Ruth Williams

Room Service Improves Patient Food Intake and Satisfaction With Hospital Food

Cancer therapy causes side effects that interfere with oral intake. Frequently, patients undergoing such therapy suffer from anorexia, nausea, vomiting, food aversions, dysgeusia, and xerostomia, all which adversely affect oral intake. Adequate nutrition intake is an important part of therapy for the cancer patient, especially when that patient is a child. Children who are well nourished are better able to withstand infection and tolerate therapy. Parents and staff at our hospital have worked diligently to improve patients oral intake with limited success. Hence, a multidisciplinary team was organized to develop a new approach to food services that would improve patients oral intake. The team initiated patient room service, and patients were allowed to call the kitchen when they were ready to eat. The system works much like room service in a hotel. After the introduction of room service, patients caloric intake improved significantly (P = .008), and protein intake increased by 18%. Patient satisfaction with hospital food service also improved; excellent ratings increased by as much as 35%. We conclude that room service is a viable alternative to traditional food services in the pediatric oncology setting and may be useful in other patient populations, such as maternity and general pediatrics.

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.

A Model for Making Outcomes Research Standard Practice in Clinical Dietetics

In todays rapidly changing health care environment, it is imperative that dietitians demonstrate the importance of their role as health care providers by initiating and participating in outcomes research. Patient care should be based on empirical studies, and clinical dietitians should participate in or be at the helm of such investigations. Nutrition research is usually accomplished and reported by persons with MD or PhD degrees who do not have clinical training in nutrition and does not often address situations encountered by dietitians in clinical settings. This article examines the extent to which clinical dietitians are conducting and reporting outcomes research, their attitudes about such research, and how they think they could best acquire the skills needed to incorporate outcomes research into their practice. Results indicate that clinical dietitians are not writing a substantial percentage of articles and that reports of outcomes research are not commonly included in clinical nutrition journals. Clinical dietitians appear to value the inclusion of research in clinical practice, but they are not spending a great amount of time doing research. Dietitians report being comfortable about participating in research but not about designing, conducting, and reporting research. Results from several surveys were used to develop a model for integrating research in clinical practice. This model includes the research process as a basis for clinical practice. A model for collaborative efforts between clinical and academic dietitians is also proposed and emphasizes the responsibility of academic dietetics training programs in the integration of research and clinical practice.

Complications and effectiveness of gastrostomy feedings in pediatric cancer patients

Purpose The objective of this study was to assess the complications and efficacy of gastrostomy (GT) feedings in pediatric cancer patients. Patients and Methods We reviewed the medical records of 33 pediatric cancer patients who received enteral nutrition via a GT. Results Median age was 9.4 years (range, 1–19.8 years), and 28 of the 33 patients had solid tumors. Seventeen patients had a significant weight loss (median, 8.5%) and therapy-related weight loss was anticipated in 16 patients. The GT device was placed an average of 5.5 months after diagnosis. Twenty-five patients were fed via a tube and eight via a button device. The tube was placed surgically in 21 cases (including all eight button types) and endoscopically in 12. Nutritional support lasted a median of 9.5 months. One or more complications occurred in 30 patients and were categorized as (a) insertion site reactions (inflammation, 23; infection/colonization, 14; exuberant granulation tissue, 6); (b) mechanical problems (leaking, 3; obstruction, 2; breakage, 1; accidental dislodgement, 2); (c) insertion site bleeding, 8; and (d) feeding intolerance, 12. Only one insertion site cellulitis progressed to a systemic infection. All eight patients with a button GT experienced insertion site complications, with local infection occurring significantly more often in patients with the button than in those with the tube GT. There were no significant associations between insertion technique and type of complication. Twenty-seven patients (82%) achieved or maintained ideal body weight with this intervention. Conclusions GT feeding was associated with minor complications, but permitted effective nutritional support for pediatric cancer patients.

Mutations in MFSD8/CLN7 are a frequent cause of variant-late infantile neuronal ceroid lipofuscinosis.

The neuronal ceroid lipofuscinoses (NCL) are a group of genetically heterogeneous neurodegenerative disorders. The recent identification of the MFSD8/CLN7 gene in a variant‐late infantile form of NCL (v‐LINCL) in affected children from Turkey prompted us to examine the relative frequency of variants in this gene in Italian patients with v‐LINCL. We identified nine children harboring 11 different mutations in MFSD8/CLN7. Ten mutations were novel and included three nonsense (p.Arg35Stop, p.Glu381Stop, p.Arg482Stop), four missense (p.Met1Thr, p.Gly52Arg, p.Thr294Lys, p.Pro447Leu), two splice site mutations (c.863+3_4insT, c.863+1G>C), and a 17‐bp deletion predicting a frameshift and premature protein truncation (c.627_643del17/p.Met209IlefsX3). The clinical phenotype, which was similar to that of the Turkish v‐LINCL cases, was not influenced by type and location of the mutation nor the length of the predicted residual gene product. As well as identifying novel variants in MFSD8/CLN7, this study contributes to a better molecular characterization of Italian NCL cases, and will facilitate medical genetic counseling in such families. The existence of a subset of v‐LINCL cases without mutations in any of the known NCL genes suggests further genetic heterogeneity.

Oral glutamine supplementation decreases resting energy expenditure in children and adolescents with sickle cell anemia.

Objectives:To determine the effects of orally administered glutamine on the resting energy expenditure (REE) and nutritional status of children and adolescents with sickle cell anemia. Methods:Twenty-seven children and adolescents (13 boys, 14 girls), 5.2 to 17.9 years old (median 11.0 years), received orally administered glutamine (600 mg/kg per day) for 24 weeks. Measures of REE and other nutritional parameters were compared at baseline and 24 weeks. Results:After 24 weeks, the patients’ median REE (kcal/d) decreased by 6% (P = 0.053) as indicated by the Harris Benedict equations and by 5% (P = 0.049) as indicated by the modified equations. Patients with less than 90% ideal body weight had even greater declines in REE after 24 weeks (P < 0.03 and 0.02, respectively). Improvements in nutrition parameters and in two amino acids in the plasma were observed. Conclusions:After 24 weeks of orally administered glutamine, children and adolescents with sickle cell anemia had a decrease in REE and improvement in nutritional parameters. Those who were underweight had a greater decrease in REE than those of normal body weight. Lowering REE may be an effective way to improve the growth of these children and adolescents.

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...

Characterizing dietary intake and physical activity affecting weight gain in kidney transplant recipients

Context— Weight gain after kidney transplantation affects 50% to 90% of kidney transplant recipients. Factors leading to weight gain in recipients are thought to include a change in lifestyle (eg, dietary intake and physical activity), age, race, sex, and immunosuppressant medications. Objective— To examine dietary intake and physical activity of kidney transplant recipients at baseline and 3 and 6 months after transplantation to identify contributing factors to weight gain. Design— Descriptive, correlational study using secondary data from a larger parent study examining genetic and environmental contributors to weight gain after kidney transplantation. Participants and Setting— Forty-four kidney transplant recipients at a mid-South university hospital-based transplant institute who had dietary intake, physical activity, and clinical data at baseline and 3 and 6 months were included. Main Outcome Measures— Dietary intake, physical activity, weight, and body mass index. Results— Mean weight gain increased by 6% from baseline to 6 months. Interestingly, dietary intake did not change significantly from baseline to 6 months. Hours of sleep per day decreased during the same period (P = .02). Dietary intake, physical activity, age, race, sex, and immunosuppression showed no significant relationship to weight gain at 6 months. Conclusion— Little consideration has been given to dietary intake and physical activity of kidney transplant recipients and the effects of these variables on weight gain. Further studies with a larger sample are needed, as weight gain after transplantation is a significant risk factor for diminished long-term outcomes.

A Comparison of Calorie and Protein Intake in Hospitalized Pediatric Oncology Patients Dining With a Caregiver Versus Patients Dining Alone: A Randomized, Prospective Clinical Trial:

Hospitalization and cancer therapy can contribute to decreased food intake in children and adolescents with cancer, making it a challenge to meet their nutritional needs. The affect of hospitalization and the eating environment for pediatric oncology patients has not been studied very well, and the effect of altering the social aspect of mealtime for hospitalized pediatric oncology patients has not been studied at all. The authors conducteda randomized, prospective clinical trial to determine if hospitalized pediatric oncology patients consume more protein and calories when eating with afamily member or when eating alone in their room at mealtime. All food and beverage intake was recorded for 3 consecutive days, and a food service satisfaction survey was completed on Day 3. Food records were analyzed for calorie and protein intake, and surveys were analyzed for patient/parent satisfaction. The study was completed by 200 hospitalized patients and their parent/caregiver. Overall, neither calorie nor protein intake differed significantly between the two groups, but patient/parent satisfaction was significantly higher in the group of patients who dined with their caregiver. By using analysis of variance, the authors found that ideal body weight and years of sickness were significantly associated with calorie and protein intake.

Comparison of Energy Prediction Equations with Measured Resting Energy Expenditure in Children with Sickle Cell Anemia

OBJECTIVEnTo determine the accuracy of energy prediction equations when compared with measured resting energy expenditure (REE) in children with sickle cell anemia. To develop a modified equation that more accurately estimates the energy needs of children with sickle cell anemia and to cross-validate these on a different set of patients (test patients).nnnDESIGNnREE was measured in children using indirect calorimetry and compared with predicted values using the Harris-Benedict and the Food and Agriculture Organization/World Health Organization/United Nations University equations (WHO).nnnSUBJECTS/SETTINGnEighteen patients participated in the original sample that compared predicted with measured energy expenditure. The modified equations were developed using the original 18 patients. A test population of 20 different patients was used to validate the modified equations.nnnSTATISTICAL ANALYSISnWilcoxon signed-rank test was performed to compare measured with predicted REE. The correlation analysis method and multiple linear regression method were used to develop 2 modified versions for the Harris-Benedict and WHO prediction equations.nnnRESULTSnWhen compared with the mean predicted REE using the Harris-Benedict and WHO equations, the mean measured REE was 14% and 12% greater than both (P=.005 and P=.014, respectively). Two modified equations were developed from the Harris-Benedict and WHO equations. Based on the data from the test patients, the mean measured REE was 15% greater than the mean predicted REE based on the Harris-Benedict and WHO equations (P=.0001 for both). When the modified Harris-Benedict and WHO equations were used, there was almost no difference in the mean measured REE and the mean predicted REE (mean difference using Harris-Benedict = 14, P = .9273; mean difference using WHO = -13, P = .6215).nnnCONCLUSIONnBoth energy prediction equations underestimated REE in children with sickle cell anemia. The 2 modified versions of the energy prediction equations that we propose predicted the energy needs of these children much more accurately; however, the modified equations need to be validated through application to other children with sickle cell anemia.