The document discusses nutritional screening, assessment, and interventions for pediatric oncology patients undergoing chemotherapy and/or radiation therapy. It outlines various nutrition-related side effects from different treatments and drugs. It also describes methods for evaluating nutritional status and providing counseling, dietary supplements, enteral or parenteral nutrition support when needed to address malnutrition risks and treat side effects.

1. Poonam Shah, RD , PG (Critical Care and Cancer) Research Dietitian Pediatric Oncology Department Tata Memorial Hospital

2. 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

3. Intensive chemotherapy regimes, multi-modal therapy, “dose-intensive” regimens given over a shorter time period. Location of the disease, (intra-abdominal disease) Side effects -nausea and vomiting, reduce/alter sense of taste, making food unpalatable. Children are still growing. High nutritional needs per kg of body weight and lower reserves. 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.

5. 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

6. Cachexia is a severe state of malnutrition involving anorexia, weight loss, and muscle wasting. ETIOLOGY OF CACHEXIA

7. 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

8. Evaluation of nutritional status w.r.t : A nthropometrics- Weight loss ≥ 5 % over 1 month, IAP classification, grade of malnutrition, wt-for-age, ht-for-age, BMI-for-age,MUAC, TSF…. B iochemical parameters- Serum Albumin, Serum Proteins…. C linical parameters- nausea, vomiting, loose motions, poor intake, swallowing difficulties…. D ietary recall- FFQ, any supplements, food allergy, food diary….

9. 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

10. 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…

11. No pediatric bags available Dextrose, amino acid and lipids given individually. Peripheral PN / PICC Transient phases : < a week

12. 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

13. 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

14. 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

15. Drugs- Vincristine (VCR) Drink plenty of fluids. Warm and hot fluids work especially well. Eat a lot of high fiber foods

16. 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.

17. 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

18. 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

19. When ANC < 500  neutropenia Seen in: All AML patients ALL patients in induction, re-induction or anytime Patients undergoing transplant

20. 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.

21. 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

22. Head and neck Anorexia Mucositis Dysgeusia Nausea and vomiting Dysphagia Diminished salivation Thoracic Esophageal damage Dysphagia Abdominal or pelvic Nausea, vomiting Diarrhea Intestinal strictures

23. Amino acids- Glutamine, Arginine Antioxidants – Vit C, Vit E, Beta carotence, Trace elemts ( Zn, Cu,Se, Mn), Taurine Fatty acids- Omega 3 fatty acids

24. Body fat Physical activity Drink and foods that promote weight gain Plant foods- fruits/ vegetables Animal foods Alcoholic drinks Preservations , Processing