Emily Loghmani

Effect of nutrition staging on treatment delays and outcome in stage IV neuroblastoma

The effect of the state of nutrition of 18 children with Stage IV neuroblastoma at diagnosis and during initial therapy, was evaluated with respect to treatment delays, drug dosage alterations, tumor response, days to first event (relapse or death), and survival. All patients received similar therapy (CCSG protocol CCG 371). Based on nutrition staging at diagnosis, nine were classified as malnourished; four were randomized to receive total parenteral nutrition (TPN) and four peripheral parenteral nutrition plus enteral nutrition for 28 days (through 2 chemotherapy courses), and one died before randomization. Nine were nourished at diagnosis; seven received a comprehensive enteral nutrition program and two received TPN. By life‐table analysis, the duration of remission was significantly greater in the nourished than the malnourished (P < 0.01) and a trend towards improved survival was evident at one year (P = 0.08). The median length of survival for children nourished at diagnosis was approximately 12 months, whereas those malnourished had a median survival of only 5 months. Nine children remained nourished or were becoming renourished during the first 21 days of therapy, and one of these had treatment delays and decreased drug dosages. Seven were becoming malnourished or remained malnourished during this period and six had treatment delays (P < 0.01). These data support the idea that nutrition staging at diagnosis and during initial treatment should be an integral part of protocol design and initial evaluation of children with Stage IV neuroblastoma.

Short- and long-term effectiveness of enteral and parenteral nutrition in reversing or preventing protein-energy malnutrition in advanced neuroblastoma a prospective randomized study

The effectiveness of enteral and parenteral nutrition regimens in preventing or reversing protein–energy malnutrition (PEM) and in preventing treatment delays was evaluated in 32 children receiving treatment for newly diagnosed Stage III (3 patients) and IV (29 patients) neuroblastoma. Ten of 18 malnourished patients were randomized to central parenteral nutrition (CPN) and 8 to peripheral parenteral nutrition (PPN) plus enteral nutrition for 4 weeks and then received enteral nutrition (EN: intense nutrition counselling, oral foods and supplements) for weeks 5 through 10. Ten of 14 nourished patients received EN and 4 CPN for 4 weeks and EN thereafter. Dietary, anthropometric and biochemical measurements were determined for weeks 0, 1, 2, 3, 4, 7, and 10 for 24 patients who completed the protocols. In malnourished patients, both CPN (seven patients) and PPN (seven patients) were effective in reversing PEM in the first 4 weeks; thereafter, EN effectively maintained nutritional gains in both groups. In nourished patients, EN (seven patients) was not as effective as CPN (three patients) in preventing PEM during the first 4 weeks; afterwards, EN maintained gains in the CPN group but did not promote needed increases in weight nor fat reserves in the EN group. Patients supported by parenteral nutrition (PN, weeks 1–4) had fewer treatment delays (2/17, 12%) than EN patients (4/7, 57%, P <0.05). These data indicate that PN reverses or prevents PEM and prevents treatment delays during the first 4 weeks of intense oncologic treatment and provides nutritional benefits which can be maintained with EN thereafter.

Lower glycemic response to sucrose in the diets of children with type 1 diabetes

OBJECTIVE To compare glycemic responses of isocaloric mixed meals containing 2% and 17% sucrose in children with type 1 diabetes who had fasting euglycemia. STUDY DESIGN Nine children (11 to 16 years) with type 1 diabetes were randomized in a crossover design to receive 2 isocaloric diets (2% or 17% sucrose) in the Clinical Research Center. In the 2% sucrose diet, starch isocalorically replaced sucrose. RESULTS Fasting euglycemia was comparable on both study days (mean +/- SEM: 2% sucrose, 5.0 +/- 0.3 mmol/L or 90 +/- 5 mg/dL; 17% sucrose, 5.0 +/- 0.3 mmol/L or 91 +/- 6 mg/dL). The 17% sucrose diet resulted in a lower glycemic response than the 2% sucrose diet over the 4-hour study period (area under glucose response curve: mean +/- SEM, 37 +/- 3.5 mmol/L x 4 h vs 42 +/- 4.7 mmol/L x 4 h, P = .01). Peak blood glucose response was earlier and lower (2.2 to 2.8 mmol/L, 40 to 50 mg/dL) with the 17% sucrose diet. CONCLUSIONS Sucrose in moderate amounts, isocalorically exchanged for starch, lowered glycemic response between breakfast and lunch in children who were euglycemic before breakfast. These data refute concerns about adverse glycemic effects of sucrose and support the use of sucrose-containing foods in the context of a healthy meal plan.

Alternative snack system for children and teenagers with diabetes mellitus

An alternative snack system facilitates diabetes management and provides a teaching tool for age-appropriate nutrition education of children and teenagers with diabetes mellitus. The system consists of four snack sizes: Mini--7 to 10 g available glucose, Little--15 to 20 g, Big--30 to 35 g, and Super-Big--50 to 55 g. Within each category, several snack patterns are equivalent to each other in terms of available glucose and energy. By using this system, a child or teenager can eat snacks that contain different food groups and still adhere to the overall meal plan. When additional carbohydrate is needed for exercise or the prevention of nighttime hypoglycemia, a snack from the next largest category will increase available glucose by approximately 15 g and energy intake by approximately 100 kcal. Generally, for every hour of extra physical activity, a Little snack is added. When blood glucose concentrations before a nighttime snack are 4.4 to 6.7 mmol/L, a Little Snack is added to the usual bedtime snack, and when levels are less than 4.4 mmol/L, a Big snack is added. Further adjustments are made for children younger than 5 years old. The alternative snack system is a valuable nutrition education tool for the management of diabetes in children and teenagers.