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Optimum Nutritional Management of
Hospitalized Pediatric Oncology Patients:
A Case Study Qualitative Research Project
A N D R I A M . K E AT I N G , R D I N T E R N
CAPSTONE PROJECT PRECEPTOR:
ALLIE E. HUBBARD, RD
Acknowledgement
I would like to express my gratitude and appreciation
to all those whose provided suggestions and
encouragement, and helped me to complete my
major capstone project.
 Allie E. Hubbard, RD Major Capstone
Preceptor
 Ana Abad-Jorge, EdD, MS, RDN, CNSC Major
Capstone Project Reviewer
 Evelyn Joran-Thiel, MSN, CPNP, CPON
 Traci Fisher, RN, BSN
Overview
•
•
•
•
•
•
•
•
•
Introduction
Nutrition Implications of Pediatric Cancers
Project Purpose
Methods
Results
Discussion
Limitations
Future Research
Conclusions
Introduction
•
In a 2007 study, the National Cancer Institute revealed
that an estimated 10,400 children 15 years of age and
below were diagnosed with cancer. 1
•
Of those children, about 1,545 children died from the
disease in the United States.1
•
This makes cancer the leading cause of death in children
under the age of 14.1
Introduction
• The most prevalent cancers affecting children are:
• Leukemia,
• Central nervous system (CNS) tumors, and
• Lymphoma.4,5
• Leukemia is the most common pediatric cancer accounting
for approximately 28-30% of total cancer diagnoses.4,6
Brain and CNS tumors are the next most prevalent
pediatric cancer, followed by lymphoma.4-7
Introduction
Nutrition Implications of Pediatric Cancers
• Malnutrition at diagnosis exists in 6% to 50% of patients
and is dependent upon the histology, stage of disease, and
location of the cancer.17
• The side effects of malnutrition may include tissue wasting,
anorexia, weakness, anemia, hypoalbuminemia, and
skeletal muscle atrophy. 17
• Protein and calorie malnutrition is associated with a higher
incidence of infection, decreased tolerance of
chemotherapeutic treatments, and overall diminished
quality of life.17
Nutrition Implications of Pediatric Cancers
• Cancer cachexia
• A syndrome where the body is unable to absorb, metabolize, and
utilize essential nutrients, manifesting in unintentional weight
loss.19
• The pathophysiology of cachexia has not been clearly defined,
but may be caused by the outcomes of immunologic and
humoral neuroendocrine abnormalities.
• The physiological stress caused by cachexia can alter body
composition and cause metabolic alterations in carbohydrate,
lipid, and protein absorption and metabolism.17
Nutrition Implications of Pediatric Cancers
• Metabolic alterations
• Carbohydrates: increased glucose uptake and lactate production
by the tumor, hypoinsulinism, insulin resistance
• Protein: metabolism is affected by the tumor burden by altering
uptake of amino acids.
• Lipid metabolism is often less affected than the other
macronutrients. However, the depletion of fat stores is higher in
pediatric oncology patients due to increased lipolysis.1
Nutrition Implications of Pediatric Cancers
• Treatment options and their nutrition-related side effects
• The most common methods of treatment are
• Chemotherapy,
• Radiation,
• Surgery, and
• Hematopoietic stem cell transplantation (HCST).10
• Common side effects associated with cancer treatments may
include diarrhea, nausea, vomiting, mucositis, pain, fatigue,
early satiety, xerostomia, and loss of taste.2
Nutrition Implications of Pediatric Cancers
• The primary goal for the nutrition management of children and
adolescents undergoing cancer treatment is to sustain and
promote normal growth and development.26
• Determining nutritional needs of the pediatric oncology patient
should be influenced by:
• Providing adequate nutrition for the preservation of lean tissue
and to promote normal growth and development,
• Identifying and correcting the effects of protein and energy
malnutrition and metabolic abnormalities, and
• Maximizing quality of life for the patient.16
Nutrition Implications of Pediatric Cancers
• Nutrition requirements for children with cancer28
Calories
Infants: Birth to 12 months: Use RDA for age for appropriate weight infants. Use catch-up growth
calculation if underweight
Older children (>1 year): Use BMR table multiplied by additional factors:
• Appropriate weight for height: BMR x 1.6
• Obese: BMR x 1.3
• Sedentary with 5% weight loss: BMR x 1.4-1.6
• 10% weight loss from usual weight or weight is 90% or less of usual or ideal weight: BMR x 1.8-2.0
Use adjusted weight calculation for obese children; BMI weight at the 75th percentile may also be
used to calculate energy needs in obese children
HSCT: BMR x 1.6 during immediate post-transplant course; BMR x 1.4 following engraftment and
medically stable.
Protein
•
•
•
•
Infants birth to 6 months: 3 g/kg/day
Infants 6 to 12 months: 2.5-3 g/kg/day
Children: 2-2.5 g/kg/day
Adolescents with increased lean body mass: 1.5-1.8 g/kg/day
Fat
10-30% of calories
Nutrition Implications of Pediatric Cancers
Nutrition support in children with cancer
• The goal of nutrition support is to provide adequate nutrients to
meet the demands of the growth and development, and also to
reverse the possibility of protein-calorie malnutrition.
• Nutritional support for patients that are malnourished due to
inadequate oral intake has been shown to improve nutritional
intake and outcomes.15
Nutrition Implications of Pediatric Cancers
Enteral Nutrition
Parenteral Nutrition
The preferred method as it is the safest way
for the provision of nutrients in children with
an undamaged and functional gastrointestinal
(GI) tract.
This method is used when pediatric patients
are unable to meet nutritional needs via oral
diet or enteral feeds.
It also helps to prevent intestinal atrophy,
toxicity, and complications of intravenous
infusion. Decreased liver abnormalities.
Notable reduction in GI toxicity from cancer
therapies due to a better response from
treatment.31,41-42
Benefits of PN include reversal of protein
energy malnutrition, restoration of immunecompetence, and tolerance to anti-neoplastic
therapies.
In patients with a functioning GI tract, this
method is preferred due to the proven efficacy
while also decreasing the risk of infection.
PN may be used if a child has an immature GI
tract, an intestinal obstruction, had a surgical
resection of a tumor located in the bowel, or if
chemotherapy or radiation therapy delays the
use of EN.
Nutrition Implications of Pediatric Cancers
Nutritional intervention is indicated if:15
•
>5% weight loss from Usual Body Weight or during therapy
•
Crossing > 2%-ile channels on growth charts
•
Not meeting > 80% estimated nutritional needs through oral intake (food and
supplements)
•
Impending treatment will adversely affect nutritional status and meet nutritional
needs orally
•
The oncologic prognosis warrants TPN or EN
•
Determination of TPN versus EN is dependent upon the ability to safely
tolerate/absorb nutrients via GI tract.
•
Candidacy for EN can be determined if tolerance can be alleviated by changing
formula or using antiemetic’s/motility agents.
Nutrition Implications of Pediatric Cancers
• Barriers to adequate nutrition support18
• Initial low infusion rates
• Feeding interruptions due to medical procedures
• Holding feeds for specific medication administration
• Potential side effects related treatment protocols
• Neutropenia or thrombocytopenia increases risk for bleeding when
nasoenteric tubes are inserted; however, clinical trials have not
supported this theoretical risks.18
Project Purpose
• Determine barriers to optimizing nutrition support at UVAHS
• Investigate current practice and the medical team’s
preference for use of a particular form of nutrition support.
• Provide evidenced-based recommendations for the
nutritional management of pediatric oncology patients.
• Promote the importance of utilizing EN feedings as a
standard nutritional intervention during treatment.
Methods
•
•
•
This study used a case series mixed methods approach to
investigate nutrition support practice management at
UVAHS.
Data was retrospectively collected on 3 patients between
February 2013 – March 2013.
Selection criterion for the hospitalized patients were
based on the following:
• UVAHS pediatric oncology patient and
• Patients receiving long-term nutritional support via EN
or PN.
Methods
• Patient Overview:
• T.W., a 7 year old male with anaplastic
medulloblastoma
• N.P., an 11 month old male with infantile AML
diagnosis
• N.M., a 7 year old female with medulloblastoma of the
cerebellum
Methods: Quantitative Data
•
Retrospective data was collected on the three selected patients using the
EPIC electronic medical records to include:
Specific cancer diagnoses
Reason for admissions
Previous surgical and medical history
Anthropometrics (weight (kg), length (cm), head circumference (cm), % weight
loss)
• Oncologic treatments received & other relevant medications
• Degree of malnutrition assessed by the Waterlow Criteria
• Nutritional intake data included:
•
•
•
•
• PN data (if applicable): PN order, goal caloric provision (kcal/kg) from PN, and actual
intake
• EN data: formula, caloric density, goal feeding schedule, route, goal caloric provision
(kcal/kg), and actual intake
• Patient’s nutritional goals and percentage of the goals achieved
• Noted barriers to starting or advancing nutritional support
Methods: Qualitative Data
• In order to obtain information on the nutritional support
practices at UVAHS, interviews were conducted with various
members of the pediatric oncology team:
• Pediatric oncology nurse practitioner (NP),
• Pediatric oncology bedside nurse (RN), and
• The pediatric oncology RD employed at UVAHS.
• These professionals provided their perspectives on the
ideal approach and challenges in the management of
pediatric oncology patients
Methods
Methods
Methods
Methods
• All of the collected data was recorded and organized into a
Microsoft Excel spreadsheet.
• Basic descriptive statistics were used for data analysis.
• The data obtained in this study was used to provide a
general overview of the outcomes and current nutritional
practices at UVAHS, as well as to investigate the use of EN
versus PN at UVAHS.
Results
T.W. Highlights
•
December 21st, 2011: Weight of 19.5 kg (3.45% weight-for-age);
76% of IBW, BMI-for-age 2.90th%-ile
•
February 2012: Placement of G-tube. Weight of 18.7kg; initiated on
nocturnal G-tube feeds
•
March 2012: Weight of 20.6 kg, Up ~2kg in a month since the
placement of the G-tube.
July 2012: Weight of 21.55 kg (8% weight-for-age); 90% of IBW and
improved BMI-for-age 13th%-ile
•
•
Main challenges with nutrition support: EN held for episodes of
emesis, TPN held due to central line infection, Bone Marrow
procedure, cellulitis, peritoneal infection, EN caloric density
Results
N.P. Highlights:
•
•
•
•
•
Admitted to PICU August 14th, 2012: 9.2 kg (21st %-ile), weight for length:
29th%-ile (Percentile); On TPN feeds initially started on trophic NG feeds
August 26th, 2012
October 2012: Weighed 9.86 kg (47%ile weight for age) upon transfer to
the floor, gaining an average of 10 grams per day since admission due to
EN support.
October 23rd, 2012: Placed on bowel rest with TPN initiated but resumed
EN feeds on November 16th, 2012
November 2012: Weighed 10.17 kg (50% weight for age) due to continued
progress with EN support
Main challenges with nutrition support: radiation schedule (M-F),
anesthesia, pneumatosis, increased risk for mucositis and concern for
typhilits
Results
N.M. Highlights:
•
•
•
•
•
October 3, 2012: Weight of 24.2 kg, down from UBW of 29 kg in 3.5
months (17% weight loss since diagnosis). Decision made to place G-tube in
anticipation of upcoming chemotherapy regimen.
October 24, 2012: Weight of 26 kg, Up 1.8 kg due to improved appetite
while on steroid therapy. G-tube placed, continuous nocturnal feeding
regimen initiated.
December 6, 2012: Weight of 30.9 kg and a weight-for-age percentile of
90th. Weight improved significantly since g-tube placement. Had regained
beyond UBW.
March 4, 2013: Weight of 25.2 kg (18% weight loss) due to feeding
intolerance with g-tube feedings, severe abdominal pain, and emesis. The
RD recommended interventions to advance back to goal feeds but
recommendations were not implemented per the primary team.
Main challenges with nutrition support: Significant frequency of N/V,
intolerance to continuous feeds overnight (previous regimen bolus),
infection at the g-tube site
Results
What are the advantages and disadvantages to using parenteral nutrition support?
• Advantages: Eliminates burden of oral intake, relieves tension between child and parent,
electrolytes are easier to maintain with TPN, extra bolster of nutrition.
• Disadvantages: Higher risk for infection, damaging to the liver.
What are the advantages and disadvantages to using enteral nutrition support?
Advantages:
• NP: provide oral medication through tube, alleviate tension with child and parent, not as expensive
as TPN, easier to administer.
• RN: The ability to meet nutritional needs if the patient refuses to take all calories by mouth
• RD: more physiologic, improved benefits in terms of maintaining the gut mucosa. less expensive
than TPN and has lower risks for infection
Disadvantages:
• NP: “Children hate the NG tubes”, tube dislodgement during emesis, source of infection, g-tube
requires surgical placement.
• RN: family and patient adapting to meeting all calorie needs via NGT/GT versus via mouth
• RD: tube placement which may require surgery, uncomfortable nasoenteric tubes, possible selfimage issues, patients with active mucositis without prior enteral access, team hesitant to place a
tube that might irritate the mucositis or cause bleeding in a child with thrombocytopenia.
Results
At what point do you feel that nutrition support is indicated in this patient
population?
• NP: weight loss of 5-10% usual body weight
• RD: lost >5 of their UBW, upcoming treatments , anticipated side effects when
making recommendations, Anticipate PO intake in the interim, overall % weight
loss, nutrition status prior to diagnosis
• RN: Depends which attending is on service and how the parents feel about the
lack of PO intake
How do you feel nutrition management of the pediatric oncology patient could be
improved?
• Improved patient education handouts for clinic
• Earlier initiation of nutritional support
• RD to follow-up with patients in the outpatient clinic
Discussion
• The quantitative data collected within this study
showed that each of the three patients did not receive
adequate nutritional support with EN during their
admissions.
• Data also showed that when nutrition support was
initiated it was not advanced to the goal rate or was
often delayed due to procedures during at least one
admission date recorded for each patient.
Discussion
• Each of the health care professionals identified the lack of
protocols regarding the initiation of nutrition support as a
barrier to initiating and optimizing nutritional support
delivery.
• The data from our study suggests nutrition management is
not consistently being carried out per those guidelines
despite timely and repeated RD recommendations.
• The outpatient clinic was identified as an area where
nutrition management is lacking, and that the presence of
the RD in clinic would be beneficial.
Limitations
• Small sample size (n=3)
• Retrospective data collection from previous admissions
• Intermittent data collection due to prolonged admissions or
serial admissions
• Limited target group for qualitative data collection
Future Research
• Prospective study with daily serial data collection upon
admission to more closely monitor recommendations and
time/barriers to implementation.
• Expand survey population for medical health professionals
• Include families of patients in further qualitative data
collection for a more robust and comprehensive
perspective
• Survey other facilities to compare protocols for nutrition
intervention
Conclusions
• In a few circumstances, the appropriate route of nutrition
support, whether EN versus TPN, were utilized in an
effective manner.
• However, this was the exception rather than the norm.
• The establishment of nutrition support protocols would
uniformly provide pediatric oncology healthcare professions
with guidelines for the timely initiation of appropriate
nutritional support in our pediatric oncology patients and
help to support normal growth and development during
treatment.
Conclusions
• Furthermore, the availability of an RD in the outpatient
clinic is very important to having an effective medical
staff in which to provide recommendations for
nutritional support and information on symptom
management in the pediatric oncology patient
following the continuum of care.
Questions?
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