Transcript Case Study Presentation

The Role of the RD in the
Treatment of Pediatric Acute
Lymphocytic Leukemia
Natalie Navarre, Sodexo Dietetic Intern
Agenda
 Cancer & Leukemia
 Bone Marrow & Lymphatic System
 ALL:
•
Diagnostic techniques
•
Treatments
•
Side effects
•
Common Medications
 Medical Nutrition Therapy: ADIME
 Presentation of case study patient
One in
300 Boys
One in
333 Girls
13,400
Children
Annually
Cancer & Leukemia
 Cancer: Abnormal cell proliferation and growth
 Malignant vs. Healthy cells
•
Containing damaged DNA
•
Invasion of tissues and organs
 Leukemia: Cancer of the blood and bone marrow
•
Sub-types: ALL, CLL, AML, CML
•
Rapid invasion of the blood, tissues, and organs
Cancer Incidence Statistics
Blood Cell Differentiation
Lymphatic System
B-Cells
 Proper immune
function
 T-cells & B-cells
reside in lymph
nodes
 Filters lymph of
toxins, dead cells,
debris, infectious
organisms
T-Cells
Acute Lymphocytic Leukemia (ALL)
 Most common form of childhood leukemia
 White blood cells  only affects lymphocytes
•
Includes T-lymphocytes and B-lymphocytes
 Acquired genetic injury to a single cell in the
marrow
•
Presence of damaged DNA leads to over
production of lymphoblasts
 Poor immune function
•
Immature and abnormal lymphoblasts not able to fight infection
 Rapid influx of leukemic blasts  Decreased healthy blood
cells
Etiology & Risk Factors
 NO KNOWN ETIOLOGY!
 Risk factors of ALL:
•
Genetic risk factors
•
Lifestyle risk factors
•
Environmental risk factors
Signs & Symptoms
Sign/Symptom
Possible Reasoning
Fatigue/pale skin
-Anemia (low red blood cells)
Infections and fevers
-Increased immature WBCs
Headache, seizures, vomiting
-Migration of leukemia cells into CNS
Easy bleeding or bruising
-Lack of blood platelets
Bone or joint pain
-Result of bone marrow being too “full”
Loss of appetite/Weight loss,
Abdominal Pain
-Spleen and/or liver enlargement – pushing
against stomach
Swollen lymph nodes
-Collection of lymphoblasts in lymph nodes
Dyspnea
-Migration of leukemia cells to middle of chest
Common Lab Values
 CBC 
lab values
•
White blood cell
count 
•
Red blood cell
count 
•
Platelets 
•
Hemoglobin 
•
Hematocrit 
 WBC value on CBC
determines risk
groups
•
Low/Standard Risk: 110yrs old +
less
than 50,000mm3
•
High Risk: Less than
1yr or older than
10yrs + WBC greater
than 50,000mm3
Diagnosing ALL
 CBC & blood smear
 Bone marrow biopsy & aspiration
 Lumbar puncture – cerebrospinal fluid
Healthy Lymphocytes
 Flow cytometry – type of leukemia
 Cytogenic analysis – presence of
genetic abnormalities
•
ALL Lymphoblast Cells
May help determine prognosis
Tr e a t m e n t s
Chemotherapy
Total Body
Radiation
Bone Marrow
Transplant
• 1) Induction – goal to achieve remission
• 2) Consolidation – lingering leukemia
cells
• 3) Maintenance
• High energy radiation  targets
and destroys cancerous cells
• Infusion of healthy blood stem
cells into the bone marrow
• High risk ALL and relapsed ALL
Bone Marrow Transplant
PRE-Bone Marrow Transplant: 4-10 days
•High-dose chemotherapy + Total body radiation
•Destroys blood forming cells in bone marrow & leukemia cells
•Purpose make room for new, healthy cells and destroy immune system
POST-Bone Marrow Transplant: Days +0 to +30
•Signs of engraftment – Days 10-20 usually
•ANC >500mm3 x 3 days
•Platelets 20,000-30,000 per microliter
•Pancytopenia – high risk for infection
POST-Bone Marrow Transplant: Days +31 to +100
•Increased risk for complications up to day +100
•Blood cell counts increase and immune system gets stronger
Side Effects of Treatment
Chemotherapy
Total Body
Radiation
Bone Marrow
Transplant
• Nausea, vomiting, diarrhea, constipation
• Mucositis, decreased appetite
• Jaw pain, alopecia, fatigue, elevated glucose
and triglycerides, hepatic insufficiency
• Nausea, vomiting, diarrhea
• Mucositis, dysphagia, altered taste/smell
• Malabsorption, ↓saliva production,
fluid/electrolyte imbalances
• Poor intake  need for nutrition support
• Mucositis, diarrhea, vomiting, low blood counts
• C.Difficile – common
• Immunosuppression – viral, fungal, bacterial
• Exacerabtion of side effects
Graft vs. Host Disease (GVHD)
 Donor stem cells reject recipients body
 Increased risk with allogeneic
transplants
 Acute GVHD  within first +100
days
•
Abdominal pain, N/V/D, jaundice,
skin rash
GVHD – stage I
 Chronic GVHD  after first +100 days
•
Dry mouth, dry eyes, chronic pain, weight loss, muscle weakness
 Prevention: prophylaxis and immunosuppressive drugs
 Treatment: steroids and immunosuppressive drugs
Common Medications
 Motility agents  gastroparesis, GERD, feeding intolerances
 Proton Pump Inhibitors  ulcers, GERD
 Anti-Emetics  nausea and vomiting
 Medicated mouth wash  mucositis
 Chemotherapeutic Agents  methorexate, cisplatin, PEGAsparaginase
 Immunosuppressive Agents  prevent transplant rejection
 Prophylactic Agents  prevention medications; GVHD,
infections
Emerging Research
 Children’s Oncology Group (COG) and National Cancer
Institute (NCI)
 Targeted chemotherapy and high-dose chemotherapy
 COG-AALL1131: combination chemotherapy with different
dosages and combinations
 COG-ACCL0934: giving specific antibiotics post-transplant
prophylactically to prevent infection
 Survival Rates are INCREASING!
•
1976-2006 increased from 41%-67%
•
Currently more than 85%
5 year survival rate!!!
Nutritional Management of Pediatric
Acute Lymphocytic Leukemia
Role of the RD
 MAIN GOALS:
•
Identify malnutrition & growth failure
o Direct correlation between malnutrition and intensified
treatment regimens
o Cancer cachexia
•
Manage nutrition related side effects
•
Ensure meeting 100% of needs PO,
enterally, or parenterally
•
Improve patients nutritional status
through interventions
Nutrition Screening
 Screening criteria for oncology patients at nutritional
risk:
•
Total weight loss greater than 5% over past month
•
Under 10th or over 90th %ile for wt. for age & wt. for ht.
•
Height < 10th %ile
•
Weight < 90% of IBW
•
TSF < 10th %ile, MAMC < 5th %ile
•
BMI < 5th or >85th %ile
•
Consuming less than 80% of needs
Assessment

Medical History

Anthropometric
Data
Medical, Surgical,
Medication History
-Past Procedures or
diagnoses that may impact
nutrition status
-Medications that alter
absorption of nutrients,
cause GI upset

Physical
Observations

Ins & Outs

Dietary History
Anthropometric
Data
-Track weight trends and
growth velocity
-% wt loss from UBW and %
IBW
-< 10%ile  growth
impairment, inadequate
nutrition
-Fluid shifts

Biochemical Data

Nutrient
Requirements
Physical
Observations
-Signs of Wasting
-Edematous
-Dry skin, chapped lips
-Wound healing
-Pale, fatigued
-Level of Pain
-Frame size

Assessment: Biochemical
Data
Vitamin D & Calcium:
•
Transplants patients – steroids & TBI alter bone metabolism
•
Decreased absorption of Calcium and associated with low vitamin D
 Vitamin K: measured with Prothrombin time
•
Multiple antibiotics  decreased absorption
 Zinc: low levels related to diarrhea
 Electrolytes: fluid retention, third spacing, increased excretion
 Hyperglycemia & Hypertrygliceredemia
 LFTs
Assessment: Nutrient
Requirements
 No specific nutrition
 Children > 1 year
protocols for pediatric
oncology
•
 Goals of nutrient
Basal Metabolic
Rate (BMR) x Stress
Factor
requirements:
1) Promote growth, prevent
catabolism
 Children < 1 year
•
2) Identify/Prevent proteinenergy malnutrition
3) Continuous re-evaluation

Estimated Energy
Requirement
Equations can be found
on last page of packet!
BMT Nutrient Needs
AGE
CALORIES
0-12 mo
BMR* x 1.6-1.8
1-6 yrs
BMR x 1.6-1.8
7-10 yrs
BMR x 1.4-1.6
2.5-3
gm/kg/day
2.4 gm/kg/day
11-14 yrs
BMR x 1.4-1.6
2 gm/kg/day
15-18 yrs
BMR x 1.5-1.6
1.8 gm/kg/day
> 19 yrs
BEE** x 1.5
1.5 gm/kg/day
PROTEIN
(g/kg/d)
3 gm/kg/day
Source: The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010.
Diagnosis
P roblem
• Inadequate oral intake
• Malnutrition
• Inadequate protein-energy
intake
• Predicted suboptimal intake
E tiology
• Side effects of treatments
• Treatments
• Side effects of diagnosis
Signs/
Symptoms
• Intake less than x% of needs
• Stool output
• Dietary history
• Weight loss
Example PES Statements
 (P) Inadequate oral intake related to
(E) decreased appetite as evidenced by
(S) oral intake meeting only 25% of estimated needs.
 (P) Atered gastrointestinal function related to
(E) radiation therapy as evidenced by
(S) stool output exceeding 2,000mL/day
Interventions
 Purpose & Goals:
•
Manage treatment related side effects
•
Prevent weight loss and malnutrition
•
Preserve lean body mass
 Common side effects requiring intervention:
•
Nausea/Vomiting
•
Diarrhea
•
Neutropenia
•
Mucositis
•
Loss of appetite
•
Nutrition Support
•
Changes in taste
•
Triglycerides
Nausea/Vomiting
 Cytotoxic effect on CNS
 Complications: weight
loss, dehydration,
electrolyte imbalance,
food aversions
 Interventions
•
Anti-emetics
•
Avoid high fat, high sugar
food/drinks
•
Small, frequent feedings
Food Aversions
 Association of food with
unpleasant internal
response
 Interventions:
•
Avoid favorite foods
before treatments
•
‘Scapegoat’ – prevent
changes from normal
eating pattern
Taste Changes

Alteration of taste buds

Metallic, chemical, or burnt
taste in mouth

Increased/Decreased
sensitivity to bitter, salty,
sweet

Interventions:
•
Bitter/Metallic  add sugar,
vinegar, citrus juice
•
Sweet
•
Add spices/seasonings
•
Trial different temperatures
•
Aromatic foods
add salt or water
Mucositis
 Inflammation and
breakdown of oral
mucosa
 Severely inhibits oral
intake &  quality of
life
 Interventions
•
Soft, pureed foods
•
Avoiding spicy/salty foods
•
Enteral/Parenteral
nutrition
Diarrhea



May decrease appetite &
inhibit intake
Dehydration, electrolyte
imbalances, malabsorption,
altered GI motility
Interventions:
•
Low-fat, low-lactose diet
•
Avoiding caffeine, high
sugar, high osmolality
beverages
•
Provide education
•
Increase fiber intake
•
Change formula
 Triglycerides
 Medication side effect
 Monitor weekly
 Interventions:
 Omega-3 Fish oil
supplement 
Coromega
GVHD


Most commonly affected in
acute GVHD: skin, gut, liver
May lead to mucosal
breakdown, malabsorption,
protein catabolism

May require bowel rest & PN

Interventions:
•
Guide food intake
progression back to regular
diet
•
Bowel rest (TPN)  Oral
feeding  Solids  Expand
diet  Resume regular diet
•
Wean TPN when PO meets
50% of needs
Neutropenia
 Compromised immune
system  high risk for
infection
 Neutropenic diet first 100
days post-transplant
 Intervnetions:
•
Neutropenic diet
education
•
Safe food handling
•
Safe eating techniques
Loss of Appetite/Early Satiety
 Culmination of side effects & treatment
 Interventions:
• Small frequent meals
• Liquid oral supplements
between treatment
• Calorie count
• Appetite Stimulant
Appetite
Method of Action
•
Providing
favorite
foods
Stimulant
Megace
-Progesterone: increases appetite, causes weight gain
Marinol
-Cannabinoids class: Affects area of brain that
controls nausea, vomiting, and appetite
Periactin
-Antihistamine: side effect of increased appetite
 High calorie,
high protein
foods
 Oral
supplements
(caution High
osmolality)
 Difficult to
meet 100% of
needs
 Indications:
mucositis, intake
<80% x 3-5 days
 Shown to
reverse
malnutrition
 Formula:
-patient’s age
-GI function
-formula
composition
-cost/insurance
Semielemental &
elemental
formulas
common
3. PARENTERAL NUTRITION
 Promotes
normalized
feeding
2. ENTERAL NUTRITION
1. ORAL NUTRITION
Nutrition Support
Failure to
meet needs with
EN and orally
Increased risk
for infection –
NOT
recommended
during chemo
TPN via
central line
Complications:
-gut atrophy
-infections
-cholestasis
Enteral & Parenteral Nutrition
 Enteral Nutrition:
•
Start at 10cc, increase
10cc every 8 hours
to goal
•
Trophic feeds of 3-5cc/hour
for gut integrity
 Total Parenteral Nutrition:
•
D: start 5-6mg/kg/min
advance by 1-2mg/kg/min
every 24hr to max
15mg/kg/min
•
AA: Start at DRI
•
IL: 20-60% kcals
 Post-Bone Marrow Transplant:
•
Combination of EN and PN  acceptable and costeffective option
•
Candidates: reduced-intensity conditioning regimens,
anticipated mucositis, poor nutritional status prior to
transplant
Monitoring & Evaluation
 Meeting 100% of estimated needs for growth &
development
 Growth chart trends
 Intake/Output
 Management of nutrition related side effects
•
Prevent malnutrition
•
Weight maintenance
•
Route of nutrition support adjusted as needed
Case Study Patient
J.B. – 13 year old male - Relapsed ALL
History & Recent Admissions
February, 2008
• Initial admitting
Dx: septic shock
-N/V on admit
•Bone marrow
aspiration and flow
cytometry  Dx
ALL with AML1
gene amplification
•Tx Plan: COG
AALL0331
July, 2012
August, 2012
•Oncology f/u
•Treatment finished
July, 2011
-ALL in remission
•Outpatient weight
mgnt clinic
•Bone scan 
Osteopenia
•Learned food
aversions since
chemo
•Wt: 66.8kg
•Ht: 166.2cm
•Primary focus:
food aversions
History & Recent Admissions
November 18, 2012: BMT prep
9/10-9/21/2012
•Presenting with
headache
•Relapsed ALL
9/30-10/12/2012
•Presenting with
mucositis related
to chemotherapy
10/23-10/23/2012
•Chemotherapy –
induction 3 per
AALL1131
•Admitted for BMT prep – TBI
•Completed induction phase 3 per AALL1131
 increased fatigue, decreased PO intake
•Day -12 to Day +0:
-Cranial radiation, TBI, Chemotherapy,
Imunnosuppressive agent
•Medications: Anti-emetics, PPI, Swish &
Swallow, Anti-depressant, BP 2/2 to meds
•Diet Order: Regular Diet
•Seen by nutrition day -7  nutritional status
intact – expect decline with therapy regimen
11/26/12:
Initial Nutrition Assessment
•Diagnosis:
intakeALL •Medications:
• Monitoring/Evaluation:
•J.B.
– 13y.o.Inadequate
male withoral
relapsed
prophylaxis, antibiotics,
related tofor
chemotherapy
evidenced
1. Monitor tube
feeding
tolerance
admitted
TBI/chemo inasprep
for anti-emetics,
Swish
& swallow,
antiby patient
report of no appetite today depressant,
post-transplant
– goal
BMT
(Day +0)
pain meds,
BPto tolerate
and not eating anything yet today.
feeds and reach goal rate 100cc/hr
•Active problems: Osteopenia, food
•Estimated Requirements:
•Intervention:
2. Monitor
goalx of
weight
aversions,
overweight, relapsed ALL, 2320
caloriesweight
(WHO –REE
1.3nostress
1) Continue
and D
loss greater than 2% in one week
mucositis
2/2 regular
chemo,diet
vitamin
factor)
encourage PO intake
deficiency
97-130 gm protein (1.5-2 gm
2) Start enteral feeds Day +1 of:
protein/kg)
Peptamen
Jr. PreBio
– start at 10cc 2400 ml fluid normal maintenance
•Height:
11/18/12:
165 cm
and increase 10cc every 8 hours to (needs based on weight at admission of
(64.29%ile)
goal of
100cc/hr64.8 kg
•Weight:
11/26/12:
65kg)
--Add 2 –pkts
Beneprotein
by day 3
(89.06%ile)
127%
IBW
of feeds
•Diet: Regular diet
--To provide
2450kcal,
84 gm labs,
•Biochemical:
low
hematological
low protein
Mg, ALT and GGT, fibrinogen
•Medical Course: (+) C. Difficile,
and PTT
asymptomatic HTN 2/2 to medications,
• Food/Nutrient Delivery:
10/10 allogeneic BMT scheduled for
PO Pre-BMT; PO + NGT day +1
today
11/29/12:
Nutrition Follow-Up
•Diagnosis:
Inadequate
oral intake
•Height:
11/18/12:
165 cm
related to chemotherapy/stem cell
(64.29%ile)
transplant as evidenced
by PO intake
•Weight:11/28/12:
63.9 kg
of less than
25% of 64.8
estimated
needs.
11/26/12:
kg
(87.8%ile) – 125% IBW
•Intervention:
1) Continue regular
diet andlabs still
•Biochemical:
hematological
intake
as and
desired
low,encourage
Mg remainsPO
low,
ALP
GGT,
2) TPN
to meet 100%
of needs 
–
IgG,
consistently
 albumin,
2400ml, D19%, AA5.3%, IL0%
Triglycerides
2058kcal, 127gm protein, 4.9mg
CHO/kg/min
•Medications:
prophylaxis meds,
antibiotics, anti-emetics, Swish &
• Food/Nutrient
Delivery:
swallow,
anti-depressant,
pain meds,
PO ad neupogen,
lib + TPN additional
BP +IVIG,
antibiotics
• Monitoring/Evaluation:
1. Monitor Requirements:
tube feeding tolerance
•Estimated
post-transplant
Remained
the same– goal to tolerate
feeds and reach goal rate 100cc/hr
– not
met, diet
discontinued for now.
•Diet:
Regular
-Peptamen Jr. PreBio at 3cc/hr
2. Monitor weight – goal of no weight
loss greater
•Medical
Course:than
DAY2%
+3 in one week –
met, ongoing
-Presenting
with rash on face, back,
and arms
3. Monitor TPN
– goal to receive 100%
-Transfusions:
IVIG
of estimated
-C.diff
negative needs from TPN
12/04/12:
Nutrition Follow-Up #2
•Diagnosis: Altered GI function related • Monitoring/Evaluation:
•Height: 11/18/12: 165 cm
to TBI and Cranial Radiation as
1. Monitor TPN – meeting goal rate and
(64.29%ile)
•Estimated Requirements:
evidenced by 7 days of loose stools and
100% of needs – met
•Weight:12/04/12: 69.5 kg
PO&EN: 2320 calories
TPN dependence.
11/28/12: 63.9 kg
LESS 10% for TPN = 2070kcal
1. Monitor weight – goal of no weight
(93.6%ile) – 136% IBW
•Intervention:
loss greater than 2% in one week –
•Diet: Regular diet
1) Continue TPN at maintenance until
met, ongoing
•Biochemical: hematological labs still •PN: 2400ml – D19% (456gm, 1550kcal),
PO intake improves and diarrhea is
low, Mg remains low, ALP and GGT, AA5.3% (2gm/kg, 508kcal). TV=
resolved – meeting 100% of needs 2. Monitor Intake – goal to improve
consistently  albumin, 
2058kcal 127gm protein,
from TPN
intake as able
Triglycerides, BUN, Na and Cl,
4.9mgCHO/kg/min. *IL held due to high
2) Encourage PO intake as able
 K,  zinc
triglycerides
3) Lower CHO containing beverages to
help control diarrhea. Spoke with
•Medications: prophylaxis meds,
•Medical Course: DAY +8
mom about foods to avoid with
antibiotics, anti-emetics, Swish &
-rash improving – unknown etiology
diarrhea
swallow, anti-depressant, pain meds, - Triglycerides – unknown etiology
BP, IVIG, neupogen, additional
-platelet transfusion
• Food/Nutrient Delivery:
antibiotics
PO ad lib + TPN
12/11/12:
Nutrition Follow-Up #3
•Diagnosis:
Inadequate
oral
•Height: 11/18/12:
165
cmintake
related
to mucositis secondary to
(64.29%ile)
chemotherapy
as evidenced
•Weight:12/11/12:
74.8 kgby
receiving 100%
of needs
from
12/06/12:
70.2
kg TPN.
PO ad lib +Requirements:
TPN + NG Trophic feeds
•Estimated
of Peptamen
Jr. PreBio
PO+EN:
2320 calories
LESS 10% for TPN = 2070kcal
• Monitoring/Evaluation:
1.•Diet:
Monitor
ability
to transition to NGT
(96.56%ile) – 146% IBW
Regular
diet
Obesity related to fluid retention and
feeds
– goal– to
tolerate
without
•PN:
2400ml
D19%
(456gm,
1550kcal),
steroids
as evidenced
by BMI/age
nausea,
vomiting,
diarrhea
•Biochemical:
hematological
labs still AA5.3%
(2gm/kg,
508kcal).
TV=
th
above
theremains
95 percentile
– however
in
low, Mg
low, ALP
and GGT,
2058kcal 127gm protein,
view of diagnosis, not addressed at present. 2. Monitor fish oil effects on
consistently  albumin, 
4.9mgCHO/kg/min. *IL held due to high
triglycerides – goal to decrease
Triglycerides,  zinc, PTT
triglycerides
•Intervention:
triglyceride level
1)•Medications:
Continue maintenance
prophylaxisTPN
meds,
•Medical Course: DAY +15
2)antibiotics,
Start trophic
NG
feeds
of
2.-Changing
Monitor weight
anti-emetics, Swish &
nature –ofgoal
rashof– no
signweight
of
Peptamen
Jr. PreBio at 3cc/hr
loss greater than 2% in one week –
swallow,
anti-depressant,
pain meds, engraftment
24 hrs
– monitor
tolerance.
met, ongoing
BP,for
IVIG,
neupogen,
additional
-platelet
transfusion
3)antibiotics,
If tolerating
NG feeds x 24 hrs
–
+methotrexate,
lasix
-Hypertriglyceredemia – normal lipid
increase to 5cc/hr for next 24 hours panel – 2/2 to medications
•
Food/Nutrient Delivery:
Lab Trends: 11/25/12 - 12/10/12
Basename
12/10/12
WBC (K/UL)
0.1 
<0.1 
<0.1 
0.1 
0.1 
0.4 
HGB (g/dL)
8.8 
7.4 
9.6 
8.1 
9.4 
10.4 
PLT (K/UL)
11 
19 
33 
19 
116 
162
NEUTS (%)
0

0
7
1
60
LYMPHS (%)
Mg (mg/dL)
ALP (u/L)
2
1.7
41 
100 
1.4 
45 
--1.4 
50 
2
1.4 
69 
2
1.4 
64 
36
1.5 
67 
GGT (u/L)
93 
110 
110 
154 
160 
179 
Albumin
(gm/dL)
Triglycerides
(mg/dL)
2.4 
2.4 
2.7 
2.7 
2.8 
3.0 
305 
435, 554 
on 12/5
552 
401 
Zinc
(mcg/mL)
12/07/2012 12/04/2012 11/29/2012 11/26/2012 11/25/2012
0
0.44mcg/mL

on 12/1
Continuation of JB’s Hospital Course
 December & January Inpatient:
•
Acute Grade 2 GVHD  rash > 50% of body + average 500-1000cc
diarrhea/day  started on high dose steroids

12/18/12: Concern for EFAD due to ~3 weeks TPN without lipids and
minimal lipids in diet

12/20/12: Appetite stimulant started – Megace

Discharged home on 12/31/12
 Most recently seen by nutrition on 2/18/13:
•
•
•
Reverted back to food aversions – only eating chicken nuggets, macaroni and
cheese, and grilled cheese
Goal to try two new foods a week
Will be seen weekly by AIDHC nutrition
Date
11/30/12
12/4/12
Coromega:
15gm lipid
12/7/12
12/11/12
12/12/12
12/18/12
12/20/12
EN Regimen
PN Regimen
Discontinued
D19, AA5.3, IL0
=>2058kcal, 127gm protein,
4.9 GIR -- Maintenance
Discontinued
Maintenance TPN
D19, AA5.3, IL0
100% of needs
Discontinued
Maintenance TPN
D19, AA5.3, IL0
100% of needs
Peptamen Jr. PreBio 3cc/hr Maintenance TPN
D19, AA5.3, IL0
100% of needs
Increased to 5cc/hr
D17, AA1.8gm/kg, IL0 =>
~90% of needs
Increased to 10cc/hr
D17, AA1.8gm/kg, IL0 =>
~90% of needs
10cc/hr
D17, AA1.8gm/kg, IL0 =>
~90% of needs
1/2/13
Discontinued
Providing 700-900kcal (~40%
of needs) -Continue weaning
1/6/13
Discontinued
1/7/13
Discontinued
900ml overnight => 664kcal,
36gm pro -- (~32% of needs)
Discontinued
PO Intake
Nothing
-Poor
-Some cheese puffs
and Gatorade
-Poor
-Slushies, Gatorade
-Minimal intake
-Minimal intake
-Some cheese curls,
crackers, and gatorade
-Trialing Boost
supplements
-Megace started
-Dry cereal, bowtie
pasta, soft pretzel,
24oz fluids
-Appx 1,000kcal
-Improving with
appetite stimulant
100% of needs from PO
intake
Critical Comments
 Current research in line with interventions
 Hospital protocol – allowed for early intervention
 Anthropometrics:
• Consider TSF and MAMC to get better assessment of dry
weight
 Nutrition Counseling – developing relationship with
patient; interaction with mom
Key Points
 Meet 100% of patients estimated needs
•
•
Prevent malnutrition
Promote growth and development
 Anticipate side effects – intervene early
 Manage side effects associated with treatment
 Promote quality of life to best of our ability
A very special Thank You to
Michell Fullmer, the pediatric
oncology dietitian at AIDHC, for
her guidance and support through
this case study!
& Thank you to ALL of
the dietitians at AIDHC
for your endless
support!
Questions?
References
•
•
•
•
•
•
•
•
•
•
Survival Rates for Childhood Leukemia. American Cancer Society Web site.
http://www.cancer.org/cancer/leukemiainchildren/overviewguide/childhood-leukemia-overviewsurvival-rates. January 21, 2013. Accessed February 28, 2013.
Be The Match: Parents and Families. National Marrow Donor Program Web site.
http://marrow.org/Patient/Patients_and_Families.aspx. 2013. Accessed February 28, 2013.
Cancer Facts and Figures 2012. American Cancer Society Web site.
http://www.acco.org/LinkClick.aspx?fileticket=EcECXIUZyeA%3d&tabid=670. 2012. Accessed February
25, 2013.
Childhood Leukemia. American Cancer Society Web site.
http://www.cancer.org/acs/groups/cid/documents/webcontent/003095-pdf.pdf. January 18, 2013.
Accessed January 20, 2013.
Acute Lymphoblastic Leukemia. Leukemia and Lymphoma Society Web site.
http://www.lls.org/content/nationalcontent/resourcecenter/freeeducationmaterials/leukemia/pdf/all.
pdf. Accessed December 28, 2012.
General Information About Childhood Acute Lymphoblastic Leukemia. National Cancer Institute Web site.
http://www.cancer.gov/cancertopics/pdq/treatment/childALL/Patient
/page1. Accessed January 3, 2013.
Acute Lymphoblastic Leukemia. Boston Children’s Hospital Web site.
http://www.childrenshospital.org/az/Site759/mainpageS759P0.html. Accessed December 28, 2012.
Childhood Acute Lymphoblastic Leukemia. Children’s Hospital Cleveland Clinic Web site.
http://my.clevelandclinic.org/childrens-hospital/health-info/diseases-conditions/cancer/hic-childhoodacute-lymphoblastic-leukemia.aspx. Accessed January 3, 2013.
Selected Normal Pediatric Laboratory Values. Prentice Hall Web site.
http://wps.prenhall.com/wps/media/objects/354/362846/London%20App.%20B.pdf. Accessed January
31, 2013.
Sacks N, Wallace E, Desai S, et al. Oncology, Hematopoietic Transplant, and Survivorship. A.S.P.E.N.
2010: 349-373.