Transcript Malnutrition and Nutrition Intervention in Childhood Cancer

Malnutrition and Nutrition
Intervention in Childhood Cancer
Introduction
 In United States 10,400 children under 15 diagnosed
with cancer in 2007
 Overall cure rate for childhood cancer now exceeds
70%

Major attention being placed on reducing the side effects of
therapy
(American Cancer Society 2007)
Introduction
 Studies suggest up to 46% of children with cancer
experience malnutrition
 Malnutrition: characterized by deficiency or excess of
energy with measurable adverse effects on clinical
outcome

Energy key component of malnutrition, but vitamin & mineral
deficiencies also greatly contribute

Children particularly vulnerable
(Sala et al 2004)
How To Assess Nutritional Status
 No consensus on how to define malnutrition
 Most common practices plotting weight-height
ratios

Z-scores: more than 2 standard deviations below mean
 Other practices include:

Voluntary food intake less than 70% of estimated requirements

Adipose energy reserves (triceps skinfold thickness) less < 5th
percentile
(Andrassy & Chwals, 1998)
How To Assess Nutritional Status
http://www.medscape.org
How To Assess Nutritional Status
http://www.ltcconline.net/greenl/courses/201/probdist/zScore.htm
Nutritional Needs of Healthy Children
 Normal Children 4-8 years
 Calories:
 Protein:
1600
15 grams
 Calcium:
800 mg
Dietary Reference Intakes (DRIs), AMDR, EER
Nutritional Needs of Children
 Children receiving cancer treatment

Increased calorie needs due to raised metabolic rate

Increased protein needs to prevent wasting
 2g/

per kg of body weight per day
Adequate Calcium and Vitamin D intake essential
 More
than 1,000 mg calcium
 More
then 10 mg vitamin D
 Promote
proper bone growth
(Shawn and Lawson 2007)
What Causes Malnutrition During Childhood
Cancer
 One overall common reason – an inability to
consume or digest food and nutrients

Side effects of chemotherapy and other aggressive treatments

Increased metabolic demands of the cancer
What Causes Malnutrition During Childhood
Cancer
Chemotherapy and Aggressive Treatment
 Kills rapidly dividing cells, including epithelial cells in
digestive tract

Unable to absorb nutrients
 Side effects of chemotherapy





Anorexia
Mucositis – inflammation of mucous membranes lining digestive tract
Vomiting
Diarrhea
Alterations in taste
 Cachexia: wasting syndrome

Loss of weight and atrophy of muscle, resulting in intense fatigue, weakness
(Barr, 2002)
What Causes Malnutrition During Childhood
Cancer
The Type & Stage of Cancer
 The type of cancer also affects nutritional status of
child when based on type, stage, and metastatic
status of disease
(Bauer et al 2011)
What Causes Malnutrition During Childhood
Cancer
The Type & Stage of Cancer
High Risk Factor for
Undernourishment
•Advanced Solid Tumors
- Neuroblastoma
•Aggressive Tumors
•Tumors in late stages of
malignancy
(Bauer et al 2011)
Moderate Risk Factor
for Undernourishment
•Nonmetastatic tumors
•Diagnosis with favorable
prognosis
Side Effects of Malnutrition During Cancer
 Increased treatment time
 Decreased quality of life after survival
 Greater chance of becoming underweight or
overweight
Side Effects of Malnutrition During Cancer
Increased Treatment Time
 Malnutrition reduces effectiveness of chemotherapy

Increases length of time children must spend in hospital
 Malnutrition also increases likelihood of developing
infection
(Bauer et al 2011)
Side Effects of Malnutrition During Cancer
Decreased Quality of Life After Survival
 Lower chances of patients’ survival post-treatment

“Undernourishment has significant role in survival rate
especially in children with solid tumors and metastatic
diseases…”
(Bauer et al 2011)
Side Effects of Malnutrition During Cancer
Becoming Underweight or Overweight
 Specific cancer types more likely to cause a child to
become underweight or overweight later in life if
experience malnutrition during treatment
(Bauer et al 2011)
Side Effects of Malnutrition During Cancer
Becoming Underweight or Overweight
Underweight:
soft tissue sarcoma, neruoblastoma, non-Hodgkin’s lymphoma, brain
tumors, male leukemia patients, non-amputated females with bone
cancer, Wilms tumors, survivors of Hodgkin’s disease
Overweight:
acute lymphoblastic leukemia and those receiving cranial radiation
therapy for brain tumors

Possible Reasons  total body radiation, abdominal radiation, very young age, use of
anthracyclines or actinomycin
(Bauer et al 2011)
Side Effects of Malnutrition During Cancer
Short-Term Consequences
Long-Term Consequences
Wasting of muscle and fat mass
Growth impairment, reduced final height
Decreased tolerance of chemotherapy/
Increased treatment time
Decreased long-term survival
Treatment delays
Retardation of skeletal muscles
Fatigue
Risk for secondary cancers
Drug dose alteration
Abnormal bone mineral density
Greater levels of psychological distress
Decreased quality of life
Higher susceptibility to infections
(Bauer et al 2011)
Nutritional Intervention – During Therapy
 Supplemental (oral feeding)

Best when patient has reduced oral intake but no change in
nutritional status

Be flexible! Studies show flexible menu choice and meal times
increase children’s food, protein, and energy intake (Houlston et al., 2009)
 Enteral (tube feed)

Best when child’s gut still functioning
 Parenteral (intravenously)

Used if child has gut dysfunction >5 days
(Houlston et al., 2009)
Comparing The Three Treatments
 Past research has indicated when normal oral intake not
possible, enteral nutrition has more physiological benefits

Maintenance of height and activity of villi and brush border enzymes

Preservation of specific gut nutrients (glutamine, short-chain fatty acids)

Upholds mucosal membrane

Fewer infections
 However many studies are continuing to show parenteral
nutrition better at correcting and preventing malnutrition
(Braunschweig et al, 2001 and Woodcock et al 2001)
Enteral Compared with Parenteral Nutrition:
Meta Analysis
Carol Braunschweig, Paul Levy, Patricia Sheean, Xin Wang
 Objective:
researchers used results of 27 previous cancerpatients and examined relations among nutrition
intervention methods to complications and
mortality rates in order to determine whether
results supported use of tube feeding instead or
parenteral nutrition
(Braunschweig et al 2001)
Enteral Compared with Parenteral Nutrition:
Meta Analysis
Carol Braunschweig, Paul Levy, Patricia Sheean, Xin Wang
 Results:

27 studies showed lower rate of infection with tube feedings
(enteral nutrition) overall

However, when patients already malnourished,
parenteral nutrition deemed more effective

Tube-feedings associated with significantly higher risk of
mortality and infection
(Braunschweig et al. 2001)
Nutritional Interventions – After Therapy
 Once children have entered remission, nutrition
rehabilitation still may be needed
 Chemotherapy side effects may exist such as:

Diarrhea

Constipation

Sore Mouth

Weight Loss/Poor Appetite

Poor Digestion
 Combat these ailments nutritionally!
Nutritional Interventions – After Therapy
 Study “Dietary Intake after Treatment in Child
Cancer Survivors” assessed dietary intake after
treatment of childhood cancer survivors
 Monitored dietary intake of 50 childhood cancer
survivors

Parents kept 3-day food diary
(Cohen et al 2011)
Nutritional Interventions – After Therapy
 Results: of the 50 Childhood Cancer Survivors

20% overweight or obese

54% consuming above their estimated energy requirements

50% of children did not meet requirements for folate

32% of children did not meet requirements for calcium

44% of children did not meet requirements for iron
(Cohen et al 2011)
Nutritional Interventions – After Therapy
Nutrient Intake of Childhood Cancer Survivors
Meeting requirements for all nutrients except:
Percent not
meeting
requirements
Normal
Children
Folate
50%
2%
Calcium
32%
31.5%
Iron
44%
1%
Nutrient Intake
(Cohen et al 2011)
Nutritional Interventions – After Therapy
 Conclusion and Implication of Study
 Calcium
 Greater
Deficiency:
risk of developing complications related to
osteoporosis
 Children
should consume calcium-rich foods daily
(milk, cheese, yogurt)
 Participate
(Cohen et al 2011)
in weight-bearing exercise
Nutritional Interventions – After Therapy
Conclusion and Implication of Study Continued
 Folate
 Link
Deficiency:
between decreased folic acid and increased risk for
homocysteine accumulation
 Increase
vegetable consumption – especially leafy
green vegetables
 Fortified
(Cohen et al 2011)
foods (fortified cereals, breads, pastas)
Nutritional Interventions – After Therapy
Conclusion and Implication of Study Continued
 Iron
Deficiency
 Iron
deficiency anemia
 Red
meat
 Supplements

another alternative
Hard to meet iron requirements
(Cohen et al 2011)
Take Home Points
 Malnutrition results from chemotherapy and other aggressive
treatments & increased metabolic rates due to type of cancer
 Main side-effects of malnutrition include:

increased treatment time

decreased quality of life after survival

greater chance of becoming underweight or overweight
 Parenteral nutrition best used when child malnourished
 After therapy, folate, calcium, and iron most problematic
nutrients