pediatric oncology112016 the benefit of optimal caloric and nutrient intake .pptx

Nutrition management of pediatric oncology and hematology

1. Nutrition management of pediatric oncology and hematology Guidelines Sahar Khairy Professor of Pediatrics Nutrition consultant

2. Malnutrition A malignant tumor leads to changes in a child’s metabolism failure to down regulate energy expenditure reduced energy intake and an increased lipolysis . All of these factors lead to an ineffective use of nutrients and contributes to the development of malnutrition

3. Tumor types associated with malnutrition for pediatric oncology patients High risk factor for undernourishment Moderate risk factor for undernourishment High risk factor for fat accumulation Solid tumors with advanced stages Wilms tumors Neuroblastoma stage III and IV rhabdomyosarcoma Ewing sarcoma Medulloblastoma Multiple relapsed leukemia and lymphoma Head and neck tumors Post stem cell transplantation (graft vs. host-disease) Diencephalic tumors Infants diagnosed < 12months Non metastatic solid tumors Uncomplicated acute lymphoblastic leukemia Advanced diseases in remission during maintenance treatment Acute lymphoblastic leukemia receiving cranial irradiation Craniopharyngeoma Malignancies with large and prolonged doses of corticosteroid therapy or other drugs increasing body fat stores Total body or abdominal or cranial irradiation

4. Goals of Nutrition Therapy Optimal nutritional status is an important goal in the management of individuals diagnosed with cancer. Whether patients are undergoing active therapy recovering from cancer therapy or in remission and striving to avoid cancer recurrence the benefit of optimal caloric and nutrient intake is well documented

5. The goals of nutrition therapy are to accomplish the following Prevent or reverse nutrient deficiencies. Preserve lean body mass. Help patients better tolerate treatments. Minimize nutrition-related side effects and complications. Maintain strength and energy. Protect immune function, decreasing the risk of infection. Aid in recovery and healing. Maximize quality of life.

6. Dietary Requirements Energy <1 year : 120-150kcals/kg >1 year : Schofield x 1.5-1.8 combined activity and stress factor Decrease energy requirements post surgical resection and during maintenance chemotherapy

7. Protein <1 year : 2-4g/kg >1 year : RDA for age x 1.5-2 Restrict protein to RDA during tumour lysis syndrome Supplement glutamine at 0.57g/kg, before and during selected intensive chemotherapy regimes to decrease duration of mucositis Dissolve glutamine powder in at least 100mls cold clear liquid and administer as a swish and swallow solution

8. RDA for Proteins

9. Fat < 2 year : 30-50% NPE > 2 year : 30% of NPE Restrict fat to 2g/kg if patient is neutropenic or if INR is prolonged

10. Fluid Infants : 120-150mls/kg 1-6 years : 80-95mls/kg 7-18 years : 50-75mls/kg Fluid restriction may be indicated during cardiac failure

11. Nutritional strategies for children Nutritional strategies Indications Oral route In all patients with functional gastrointestinal tract Meeting 95–100% of estimated energy needs Tube feeding ( nasogastric ) Inability to ingest full energy requirements (90%) through oral diet for 3–5d Severe mucositis >3d PEG jejunostomy Inability to meet full energy needs through tube diet for 3–5d Severe vomiting for 3–5d Weight loss despite tube feeding Parenteral nutrition Altered gastrointestinal absorption for 3–5d Severe vomiting and diarrhea Severe pancreatitis Intestinal manifestation of graft vs. host disease Paralytic ileus

12. Biochemistry Monitoring schedule for patients with cancer Outpatients on oral or enteral feeds Hospitalised patients on oral or enteral feeds Hospitalised patients on PN Parameter Monthly Weekly Daily Electrolytes, glucose Monthly Weekly Weekly Urea, Creatinine Monthly Weekly Daily to weekly Calcium, phosphorous, magnesium As indicated Monthly Weekly Triglyceride Monthly Weekly Weekly LFT’s As indicated As indicated Monthly Trace elements As indicated As indicated Monthly Carnitine As indicated As indicated Monthly Vitamin levels

13. Goals for nutritional repletion 90% Weight for age or 90% weight for height Arm fat area > 5th percentile Subscapular skinfold > 10th percentile MUAC > 14.5cm

14. Nutritional strategies for children It is critical to thoroughly evaluate the Diagnosis prognosis degree of malnutrition function of the gut and ease of delivery before embarking on the plan of nutritional support Caution must also be exercised to avoid refeeding syndrome, the metabolic complication that is caused by rapid repletion of potassium, phosphorous, and magnesium in a severely malnourished or cachectic patient

15. Oral feeding Oral feeding is the method of choice in patients with a low nutritional risk not complicated by relapse , sepsis or major abdominal procedures It is recognized that the greatest limitation of nutritional supplements in the pediatric population is patient acceptance

16. Oral feeding Oral feeding interventions defined as combination of intense nutrition counselling and nutritional supplementation have been found to be effective in preventing malnutrition in nourished children who have less advanced disease or disease in remission on maintenance therapy and children with ALL with a good prognosis .

17. Oral feeding Nutritional intervention with counselling to encourage nutrient dense meal consumption may begin during hospitalization is most effective when the child is between cycles of therapy and is continuing treatment as an outpatient During this time there is less interruptions for tests, allowing parents or caretakers to provide favourite foods more easily It has proved ineffective in preventing malnutrition in children undergoing induction

18. Entry criteria for the provision of enteral feeding Present state of malnutrition at diagnosis that failed to or is not expected to improve within 1 week No improvement in nutritional status with food based supplements or supplementary drinks alone Weight loss after diagnosis > 5% from the weight at diagnosis Voluntary food intake is < 70% of estimated requirements for 5 days with no improvement after prescription of dietary supplementary drinks Anticipated gut dysfunction due to treatment for more than 5 days for wellnourished patients.

19. Enteral feeding Enteral feeding has shown to be effective in maintaining and improving the nutritional status of children with cancer during the intensive phase of treatment. It is considered a Safer Simpler more physiologic and economic intervention method more acceptable and better tolerated by children..

20. Enteral feeding Data has also shown a positive correlation between increases in weight and mid-arm circumference and the duration of enteral feeding

21. why energy requirements are often not met in children with malignancies receiving naso -gastric feeds Low infusion rates during initial days of feeding Feeding interruptions due to medical procedures Gastro-intestinal intolerance Suboptimal prescribed energy goals

22. Enteral feeding Concerns have been raised about the safety of placing nasogastric tubes when patients are vomiting neutropenic or thrombocytopenic Platelets were given before tube placement if the platelet count was < 20000uL.

23. Type of feed energy enriched formula increase in energy density did not lead to an increase in GI side effects. repletion of fat stores and an increase in muscle protein mass as increase in MUAC, biceps and triceps skinfold measurement. increase in the weight for height scores and patients

24. Enteral feeding The enriched formula (1.5kcal/ml) is however more effective in improving the nutritional status and meeting the dietary requirements of patients with malignancies. If the gastrointestinal tract is patent but functionally compromised, a semi-elemental formula may be better tolerated.

25. Enteral feeding Infusion Methods and Formulas Enteral nutrition or tube feedings can be delivered at various rates. When possible, the bolus method is preferable because it mimics normal feeding requires less time and equipment and offers greater flexibility to the patient

26. Enteral feeding Continuous or cyclic drip feeding Caloric/nutrient and free-water requirements need to be determined first to plan rate and time recommendations. Enteral feeding pumps provide reliable, constant infusion rates and decrease the risk of gastric retention. Assuming that no compounding factors are present, feeding into the stomach (25–30 cc/h) can start at a higher rate than feeding into the jejunum (10 cc/h); rates can be increased, with tolerance, every 4 to 6 hours until the rate reaches that needed to deliver the required caloric/nutrient needs. Continuous feeds can be cycled to run at night to allow greater flexibility and comfort. If it is physically possible, these nocturnal feeds can allow daytime oral or bolus feedings to meet nutritional goals and provide a more normal lifestyle.

27. Enteral feeding Assuming that no compounding factors are present, feeding into the stomach (25–30 cc/h) can start at a higher rate than feeding into the jejunum (10 cc/h); rates can be increased, with tolerance, every 4 to 6 hours until the rate reaches that needed to deliver the required caloric/nutrient needs.

28. Enteral feeding Bolus and intermittent feeding Caloric/nutrient and free-water requirements need to be determined to plan the feeding schedule. Bolus feedings can be offered several times (3–6 times) each day; as much as 250 to 500 cc can be given over 10 to 15 minutes. Bolus feeding should be used ONLY when the endpoint of the tube is in the stomach A gravity drip from a bag or syringe with a slow push can be used to administer the formula.

29. Enteral feeding Bolus and intermittent feeding it should NEVER be used when feedings are delivered into the duodenum or jejunum. This precaution protects against gastric distention and dumping . Diarrhea is a common side effect of this infusion method but can be controlled with a change in formula, additions to the formula, and a change in the amount of formula given over a definite period of time.

30. Enteral feeding Transition to Home The patient and/or caregiver is given enough time for education and is proficient in the use of the tubes, site care, and the use of the pump. The patient is discharged to a safe and clean environment. Regular medical follow-up is arranged to ensure appropriate function of the feeding tube and optimization of the nutrition plan.

31. TPN PN can be used as an adjunct to enteral nutrition or as the sole source of nutrition in patients who are unable to maintain oral intake or tolerate enteral feeds . Parenteral nutrition is an appropriate choice for patients who receive the most intense treatment associated with high nutritional risk, especially those considered malnourished at diagnosis

32. Inclusion criteria for the administration of TPN Unable to meet dietary requirements with enteral feeding alone Abnormal functioning of the Gastro-intestinal tract (GIT) due to Severe oral mucositis preventing oral or nasogastric feeding Typhlitis GVHD involving the GIT

33. Exit criteria Aggressive nutritional support should continue until recovery of GI function allows return to enteral feeds to meet dietary requirements.

34. Tapering off parenteral nutritional support The taper involves a gradual reduction in rate and time Parenteral nutritional support cannot be abruptly discontinued When transitioning to enteral feeds , parenteral support can be decreased to 50% when enteral feeds reach 33% to 50% of the goal rate it can be discontinued when enteral feeds reach 75% of goal and are tolerated When transitioning to oral nutrition , parenteral solutions can be decreased to 50% when the patient is tolerating a full liquid diet or beyond and can be discontinued once solid foods are tolerated in addition to the consumption of adequate fluids

35. 5) Recording Follow up sheets

36. Follow up / Discharge Provide referral letter for continuing nutrition support at referral hospital. Provide NSP referral to obtain dietary supplementation if indicated. Monitor MUAC, weight and height at monthly outpatient visits. Calculate % EWA, EHA,EWH and classify according to Waterlow and WHO criteria. High risk for the development of obesity in patients on chemotherapy regimens that include steroids, especially in AML and ALL. Healthy eating guidelines should be provided with the emphasis on weight maintenance to prevent growth stunting in these cases.

37. Bone marrow transplant is used in the treatment of solid tumors, hematologic diseases and auto-immune disorders. It is a sophisticated therapeutic procedure consisting of the administration of high dose chemotherapy followed by the intravenous infusion of hemopoietic stem cells to re-establish marrow function in patients with damaged or defective marrow.

38. Diseases treated by bone marrow transplantation Hematologic malignancies Solid tumours Other pathologic conditions AML Testicular cancer Severe aplastic anemia CML Ovarian cancer B- thalassemia ALL Glioma Severe combined immunodeficiency CLL Neuroblastoma Autoimmune disorder Non- Hodgkin lymphoma Amyloidosis Hodgkin’s disease Heriditary metabolic disorders

39. Bone marrow transplant Nutritional related complications of BMT Severe and prolonged mucositis and esophagitis caused by total body irradiation. Insults to the GIT by graft versus host disease (GVHD) leading to abdominal pain and severe diarrhea. Altered taste, xerostomia , excessive saliva, nausea, vomiting, anorexia, steatorhea and multiple organ dysfunction may occur. Malnutrition caused by the use of high dose steroids and anti- virals to manage GVHD . The duration and intensity of symptoms as well as the stress of treatment may prevent oral intake for 1-7 weeks post transplantation, making PN the preferred method of nutrition support

40. Bone marrow transplant Acute GVHD and the GIT Major complication occurs from 7-10 days to <3 months after allogenic BMT in 30-60% of patients If liver is involved, severe cholestasis occurs as a result of the destruction of small bile ducts which leads to increased serum bilirubin concentrations and impairment of liver functions Upper intestinal GVHD symptoms include anorexia, dyspepsia, and the inability to eat. Lower gastrointestinal GVHD presents with severe diarrhea which may be associated with bleeding, cramping abdominal pain requiring medication and refractory nausea and vomiting . Patients with severe GVHD may require a period of bowel rest with TPN.

41. Bone marrow transplant Metabolic alterations Impaired glucose tolerance due to steroid or cyclosporine administration or septic complications Pancreatic B cell function may be negatively affected Elevated serum cholesterol and triacylglycerol concentrations in patients maintained on long term cyclosporine therapy for chronic GVHD Altered vitamin status as a result of poor intake and malabsorption of water and lipid soluble vitamins

42. American cancer society 2014 Recommendations for children with low leucocytic

43. Role of low microbial diets in Bone Marrow Transplant Low microbial diets have been used on the premise that it may reduce the risk of bacterial infection in patients with compromised immune systems due to the reduced exposure to potential pathogens in the gastrointestinal tract.

44. This is done mainly to minimize the infection risks. - Avoid large crowds (this may contain infected people). Stay away from sharp objects that can cause injury. Usage of body lotion after every wash (dry skin is more susceptible to infections). - Frequent hand washes with plenty of water and soap, especially before and after meals. - Wear mask and gloves wherever possible. - Nutritious meal consisting of essential minerals and vitamins, especially, iron, zinc and copper to improve the WBC count, with applying strict measures of food safety. Precautions with leucopenic patients:

45. Basic Guidelines for a Neutropenic Diet Avoid all uncooked vegetables and most uncooked fruits. You may eat fruit that you can peel a thick skin off of, such as a banana or an orange. Cooked vegetables and canned fruits and juices are safe to eat . Cook meat until it's well-done. Thoroughly cook eggs (no runny yolks). Avoid salad bars. Buy vacuum-packed lunch meats instead of freshly sliced meats. Consume only pasteurized milk, yogurt, cheese and other dairy products. Avoid soft mold-ripened and blue-veined cheeses such Avoid well water or boil it for one minute before drinking. At home, it's okay to drink tap water or bottled water.

46. Allowed Avoid Milk and dairy products Only pasteurized milk, yogurt, cheese, or other dairy products Soft, mold-ripened, or blue-veined cheeses, including Brie, Camembert, Roquefort, Stilton, Gorgonzola, and blue cheese Mexican-style cheeses, such as queso blanco Breads, cereal, rice, and pasta Breads, bagels, muffins, rolls, cereals, crackers, noodles, pasta, potatoes, and rice are safe to eat as long as they are purchased as wrapped, pre-packaged items, not sold in selfservice bins. Bulk-bin sources of cereals, grains, and other foods

47. Allowed Avoid Meats and nuts Ensure all meats, poultry, and fish are cooked thoroughly. Use a food thermometer to be sure that meat and poultry reach the proper temperature when cooked. Vacuum-sealed nuts and shelf-stable nut butters Raw or lightly cooked fish, shellfish, lox, sushi, or sashimi Raw nuts or fresh nut butters Eggs Cook eggs until the yolks and whites are solid, not runny. Pasteurized eggs or egg Custard Raw or soft-cooked eggs – this includes over-easy, poached, soft-boiled, and sunny side up Foods that may contain raw eggs, such as Caesar salad dressing, homemade eggnog, smoothies, raw cookie dough, hollandaise sauce, and homemade Mayonnaise

48. Allowed Avoid Fruits and vegetables Raw vegetables and fruits and fresh herbs are safe to eat if washed carefully under running water and lightly scrubbed with a vegetable brush. Fresh salsas and salad dressings found in the refrigerated section of the grocery store – choose shelf-stable salsa and dressings instead Any raw vegetable sprouts (including alfalfa, radish, broccoli, or mung bean sprouts) Desserts and sweets Fruit pies, cakes, and cookies; flavored gelatin; commercial ice cream, sherbet, sorbet, and popsicles; sugar; commercially prepared and pasteurized jam, jelly, and preserves; syrup; and molasses are safe to eat. Unrefrigerated, creamfilled pastry products Raw honey or honeycomb – select a commercial, grade A, heat-treated honey instead

49. Allowed Avoide Water and beverages Use only water from city or municipal water services or commercially bottled water. Pasteurized fruit and vegetable juices, soda, coffee, and tea Water straight from lakes, rivers, streams, or springs Well water unless you check with your doctor first Unpasteurized fruit and vegetable juices Sun tea – make tea with boiling water and use commercially prepared tea bags Vitamin- or herbalsupplemented waters (these provide little, if any, health benefit)

50. Long-term plan There is a high risk of obesity in patients who survive pediatric cancers especially ALL and AML. This may be related to the impact of therapy on the patient’s height, a reduction in physical activity and a resulting change in body composition. Some chemotherapy regimens, especially those including steroids, may promote excessive weight gain. It is recommended that healthy diet principles and acceptable activity options for weight maintenance and control be provided in cases where malnutrition is not a concern. Food restrictions during intensive treatment may make treatment more difficult. The goal should be placed on weight maintenance to prevent stunting of overall growth. Growth hormone deficiency, with decreased growth velocity and delayed onset of puberty, has been observed in children treated with BMT. Other endocrine complications have also been attributed to anti- neoplastic therapies; many that are not apparent until the child matures. Regular evaluations of the endocrine glands are recommended.

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