer significant on day 30, which may be due to the short-term immunologic benefits of the formula. None of the other assessed immunologic parameters differed. AGP elevation is typically observed in tumor-bearing patients and is an acute phase response in other disorders requiring pharmacologic intervention. Because AGP may bind or trap many basic vs acidic drugs, each of these presentations necessitates an adjustment of a dosing regimen; thus, modulation of AGP via dietary components may lead to more consistent chemotherapy. PINI is a sensitive, universal tool where lower scores indicate less risk for morbidity or mortality among hospitalized patients. As suggested by several investigators [26,30,31], PINI may be a rapid and useful clinical tool to assess both inflammatory and nutrition status among pediatric, critically ill patients. It is noteworthy that the PINI score, which includes CRP, AGP, albumin, and prealbumin (as indicators of inflammation and nutrition status), was significantly reduced in the +FOS group. The authors suggest the effect of dietary FOS on this inflammatory index may be due to modulation of AGP levels. Over the course of advancing disease and throughout the therapeutic period, PINI should be considered in future research on nutritional status and prediction of prognosis in advanced cancer especially as dietary intervention and nutrition support improves [32]. Walsh et al [33] recently noted elevated IL-6 levels correlated with high PINI and CRP values in patients with advanced cancer. CRP is virtually absent in the normal healthy individual. On the other hand, CRP increases during inflammatory processes, such as cancer, arthritis and cardiovascular disease, and throughout the normal course of pregnancy. Although IL-6 did not differ in this study, a study by Guigoz and colleagues [34] demonstrated a significantly decreased expression of IL-6 mRNA in peripheral blood monocytes of elderly people consuming 8 g FOS/d for a period of 3 weeks. Despite the anti-inflammatory effect of FOS shown in this study with the PINI and AGP data, IL-6 and CRP levels did not differ between the groups, but may be an area of interest for future research. The plethora of biochemical and hematologic data indicated no clinically significant changes during the study period. None of the 14 biochemical parameters or any of the 9 hematologic outcomes indicated any clinical impact by an average intake of 1.22 F 0.24 g/d in the +FOS group at days 13 or 30 relative to baseline data assessed at day 0. It is reassuring that the dietary intervention did not alter these parameters in this ill population, and that the values remained within reference ranges for children. Tolerance of FOS without significant changes in perceived gastrointestinal status in healthy children has been documented [35]. The children with cancer in this study also
S. Zheng et al. / Nutrition Research 26 (2006) 154 – 162
tolerated the addition of FOS to an established enteral feed. In another study of a vulnerable population, Barshop and colleagues [36] demonstrated that FOS was tolerated even among individuals with diagnosed hereditary fructose intolerance. The subjects in the Barshop et al study tolerated approximately 0.22 F 0.13 g FOS/kg body weight during a short-term period. The exposure in the study reported here approximated 0.06 F 0.02 g FOS/kg body weight and provides additional information to support the tolerance and safety of FOS in high-risk individuals. This safety assessment is reinforced by the unremarkable presentations of the biochemical and hematologic data obtained throughout the study. As in other studies, some subjects in the FOS group reported symptoms of intolerance, possibly during a period of adaptation. However, in this study, these symptoms were not considered to be of clinical detriment and did not affect the overall ability of subjects to continue their treatment. The positive change in z-scores even during the relatively short course of this study show the value of nutritional support during cancer treatment and the safety of FOS in this population. In the present study, 29 children diagnosed with cancer were fed an FOS-containing enteral product for a period up to 30 days, resulting in a significant increase in some lactic acid bacteria. Inflammatory status was reduced in the FOSsupplemented group. Physical growth as assessed by z scores was positive in each study group, indicating the nutritional status was not compromised by FOS. The study supports the growing clinical evidence that certain populations, including children with cancer, could benefit from a nutritionally appropriate, prebiotic-containing enteral formula. Further research is required to enhance our understanding of optimal effective prebiotic doses and immunomodulatory mechanisms. Acknowledgment The contributors to this article are grateful for the excellent administrative coordination, editorial support, and critical review provided by Laura Czerkies and the sponsorship of Nestle´ SA (Vevey, Switzerland). References [1] Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer 1998;34:503 - 9. [2] ReyFerro M, Castano R, Orozco O, Serna A, Moreno A. Nutritional and immunologic evaluation of patients with gastric cancer before and after surgery. Nutrition 1997;13:878 - 81. [3] Hochwald SN, Harrison LE, Heslin MJ, Burt ME, Brennan MF. Early postoperative enteral feeding improves whole body protein kinetics in upper gastrointestinal cancer patients. Am J Surg 1997; 174:5325 - 30. [4] Bachmann P, Gordiani B, Ranchere J-Y, Lallemand Y, Combret D, Latour J-F, et al. E´valuation de l’indication et de la qualite´ de la prise en chage nutritionnelle en cance´rologie me´dicale. Nutr Clin Me´tab 1998;12:3 - 11.
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