Onco-Pediatric Nutrition

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Onco-Pediatric Nutrition

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

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