Nutritional Support of the Child With Cancer Mary Jo Hanigan, RN, MN, OCN

and

Georgia A. Walter, RD, MPH

The purpose of this article is to outline how the disease, treatment, and psychological state of a child with cancer impact on the child’s nutritional status. The methods of assessing nutritional status, including anthropometric measurements, laboratory indices, clinical observation, dietary assessment, and psychosocial evaluation, are summarized. After nutrition assessment, the pediatric oncology nurse and the dietitian, along with the oncologist, the family, and the child, develop a plan of care. The specific roles of the pediatric oncology nurse and dietitian in the nutrition intervention are described. © 1992 by Association of Pediatric Oncology Nurses.

NUTRfTIONAL going of i

SUPPORT of is

ponent

a

child under-

therapy integral comprehensive pediatric oncology cancer

an

com-

care. 1,6 Pediatric oncology nurses and pediatric

oncology

dietitians

involved in the preven-

are

tion, assessment, and early intervention of nutritional complications in this group of patients. The nursing process can be used to organize and manage nutritional support for the child with

cancer.

The

goals

of

pediatric nutritional

support are to prevent or reverse nutritional deficits, promote normal growth and development,

morbidity and mortality, and maximize quality of life. 7

minimize

the

_

The Effect of Disease

on

Nutrition

Unlike adults with cancer, children diagnosed with malignancy rarely present with malnutrition. If it does occur, the cause is usually not protein energy malnutrition (PEM) but rather caloric deficiency.8 Malnutrition in children with cancer is most often associated with tumor progression and treatment toxicity.8 The metabolic effects of From Pediatric HematologylOncology ϵ BMT, and Department of Food and Nutritional Services, University of Nebraska Medical Center, Omaha, NE. Address reprint requests to Mary Jo Hanigan, RN, MN, OCN, Pediatric Hematology/Oncology ϵ BMT, University of Nebraska Medical Center, 600 S 42nd St, Omaha, NE

68198-2165. © 1992 by Association by Pediatric Oncology Nurses.

1043-454219210903-0002$03.OO10

malignancy on

nutrition vary according to type and stage of disease, host factors, and tumorto-patient growth dynamics. Cachexia is often documented and is manifested by changes in energy, glucose, fat, and protein metabolism. 9 It has been postulated that malignant proincrease energy expenditure, resulting in increase in negative energy balance and pro-

cesses an

gressive weight loss.9 Resting metabolic expenmagnitude of weight loss in patients

diture and

cancer have been shown to be strongly correlated. 1 0,11 The hypermetabolism and concomitant increased caloric expenditure of patients with cancer, especially those with progres-

with

or advanced disease, are the hallmarks of the cancer cachexia syndrome. The syndrome is characterized clinically by anorexia, muscle wasting, loss of body fat, weight loss, weakness, hypoproteinemia, anemia, electrolyte disturbances, and hormonal dysfunctions. It is important to note that controversy exists about whether cancer cachexia is related to a hypercatabolic state or decreased nutrient intake. In either case, the pediatric patient is developmentally at significant risk for malnutrition and/or cachexia because of increased metabolic rate. 6 Certain cancers release mediators, such as hormones, peptides, kinins, and prostaglandins, that alter host metabolism and promote malnutrition.12 Locally invading solid tumors can impinge on structural and physiological processes,

sive

110

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111

causing fluid and electrolyte disturbances, hy-

The Effect of

Therapy on Nutrition

poalbuminemia, anemia, and abnormalities in mineral deposition. 13 Patients who have cancer experience increased gluconeogenesis, especially in the liver, which contributes to lactate release.9 Lactic acidosis ensues, causing muscle wasting of protein. Glucose tolerance can become impaired and may be related to defects of insulin metabholism.14 The mechanism by which this occurs is under investigation. The oxidation of glucose can be decreased in the patient who has cancer and is probably caused by a disruption of the regulatory enzyme process. 15 On the other hand, fat oxidation is significantly increased in patients with cancer and may be consequential to other changes in the body’s metabolic pathways.9 Hyperlipidemia and increased triglyceride mobilization have been reported. 16 Abnormalities in protein metabolism cause significant morbidity in children with cancer. Negative nitrogen balance is prevalent and may be directly attributed to the pathogenesis of the

tumor.9 Hypoproteinemia is a common finding, especially in those children receiving high-dose, multimodality therapy. The probable cause is decreased albumin synthesis.&dquo; Interestingly, hypoproteinemia often occurs in the presence of normal anthropometric indices, such as weight and height, skinfold measurements, and muscle mass, leading to the hypothesis that it mqy be more reflective of response to the acute metabolic responses of fever and infection in patients with cancer rather than to depletion of body

mass.’8

Chemotherapeutic regimens undoubtedly employ agent(s) that have nausea and vomiting as a common toxicity. Some agents are more emetic than others. The incidence of nausea is as high as 70% for patients receiving certain chemotherapeutic agents In children already at risk for nutritional compromise, nausea and vomiting can promote other deleterious compli. cations such as metabolic imbalances, dehydra-

tion, anorexia, stomatitis, and depression. Clinical research continues to be directed at

seeking relationships between administration of antineoplastics and the onset and severity of nausea and vomiting as well as regimens to improve antiemetic control in children. 24-29 Alnew advances in serotonin antagonists have been promising, no completely effective antiemetic regimen has been found, nor have the exact mechanisms causing nausea and vomiting been elucidated. Considerations in selecting antiemetic therapy include the emetogenic potentiaLof each chemotherapeutic agent, expected time for onset of emesis, relative efficacy of the antiemetic, site of action, and potential side effects 3° Problems of emetic control in children include the predisposition to dystonic reactions in younger children, daily prophylaxis to those receiving consecutive daily therapy, anticipatory emesis, and delayed emesis?2 In addition to the emetic effects of chemo-

though

Nonetheless, PEM,

syndrome of nutritional by hypoproteinemia and a complication of cancer a

abnormalities heralded

protein depletion,

Chemotherapy is documented as a main contributor to treatment-related nutritional compromise in patients with cancer.17,19-21 Antineoplastic agents cause anorexia, nausea, vomiting, and stomatitis, and they have been associated with changes in taste and smell. Problems such as uncontrolled vomiting or painful mucositis can alter nutrient intake for an extended period of time and establish poor eating behavior. Learned food aversions induced by the association of food with the unpleasant side effects of the disease and/or treatment occur frequently and can be strong. 22 It may be difficult for young children to differentiate the conceptual relationships between disease, treatment, and side effects, further compromising their willingness to maintain nutrient intake in spite of short-term effects.

is

that increases metabolic and caloric demands in patients unable to meet these demands. 5 Children with PEM have decreased or inadequate anthropometric indices, impaired immunity, and subnormal biochemical levels of albumin, prealbumin, fibronectin, and other protein-specific components. They also experience muscle wasting. PEM is not the sole cause of cachexia and malnutrition in patients with cancer, but it is one that is insidious and can easily exacerbate other clinical problems.

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112

such as of essential vitamins, purines, and prymidines in both healthy and malignant cells. 17 Other antineoplastics, such as cisplatinum, induce renal tubular dam-

therapy,

certain

antineoplastic agents

the antimetabolites inhibit

use

hypocalcemia, hypomagnesemia, and hypophosphatemia. Some exhibit specific alterations in nutrient meagents age

or cause

hypokalemia, tabolism

as

is the

case

with methotrexate, which

causes folate deficiency. Biologic response modifiers have been associated with severe diarrhea, anorexia, taste alteration, nausea, and ’

stomatitis 31 Radiation therapy causes cell death by damthe DNA of all cells with which it comes into contact, healthy as well as cancerous. The extent and severity of its damage depends on the site of administration, total dose administered, and duration of treatment Radiation neu-

aging

ritis, esophagitis, and enteritis complicate nutriintake and absorption. Potential adverse nutritional effects can occur after radiation to the head and neck region, the thorax, and the abdomen.32 Side effects of radiation that specifically alter nutrient intake and absorption are ent

vomiting, lethargy, somnolence, taste alteration, mucositis, dysosmia, xerostomia, dysphagia, ulcerations, diarrhea, pain, and depression. The effects can emerge acutely or present weeks to months after therapy, causing chronic problems. Although poor nutritional status can not be directly correlated to infectious processes, poor nutrition is associated with impaired immunity, both B-cell and T-cell function 5 Chemotherapy and radiation therapy impair bone marrow function and lead to immunosuppression of patients, nausea,

which is often more severe in the presence of malnutrition. Finally, patients with indwelling central venous access have an increased risk for infection, especially while receiving total parenteral nutrition (TPN).33

The Effect of on Nutrition

Psychological State

Like adults, children diagnosed with cancer adapt in a wide myriad of behaviors that are individualized for each particular patient’s normal method of coping. Regardless of the developmental age, the child with cancer is able to express negative feelings such as fear, react and

insecurity, anger, confusion, withdrawal, hopelessness, and apathy. The child may use eating and/or drinking as a bargaining tool or mechanism by which to gain control from adults. The anorexia of children with cancer is multifactorial and appears to be partly psychologically related 9’22,34 lf depressed or somnolent, children, like adults, may lose interest in the social pleasures of eating, especially if eating evokes nausea or pain. Many children are confused and frightened by the hospital experience and refuse to eat or drink food not prepared by their primary caregiver. To further complicate the many psychological variables that can affect the nutritional intake of patients with cancer, superimposed, extrinsic psychological factors can have a significant impact on the family. For instance, parents may feel guilty about the diagnosis of cancer in their children and frequently anguish about their own responsibility in the causation of the disease. Some may even speculate that food they included in or restricted from the child’s diet caused the cancer (K. Ruccione, personal communication, March 13, 19991). Parents may project this guilt on themselves and/or feel blame from the child’s grandparents, extended family, or friends. Young children, who are sensitive to the anxieties and stresses of their parents, can internalize their parents’ negative feelings about eating and drinking and be at higher risk for maladaptive eating-related behavioral problems. Furthermore, society itself can impose nutritional values on the child and family in two distinct ways. First, a general impression among lay people is that diet and nutrition can cause cancer.35 This presents another source of blame to the child and family. Second, society expects that eating habits and management of nutrition are the responsibility of parents, and that eating problems do not occur in children of &dquo;good&dquo; parents. Lack of nutritional health in children is often considered a parental failure. Risk factors for nutritional complications in children undergoing cancer therapy are shown in Table

1. ~’~’~·1 ~~1 s.36 The >yufritional

Plan of Care

Children diagnosed with cancer should receive a baseline diagnostic consultation with a pediatric dietitian. Pediatric oncology nurses and

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113

TABLE 1. Risk Factors of 1‘Iutrjtional Children With Cancer

Complications in

Anthropometric Measurements Measurements of height, weight, and head circumference (for those children under 3 years of age), combined with the use of the national Center for Health Statistics (NCHS) growth charts (appropriate for age and sex of child), provide a baseline evaluation at diagnosis and a basis for chronological assessment Height and weight are followed serially throughout treatment.

the consulting dietitian work collaboratively with the health care team to formulate a nutritional plan of care. 37. ’

Assessment

The primary goal of nutrition intervention is to promote normal growth and development. Because the diagnosis of cancer automatically places a child at nutritional risk, a baseline assessment is initiated as soon after diagnosis as possible. Dietary assessment is an ongoing process and continues throughout and after completion of treatment. It should include anthropometric measurements, biochemical indicators, clinical inspection, dietary history, and socioeconomic evaluation.

For infants less than 2 years of age or less than 1 meter tall, recumbent length is more precise than standing height. For children older than 2 years or taller than 1 meter, standing height may be measured without shoes. In either case, data should be plotted on the appropriate age-related growth chart. If recumbent length is measured, data should be plotted on the birthto-36-month chart; if standing height is measured, it should be plotted on the 2 to 18-year chart. Height should be evaluated at 3-month intervals? Height also needs to be plotted on sex-specific NCHS growth charts. Head circumference, which is an indicator of brain growth, should be measured every 3 months and plotted through 3 years of age on the birth-to-36-month NCHS growth chart. A decrease in the height-for-age or weightfor-age percentile may indicate malnutrition. Weight measurements should be used .cautiously to evaluate nutritional status because treatment with steroids, intravenous hydration, and therapeutic diuresis affect interpretation. Any child with height for age or weight for age less than the 10th percentile should be considered at nutritional risk. Weight-for-height assessment has been found to be a reliable indicator of nutritional status in children with cancer. In fact, weight-forheight has been reported to be a more useful indicator in identifying clinical malnutrition than weight-for-age determination. 313 In classifying PEM using weight for height on NCHS growth charts, the 25th to 75th percentile is considered normal; the 5th to 10th percentile is considered mild to moderate PEM, and less than the 5th percentile is considered severe PEM .36 In adolescents, weight for height can be calculated as

folloWS7:

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114

Weight (kg) % = Height (cm) %

Patient’s actual weight Patient’s actual height

100

x S S

S

50th percentile weight/age

50th percentile height/age’

In classifying PEM for adolescents using the calculated value, less than 90% standard weight for height is considered inadequate. 38 Skinfold measurements are a useful tool in assessment of the child with cancer. However, they can be affected by the patient’s condition (edema or obesity) as well as the degree of experience of the person taking the measurement and the quality of the equipment. Although plastic calipers are economical, they are not recommended because of their low level of accuracy. Lange calipers (Cambridge Scientific Industries, Inc., Cambridge, MD) are one example of calipers that are accurate and recommended for clinical use. Commonly used skinfold indicators include triceps skinfold (TSF) in centimeters, midarm circumference (MAC) in centimeters, and midarm muscle circumference (MAMC) in centimeters. TSF and MAC are actual measurements, and MAMC is calculated as:

with

protein-calorie malnutrition. Howbecause the transferrin value is increased ever, iron by deficiency, infection, and stress, it is often difficult to interpret the underlying reason for its abnormal value 40 Serum prealbumin. Prealbumin has been noted to be a more sensitive indicator of early malnutrition. 40 Low levels have frequently been observed in children with cancer Hemoglobin and hematocrir; Hematologic indicators that are frequently used in determining nutritional status in children are hemoglobin and hematocrit. However, they are easily affected by disease and therapy and are not useful in evaluating nutritional status in the oncology severe

patient. Clinical

Percentiles for TSF, MAC, and MAMC have been published .39 TSF and MAMC less than the 15th percentile and MAC less than the 60th percentile of standard have been defined as below nor-

Although drug therapy can often cause effects that are similar to the effects of nutrient deficiencies, it is useful to consider individual nutrient deficiencies as a cause and follow the observation with a diet history and/or biochemical evaluation. However, clinical signs of a deficiency are usually seen only in advanced deficiency. A more useful clinical observation is how the patient’s clinical status may affect food intake. The condition of the mouth may reflect the condition of the entire gastrointestinal (GI) tract and may make food intake painful. Fluid status, both edema and dehydration, may be visualized easily, especially by consistent health care providers. The wasting of PEM is also often detected

mal 38

clinically.

MAMC

=

MAC -

[TSF

x

(3.146)].

Biochemical

Dietary

Certain routine laboratory measures contain indicators of nutritional status; however, the disease process can often limit their usefulness in evaluating the child with cancer. Serum albumin. Although decreased albumin can be an indicator of poor nutrition, it has been observed that in cancer patients, hypoalbuminemia is more often related to causes other than malnutrition.18 Changes in albumin can also be caused by hydration status, infusion of albumin, liver disease, sepsis, trauma, malabsorption, infusion of blood products, or chronic

disease. Serum transferrin. Another indicator of protein status, transferrin is decreased in patients

Assessment of the patient’s dietary intake includes an inventory of what is eaten and an assessment of the patient’s drug therapy and its effect on nutrition. The diet can be evaluated by a 24-hour recall, 3- to 5-day food records, or a report of food frequencies. Analysis of the diet for calories, protein, and major nutrients is useful in determining the adequacy of the diet and in determining if supplementation is necessary.

Psychosocial-Cultural The patient’s socioeconomic status can have an effect on nutrition. Pediatric oncology social workers collect valuable information that can be

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115

used in the nutritional assessment. Pediatric dietitians must be skillful in extracting additional information that more specifically outlines the patient’s nutritional status. Poor dietary habits of the child may be reflected by the parents’ customary habits. The parent’s relationship with the child will impact on their ability to adequately nourish the child. Financial impairment also affects a family’s ability to provide appropriate nutrition. In addition, parents with limited educational and/or parenting skills may be unable to synthesize information and engage in activities to adequately nourish the patient. Assessment.Guidelines

The natural extension of the assessment process is rapid, ongoing evaluation with early intervention. A loss of real weight or a decline in is an indication for more intense nutritional intervention. Energy reserves, as observed by skin-

height-for-age

or

weight-for-age percentiles

fold measurements, should be maintained. 42 The American Academy of Pediatrics Committee on lyutrition Special Task Force addressed the special needs of children with malignancies. The five criteria for initiating nutritional intervention in children with malignancies are given in Table 2.42 These guidelines can alert the health professional to a child who is at nutritional risk and who would benefit from a more intensive nutritional intervention. Guidelines in determining practice standards in the area of nutrition and childhood cancer can be obtained from Quality TABLE 2. Criteria for Hutridon Intervention in Children With Malignancies _______

___

_____

Assurance Criteria for Pediatric Nutrition Condition : A ModeL~3

Planning The

pediatric oncology

and the dieti-

nurse

tian, in collaboration with the child’s parents and

oncologist, should develop a nutritional care on the assessment data. The plan should include reasonable, realistic goals. Bethe

plan based cause

nutritional status has been shown to have

prognostic implications in children with cancer,3 the family and child (when age is appropriate) should be instructed about the significance of the nutritional plan and agree to participate in its implementation and evaluation. Resolution of the underlying problems leading to impaired nutrient intake

stomatitis,

or

absorption,

such

must be central to the

must be coordinated with the

team-including tory

care

the

as

anorexia

or

pain. The plan

multidisciplinary

pediatric staff

and ambula-

nurses, to insure that the

goals

are

consistent with the

objectives of therapy, which frequently change throughout the disease course. Aggressive nutritional therapy should accompany aggressive medical management, especially for children identified at risk. When necessary, the hospice and/or home health care team should be included in the planning process.

Intervention

Education of the parents and child about normal childhood nutrition and the ramifications of the diagnosis on nutritional status is fundamental to the implementation and success of the plan. Large pediatric cancer centers with a multidisciplinary model of patient care may have

teaching protocols whereby teaching responsibilities are shared by the nurses and dietitians.

Lay literature about diet and cancer is available in several languages from various cancer organizations. Even patients identified as low risk for dietary complications should be instructed about dietary requirements and anticipated changes to prevent problems and optimize their tolerance of therapy. Myths about diet influences on cancer causation and/or treatment should be dispelled. Families need to understand basic information about the effects of the disease and therapy on nutri-

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116

tion. to

They should

be

taught practical strategies

improve dietary intake such as offering more

smaller meals when the child is ansupplements rich in high-density calories should be readily available to the child. The National Cancer Institute has published a comprehensive and useful guide of techniques to improve nutritional intake in patients with cancer. Charts outlining recommendations for protein and calorie supplementation are included 4a If the child is still unable to maintain protein and calorie requirements with added food and/or drinks, it may be necessary to use a commercial dietary supplement, which can be in powder or liquid form. Both food and commercial dietary supplementation can be maintained easily on an outpatient basis. Nurses are responsible for assessing and managing treatment toxicities that interfere with or affect nutritional status. Daily weight measurements, calorie counts, and close monitoring of fluid status and electrolytes provide valuable information and should be obtained as a nursing standard of care. Analgesia and antiemetic protocols may also help to promote dietary intake. Conservative methods to alleviate nausea, such as drinking carbonated beverages, should be employed. Rigorous oral hygiene can prevent stomatitis, decrease its severity, and promote an overall feeling of well-being, which may enhance appetite. Oral medications to correct nutrient deficiencies, such as magnesium gluconate, potassium replacement, leucovorin, and multivitamins, should be administered as ordered. However, despite all attempts to promote adequate oral intake, some children are unable to maintain calories adequate to promote growth. Other children, due to disease location or treatment, experience damage to the GI tract that prohibits enteral feeding. TPN then becomes necessary to provide the desired calories, carbohydrates, fat, electrolytes, vitamins, and trace elements. The main goal of using TPN in cancer patients is to maintain or replenish the patient’s protein mass in proportion similar to the predi-

frequent,

orexic. Food

agnostic body composition.

45

Consideration of when to initiate TPN includes muscle wasting, inability to ingest adequate age-specific calories from food and/or fluid, weight for height less than the 5th percentile, weight loss greater than 5% of baseline, and

prolonged biochemic evidence of metabolic disturbances.5.17 Certain treatment protocols from the collaborative pediatric oncology study groups highly recommend the initiation of TPN as supportive care during periods of intense therapy. Most pediatric cancer centers use a standardized pediatric TPN preparation employed for nutrition support in appropriate patients. However, controversy exists regarding the initiation and use of TPN because of the possible effect on tumor growth as well as its actual therapeutic benefit in reversing malnutrition, especially in advanced disease states 45 Some clinicians are also concerned with the incidence of complications such as central catheter-related infections and fluid overload that can occur with TPN. 46 Nonetheless, TPN has been shown to be effective in reversing malnutrition in certain groups of children with cancer and should be instituted when warranted.1.5

Summary Management of the complex nutritional needs cancer requires coordination of pediatric oncology nursing and pediatric dietary services. The anticipated alterations of nutritional intake, absorption, and metabolism caused by the disease and treatment must be integrated with principles of normal childhood nutrition to provide a comprehensive, developmentally based nutritional care plan. Ini’al dietary assessment at the time of diagnosis is essential for an effective long-term plan. The child and family must be included in the assessment, planning, implementation, and evaluation of the plan. Nurses must make astute observations at of the child with

all stages of the treatment process and alert the dietitian to potential complications so that early intervention can be initiated. Dietitians should monitor the nutritional status of all high-risk children throughout treatment. Aggressive nutritional intervention should be instituted when the treatment goals warrant an aggressive medical approach. Although the precise role of good nutritional status in children undergoing cancer therapy may be difficult to quantify, it is clear

that adequate nutritional support optimize the child’s tolerance of and adaptation to cancer

therapy.

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Nutritional support of the child with cancer.

The purpose of this article is to outline how the disease, treatment, and psychological state of a child with cancer impact on the child's nutritional...
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