Karen Ringwald-Smith

Algorithm for nutritional support: Experience of the metabolic and infusion support service of St. Jude Children's Research Hospital

The Metabolic and Infusion Support Service (MISS) at St. Jude Childrens Research Hospital was established in 1988 to improve the quality of nutritional support given to children undergoing therapy for cancer. This multidisciplinary group, representing each of the clinical services within the hospital, provides a range of services to all patients requiring full enteral or parenteral nutritional support. In 1991, the MISS developed an algorithm for nutritional support which emphasized a demand for a compelling rationale for choosing parenteral over enteral support in patients with functional gastrointestinal tracts. Compliance with the algorithm was monitored annually for 3 years, with full compliance defined as meeting all criteria for initiating support and selection of an appropriate type of support. Compliance rates were 93% in 1992, 95% in 1993 and 100% in 1994. The algorithm was revised in 1994 to include criteria for offering oral supplementation to patients whose body weight was at least 90% of their ideal weight and whose protein stores were considered adequate. Full support was begun if no weight gain occurred. Patients likely to tolerate and absorb food from the gastrointestinal tract were classified into groups defined by the absence of intractable vomiting, severe diarrhea, graft‐vs.‐host disease affecting the gut, radiation enteritis, strictures, ileus, mucositis and treatment with allogeneic bone marrow transplant. Overall, the adoption of the algorithm has increased the frequency of enteral nutritional support, particularly via gastrostomies, by at least 3‐fold. Our current emphasis is to define the time points in therapy at which nutritional intervention is most warranted. Int. J. Cancer Supplement 11:76–80, 1998.

Effect of Body Mass Index on the Outcome of Children With Acute Myeloid Leukemia

The effect of body mass index (BMI) on the treatment outcomes of children with acute myeloid leukemia (AML) is unclear and needs further evaluation.

Establishing the use of body mass index as an indicator of nutrition risk in children with cancer

Background: The negative health consequences of malnutrition in the pediatric oncology patient are well known. The purpose of this study was to determine the usefulness of body mass index (BMI) for age as a tool to prospectively identify pediatric cancer patients at risk for malnutrition and to determine the BMI percentile that would be required to identify at-risk patients. Methods: This study was conducted by a retrospective chart review of 1839 newly diagnosed acute lymphoblastic leukemia patients at St. Jude Childrens Research Hospital. Those falling below the 10th percentile on any one category of height for age (HFA), weight for age (WFA), or weight for height (WFH) were classified with regard to nutrition risk and compared with those identified as at risk by BMI for age (BFA). The BMI percentiles of the lower 9th–11th percentile patients on the HFA, WFA, and WFH growth charts were averaged in an attempt to determine a useful value to identify nutrition risk. Results: Lack of agreement was found to...

Enteral Nutrition Support in a Child After Bone Marrow Transplantation

Bone marrow transplantation (BMT) has been associated with numerous negative side effects, which include prolonged anorexia. Historically, parenteral nutrition has been the method of choice for nutrition support. The possibility that enteral feedings may be a practical form of nutrition therapy for those BMT patients who have prolonged anorexia and who have adequate gastrointestinal function was investigated. RR, a 10-year-old male, was diagnosed with acute lymphocytic leukemia in March 1989. The patient received a bone marrow transplant in July 1992 from a human leukocyte antigen genotype-matched sibling. Because of the patients prolonged anorexia, he was started on enteral feedings via a percutaneous endoscopic gastrostomy feeding tube on day +63. Over the next 300 days of enteral nutrition support the patients nutritional status improved as demonstrated by an increased weight and height and the maintenance of normal visceral protein stores. This suggests that enteral feedings may be beneficial for those BMT patients who have prolonged anorexia and have adequate gastrointestinal function.

Energy expenditure in children undergoing hematopoietic stem cell transplantation

Prior studies suggest that patients undergoing hematopoietic stem cell transplantation (HSCT) for malignancy have nutritional needs that are greater than their estimated needs. To determine whether energy estimation equations accurately predict energy expenditure of pediatric patients undergoing HSCT, we prospectively compared the estimated energy expenditure (EEE) and measured energy expenditure (MEE) of 40 patients at four time-points. We also investigated whether energy requirements changed during the transplant period. MEE was determined by indirect calorimetry. Data from 34 patients (autologous HSCT = 10, allogeneic HSCT = 24) were sufficient for analysis. The World Health Organization equation adequately approximated MEE only on day 14 after HSCT. At all other time-points, measured energy expenditure was significantly less than estimated energy expenditure obtained by using the WHO equation (applicable to all patients), the Seashore equation (for patients <15 years of age; n = 19), or the Harris-Benedict equation (for patients ⩾15 years of age; n = 15). The median measured energy expenditure varied significantly over the study period and was greatest on day 14 after HSCT. Until accurate equations have been identified for estimating these patients’ needs, the use of indirect calorimetry may be medically warranted.

The Weaned Pig as a Model for Doxorubicin-Induced Mucositis

Background: Chemotherapy-induced mucositis (CIM) complicates cancer therapy and limits maximum tolerated doses and efficacy. Rodent models do not reproducibly mimic clinical CIM, so alternative models are needed. Methods: CIM severity was assessed after weaned pigs were treated with doxorubicin (5 and 3.75 mg/kg) using clinical observations, laboratory parameters and gastrointestinal structure and functions. Bovine colostrum was provided as an experimental intervention to the pigs treated receiving the 3.75 mg/kg dose. Results: Doxorubin at 3.75 mg/kg decreased food intake and weight gain (p < 0.05) and caused diarrhea and vomiting that coincided with damage to the small intestine mucosa based on histological scoring (p < 0.05). It resulted in higher serum TNF-α concentrations, increased chloride secretion and reduced brush border membrane disaccharidase activities and carrier-mediated glucose uptake (all p < 0.05). The gastrointestinal damage and dysfunction resemble the clinical and laboratory features of CIM in humans; these can be partially prevented by providing cow colostrum. Conclusion: The weaned pig is a relevant large animal for studying CIM and evaluating existing and experimental interventions for mucositis.

The Evaluation of Factors Believed to Contribute to Obesity in Acute Lymphocytic Leukemia Survivors

Background. Obesity rates for pediatric acute lymphocytic leukemia (ALL) survivors vary from 11% to 57%. Researching dietary behaviors may identify dietary risks leading to obesity and opportunities for intervention. Objective. To evaluate the relationship between caloric and macronutrient intake on the incidence of obesity in pediatric ALL. Design/setting/participants. Retrospectively reviewed data of 142 participants was examined. Participants were grouped into categories based on body mass index (BMI) for adults and Centers for Disease Control and Prevention growth charts for children. Twenty-four-hour food recall records were reviewed to assess dietary intake. Confounding factors and caloric/macronutrient intake were compared across obesity classes. Main outcome measurements. Macronutrient levels were compared between groups. Descriptive data examined. BMI at enrollment on BONEII, age at diagnosis, ethnicity, gender, corticosteroid use, cranial radiation therapy, and standard/high risk. ALL group. Results. Thirty-nine percent of participants were overweight/obese. ALL survivors who consumed a higher percentage of their calories from protein were more likely to be underweight/normal weight while participants who consumed more calories and total carbohydrates were more likely to be overweight/obese. There was no relationship with the other factors examined. Conclusion. Dietary interventions should be designed to ensure patients consume adequate amounts of protein while limiting portion sizes and carbohydrate-based snacks.

Nutritional Status Potential Impact on Survival in Children with Acute Lymphoblastic Leukemia

Abstract The prognosis of children with ALL has significantly improved in the past two decades due to advances in antineoplastic therapy. Poor nutritional status has been suggested to adversely affect survival in patients with various cancers. To determine if WT/HT at diagnosis could be utilized as a prognostic factor in childhood ALL we conducted a retrospective analysis of 1839 patients newly diagnosed between 1962 to 1992. The US National Center for Health Statistics Growth Charts were used to determine ideal weight for height values, with individual values calculated as the weight at the fiftieth percentile for the corresponding height. A cut-off point of

Comparison of Resting Energy Expenditure Assessment in Pediatric Oncology Patients

BACKGROUND Evaluation of energy requirements is an important part of the nutrition assessment of pediatric oncology patients. Adequate provision of energy in this population is of extreme importance because of the prevalence of malnutrition and its effect on growth, development, quality of life, morbidity, and mortality. Numerous methods are used in clinical practice for estimating the resting energy expenditures (REE), specifically indirect calorimetry and predictive equations. A relatively new instrument used to assess REE is the hand-held indirect calorimeter. The purpose of this quality improvement project was to compare the accuracy of REE measurements taken by a hand-held indirect calorimeter and predictive equations to that of a standard indirect calorimeter metabolic cart. METHODS Patients receiving therapy for pediatric cancer, aged 7-18 years, and having a weight ≥15 kg and scheduled for a REE nutrition assessment were eligible. Sequentially, the patients REE was assessed with the cart and the hand-held indirect calorimeter along with the predictive equation calculation. RESULTS Post hoc pairwise comparisons revealed that all 3 methods were significantly different from one another (P < .0001). When compared with the cart, the portable hand-held calorimeter was found to underestimate REE by 11.9%, whereas predictive equations overestimated REE by 12.4%. CONCLUSION Our quality improvement project suggests that the hand-held indirect calorimeter underestimated REE, and predictive equations overestimated REE in pediatric oncology nutrition assessment. Therefore, we recommend that these limitations in assessment be considered when assessing REE using a hand-held indirect calorimeter or predictive equations.

Nutrition Management of Children With Osteosarcoma

Children with cancer are at risk of developing nutrition deficiencies as a result of both disease progression and treatment. Providing timely and appropriate nutrition intervention is paramount to ...