onco-pediatric nutrition

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

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Page 1: Onco-Pediatric Nutrition

Poonam Shah, RD , PG (Critical Care and Cancer)Research DietitianPediatric Oncology DepartmentTata Memorial Hospital

Page 2: Onco-Pediatric Nutrition

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

Page 3: Onco-Pediatric Nutrition

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.

Page 4: Onco-Pediatric Nutrition
Page 5: Onco-Pediatric Nutrition

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

Page 6: Onco-Pediatric Nutrition

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

ETIOLOGY OF CACHEXIA

Page 7: Onco-Pediatric Nutrition

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

Page 8: Onco-Pediatric Nutrition

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….

Page 9: Onco-Pediatric Nutrition

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

Page 10: Onco-Pediatric Nutrition

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…

Page 11: Onco-Pediatric Nutrition

No pediatric bags available

Dextrose, amino acid and lipids given individually.

Peripheral PN / PICC Transient phases : < a

week

Page 12: Onco-Pediatric Nutrition

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

Page 13: Onco-Pediatric Nutrition

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

Page 14: Onco-Pediatric Nutrition

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

Page 15: Onco-Pediatric Nutrition

Drugs- Vincristine (VCR)

Drink plenty of fluids. Warm and hot fluids work especially well. Eat a lot of high fiber foods

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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.

Page 17: Onco-Pediatric Nutrition

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

Page 18: Onco-Pediatric Nutrition

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

Page 19: Onco-Pediatric Nutrition

When ANC < 500 neutropenia

Seen in: All AML patients ALL patients in induction, re-induction or

anytime Patients undergoing transplant

Page 20: Onco-Pediatric Nutrition

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.

Page 21: Onco-Pediatric Nutrition

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

Page 22: Onco-Pediatric Nutrition

Head and neck Anorexia Mucositis Dysgeusia

Nausea and vomiting Dysphagia Diminished salivation

Thoracic Esophageal damage Dysphagia

Abdominal or pelvic Nausea, vomiting Diarrhea Intestinal strictures

Page 23: Onco-Pediatric Nutrition

Amino acids- Glutamine, Arginine

Antioxidants – Vit C, Vit E, Beta carotence, Trace elemts ( Zn, Cu,Se, Mn), Taurine

Fatty acids- Omega 3 fatty acids

Page 24: Onco-Pediatric Nutrition

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

Page 25: Onco-Pediatric Nutrition