Onco-Pediatric Nutrition
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Transcript of Onco-Pediatric Nutrition
Poonam Shah, RD , PG (Critical Care and Cancer)Research DietitianPediatric Oncology DepartmentTata Memorial Hospital
Malnutrition Pediatric nutritional screening and assessment Nutritional Intervention Nutrition related side-effects in chemotherapy - Neutropenic diet - Diet in various side effects Nutrition related side-effects in Radiation. Immunonutrition Prevention
1. Intensive chemotherapy regimes, multi-modal therapy, “dose-intensive” regimens given over a shorter time period.
3. Location of the disease, (intra-abdominal disease)
5. Side effects -nausea and vomiting, reduce/alter sense of taste, making food unpalatable.
7. Children are still growing.
9. High nutritional needs per kg of body weight and lower reserves.
11. Weight loss of even a small amount can be significant in proportion to their size. E.g. a one kg weight loss in a child weighing 10 kg is equivalent to a 10% loss in their body weight.
HIGH NUTRITIONAL RISK Advanced stages of solid tumors: Wilms’ tumor Neuroblastoma leukemia Rhabdomyosarcoma Ewing’s sarcoma Non-Hodgkin’s lymphoma Acute myeloblastic leukemia Multiple relapse leukemia Medulloblastoma and other
highgrade brain tumors Head and neck tumors Stem cell transplantation
LOW NUTRITIONAL RISK Nonmetastatic solid tumors Low-risk acute lymphocytic
leukemia Disease in remission
Cachexia is a severe state of malnutrition involving anorexia, weight loss, and muscle wasting.
ETIOLOGY OF CACHEXIA
Short term - Underweight ( lower weight for height) /wasting - cancer cachexia
Long term - Short stature ( lower height for age) /Stunted - Increased risk of treatment related complications -Reduced tolerance of therapy - Altered drug metabolism -Increased susceptibility to infection -Improper physical and psychological development - Poor treatment outcomes
Evaluation of nutritional status w.r.t : Anthropometrics- Weight loss ≥ 5 % over 1 month, IAP
classification, grade of malnutrition, wt-for-age, ht-for-age, BMI-for-age,MUAC, TSF….
Biochemical parameters- Serum Albumin, Serum Proteins….
Clinical parameters- nausea, vomiting, loose motions, poor intake, swallowing difficulties….
Dietary recall- FFQ, any supplements, food allergy, food diary….
Pediatric Subjective Global Assessment Tool(PEDSGA) is a patient-generated nutrition assessment form designed to expedite efficiency at which children at nutritional risk are identified and nutritional intervention can be initiated.
Not validated as yet
Counselling Dietary supplements Appetite stimulants Enteral nutrition poor oral intake, mucositis, oral ulcers, certain brain tumours,
medullablastomas, … Parenteral nutrition enterocolitis, mucositis of GIT, severe colitis, certain
nasopharynx cancers…
No pediatric bags available
Dextrose, amino acid and lipids given individually.
Peripheral PN / PICC Transient phases : < a
week
Anorexia / reduced appetite- MTX, Asparaginase, Cyclophosphamide, Dactinomycin, Fluorouracil
Taste changes /metallic taste- Carboplatin Early satiety/ feels full quickly- MTX
Nausea/Vomiting –MTX, Asparaginase, Cyclophosphamide, Dactinomycin, Fluorouracil
Mucositis/esophagitis – MTX, Cyclophosphamide
Diarrhea – MTX, Dactinomycin, Fluorouracil
Constipation - VCR induced, reduced fiber
Drugs- MTX, Asparaginase, Cyclophosphamide, Dactinomycin, Fluorouracil
Drink liquids at least an hour before or after mealtime instead of with your meals.
Drink cold liquids throughout the day Dry foods such as toast or crackers, plain biscuits, / Sip cold
liquids throughout the day. Eat foods cold or at room temperature Consume ice-creams if the patient doesn’t have cold. Suck on a candy in mouth Avoid spicy, oily, masaledars foods. Once vomiting settles down initiate feeding by clear liquids
like soups and kanji. Distract the kids
Drugs- MTX, Dactinomycin, Fluorouracil
Drink plenty of fluids ORS solution in sips and not in one shot BRAT Diet Eat food at or near room temperature , not
very hot or very cold foods. Avoid extra sweet foods like sweets and
chocolates Avoid Milk and milk based products
Drugs- Vincristine (VCR)
Drink plenty of fluids. Warm and hot fluids work especially well. Eat a lot of high fiber foods
Eat small amounts of meals often and slowly. Do not leave long gaps between meals
Avoid gas forming foods Avoid eating 1-2 hours before and after any
chemotherapy. Avoid oily and greasy foods.
Drugs- MTX, Cyclophosphamide Good oral care If required use straw to drink fluids. Consume more milkshakes which are smooth and
calorically densed Suck on ice cubes Eat foods cold or at room temperature. Eat soft and pureed foods Avoid hot and warm foods that can irritate a tender
mouth and throat. Avoid irritating , acidic foods
Chemotherapy + Radiation ( not below 3 years) In ALL patients, may develop TLS -During induction and re-induction ( 1# and 4#)
steroids low salt, no concentrated sweets. - In 2 # Tb 6 MP avoid milk with it. - In 3#, chemotherapy and radiation mucositis,
radiation burns, nausea, vomiting. - In maintenance mostly stable counts. On oral
chemo appetite maybe better than earlier.
In AML patients neutropenic diet
When ANC < 500 neutropenia
Seen in: All AML patients ALL patients in induction, re-induction or
anytime Patients undergoing transplant
No left over foods No outside/roadside/restaurant foods All fruits which rinsed and peeled.- Prefer thick skinned fruits. Avoid fruits strawberries,
grapes, cherries. All vegetables to be cooked No raw nuts. Diary products – pasteurized products Sealed packed packaged foods Avoid meat products, eggs,etc.
Chemotherapy + Radiation + Surgery Size of tumor – penetrating neighboring
organs- May not tolerate concentrated feeds, respiratory distress
Site of tumor – nasophargynx, chest wall, cheek bone, neck region, Stomach region
Stage of disease
Head and neck Anorexia Mucositis Dysgeusia
Nausea and vomiting Dysphagia Diminished salivation
Thoracic Esophageal damage Dysphagia
Abdominal or pelvic Nausea, vomiting Diarrhea Intestinal strictures
Amino acids- Glutamine, Arginine
Antioxidants – Vit C, Vit E, Beta carotence, Trace elemts ( Zn, Cu,Se, Mn), Taurine
Fatty acids- Omega 3 fatty acids
Body fat Physical activity Drink and foods that promote weight gain Plant foods- fruits/ vegetables Animal foods Alcoholic drinks Preservations , Processing