UNIVERSITY OF VIRGINIA HEALTH SYSTEM DIETETIC INTERNSHIP
Optimum Nutritional Management of Hospitalized
Pediatric Oncology Patients: A Case Series Based QI
Research Project
Andria M. Keating, RD Intern
Capstone Project Preceptor:
Allie E. Hubbard, RD
May 2013
Table of Contents
I.
Abstract……………………………………………………..
II.
Introduction…………………………………………………
4-5
III.
Literature Review…………………………………………...
6 - 34
IV.
Purpose of study……………………………………………
35
V.
Mixed Methods Case Series Study Methodology………….
36 - 39
VI.
Results……………………………………………………....
40 - 74
VII.
Discussion…………………………………………………...
75 - 79
VIII.
Conclusion and Recommendations………………………….
80 - 81
IX.
References……………………………………………………
82 - 85
X.
Appendix A: Nutritional Assessment…………………………. 86 - 87
XI.
Appendix B- Pediatric Oncology Nutrition Data Form………. 88
XII.
Appendix C- UVA Health System Interview Guide………...... 89 - 94
XIII.
Appendix D: Algorithm for Nutritional Intervention…………. 95
1
2-3
ABSTRACT
Introduction - As medical advancements in the field of pediatric oncology have developed,
the overall survival rate for this population has improved and focus has shifted to the increased
importance of supportive care treatments for children with cancer. Unfortunately, despite
medical advancements, pediatric oncology patients remain susceptible to malnutrition due to risk
of rapid weight loss, which can lead to a poor prognosis. The implementation of timely and
adequate nutritional support, when indicated, is important in promoting optimal nutrition status
and quality of life for patients. Nutritional support is often given to the children with inadequate
nutritional intake in the form of enteral nutrition (EN) or parenteral nutrition (PN) support.
Purpose - The purpose of this mixed methods study performed at University of Virginia
Health System (UVAHS) was to evaluate the nutritional management of pediatric oncology
patients using a case study approach, and to identify the barriers to providing optimal nutrition
support for the three selected patients.
Methods- Data collection began in February 2013 and included the selection of specific
pediatric cancer patients who received EN and PN support. A total of 3 patients were selected by
the UVAHS Pediatric Oncology RD. Selection criterion for the hospitalized patients were based
on the following: a) UVAHS pediatric oncology patient and b) patients receiving long-term
nutritional support via EN or PN feedings. The mixed methods case series involved quantitative
data collection through the UVAHS EPIC electronic medical record system. Quantitative data
collection identifies barriers to providing optimal nutrition support due to complications of
symptom management which may arise from treatments the patients are receiving and also the
2
slow initiation of nutrition support. Qualitative research was also conducted through interviews
with various members of the pediatric oncology health care team.
Results - The quantitative data obtained from our study identified the importance of choosing
the appropriate method for providing nutrition support whether via TPN versus EN. Improved
weight maintenance was demonstrated by the quantitative data collection for a patient receiving
a g-tube placement prophylactically prior to treatment. The qualitative data identified
inconsistent initiation of nutrition support, further supporting the benefit of protocols regarding
the initiating and advancing adequate nutrition support. Each of the health care professionals
identified the lack of protocols regarding the initiation of nutrition support as a barrier to
initiating and optimizing nutritional support delivery. The data from our study suggests nutrition
management is not consistently being carried out per those guidelines despite timely and
repeated RD recommendations. The outpatient clinic was identified as an area where nutrition
management is lacking, and that the presence of the RD in clinic would be beneficial.
Conclusion - Ultimately the quantitative and qualitative together identify a pattern of
insufficient nutritional support provided to the three patients reviewed for the case series study.
The findings from the qualitative and quantitative results suggest the need for quality
improvement in providing optimal nutritional support for our pediatric oncology patients at
UVAHS Children’s Hospital, potentially through the establishment of nutrition support
protocols.
3
INTRODUCTION
According to a 2007 study by the National Cancer Institute, an estimated 10,400 children
under the age 15 were diagnosed with cancer and about 1,545 children died from the disease in
the United States. These statistics make cancer the leading cause of death by disease among
children 1 to 14 years of age in the United States. 1 Cancer is a disease in which the cells begin to
multiply uncontrollably. Abnormal production of cells results in loss of control during growth,
absence of differentiation, attack of native tissues, and the possibility of metastasis. Cancer can
develop in one or more tissues or organs.1 Healthy division of DNA within cells requires tumor
suppressor genes to help slow the cell growth. However, in the division of cancerous cells the
tumor suppressor genes are turned off, and the cells cannot detect uncharacteristic defects.
Therefore, the DNA is left vulnerable for alterations or damages in the cell structures.1
Pediatric oncology patients are susceptible to malnutrition due to rapid weight loss,
which can lead to a poor prognosis. The implementation of timely and adequate nutritional
support when indicated is important in promoting optimal nutrition status and quality of life for
patients. Nutritional support is often given to the children with inadequate nutritional intake in
the form of enteral nutrition (EN) or parenteral nutrition (PN) support 1. The enteral route is
typically preferred as it is the safest way for the provision of nutrients in children with an
undamaged and functional gastrointestinal (GI) tract, and prevents intestinal atrophy, toxicity,
and complications of intravenous infusion.1 However, there are few randomized prospective
clinical trials exploring the benefits and consequences of nutritional support for the pediatric
population, and further research is needed to establish guidelines for the optimal implementation
and efficacy of nutritional interventions.1 This mixed methods study performed at University of
4
Virginia Health System (UVAHS) evaluated the nutritional management of the pediatric
oncology population using a case study approach in order to identify the barriers to providing
optimal nutrition support for pediatric oncology patients.
5
LITERATURE REVIEW
Overview of Cancer and Treatments in Pediatric Patients
The leading cause of death for children under the age of 15 years is pediatric cancer. It is
estimated that 11,630 children in the United States under the age of 15 years old will be
diagnosed with cancer in 2013.42 An estimated 1,310 children are expected to die from cancer in
2013. 42 One third of the deaths will represent children with leukemia.42 Fortunately, the event
free survival rate for children who have received a cancer diagnosis is nearing 75 percent, and
the overall mortality rates for children with cancer has declined by 68% in the last four decades.
3,42
Most Common Pediatric Cancers
The most prevalent cancers affecting children are leukemia, central nervous system
(CNS) tumors and lymphoma.4-5 Leukemia is the most common pediatric cancer accounting for
approximately 28-30% of total cancer diagnoses.4, 6 Brain and CNS tumors are the next most
prevalent pediatric cancer, followed by lymphoma.4-7 An overview of the incidence of the most
common forms of cancers in children can be found in Figure 1.
Leukemia is a cancer in the blood-forming tissues of the body.7 There are two variations
of leukemia: acute lymphatic leukemia (ALL) and acute myelogenous leukemia (AML). ALL is
a cancer of the blood and bone marrow in which too many bone marrow stem cells develop into
white blood cells called lymphocytes.8 Most treatment plans utilize chemotherapy in the fight
against ALL but some cases also warrant the use of radiotherapy.8 ALL has an 83.8% five year
survival rate. 5AML is the most common form of acute leukemia accounting for 15% of all
childhood cancers.9 Modern induction chemotherapy is used to treat AML and results in a
remission rate of 50-90%.5 AML has a 56.7 % five-year survival rate.5
6
Brain tumors are the largest group of solid tumors in children.7 Medulloblastoma is a
brain tumor that begins formation in the cerebellum and then metastasizes via the cerebrospinal
fluid 11. Medulloblastoma is the most common embryonic brain tumor representing 20% of
intracranial neoplasms in the pediatric population, and mainly affects children younger than 15.11
Current treatment for medulloblastoma consists of surgical resection followed by a course of
radiotherapy, craniospinal radiotherapy, and chemotherapy.11 Brain tumors such as
medulloblastoma have an 85% five year survival rate.41.
Lymphoma, another type of blood cancer, is most common in children below the age of
15 years. There are two different types of lymphoma: Hodgkin’s (HL) and non-Hodgkin’s
lymphoma (NHL).12 HL is a highly curable malignancy, which can be cured with radiation
therapy, chemotherapy, or a combination of both.13 NHL is the infiltration of malignant B cells
or T cells in the lymph system and is also treated through the use of radiation, chemotherapy, or
both, depending on the disease type and stage. 14 Radiation is highly effective when used to treat
lymphoma, resulting in a 96% survival rate, which is the highest survival rate among all pediatric
cancers.10
7
Figure 1: Childhood Cancer Incidence Rates. 5
Common Cancer Treatments in Pediatrics
Pediatric cancer requires a multimodal treatment approach to provide effective treatment
for the patient.2 The most frequently occurring methods of treatment are surgery, radiation,
chemotherapy, and hematopoietic stem cell transplantation (HCST).10 However, these treatments
can often nutritionally deplete the patient. Intensive courses of treatment can place the child at
risk for acute malnutrition due to their limited nutrient stores and increased demands for growth.2
Often, the treatments for pediatric cancer can cause side effects that inhibit adequate nutritional
intake. Common side effects associated with cancer treatments may include diarrhea, nausea,
vomiting, mucositis, pain, fatigue, early satiety, xerostomia, and loss of taste.2
Chemotherapy: Chemotherapy is used in the treatment of cancer by inhibiting DNA
synthesis of both the normal tissues and the malignant cells present in the child.16 Common side
effects from chemotherapy treatment can disrupt the nutritional management of the pediatric
8
patient due to nausea and vomiting, mucositis, hepatic insufficiency, renal failure, fluid retention,
diarrhea, flu-like syndrome, dehydration, ileus, constipation, hypertriglyceridemia, xerostomia,
pancreatitis, and hypercalcemia.16 However, the severity of the side effects depend upon the
precise medication, dosage, duration, rate of metabolism, and the predisposition of the child. 16
Furthermore, the use of chemotherapeutic agents in children can lead to malabsorption and
changes made to the gut flora, which ultimately may result in unintended weight loss or frequent
diarrhea.16 Table 1 below reviews the nutritional implications of the common chemotherapeutic
agents.
9
Table 1. Common Chemotherapeutic Agents and their Nutritional Implications17
Drug
Antitumor Spectrum
Nutritional Implications
Cisplatin
Testicular and other germ cell
tumors, brain tumors,
osteosarcoma, neuroblastoma
Nausea and vomiting, renal
insufficiency
Cyclophosphamide
Lymphomas, leukemia,
sarcomas, neuroblastoma
Nausea and vomiting, fluid
retention
Cytarabine
Leukemia, lymphomas
Nausea and vomiting,
mucositis, flu-like syndrome
Methotrexate
Leukemia, lymphomas,
osteosarcoma
Mild mucositis, hepatic
insufficiency, renal failure
ALL, AML, Lymphomas,
most solid tumors
Nausea and vomiting,
mucositis, diarrhea
Etoposide
ALL, AML, lymphomas,
neuroblastoma, sarcoma, brain
tumors
Vincristine
ALL, lymphomas, most solid
tumors
Nausea and vomiting,
mucositis, diarrhea,
Syndrome of Inappropriate
Antidiuretic Hormone
Secretion (SIADH),
constipation
Alkylating Agents:
Antimetabolites:
Antitumor Antibiotics:
Doxorubicin
Plant Product:
Radiation Therapy: Radiation therapy can be used in combination with surgery and
chemotherapeutic agents as part of an overall treatment plan.16 Radiation therapy works by
destroying the genes of malignant cells along with the abnormal tissues that are replicating. 16
10
Ultimately the cancerous cells are killed by the radiation treatment and the tumorous mass will
shrink.16 Radiation therapy can have deleterious side effects on the child depending on the
region of the body radiated, dose, fractionation, length of time, and field size of the radiation
administered as well as the use of other antitumor therapies, and the overall initial nutritional
status of the child.16 Table 2 demonstrates the common nutrition-related implications in relation
to the location of the radiation therapy provided.
11
Table 2: Nutritional Implications of Radiation Therapy and the Nutritional Side Effects17
Radiation Site
Nutritional Side Effects






























Central nervous system:
Brain and Spinal Cord
Head and neck:
Tongue, Larynx, Pharynx, Oropharynx,
Tonsils, Salivary Glands
Abdomen and Pelvis:
GI Tract, Reproductive Organs, Rectum,
Colon, Testicles
Total body radiation:
Anorexia
Nausea and vomiting
Fatigue
Alterations in pituitary functions
Growth Failure
Nausea
Sore mouth and throat
Mucositis, esophagitis
Fatigue
Loss of appetite
Altered taste and smell
Tooth decay
Altered salivation
Dysphagia
Nausea and vomiting
Diarrhea
Steatorrhea and malabsorption
Fluid and electrolyte imbalances
Abdominal Cramping
Bloating
Gas
Enteritis and Colitis
Lactose Intolerance
Fatigue
Loss of appetite
Nausea, vomiting, diarrhea
Mucositis, esophagitis
Altered taste acuity and salivation
Anorexia
Delayed growth and development
Surgery: Surgery, which is most often used as a part of the treatment plan to obtain a
biopsy and then for possible removal of the tumor or organ affected by the cancer, results in
additional complications impacting nutritional status.10 The complications that often arise as a
result of surgical treatment can include insufficient oral energy and protein intake. Surgical
12
treatment may result in the inability to absorb nutrients efficiently depending upon the location
of the resected tumor.16 Postoperative complications that can arise from the removal of tumors
located in the GI tract or intraperitoneal organ surgery may result in impaired swallowing
function, the deterioration of gastric emptying, and an ileus of the small bowel.17 The nutritional
status of the child can determine the overall outcome of treatment for surgical recovery. A wellnourished child prior to surgery will have fewer surgical complications compared to those with
preoperative malnourished status. The child with a preoperative malnourished status will have
difficulty with improved wound healing and complications could result in increased risk for
morbidity and mortality.17
Effects of Malnutrition on Cancer: Outcomes, Survival, and Recurrence
Malnutrition in cancer patients is associated with a poor prognosis, and weight loss is an
important predictor of mortality.18 Malnutrition discovered at diagnosis exists in between 6% to
50% of the patients and is dependent upon the histology, stage of disease, and location of the
cancer.17 The side effects of malnutrition may include tissue wasting, anorexia, weakness,
anemia, hypoalbuminemia, and skeletal muscle atrophy. 17 Malnutrition that is associated with
protein and calorie malnutrition is associated with a higher incidence of infection, decreased
tolerance of chemotherapeutic treatments, and overall diminished quality of life.17 Malnutrition
has also been linked with delaying therapy which ultimately increases a child’s risk for relapse.18
All patients who are battling cancer should undergo nutritional screening to identify the presence
of malnutrition and to determine the proper method of nutritional intervention.
Physiology of Cancer Cachexia and Its Impact on Nutrition Status
Cancer cachexia is a syndrome where the body is unable to absorb, metabolize, and
utilize essential nutrients, manifesting in unintentional weight loss.19 The pathophysiology of
13
cachexia has not been clearly defined, but may be caused by the outcomes of immunologic and
humoral neuroendocrine abnormalities. The physiological stress caused by cachexia can alter
body composition and cause metabolic alterations in carbohydrate, lipid, and protein absorption
and metabolism.17 Alterations in absorption of macronutrients will lead to weight loss due to the
wasting of muscle and adipose tissues, which can induce inadequate intake and anorexia.17
Cytokines, produced by the cells of the immune system, control the feeling of satiety and
gastric emptying in children. Children with cancer have higher concentrations of cytokines,
contributing to the nutritional implications of cancer cachexia.17 Laboratory investigations
determined the release of cytokines during cachexia is similar to the stimulatory or inhibitory
effects of neuropeptides.18 Leptin is secreted by the adipose tissue which stimulates the release of
anorexigenic compounds and inhibits the release of an appetite stimulant known as neuropeptide
Y.18 An abnormal presence of serum leptin has been found in children with cancer.18 Table 3
reviews the role of cytokines with the response of metabolic hormones during the process of
cancer cachexia.
Table 3: The Role of Cytokines and Hormones in Cancer Cachexia17
Cytokine
Tumor Necrosis Factor
Interleukin-1
Interleukin-6
Interferon
Peptide YY
Ghrelin
Effect on Nutrition
 Suppresses lipoprotein lipase, increases corticotropinreleasing hormone which suppresses food intake
 Blocks neuropeptide Y induced feeding; increases
corticotropin releasing hormone
 Induces cachexia and acute phase proteins in animal models
 Induces cachexia; INF-g antibodies reversed wasting
 Levels increased with greater disease burden; inverse
correlation with BMI
 Low values associated with greater disease burden
14
Pediatric oncology patients can experience significant metabolic changes as a result of
cancer cachexia that may result in growth failure including altered metabolism and negative
energy balance.18 Alterations in metabolism due to cancer can affect each of the three
macronutrients: carbohydrates, proteins, and lipids.19 The changes associated with carbohydrate
metabolism can include the process of glucose uptake and lactate production by the tumor,
hypoinsulinism, and insulin resistance. Protein metabolism is affected by the tumor burden by
altering uptake of amino acids. There may also be an association with decreased protein
synthesis in muscle tissue as protein turnover is increased and protein synthesis is decreased in
pediatric oncology patients; this effect may vary throughout the course of the child’s disease.1,18
Lipid metabolism is often less affected than the other macronutrients. However, the depletion of
fat stores is higher in pediatric oncology patients due to increased lipolysis.1 Furthermore,
children with pediatric cancers have increased resting energy expenditure which may lead to the
presence of cachexia. Some research suggests that the change in basal metabolic rate is related to
increased protein synthesis during certain stages of their cancer.18 Figure 2 further presents the
pathophysiology of cancer cachexia.
15
Figure 2: The Pathophysiology of Cancer Cachexia44
Cancer
Chemotherapy
Anorexia
Malabsorption
Food intake
Lean Body
Mass & Fat
Mass
Pro Cachectic
Factors
Proteolysis
Lipolysis
Weight Loss
Cachexia
Risk of Malnutrition during Cancer Treatment
Malnutrition is a common complication in the medical management of the pediatric
oncology patient that affects the patient’s energy levels and overall quality of life.20
Approximately 40-80% of children become malnourished during their cancer treatments due to
the aggressive nature of the treatment protocols and their negative side effects.17 A child with
poor nutritional status is at higher risk for decreased immune function, delayed wound healing,
and disturbances in the metabolism of drug therapies; it can also lead to poor tolerance of the
therapy.1,10
A retrospective study of 455 children with different malignancies was conducted utilizing
the weight-to-height ratio prior to receiving therapy. The study concluded that the patients had
<80% of age-adjusted decreased significantly for survival after treatment. Children with a
16
localized disease had a difference of 30% for the survival of well-nourished patients post 36
months after treatment. The patients that had a compromised state of nutrition prior to the
implementation of treatment had a significant association with relapse post therapeutic treatment
for patients with solid tumors.20
Malnutrition: Definition and Assessment
Malnutrition is the pathological state that results from inadequate nutrition and includes
under nutrition, over nutrition, and deficiencies of micronutrients. Protein and energy
malnutrition is an example of under nutrition, and is the most common form of malnutrition
associated with cancer patients.5 Malnutrition often presents itself as tissue wasting, anorexia,
weakness, anemia, hypoalbuminemia, and skeletal muscle atrophy.5
Children with cancer should be screened for nutritional risk at initial diagnosis and
followed closely throughout treatment for the prevention of protein and energy malnutrition.5
The pediatric patient’s weight, length or height for age, head circumference, and body mass
index should be assessed using the appropriate World Health Organization (WHO) growth chart
for infants less than 2 years of age and the National Center for Health Statistics / Center for
Disease Control (NCHS/CDC) growth chart for those children older than 2 years. The WHO
recommends the weight-for-height index to assess the nutritional status of children and
adolescents.1
The Waterlow criteria should be used to determine the child’s level of malnutrition using
the following equation:28
% standard= actual weight measure/ expected weight measure (50th percentile)
17
The percent standard can then be utilized to assess the degree of acute or chronic malnutrition.
Table 4 below reviews the standards for classifying a child with mild, moderate, or severe
malnutrition using the Waterlow criteria.
Table 4: Waterlow criteria for assessing nutrition status in pediatric patients18
Acute Malnutrition
Chronic Malnutrition
(Current weight/50th percentile (Current height/50th percentile
weight for height)
height for age)
>0.90
>0.95
Stage 0
Stage 1 (mild malnutrition)
0.80-0.90
0.90-0.95
Stage 2 (moderate
malnutrition)
Stage 3 (severe malnutrition)
0.70-0.79
0.85-0.89
<0.70
<0.85
Furthermore, physical signs of malnutrition can be identified during a nutrition-focused
physical exam. Table 5 demonstrates the current physical signs to identify when assessing the
child’s nutritional status.
18
Table 5: Clinical Assessment of Malnutrition in Children: Physical Signs of Nutrient
Deficiencies18
Physical Signs
Nutrient Deficiency
General appearance: edema, muscle wasting,
decreased subcutaneous fat, growth failure
Hair: dull, dry, may be thin and sparse, easily
pluckable, color changes
Eyes: Pale and dry membranes, or red and
inflamed membranes, Bitot’s spots, corneal
xerosis (dull and hazy) or scarring, cracking in
the corner of the eyes
Lips: Redness and swelling, angular stomatitis
Protein, calories
Tongue: Swelling (glossitis), raw tongue,
magenta or purplish in color, smooth tongue,
sores
Teeth and Gums: May be missing teeth, bad
color and visible decay or cavities, spongy,
swollen and bleeding gums, recession of gums
Cardiovascular system: tachycardia, enlarged
heart, abdominal heart rate or rhythm
GI System: spleen or liver enlargement, GI
dysfunction
Riboflavin, niacin
Protein, calories
Vitamin A, iron, folate
Niacin, riboflavin, vitamin B 6
Fluoride, Vitamin C
Potassium, selenium, phosphorus, thiamine
Protein, calories
Nutrition Side Effects and Recommendations for Management
Overcoming the nutrition-related side effects of cancer treatment is a crucial step
in preventing the development or worsening of malnutrition. As previously mentioned, common
treatment-related side effects include nausea, vomiting, anorexia, mucositis, diarrhea, and
dysguesia.18 An overview of the most common side effects is reviewed below, and Table 6
offers nutritional strategies for combating the various symptoms associated with the treatmentrelated side effects of pediatric cancer.
19
Nausea and Vomiting: Chemotherapy-induced nausea and vomiting can cause significant
effects on achieving adequate nutritional intake. Uncontrolled nausea and vomiting can cause the
patient to experience complications such as dehydration, electrolyte imbalance, and physical
complications.21 The medical team should ensure management of the nausea and vomiting by
implementing a prophylactic antiemetic regimen for every cycle of chemotherapy.21 The
common treatments for the management of nausea and vomiting can include the antiemetic
medications of Promethazine, Ondansetron, and Metoclopramide.5 Eating smaller more frequent
meals, avoidance of overly sweet or high fat foods, avoiding unpleasant cooking odors,
encouragement of drinking or sipping liquids frequently throughout the day, consumption of
high carbohydrate foods and fluids, and finally avoidance of offering favorite foods during
periods of nausea as this may cause permanent dislike of the food are ways to combat the
inhibition of adequate nutritional intake during episodes of nausea and vomiting.5
Anorexia: Anorexia is the loss of appetite or inability to eat. Many cancer patients
experience this prior to diagnosis and during treatment of the disease.22 The loss of appetite in
patients with cancer-related anorexia can be due to a number of possible side effects of
chemotherapy treatments.23 A proposed cause of anorexia during chemotherapy treatment is
believed to be related to the effects of inflammatory cytokines on the hypothalamus that causes
changes in the balance of neurotransmitters, resulting in the stimulating or inhibition of food
intake. A healthy appetite relies on the balance of the appetite stimulating neurotransmitters
leptin and ghrelin; leptin inhibits appetite whereas ghrelin simulates appetite.19,23 Eating six
times a day, finishing what you started eating, “power packing” foods by adding extra cheese,
gravy, margarine, or sauce so that each bite counts, and consuming oral nutrition supplements
are ways to combat anorexia and improve nutritional intake.23
20
Mucositis: Mucositis is the inflammation of the oral mucosa that can develop
subsequently after the patient receives chemotherapy treatment.25 Swelling of the tissues can
cause the patient to experience painful mouth sores that can inhibit their nutritional intake and
can lead to development of infections in the mouth.25 Oral mucositis can be treated with
analgesics to reduce pain, and nutritional supplements can be provided to optimize caloric intake
when inhibited. 25 Patients with mucositis should avoid spicy, acidic, and hard foods, and hot
food/beverages due to the potential of irritation.25 Parenteral nutrition may be indicated if a
patient is unable to receive enteral nutrition due to severe inflammation, lesioning, ulceration and
bleeding in the oral cavity, esophagus, and lower GI tract.25
Diarrhea: Chemotherapy-induced diarrhea is a common side effect of cancer treatment
and is defined as the passing of three or more liquid stools per day.42 Chemotherapy damages
dividing cells that line the interior of the digestive tract and leads to disruption of fluid balance in
the cells, as the absorption of fluid from the GI tract into the body is decreased but fluid in the
stool is increased.42 Diarrhea can be severe enough to result in fluid and electrolyte losses that
can potentially cause life-threatening dehydration, electrolyte imbalances, and renal
insufficiency.42 Diarrhea is associated with an increased risk of infectious complications in
children experiencing neutropenia.42 Children experiencing diarrhea during their chemotherapy
treatment may need to be placed on a probiotic treatment. A standard dose of loperamide is often
given to children experiencing diarrhea along with avoidance of high fat or dairy containing
foods to resolve diarrhea episodes. 42
Dysgeusia: Dysgeusia is the altered sensation of taste and can be unpleasant for the
child.26 The papillae in the oral cavity contain taste buds that are lined with taste receptors,
which are the only epithelial cells that use neurotransmitters to transmit taste sensations to the
21
nerve fibers. Chemotherapy works to rapidly kill the division of cancerous cells but it can affect
the normal healthy cells in the oral cavity as well. 26 This damage to the taste receptors results in
dysgeusia. Patients often describe the taste changes as metallic, bitter, or a lack of taste during
consumption of foods.26 Patients experiencing the symptoms of dysgeusia will have disruptions
in appetite and digestion.26
Table 6: Nutrition Strategies for Symptom Management18
Symptoms:
Nausea/Vomiting
Anorexia
Mucositis
Diarrhea
Dysgeusia
Dietary Intervention Strategies:
Small frequent meals, high carbohydrate content, non-acidic beverages,
cold clear foods and beverages, avoid extreme temperatures and highly
seasoned items, avoid high-fat content items.
Small frequent meals, nutrient-dense foods and supplements, carbohydrate
and protein modular, create a pleasant atmosphere, dine with the child, and
vary colors/flavors/textures of foods.
Soft diet, smooth bland moist foods, frozen slushes/ice/ice cream, high
calorie liquid beverages
Low fat, cold, or room temperature foods, avoid caffeine, encourage
adequate fluid intake
Herbs, spices, and marinades, cold non-odorous foods, fruit-flavored
beverages, good oral hygiene, mint mouthwashes, lemon-flavored
beverages and sour candies
Some less common complications that arise from various cancer treatments may also lead
to comprised nutritional status and may require nutrition support, including constipation, gastritis
and typhlitis.27
Determining Nutritional Needs During Cancer Treatment
The primary goal for the nutrition management of children and adolescents undergoing
cancer treatment is to sustain and promote normal growth and development.26 All patient care
providers play a key role in assuring that the necessary nutritional care is provided as part of the
22
overall treatment plan so that optimal outcomes for every child, adolescent, or young adult
diagnosed with cancer can be reached.
Determining nutritional needs of the pediatric oncology patient should be influenced by
the following considerations: providing adequate nutrition for the preservation of lean tissue and
to promote normal growth and development, identifying and correcting the effects of protein and
energy malnutrition and metabolic abnormalities, and maximizing quality of life for the patient.16
Determining Nutritional Requirements
The nutrient needs for pediatric oncology patients are difficult to assess because they are
affected by the nutritional status, disease state, and therapy protocols. Energy requirements
should be based upon the child’s age, weight, gender, therapy, and growth needs.16 Children with
cancer should have their caloric needs estimated using the Basal Metabolic Rate (BMR)
multiplied by an appropriate stress factor. Protein requirements are increased in children with
cancer to minimize the loss of lean body mass and promote tissue repair.18 Table 7 below
provides the basal energy needs for children. At the very minimum, even in critically ill states
requiring intensive care unit admission, children with cancer should receive a minimum of their
basal energy needs. However, in general to optimize growth and outcomes, energy and protein
needs should be optimized well above the basal energy requirements. Table 8 provides the
recommended estimated nutrient needs for a child with cancer.
23
Table 7: Table Basal Energy Needs for Infants and Children 28
24
Table 8: Nutrient Requirements During Childhood Cancer28
Nutrient
Requirements
Calories
Recommendations

Infants: Birth to 12 months: Use RDA for age for appropriate
weight infants. Use catch-up growth calculation if underweight:
(kcal/kg/day=kcal/kg/day for weight age x ideal weight age (kg) /
actual weight in kg)

Older children (>1 year): Use BMR table multiplied by additional
factors:
a)
b)
c)
d)

Appropriate weight for height: BMR x 1.6
Obese: BMR x 1.3
Sedentary with 5% weight loss: BMR x 1.4-1.6
10% weight loss from usual weight or weight is 90% or
less of usual or ideal weight: BMR x 1.8-2.0
Use adjusted weight calculation for obese children; BMI weight at
the 75th percentile may also be used to calculate energy needs in
obese children

HSCT: BMR x 1.6 during immediate post-transplant course; BMR
x 1.4 following engraftment and medically stable.

Infants birth to 6 months: 3 g/kg/day

Infants 6 to 12 months: 2.5-3 g/kg/day

Children: 2-2.5 g/kg/day

Adolescents with increased lean body mass: 1.5-1.8 g/kg/day
Fat

10-30% total calories
Fluid

1-10 kg: 100 mL/kg/day

11-20 kg: 1000 mL plus 50 mL for every kg > 10 per day

21-40 kg: 1500 mL plus 20 mL for every kg > 20 per day

> 40kg: 1500 mL/m^2 body surface area
Protein
25
In addition, when epithelial cells are damaged in the GI tract due to radiation therapy, surgical
removal of localized tumors, and long-term use of antibiotics, this may further increase the needs
for vitamin and minerals in the pediatric oncology patient.16
However, at this time, recommendations for vitamin and mineral intake specifically
geared towards the pediatric oncology patient have not been determined and current practice
should be based upon the Dietary Reference Intakes.16 An age specific multivitamin with mineral
supplement is recommended.16 The use of corticosteroids treatment in the children diagnosed
with ALL and NHL that developed complications from HSCT such as Graft-Versus-Host disease
places the child at higher risk for osteopenia and fractures.16 Children undergoing HCST may
also require additional vitamin C due to the need for tissue recovery with collagen biosynthesis.16
Table 9 presents the nutrient requirements that are needed during childhood cancer.
Table 9: Nutrient Requirements During Childhood Cancer28
Vitamins
Minerals and electrolytes

Use ASPEN parenteral vitamin guidelines for age

After PN discontinued, oral multiple vitamin/mineral
without iron, during antineoplastic therapy

Provide additional vitamin C during HCT:
a) < 31 kg, additional 250 mg vitamin C per day
b) > 31 kg, additional 500 mg vitamin C per day
Iron supplementation contraindicated during oncologic
therapy and HCT



Eliminate copper and manganese from PN in presence
of hepatic dysfunction (ie, serum bilirubin > 10.0 mg/dl
Closely monitor serum electrolytes during therapy
26
Approach for Nutritional Management in Pediatric Cancer Patients
The Academy of Nutrition and Dietetics (AND) and the American Society for Parenteral
and Enteral Nutrition (ASPEN) have described the nutrition care process in depth.18 This process
contains four steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition
monitoring and evaluation.18 There is a clear link between screening and identification of
nutrition risk.15 Nutrition assessment is of the utmost importance to helping to design optimal
nutritional interventions. 15
The 2002 ASPEN guidelines state “Patients with cancer are at nutrition risk and should
undergo nutrition screening to identify those who require formal nutritional assessment with
development of a nutrition care plan.”29 The pediatric oncology registered dietitian (RD) plays a
vital role in the nutritional management of the patient. The RD is an important member of the
interdisciplinary team that includes physicians, registered nurses, speech language pathologists,
occupational therapists, and physical therapists.29 The RDs at UVAHS have developed the
Pediatric Nutrition Standards of Care for pediatric cancer patients.
The pediatric RD must screen the patient for the nutritional risk, and nutrition
assessments should include a food and nutrition related history that incorporates a 24-hour recall,
hospital intake/output records, 3-day food log, or calorie count.5 Appendix A provides detailed
outline of pertinent information that must be collected for the food and nutrition related history.
In addition to the food and nutrition-related history, the pediatric RD must obtain the
anthropometric measurements to better assess the child’s nutritional status. Key anthropometrics
include length or height, weight, weight change, body mass index, and growth pattern
indices/percentile ranks.5 As previously mentioned, the 2006 WHO growth curves should be
27
used for children <24 months of age and NCHS/CDC curves for > 24 months of age.5
Recumbent length should be used until 2 years of age, and then standing heights should be
utilized for children above 2 years of age.5 The Waterlow criterion is currently used at UVAHS
to assess the nutritional status in the oncology pediatric patient.28
The Pediatric Nutrition Standards of Care give standards for the collection of biochemical
data, medical tests, and procedures.28 The RD should evaluate the basic metabolic panel,
magnesium, and phosphorus for patients on nutritional support.28 Additionally, pediatric patients
with increased GI losses, alterations in absorption, or individuals with potential tumor lysis
syndrome should have their renal profile assessed, in addition to a comprehensive metabolic
panel.28 Liver function tests should be used to evaluate hepatic function for patients on
nutritional support that are at higher risk for toxic chemotherapy or medication regimens.15
Patients on PN support should have their serum triglycerides checked as well.15 Additionally,
blood glucose and endocrine profiles should be checked for patients on steroid therapy with
elevated serum blood glucose.15 Finally, serum levels for C-reactive protein can be used in
conjunction with prealbumin as an indicator for disease acuity, and should be used to assess the
inflammatory process.15
Using the information gleaned from the nutrition assessment, the RD is able to determine
an appropriate nutrition-related diagnosis that will ultimately drive their recommendations for
intervention. Common diagnoses for the pediatric oncology patient population are presented in
Table 10.
28
Table 10: UVA Health System Common Diagnoses28
Problem
Intake
Inadequate protein-energy
intake (5.3)
Clinical
Unintended weight loss (3.2)
Etiology
Signs and Symptoms
EN or PN infusion not yet
optimized
Infusion providing ___ % of
goal
Mismatch between energy
needs and energy intake,
decreased ability to consume
sufficient energy
Anthropometric
measurements, parenteral
report of weight loss or report
of change in usual intake
Early intervention by the pediatric RD is important for the effective management of
nutrition issues in cancer patients.17 RDs are available as a resource to the child and the family to
explain the implications of cancer and its treatment on nutritional status.18 Moreover, the RD can
work with the patient and family to help overcome the nutrition-related side effects of the
patient’s treatment regimen, as previously discussed. If oral intake is inadequate, the RD is
responsible for developing appropriate nutrition support recommendations to better meet the
child’s nutritional needs.
Nutrition Support in the Pediatric Oncology Patient
An important component for the medical treatment of pediatric oncology patients is
utilizing nutrition support when appropriately indicated.15 The goal of nutrition support is to
provide adequate nutrients to meet the demands of the growth and development, and also to
reverse the possibility of protein-calorie malnutrition. The use of nutritional support for patients
that are malnourished with inadequate oral intake will improve nutritional intake and outcomes.15
If the patient is unable to meet their needs orally, nutrition support may be provided via EN or
PN.15 The type of nutrition support initiated should be based upon the specific needs and
conditions of the patient.
29
Enteral Nutrition Support
Enteral nutrition support is nourishment given through a tube or stoma directly into the
GI tract.15 EN can be administered via a nasogastric, nasojejunal, or percutaneous endoscopy
gastrotomy tube.17 The benefits of utilizing EN in the pediatric oncology patient includes
protecting the gut integrity and preventing bacteria translocation. In patients with a functioning
GI tract, EN is preferred over PN because of the proven efficacy while decreasing the risk of
infection for the child.17
The use of EN in cancer patients has been shown to improve their appetite and energy
intake, as well as improve their nutritional status. EN has also demonstrated a notable reduction
in GI toxicity from cancer therapies due to a better response from treatment.31,41-42 EN has also
been associated with decreased risk of infections and liver abnormalities, as well as maintenance
of the gut mucosa.18
Formula selection and method of administration should be individualized based on
individual patient tolerance. In general, the lower osmolality in unflavored enteral formulas is
better tolerated among pediatric cancer patients and should be used as the source of EN.
Furthermore, due to lactose-intolerance resulting from chemotherapy, some patients may benefit
from a lactose-free product that is predigested or elemental.18
Feeding schedules utilized in the clinical setting may include the use of continuous
infusion, an intermittent bolus, or a combination of both.18 Children experiencing GI
intolerances may benefit from continuous feeds which may improve gastric emptying and reduce
nausea, vomiting, abdominal cramping, and diarrhea.18 Continuous EN may be initiated with a
full strength formula at a rate of 1-2 milliliters per kilograms per hour (mL/kg/hr) and advanced
30
by 1-2 mL/kg/hr as tolerated by the child.18 Intermittent bolus feeds provide a feeding schedule
that closely resembles the physiology of normal feeding, and provide children with the benefit of
not always having to be hooked up to the feeding pump throughout the day.18 Finally, research
has shown that a child with recurrent vomiting may benefit from post-pyloric feedings.18
Parenteral Nutrition Support
Parenteral nutrition is the delivery of nutrients intravenously. The parenteral fluids
usually consist of physiologic saline solution with dextrose, amino acids, electrolytes, vitamins,
trace elements and medications.17, 5 The benefits of including PN in the medical management of
a pediatric patient can include reversal of protein energy malnutrition, restoration of immunecompetence, and tolerance to anti-neoplastic therapies.25 However, the use of PN is associated
with a higher risk for complications including line infections, hyperglycemia,
hypertriglyceridemia, and cholestasis.5
PN is indicated for use if the pediatric patients are unable to meet adequate nutritional
needs via oral diet or enteral feeds.5 PN may be used if a child has an immature GI tract, or an
intestinal obstruction. Furthermore, patients that have had a surgical resection of a tumor located
in the bowel may have malabsorption of nutrients and may necessitate the provision of nutrition
intravenously.5 Finally, in cases of malnutrition, PN may be used if chemotherapy or radiation
therapy delays the use of EN .5
PN support can be administered through peripheral or central venous access.32 The
peripheral vascular access requires several site changes. Dextrose solutions used with peripheral
PN are limited to a concentration of 10% to 12.5% and are difficult to meet the high caloric
demands of the pediatric oncology patient.32 The risk of phlebitis, inflammation of the vein, is
higher with peripheral access.17 Central venous access allows for the dextrose to have a higher
31
concentration to the limit of 35% with amino acids at 6 %.32 However, patients on PN support
require more vigorous metabolic monitoring than those on EN support.17
Enteral Nutrition Support versus Parenteral Nutrition Support
Research supports the overall benefits of EN in pediatric oncology patients and validates
that PN should only be used as a nutritional intervention when EN is not indicated.33
Unfortunately, the use of EN is inconsistent in the pediatric oncology population despite its
known benefits when compared to the use of PN. One survey determined that EN was rarely
routinely administered prior to the initiation of PN.18,33,35 The side effects associated with
intensive chemotherapy treatment such as mucositis often discourages the use of EN feeds. In
addition, children may have neutropenia or thrombocytopenia that can increase their risk for
bleeding when the tube is inserted; however, clinical trials have not supported this theoretical
risks.18
PN is traditionally the preferred method among children receiving myeloablative
conditioning for HSCT.33,35 However, studies show that EN is well tolerated in this population as
well, with 77% of patients requiring no PN during the post-transplant period.35 Furthermore early
placement of a percutaneous endoscopic gastrostomy (PEG) for EN has been shown to eliminate
the risks of lesions in the GI mucosa.6 Early placement of the PEG tube would allow for the
provision of adequate nutrients via EN throughout the transplant process, positively impacting
nutritional status and decreasing risk of infection or tube dislodgement due to vomiting when
compared to PN and EN through a nasogastric tube.36
Clinical trials in children with cancer have found EN to be a more cost effective and safe
approach compared to PN, even in the settings of high-dose chemotherapy and bone marrow
32
transplantation.18 One study showed that body weight increased significantly in the intervention
group receiving EN compared with the control group who received PN, and all of the children in
the intervention group reached their ideal weight compared with only 21% in the control group.1
Moreover, PN can be costly for the patient in comparison to the use of EN, and also
significantly increases the patient’s risk of infection. One study showed that the monthly costs
associated with the use of gastrostomy nutritional support were 9% of those costs associated with
total PN .33-34 Furthermore, the risk of sepsis in children receiving PN is 2.4-times greater
compared to children with central venous access but that do not receive PN .37,38
Barriers to Optimal Nutrition Support in Pediatric Cancer
Barriers to providing adequate nutrition per the recommendations of the RD include
initial low infusion rates, feeding interruptions due to medical procedures, and holding feeds for
specific medication administration.40 To overcome this, careful monitoring and established
protocols utilizing higher calorie formulas and increased tube feeding volume are recommended
to compensate for the interruptions.40 Furthermore, the potential side effects related to EN may
act as barriers to providing optimal nutritional support in the pediatric patient.39 Patients that
experience frequent vomiting will benefit from antiemetic therapy, reductions in volume, and the
use of promotility agents.40
The development and validation of uniform nutrition protocols will assist in creating
consistency in the provision of optimal nutrition support among institutions treating children
with cancer.18 With a review of standards of practice for nutritional support in pediatric cancer
patients and common barriers, we will now investigate current practice and nutritional
management for cancer patients at UVA Children’s Hospital.
33
Current Practice at UVA Children’s Hospital
The most common pediatric cancer seen at UVAHS is childhood leukemia which
accounts for 33% of all pediatric cancers. According to the UVAHS pediatric oncology nurse
practitioner, approximately 75% of patients seen at UVA with leukemia have ALL, and the other
25% have AML. Cancer treatments are dependent upon the individualized patient’s diagnosis
and the severity and stage of the disease, but commonly include chemotherapy, radiation, and/or
surgical intervention. The chemotherapy agents most often used are vincristine, l-asparaginase,
methotrexate, cyclophosphamide, cytarabine, ifosfamide, etoposide, doxorubicin and cisplatin.
The pediatric oncology RD at UVAHS follows the oncology patients closely while in the
inpatient units, using the guidelines set forth by the Pediatric Oncology Standards of Care as
previously described. Unfortunately, current practice for the implementation of timely and
appropriate nutrition support has been inconsistent among this patient population.
34
PURPOSE
The purpose of this case series based mixed methods research project was to investigate
the barriers to providing hospitalized pediatric oncology patients with optimum nutritional
support at UVAHS. The specific goals of this study were to:

Determine barriers to optimizing nutrition support

Investigate the medical team’s preference for use of a particular form of nutrition
support.

Provide evidenced-based recommendations for the nutritional management of
pediatric oncology patients

Promote the importance of utilizing EN feedings as a standard nutritional
intervention during treatment.

Recommend the revision and active implementation of the pediatric nutrition
standards of care for the pediatric cancer population through review and
approval by the Pediatric Hematology Oncology Team at UVAHS

Promotion of improved nutritional management and outcomes for pediatric
oncology patients during hospitalization.
35
MIXED METHODS CASE SERIES METHODOLOGY
This study used a case series mixed methods approach to investigate nutrition support
practice management at UVA Health System and to determine the association between the
implementation of nutritional support via EN or PN feedings and nutritional outcomes and
tolerance in three selected hospitalized pediatric patients. Data collection began in February 2013
and included the selection of specific pediatric cancer patients who received EN support. The
patients were selected by the UVAHS Pediatric Oncology RD. Selection criterion for the
hospitalized patients were based on the following: a) UVAHS pediatric oncology patient and b)
patients receiving long-term nutritional support via EN or PN feedings. A total of three patients
were selected for this case series review.
Quantitative Data
The Epic electronic medical record (EMR) system utilized at UVAHS was used to
retrospectively collect data on the three selected patients. Initial data collected on each patient
included specific cancer diagnoses, reason for current admission, previous surgical and medical
history, anthropometrics including weight (kg), length (cm), head circumference (cm), oncologic
treatments received, and the degree of malnutrition assessed by the Waterlow Criteria. During
each admission nutritional intake data including PN order, actual intake, and caloric intake
(kcal/kg) from PN was obtained, if applicable. Additionally, EN intake data was obtained to
include specific formula and caloric density, feeding schedule and route, actual 24 hour intake,
and caloric intake (kcal/kg) from EN. Total caloric intake from both PN and EN was recorded as
well as the patient’s nutritional goals and percentage of the goals achieved throughout the
36
admission. Additional information regarding the barriers to starting nutritional support, percent
weight loss, and relevant medications were collected. All of the collected data was recorded and
organized into a Microsoft Excel spreadsheet as presented in Appendix B.
The quantitative data obtained through this study was used to provide a general overview
of the outcomes and current nutritional practices at UVAHS. This mixed method case series
study provided a general overview on the use of EN versus PN and the management course for
pediatric cancer patients at UVAHS.
Qualitative Data
Qualitative data collection included the RD’s recommendations for adequate provision of
calories and protein and information gleaned through interviews with various members of the
pediatric oncology health care team. Three specific healthcare professionals were interviewed
including a pediatric oncology bedside nurse, pediatric oncology nurse practitioner and the
pediatric oncology RD at UVAHS. The interview questions for the various healthcare
professionals are presented in Table 11-13. The qualitative data obtained through this study was
also used to provide a general overview of the outcomes and current nutritional practices at
UVAHS and provided a general overview on the use of EN versus PN and the management
course in pediatric cancer patients at UVAHS.
37
Table 11: Interview Questions with the Pediatric Oncology NP
Table 12: Interview Questions with the Bedside RN
38
Table 13: Interview Questions with the Pediatric RD
39
RESULTS
Introduction and Patient Demographics
This case series review study included three selected hospitalized pediatric patients. As
previously mentioned, the data collection was completed from February 2013 until the end of
March 2013 and consisted of the type of nutritional support provided, the formula order, and
actual intake of the nutritional support. The three chosen pediatric oncology patients presented
with varying degrees of malnutrition, in need of nutrition support, and were appropriate
candidates for the use of the GI tract. An overview of the demographic data, weight changes and
degree of malnutrition for each of the patients is summarized below. Furthermore, Table 14
summarizes each patient’s diagnosis, weight and height changes and degree of malnutrition at
their various admission dates.
Patient 1
The first case series patient is T.W., a 7 year old male with a history of anaplastic
medulloblastoma. For the purposes of this paper, data collection for T.W. began upon his first
presentation to UVAHS in which the current pediatric oncology RD assumed patient care in
August 2011. The patient’s weight upon the first admission used for data collection was 18.8 kg,
consistent with moderate malnutrition per Waterlow criteria. During this admission, T.W.
received a course of chemotherapy treatments consisting of cyclophosphamide and viscristine.
T.W. had several subsequent admissions due to complaints of decreased appetite, abdominal
pain, and worsening nausea. Additionally, he experienced varying levels of malnutrition and
weight fluctuations throughout his treatment, with his lowest weight of 17.8 kg in January of
2012 (Stage 2 moderate malnutrition). T.W. had a gastrostomy tube placed in February 2012,
40
which resulted in significant improvements in weight status initially. However, T.W. continued
to experience abdominal pain, nausea and vomiting which contributed to poor feeding
intolerance and weight loss despite enteral access. In July 2012, T.W. presented to UVA
Children’s Hospital with complaints of a 5 day history of worsening headaches, nausea, and
vomiting. A brain MRI showed slight increase in ventricle size and more prominent
leptomeningeal enhancement suggesting a progression of his metastatic disease. Neurosurgery
was consulted due to the results of the MRI and a ventriculoperitoneal shunt (VP) was placed to
treat intracranial pressures secondary to hydrocephalus in hopes of relieving some of the
patient’s symptoms. Unfortunately, the VP shunt did not provide much relief and patient
returned to PICU with decreased responsiveness. The pediatric palliative care team was
consulted on July 25th, 2012 and made recommendations for comfort care. T.W. expired on July
29th, 2012 during his final admission at UVA Children’s Hospital.
Patient 2
The second case series patient presented is N.P., an 11 month old male first admitted to
UVA Children’s Hospital for infantile AML. The patient has a past medical history of a full-term
infant with Bell’s palsy and history of pertussis. N.P. first presented to Pediatric Intensive Care
Unit (PICU) at UVAHS on August 14th, 2012 in critical condition due to persistent fluid
overload from new onset AML and acute kidney injury. His admission weight was 9.2 kg (21st
%-ile), and at the time of initial presentation was well-nourished (Stage 0 per Waterlow Criteria).
The patient had PN initiated upon admission. EN was started September 2nd, 2012 due to
impaired intake status-post anterior cricoid split for subglottic stenosis and he was weaned off of
TPN and lipids. N.P. continued to require NG feeds upon transfer to the floor on September 21,
2012. During the course of admission on the floor N.P. transitioned to daytime bolus feeds but
41
due to improved PO intake the physician decided to discontinue bolus feeds to allow for
continued progress with PO intake. On September 30th, 2012, N.P. was transferred back to the
PICU due to increased work of breathing and found to have recurrence in leukemia cutis. His
prolonged hospitalization continued and during that time received a combination of radiation
therapy and chemotherapy. However, due to disease progression, poor tolerance to feeds due to
anesthesia prior to daily radiation, and the development of typhlitis during his intensive radiation
and chemotherapy regimen, N.P. required PN prior to his transfer to Duke University Hospital
for radiation therapy and evaluation for cord blood transplant. Unfortunately, due to disease
progression and complications with leukemia cutis, N.P. was not a candidate for transplantation
and returned to UVAHS for comfort care. At 15 months old the patient expired on December
12th, 2012 at UVA Children’s Hospital.
Patient 3
The third patient studied in our case series is N.M., a 7 year old female diagnosed with
medulloblastoma of the cerebellum in July 2012. N.M. underwent surgical resection of her
tumor, followed by a course of radiation therapy. Due to the side effects of radiation and
significant weight loss of 15 pounds of body weight during radiation treatment, the pediatric
hematology and oncology team decided to pursue gastrostomy tube placement in October 2012,
anticipating worsening malnutrition once chemotherapy was initiated. The gastrostomy tube was
placed at the same time as her central line, just prior to her initial admission for chemotherapy.
During October 2012 upon admission N.M. was well-nourished per Waterlow Criteria though at
risk related to history of 17% severe loss of body weight. Upon admission N.M. had regained
100% of weight back as compared to the usual body weight of 67 pounds. EN was initiated via
nocturnal feeds to meet 50% of needs with the remainder of nutritional needs to be met with
42
regular diet during the day. During admission of January 2013, N.M. presented for chemotherapy
of maintenance cycle two with treatments of vincristine and cyclophosphamide. It was noted
during the admission that her weight had improved from 26 kg to 29.1 kg subsequently following
the placement of the G-tube. However during a second admission due to typhlitis in January 18th,
2013, N.M. was found to have a 9% weight loss in 2 weeks, classified as moderate malnutrition.
N.M. continues to receive chemotherapy treatments and nocturnal feeds via her G-tube. She
presented to UVAHS Children’s Hospital on February 1st, 2013 with an admission weight of
26.6 kg which was decreased from her January admission weight of 29.1 kg. N.M. presented
with symptoms of feeding intolerance with g-tube feedings, severe abdominal pain, and emesis.
During the admission of March 4th, 2013, N.M. was considered to be well-nourished per
Waterlow criteria with a weight of 25.2 kg. However, N.M. was considered to be at nutrition risk
during this admission due to 13% weight loss in a month and half. N.M. is currently undergoing
ongoing chemotherapy treatments, and continues to receiving nocturnal feeds via her G-tube.
43
Table 14: Patient Demographics
Patient
1 – T.W.
Gender
(M/F)*
M
DOB
4/29/04
Age: 7
Age: 7
Age: 7
Age: 7
Age: 8
Initial Diagnosis
Medulloblastoma
(2010)
Weight (kg)
(%-ile)
Height
(cm)
(%-ile)
Degree of
Malnutrition±
(Waterlow Criteria)
18.8 kg (3.5th%ile)
120 (26th%ile)
1-8/12/2011
19.5 kg (<5th %ile)
120
(26th%ile)
120
(26th%ile)
119.6
(8th%ile)
122.5
(10th%ile)
68 cm
(0.09th %ile)
81 cm
(73%ile)
Stage 2
(Moderate Malnutrition)
Stage 2
(Moderate Malnutrition)
Stage 2
(Moderate Malnutrition)
Stage 2
(Moderate Malnutrition)
Stage 2
(Moderate Malnutrition)
Stage 0
(well-nourished)
Stage 0
(well-nourished)
Stage 0
(well-nourished)
Stage 0
(well-nourished)
Stage 0
(well-nourished)
Stage 0
(well-nourished)
Stage 0
(well-nourished)
*moderate malnutrition
given weight loss of 9%
in 2 weeks
Stage 0
(well-nourished)
*moderate malnutrition
given 13% weight loss in
1-10/3/2012
21.5 kg (8th%ile)
22.5 kg (10tth%ile)
21.6 kg (8th%ile)
2 -N.P.
3
N.M.
M
F
9/04/11
Age: 13
months
Age:15
months
Infantile AML
(2012)
5/30/05
Age: 7
years
Medulloblastoma
(2012)
Age: 8
years
9.96 kg
(45%%ile)
10.7 kg
(60th%ile)
24.2 kg (55th%ile)
26 kg(69%ile)
30.9 kg (90th%ile)
29.1 kg (82%ile)
26.6 kg (67%ile)
25.2 kg (53th%ile)
127cm
(72nd%ile)
127cm
(72nd%ile)
127cm
(72nd%ile)
129.5cm
(75th%ile)
129.5cm
(75th%ile)
128cm
(65th%ile)
Total Admissions
Reported And Dates
2-2/09/2012
3-3/14/2012
4-4/18/2012
5-7/24/2012
1-10/12/2012
2-12/10/2012
2- 10/25/2012
3- 12/07/2012
4- 1/18/2013
5-2/01/2013
6-3/04/2013
one month
Nutrition Support Course, Management and Outcomes
The approach to nutritional management of these three patients will now be presented.
Each patient’s nutritional management course, RD recommendations, and nutrition support order
by the physician is presented in Tables 15-17.
Patient 1
For the first patient, T.W., with medulloblastoma three separate sections will be
presented, representing each of the three admissions as presented in Table 15.
As can be gleaned from this patient’s admission in August of 2011, despite this patient’s
poor nutritional status, history of weight loss and poor appetite, and the pediatric RD’s
recommendations for initiating nutrition support, he was only nutritionally managed with a
Pediatric Regular diet and supplements. T.W. was referred to clinical nutrition on December 21st,
2011, due to poor weight gain and previous use of NG feeds during previous admission at John
Hopkins with supplementation of Peptamen Jr. 1.5. During the admission of December 21st,
2011, the patient had a weight of 19.5 kg with a weight-for-age at the 3.45 percentile. T.W. had
been following a home nutrition regimen of 8 cans of Peptamen Jr. 1.5 mixed into a pitcher with
whole milk and chocolate ovaltine; he would and consumes this volume within 2 days. The
family was incorporating ways to improve caloric intake by increasing caloric value of foods.
However upon admission January 13th, 2012, T.W. had a 2 pound weight loss over the
preceding 3 weeks. T.W. had been taken off of Megace during this time and experienced a
decrease in appetite. The oncology team decided that given the patient’s recent significant weight
loss that it was indefinite to place an NG tube for improved long-term weight maintenance given
46
appetite stimulants were not facilitating hunger and would only be a short term fix. The patient’s
weight had fluctuated over the last year and half and improved significantly following the
placement of a G-tube in February 2012 with a 2.8 kg weight gain. T.W. was admitted to
UVAHS again on April 18, 2012. Throughout the course of the 3 day admission, despite the
pediatric RD’s recommendations, EN was not started to provide optimal nutrition support until
the second day of admission due to frequent episodes of emesis despite the 1 kg loss prior to
admission (5 % loss of body weight). The RD recommendations included initiating Peptamen Jr
with 3.5 cans to be supplied by nocturnal EN via NG feeds to meet 75% of nutritional needs and
to allow for PO intake during the day and the patient received full feeds as recorded by actual
intake. However, during the admission of April 2012, the intake records demonstrated the patient
was only consuming 25% of PO diet with overnight EN feeds meeting 100% of estimated EN
goal. During the patient’s 5th admission to UVAHS on July 24th 2012, the patient presented with
worsening headache, nausea, and vomiting secondary to tumor progression. The patient’s weight
at the time of admission was 21.55 kg which equates for weight-for-age at the 8th percentile.
T.W. had lost 0.9 kg from his April 2012 admission and was 90% of his IBW. Nutritional
support management was not initiated and patient was kept on a NPO diet based on
recommendations from the palliative care team for comfort care measures only.
47
Table 15. Nutritional Management Review for Patient #1 – Patient with Medulloblastoma (T.W.)
RD
Nutrition
Nutrition
Nutrition
Encounter
Order
Goals
Recommendations
Admission #1: 8/12/2011; Reason for Admission: Medulloblastoma
Medications
Comments
1 – 8/12/2011
Peds
Regular
Ensure TID
D5% ½ NS
with KCl
75-80
kcal/kg
1.5-2 gm
pro/kg
75-80 ml/kg
1.Start TPN: Dextrose 15%
and 20 gram of protein/day
to goal of 35-40 mL/hr;
Lipids 20% 100 mL/day (1
g/kg lipid)
Marinol
Ondansetron
Cyclophospha
mide
 Patient admitted with poor appetite, weight loss, and abdominal
pain. Patient began on Marinol. BMI was <5th%-ile.
 Estimated intake during this time was 40 kcal/kg or 50% of
needs or approximately half of needs.
 TPN not initiated although recommendations made
2-08/15/2011
Peds
Regular
Ensure TID
D5% ½ NS
with KCl
75-80
kcal/kg,
1.5-2.0 g
pro/kg,
75-80
mL/kg
1. Begin TPN: Dextrose
15% and 20 gram of
protein/day to goal of 3540 mL/hr; Lipids 20% 100
mL/day (1 g/kg lipid)
Marinol
Ondansetron
Cyclophospha
mide
3-08/23/2011
Peds
Regular
Ensure TID
D5% ½ NS
with KCl
80 kcal/kg,
1.5-2.0 g
pro/kg,
80 mL/kg
1.Begin TPN : Dextrose
15% and 20 gram of
protein/day to goal of 3540 mL/hr;Lipids 20% 100
mL/day (1 g/kg lipid)
PhosNak,
Potassium
Chloride,
Ondansetron










Patient is 76% of IBW (Moderate Malnutrition per Waterlow)
Reported poor PO intake>4 days
Frequent episodes of emesis
Reports Marinol is not helping appetite
Acute hepatic failure, respiratory distress due to fluid overload
TPN not initiated although recommendations made
Developed central line infection, fever, diarrhea
Unable to take NPO given emesis. TPN not initiated during
admission although recommendations made due to line
infection
NPO for Bone Marrow Procedure
Found to have veno-occlusive disease of liver
Admission # 2: Add Date 02/08/2012; Reason for Admission: Chemotherapy, further management of disease progression, and increased pain.
102/09/2012
Peds
Regular
Ensure TID
Peptamen
JR 1.5 @ 70
mL/hr over
12 hours
D5% ½ NS
with KCl
85-95
kcal/kg for
weight
regain,
2g
protein/kg
77 mL/kg
1.Begin EN:
3.5 cans of
Peptamen JR 1.5
@ 70 ml/hr over
12 hours to
provide:
45ml/kg, 67
kcal/kg, 2.0 g
pro/kg.
Morphine, Lorazepam,
Periactin, Colace,
Miralax, Ondansetron





IBW: 22.5 kg and weight is currently 18.7 kg which is 83% of
IBW
Little weight gain over the last 15 months with weight
significantly below 5% weight for age
Considered mild chronic malnutrition given weight loss
Nocturnal NG feeds will meet 75% of caloric/protein needs
and allow PO intake during day
Actual Intake: 67 kcal/kg, 2.0 g pro/kg. 45ml/kg on February
9th, 2012
Admission # 3: Add Date 03/12/2012; Reason for Admission: Chemotherapy and cellulitis surrounding G-tube stoma
1.Continue
Methadone, ondansetron, 
IBW: 22.5 kg and weight is currently 20.6 kg which is 92% of
providing
IBW.
lorazepam, clindamycin
Pediatric diet.
 Appetite improved while on steroids but declined as steroids
2. Continue
were discontinued
home G-tube
 Weight up ~2kg in a month since the placement of the G-tube.
regimen as
tolerated: 3 cans
of Peptamen Jr.
1.5 70 mL/hours
over 10hours;
Provides:52
kcal/kg, 1.6 kg
pro/kg
2.Encourage PO
intake with
snacks and
supplements
PRN (ex. Ensure
Plus)
Admission # 4: 4/18/2012; Reason for admission: Abdominal pain and erythema surrounding G tube site, fever, emesis
1-03/14/2012
Peds
Regular
Ensure TID
D5% ½ NS
with KCl
85-95
kcal/kg for
weight
regain,
2 g pro/kg,
77 mL/kg
1-4/18/2012
NPO
80-90+
kcal/kg,
2 g pro/kg,
76 mL/kg
1.Begin TPN if
unable to resume
EN: Dextrose
10%, 40 grams
of protein, 1 g/kg
of 20%
Intralipids.
2. Increase
dextrose to 15%
and then to goal
of 18%. Final
concentration of
lipids 2 g/kg.
3. Resume PO
diet with
additional
Methadone, Dilaudid,
ondansteron, decadron,
lorazepam, famotidine,
and antibiotics



IBW of 22.5 kg and 87% of IBW with 1 kg loss in the past
month (5% body weight)
Started Marinol about week ½ ago and seems to stimulate
appetite.
Recommendations made but diet not advanced due to
complications of cellulitis, peritoneal infection and began to
tolerate PO intake on 04/20/2012
Ensure Plus TID
and home EN
regimen as
medically
feasible:
Peptamen Jr 1.5
with 3 cans over
10 hour period
@ 80 mL/hr to
meet 60% of
estimated needs.
2-4/23/2012
Peptamen Jr
1.5
Nocturnal
feeds over
10 hr,
Regular
pediatric
diet
80-90+
kcal/kg,
2 g pro/kg,
76 L/kg
1. Continue PO
diet as tolerated;
encourage PO
intake
2. Chocolate
Ensure Plus
ordered TID
3. Continue
Nocturnal feeds
as tolerated.
Would dilute
somewhat given
emesis and the
fact the patient
has not reached
goal feeds with
Peptamen 1.5 at
home yet. Mix:
560 mL
Peptamen Jr. 1.5
with 160 mL
water, run at 75
ml/hr over 10
hours; would be
equivalent to 1
can of Peptamen
Jr. 1.5 + 2 cans
Antibiotics, IVF
Ondansteron, Methadone,
Morphine PCA,
Lorazepam,
Dexamethasone,
Famotidine






< 25% consumed of PO diet
Frequent N/V and believes this is related to the enteral
formula. Mother believed it was due to formula change of
Peptamen Jr to Peptamen Jr 1.5.; Feeds were held
Patient weight is currently 19.3 kg with an IBW of 22.5 kg.
T.W. is currently 87% of IBW.
Weight improved since the G-tube placement of February 9th,
2012. T.W. previous weight before G-tube placement was 18.7
kg with 83% of IBW of 22.5 kg. Patient weight was 20.6 kg
and 92% of IBW of 22.5 kg
Actual Intake: 75 kcal/kg, 2.2 g pro/kg, 75 ml/kg
Meeting 94 % kcal, 100% protein of estimated EN nutritional
goals with minimal PO intake within 24 hours.
Peptamen Jr 1.0
(44 kcal/kg, 1.3
g/kg protein,
meeting ~50% of
estimated needs)
Peptamen Jr 80-90+
1.Plan for
Antibiotics, Metadone,
1.5
kcal/kg,
discharge with
dexamethasone,
 IBW of 22.5 kg and is 87% of IBW.
Nocturnal
2.0 g pro/kg, home regimen of famotidine, lorazepam,
 Frequent emesis
feeds over
76 mL/kg
3 cans of
ondansetron, drobinol
 Actual Intake: 60 kcal/kg, 1.8 g pro/kg, 60 ml/kg
10 hrs;
Peptamen Jr 1.5
 Meeting 75% kcal, 90% protein of EN nutritional goals within
Regular
the last 24 hours
pediatric
diet
Admission # 5:07/24/2012; Reason for admission: Worsened headache, nausea, vomiting secondary to tumor progression
3-4/26/2012
1–
7/24/2012
NPO
80-90
kcal/kg,
1.5-2 g
pro/kg,
71 mL/kg
1.Peptamen Jr. 1.0 (2
cans) + Peptamen Jr. 1.5
(1 can) at 75 mL/hr over
10 hrs to provide
nocturnal feeds.
2. If not tolerating PO
diet initiate Peptamen 1.5
(5 cans) at 75 mL/hr
continuous
Zofran,
Decadron, IVF,
Pepcid,
Miralax,
Morphine PCA,
Ativan
 Weight fluctuated over the last year and half. Improved weight
since G-tube placement in Feb. 2012
 BMI has improved. IBW of 24 kg and is 90% of IBW
 Declined PO > 3 days, and persistent emesis.
 Diet unable to be advanced
2-7/26/2012
NPO
80-90
kcal/kg,
1.5-2 g
pro/kg,
71 mL/kg
1.Advance from NPO
diet to clear liquid diet
2.Provide Resource
Breeze nutritional
supplement TID
3. Continue to advance
diet as tolerated and
clinically feasible
4.If unable to advance
diet then initiate
5.Pediasure via G-tube at
10-15 mL/hr and advance
Ancef x 3,
Zofran,
Decadron,
Miralax, Pepcid
 Transferred to PICU following VP shunt placement.
 Weight tracking between the 5th and 10th percentiles on the CDC
growth curve charts since 6.5 years
 Enteral nutrition not provided due to Palliative Care
recommendations. Patient remained on NPO diet.
3- 07/29/2012
NPO
80-90
kcal/kg,
1.5-2 g
pro/kg,
71 mL/kg
by 10 mL every 6 hours
to goal of 65 mL/hr
No recommendations
made
Morphine PCA,
Fentanyl PCA,
Ativan
 Pediatric Palliative Care consulted on 7/25/2012
 Recommendations for pain control and comfort care
Patient 2: However, N.P. experienced weight fluctuations towards the end of his
prolonged admission, as his full nutritional goals were not met consistently due to inadequate
oral intake coupled with insufficient EN delivery, due to feeding interruptions due to the
radiation schedule, anesthesia, and typhilits.
As can be gleaned from this infant’s admissions, Patient 2 was managed primarily with
EN. During that admission, N.P. had been weaned off of TPN and lipids and transitioned to EN
feeds of Pediasure (Abbott Labs, Columbus, OH). At the start of radiation therapy, N.P. weighed
9.86 kg (47%ile weight for age), demonstrating adequate weight gain of approximately 10 grams
per day over the previous 2 months of admission due to EN support. During the course of
radiation, N.P. EN feeds were scheduled to be stopped at midnight while receiving radiation,
further posing a barrier to suboptimal nutrition support via EN feeds. N.P. was transitioned to
bolus feeds to optimize nutrition given limitations of his treatment schedule, although he did
have some problems tolerating afternoon bolus feeds related to post-anesthesia effects. He was
also placed on a pureed diet with nectar thick liquids during the day based on the
recommendations of the speech language pathologists. N.P. was transitioned back to nocturnal
feeds on November 11th, 2012 after completing radiation therapy, in an effort to improve
tolerance to EN feeds and to improve PO intake during the day. The patient’s weight trended up
to 10.17 kg (50% weight for age) on November 12th, 2012 and was tolerating current nutritional
regimen. However, on November 15th, 2012, the patient’s EN was placed on hold after increased
emesis and abdominal x-ray concerning for right lower quadrant pneumatosis. N.P. was started
on TPN and lipids and advanced with trial of a clear liquid diet with Pedialyte (Abbott Labs,
Columbus, OH) provided via NG tube.
53
The patient was subsequently transferred to Duke Medical Center for a bone marrow
transplant. However on December 8th, 2012, N.P. presented to UVA Children’s Hospital from
Duke Medical Center due to the rapid progression of leukemic involvement throughout multiple
organ systems. N.P. was considered to no longer be a viable candidate for transplantation and
preceded with the services of palliative care. N.P. expired on December 12, 2012.
54
Table 16. Nutritional Management Review for Patient #2 – Patient with Infantile AML (N.P.)
RD Encounter
Nutrition Order
Nutrition
Goals
Nutrition
Recommendations
Medication
Comments
Admission #1: 08/08/2012; AML worsened by Pseudomonas tracheitis
1 – 10/15/12
2-10/18/2012
Pediasure 1.0
overnight at 40
ml/hr over 12
hours via NG
D5% ½ NS with
20 mEq KCl/L
Propofol
90105kcal/kg
2.5-3 gm
pro/kg
100 ml/kg
NPO for radiation
Pediasure 1.0 with
fiber
160 mL q 3-4 hrs
x 6 daily feeds
+ Pureed tray with
Nectar thick
liquids
90-105
kcal/kg,
2.5-3 g/kg
pro,
100 mL/kg
1. Increase bolus
feeds to 135 ml x 7
daily feeds as
tolerated to optimize
nutrition with
radiation
schedule.Provides: 4
cans of Pediasure 1.0
(97 kcal/kg, 2.9 g
protein/kg)
2. As clinical
feasible, resume PO
intake per SLP
recommendations.
Offer oral pediasure
with remaining
volume via NGT as
PRN. Encourage
solids ad lib
3. When intake of
solids resume, begin
strict calorie count
Ondansetron
Dexamethason
e
Cytarabine,
1. Continue PO diet
per SLP
recommendations as
tolerated and
clinically feasible;
encourage PO intake
Stomatitis
Cocktail,
Famotidine,
Cytarabine,
Methadone,
Miralax,
Ativan
2. Continue Bolus
regimen of 160 ml q








Transferred from the PICU on enteral nutrition via NGT for
overnight feeds and daytime bolus. Previously receiving
TPN and lipids and advanced to continuous EN to overnight
with PO ad lib of baby/soft foods with additional provided
supplements of Pediasure, Carnation Instant Breakfast, and
Boost Breeze while in the PICU
Actual Intake:76 kcal/kg, 2.2 g protein/kg, 76 ml/kg
Meeting currently 76 % of estimated enteral nutrition goal
Emesis associated with suctioning of trach and hyper gag
reflex
Starting radiation M, T, Th, F through 10/28/12
Had been transitioned to bolus feeding regimen due to
feeding interruptions from radiation schedule
3 day average via NGT 10/15-10/17: 43 kcal/kg, 1.3 g/kg
protein, meeting ~43% of estimated needs.
SLP working with patient on PO intake; recommended
3-4 hours over 6
feeds per day
Purees and Nectar thick liquids
3. Calorie count to
assess adequacy of
PO intake and ability
to decrease NG feeds
4. Nutrition discharge
planning: n/a at this
time
3-10/25/2012
Dysphagia 1
Pediasure 1.0 with
fiber
160 mL q 3-4
hours x 6 daily
feeds
90-105
kcal/kg,
2.5-3 g/kg
pro,
~100
mL/kg
1. Transition back to
overnight continuous
EN regimen as
tolerated and as
medically feasible
given last scheduled
day of radiation.
Hopefully will allow
for improved
tolerance, as well as
better meet his needs
more evenly
throughout the course
of the day, and
promote increased
PO intake. Goal
Regimen as follows:
 PO diet ad
lib per SLP
recommend
ations; goal
~500
kcal/day PO
 Daytime
bolus feeds
only PRN
with
Pediasure
1.0 enteral
with fiber:
Stomatitis
Cocktail,
Famotidine,
Cytarabine,
Zofran,
Dexamethason
e, Etoposide




3 day average: 48 kcal/kg, 1.4 g/kg pro, and 25-50% PO
intake via meals
Continues on NG bolus feeds during the day to optimize
nutrition with radiation schedule.
Actual Intake: 69 kcal/kg, 2.0 g protein/kg
Meeting 72% of estimated EN nutrient needs.
4-11/01/2012
Pediasure 1.0 with
fiber
Nocturnal
Dysphagia 1 diet
with pureed foods
and nectar
thickened fluids.
90-105
kcal/kg,
2.5-3 g/kg
pro,
~100
mL/kg
160 ml at
10am, 2 pm,
or 6pm; use
only as
replacement
if patient
refuses a
meal,
otherwise
allow PO ad
lib
 Continuous
overnight
EN of
Pediasure
1.0 at 50
mL/hour
over 10
hours
 Calorie
count to
assess PO
adequacy to
attempt to
decrease
NGT feeds
1.Providing clears
(pedialye). If ongoing
bouts of emesis, will
consider IV fluid
support when NPO to
provide ½ MIVF.
2.Begin EN:
Pediasure 1.0 with
fiber
Nocutrnal:500mL,
Refuses meals than
PRN daytime bolus
feeds 160 mL at 10
am, 2 pm, and 6 pm
Colace,
Antibiotics,
Stomatitis
Cocktail,
Famotidine,
Cytarabine,
Methadone,
Zofran,
Dexamethason
e, Etoposide

3 day average: 483 mL, 48 kcal/kg, 1.4 g/kg pro, and 2550% PO intake via meals
 MD held EN overnight given large volume emesis in the
morning associated during chemotherapy
Calorie Count (3 day average): 106 kcal/kg; 2.5 g protein/kg; 57% PO
intake
 Actual Intake: 69 kcal/kg, 1.8 g protein/kg
 Currently meeting 72% of estimated EN nutrient needs.
5- 11/08/2012
6-11/15/2012
Pediasure 1.0 with
fiber
Nocturnal: 50
mL/hr x 8 hrs
Dysphagia 1; PO
ad lib
90-105
kcal/kg,
2.5-3.0
g/kg pro,
~100
mL/kg
NPO
TPN: Dextrose
15%
88 kcal/kg,
2.8 g/kg of
pro
Encourage daytime
PO intake but
continue nocturnal
continuous feeds.
1.Continue PO diet
ad lib per SLP
recommendations;
goal 600 kcal/day PO
2. Continue EN
nocturnal feeds with
Pediasure 1.0 at 50
ml/hr over 8 hours
3. Would consider
daytime bolus feeds
PRN due to
decreased PO and
weight
 Bolus Feeds
PRN:
Pediasure
1.0 of 160
ml at 10 am
2pm, and 6
pm
 If not able to
restart bolus
than
increase
nocturnal
feeds to 55
ml/hr over 9
hours or
consider
Pediasure
1.5
1.Begin TPN:
Dextrose 15%
30 g/day Trophamine
Stomatitis
Cocktail,
Famotidine,
Cytarabine,
Zofran,
Dexamethason
e, Etoposide

Pepcid,
Stomatitis
Cocktail,





Patient continues to have episodes of emesis 3x/day with
suctioning and refuses PO intake.
Calorie Count (3 day average): 63 kcal/kg1.2 g protein/kg,
Meeting 39% of needs of PO intake
Actual Intake: 31 kcal/kg, 2.2 g protein/kg
Currently meeting 77.5 % of EN estimated nutrient needs
Patient made NPO to decrease risk for aspiration
pneumatosis; increased emesis and concern for Mucositis
Actual Intake: 1,001.5 mL TPN + 153.1 mL 20% IL: 91
7-11/23/2012
8-11/27/2012
30 g/day
Trophamine
155 mL
NPO
Dextrose 15%
30 g/day
Trophamine
155 mL
NPO
Dextrose 15%
30 g/day
Trophamine
155 mL
100 mL/kg
155 mL
Zofran

90-105
kcal/kg,
2.5-3 g/kg
of pro
3 g/kg IL
100 mL/kg
90-105
kcal/kg,
2.5-3.0
g/kg of pro
3 g/kg IL
100 mL/kg
1. Resume pureed
diet when medically
feasible
2. Continue TPN with
D 15%, 30 g protein
at 42 ml/hr + 3gm/kg
IL. Adjust
electrolytes PRN
3. As medically
feasible restart NG
feeds with Pediasure
1.0. Can titrate
TPN/EN 1:1
 Start feeds at
10 mL/hr
and increase
5 ml/hr q 4
hours
 Goal is 42
ml/hr to
meet 100%
of needs
Pepcid,
Stomatitis
Cocktail,
Zofran,
Peridex,
1. Continue D15%,
30 g protein +3 g IL
in TPN; Cycle to 20
hours for
hepatoprotection2.
Resume EN when
medically feasible of
Peptamen Jr 1.0 at 10
ml/hr and increase 5
ml/hr q 4 hours to
Colace,
Pepcid,
Miralax,
Stomatitis
Cocktail,
Zofran,
Peridex,








kcal/kg, 2.9 g/kg of pro, 306.2 kcal Lipids
Currently meeting 100% of nutritional needs
Patient is neutropenic with concern for Typhlitis. MD
decided due to continued vomiting and not tolerating and
remove/replace NG tube. Concern for recurrence of
leukemia cutis and oncology to evaluate.
Actual Intake: 996.7 mL TPN + 149.7 mL 20% IL: 90
kcal/kg, 2.9 g/kg of pro, 299.4 kcal Lipids
Meeting 100% of TPN nutritional needs
MD put on bowel rest with TPN initiated. MD began clear
liquid diet with Pedialyte
11/25 average weight gain of 8 grams/day since 11/1;
meeting goal for age.
11/29 N.P. was transferred to Duke Children’s Hospital for
bone marrow transplant.
TPN Actual Intake: 1,045.9 mL TPN + 164.1 mL 20% IL:
95 kcal/kg, 2.9 g/kg of pro, 328.2 kcal lipids
Currently meeting 100% of TPN nutritional needs
goal of 42 ml/hr
Admission # 2: Date; Comfort Care
1-12/10/2012
NPO
TPN: Dextrose 15
%, 30 grams/day
Trophamine,
161 mL/day
90-100
kcal/kg,
2.5 g/kg
protein,
3 g/kg IL
97 mL/kg
Continue TPN at the
request of patient’s
parents.
Morphine
PCA and
Ativan



Rapid progression of leukemic involvement throughout
multiple organ systems. No longer a candidate for
transplantation. NGT was removed on 12/08/2012
TPN Actual Intake: 45 kcal/kg, 2.8 g/kg protein, 120.8 kcal
lipid/day
Currently meeting 51% of TPN nutritional needs
Patient 3: As can be gleaned from this child’s admissions, Patient 3 was managed with
EN support with the placement of a G-tube requested by the oncologist, given the child’s severe
weight loss during treatment. N.M. experienced a 17% severe weight loss within 4 months of
diagnosis. Upon initial visit with the pediatric oncology RD, N.M. weighed 24.2 kg on October
3rd, 2012. N.M. was able to regain to a weight of 1.8 kg prior to gastrostomy tube placement on
October 24, 2012 due to improved appetite while on steroid therapy. Following G-tube
placement, N.M.’s weight continued to improve with the provision of continuous nocturnal
feeds. The patient presented to UVA Children’s Hospital on December 6th, 2012 with a weight of
30.9 kg and a weight-for-age percentile of 90th. The weight during this admission had improved
significantly from 26 kg documented prior to placement of the g-tube and patient had regained
back to usual body weight of 30.5 kg. From October to December 2012, N.M. was following a
home EN regimen of 2-4 cans of Pediasure provided via the G-tube overnight. Unfortunately, in
January 2012, N.M. was admitted with complaints of intolerance with overnight feeds but
improved tolerance with a bolus EN regimen. N.M. weights had trended down 1.8 kg from the
previous admission weight of 29.1 kg in December to 29.1. The January admission was
complicated due to concern of infection at the g-tube site during this admission due to low grade
fever and pain around g-tube site. N.M. experienced intermittent emesis but not associated with
the EN feeds and decreased appetite.
On February 1st 2013, N.M. presented to UVAHS Children’s Hospital due to complaints
of abdominal pain and frequent episodes of emesis. Her weight upon admission was 26.6 kg,
demonstrating continued loss of 2.5 kg since January. This equates to a weight loss of 9% body
weight within a two week period and placed N.M. at risk for moderate malnutrition given the
weight loss. During the February admission, N.M. was able to tolerate nocturnal feeds once
61
again, to provide 3 cans of formula per night, meeting 55% of estimated needs via supplementary
EN. At this time the pediatric RD recommended adding a fourth can as tolerated while oral
intake remained poor. This recommendation was not implemented during the February
admission.
On March 4th, 2013, N.M. presented with a neutropenic fever and weight loss of an
additional 1.4 kg from her previous weight of 26.6 kg during the February admission, placing her
at risk for moderate severe acute malnutrition. The RD implemented recommendations for a
gradual advance back to goal feeds. However, the RD’s recommendations for an enteral formula
change were not carried out during this admission per the primary team. Currently, N.M.
continues to undergo treatment for medulloblastoma. Unfortunately, a recurrence of disease was
found April 2013 and primary oncologic care is now being provided at an outside hospital. She
continues to receive supplementary EN via her G-tube.
From October to December 2012, N.M. was following a home EN regimen of 2-4 cans of
Pediasure provided via the G-tube overnight. Unfortunately, in January 2012, N.M. was admitted
with complaints of intolerance with overnight feeds but improved tolerance with a bolus EN
regimen. N.M. weights had trended down 1.8 kg from the previous admission weight of 29.1 kg
in December to 29.1. The January admission was complicated due to concern of infection at the
g-tube site during this admission due to low grade fever and pain around g-tube site. N.M.
experienced intermittent emesis but not associated with the EN feeds and decreased appetite.
On February 1st 2013, N.M. presented to UVAHS Children’s Hospital due to complaints of
abdominal pain and frequent episodes of emesis. Her weight upon admission was 26.6 kg,
demonstrating continued loss of 2.5 kg since January. This equates to a weight loss of 9% body
62
weight within a two week period and placed N.M. at risk for moderate malnutrition given the
weight loss. During the February admission, N.M. was able to tolerate nocturnal feeds once
again, to provide 3 cans of formula per night, meeting 55% of estimated needs via supplementary
EN. At this time the pediatric RD recommended adding a fourth can as tolerated while oral
intake remained poor. This recommendation was not implemented during the February
admission.
63
Table 17. Nutritional Management Review for Patient # 3 – Medulloblastoma (N.M.)
RD Encounter
Nutrition
Nutrition
Nutrition
Medications
Comments
Order
Goals
Recommendations
Admission #1: 10/03/2012; Clinic visit, RD consulted due to severe weight loss throughout radiation therapy
1 – 10/03/2012
n/a
65-80
Zofran, Marinol
1. Continue to
 Significant weight loss 17% body weight in the last 3.5 months
kcal/kg,
(severe loss).
maximize calorie and
2-2.5 g

Weight is down from UBW of 65 # (29 kg)
protein intake with
pro/kg,

Appetite is waxing and waning with small volumes being consumed.
small frequent meals
62L/kg

Significant frequency of N/V since diagnosis
and snacks + fortifiers
+ nutrient dense
beverages
2. Agree with
consideration of
gastrostomy placement;
recommend starting
with nocturnal feeds to
help alleviate the
caloric burden, with the
option of daytime feeds
prn
Admission #1: 10/24/2012; Central line and G-tube placement and initiation of 9 cycle chemotherapy treatment
1-10/25/2012
Pediatric
65-80
1. Nutritional
Decadron,
 Well-nourished per Waterlow criteria given weight regain due to
Regular Diet kcal/kg,
supplements TID and in- Zofran,
steroids though at risk due to history of severe weight loss (17% body
D5% NS
2-2.5 g
house trial of PRN
famotidine
weight).
with 20 mEq protein/kg, feeding regimen via G PO intake of fluids is still below goal of 50 oz/day with typical intake
KCl at 30
62 mL/kg tube. The methods of
of 24-30 oz/day.
mL/hr
continuous or bolus were
discussed with family
2- 10/26/2012
D5 ½ NS
65-80
1. Begin Pediasure 1.0
Decadron,
 Hem/Onc and PSGY approved G Tube use
with 20 mEq kcal/kg,
enteral with fiber @
Zofran,
 Eating better today but hasn’t had a BM in 4 days and Miralax
KCl at 30
2-2.5 g
15mL/hr and advance by
famotidine,
administered today.
mL/hr, Mg
protein/kg, 15 mL/hr q 6 hrs as
fentanyl,
 Tolerated initiation of EN feeds via G-Tube. Discharged home on
sulfate 8
62 mL/kg tolerated to goal of 90
miralax,
nocturnal feeding regimen with daytime bolus feeds PRN.
mEq at 125
mL/hr
vincristine,
mL/hr
2. Home regimen:
cisplatin,
Pediasure 1.0 @ 90
mL/hr x 10hrs overnight;
provides 50% of
estimated needs
3. If limited PO intake
during the day,
administer 3 bolus
feeds/day (q 4-5 hours)
prn of 300 mL/bolus
Admission #3: 12/06/2012; Maintenance cycle of chemotherapy infusion
1Pediatric
50-60
1. Continue with PO
12/07/2012
Regular Diet kcal/kg ,
ad lib during the day
2-2.5 g
+ goal of 4 cans
protein/kg
62 mL/kg
Pediasure 1.0
lomustine
Sulfate drip and
miralax



overnight
Weight 30.9 kg (90%ile) upon admission; improved from 26 kg 10/24
when G-tube placed, BMI 90%
Appetite has improved with help from steroids although now
discontinued.
Parents noticed decline in appetite and started g-tube again for
nocturnal feeds (2-4 cans/night).
2. Supplement with
Pediasure bolus(es)
during the day PRN
to reach goal of 7
cans/day if taking
minimal PO
.
Admission #4: 1/17/2013; Maintenance chemotherapy cycle 2
1-01/18/2013
Pediatric
50-60
1.Resume home g-tube
Regular Diet kcal/kg,
regimen: 8 oz Pediasure
1.5-1.8 g
1.0 enteral with fiber, run
protein/kg, at 120 mL/hr x 3 feeds
58 mL/kg
per day.
2. Fluid goal of ~24-26
oz/day via PO and water
flushes
Admission #5: 1/31/2013; Abdominal pain and emesis
Zofran, Ativan,
dexamethasone,
vincristine,
mesna,
cyclophosphami
de, miralax




29.1 kg (82%ile); improved weight from 26 kg (10/24) when g-tube
placed.
UBW 67# (30.5 kg), BMI 79%ile, Length 129.5 cm, well-nourished
per Waterlow criteria
Intolerance to continuous feeds overnight and had been doing bolus
regimen at home PTA.
Home Regimen: 3-8 oz bottles per day of pediasure; over ~2 hours
with extra 4 oz. water flushes after each bolus
02/01/2013
Pediasure
1.0 enteral
with fiber
Nocturnal
60 mL/hr x
12 hours
Via g-tube
720 mL/day
Pediatric
Regular diet
55-70
kcal/kg,
1.5-1.8 g
protein/kg,
60 ml/kg
1. Initiate appetite
stimulant and
encouragement of PO
intake.
2. Nocturnal feeds of
Pediasure 1.0 with fiber
at 60 mL/hr x 12 hours; if
minimal PO intake then
add additional can via
continuous feeds @ 60
mL/hr.
3.Add water flushes of 60
mL before and after each
feed to provide 8 oz/day;
with PO goal of at least
8-16 oz/day fluids.
Antibiotics,
miralax, Ativan,
zofran
65-80
kcal/kg for
weight
regain,
1.5-1.8 g
protein/kg,
65 mL/kg
1. Regular diet and
encouragement of PO
intake, snacks ordered
BID between meals.
2. Nocturnal G-tube
feeds to provide 2
cans/night at 40 mL/hr x
12 hours, advance to 3
cans/night as tolerated.
3.Consider change to
peptide-based formula
given persistent emesis
Zofran, miralax,
phosnak TID



26.6 kg (67%ile); Weight down from 29.1 kg (1/18) with 9% weight
loss in the last 2 weeks.
UBW 67# prior to diagnosis (30.5 kg), BMI 57%ile, moderate
malnutrition given recent weight loss
Overnight feeds providing 55% of enteral nutrition goals
Admission #6: Neutropenic fever
103/04/2013
Pediatric
Regular Diet
Pediasure
1.0 with
fiber
@ 60 ml/hr
x 12 hours
overnight
via
G-tube




25.2 kg, well-nourished per Waterlow criteria, though at nutrition risk
due to 13% weight loss in the last month and a half
RD made goals for halting further weight loss and meeting >50% of
nutritional needs within 48 hours
Actual EN Intake: 23 kcal/kg, 0.85 g protein/kg, 23 mL/kg in
previous 24 hours
Meeting only 80.5% of estimated EN goals and remainder of
nutritional needs provided via PO intake
203/07/2013
Pediatric
Regular Diet
Pediasure
1.0 with
fiber
Nocturnal @
50 ml/hr x
10 hours
65-80
kcal/kg for
weight
regain,
1.5-1.8 g
protein/kg,
65 mL/kg
1. Regular pediatric diet
and encouragement of
PO intake
2. Snacks ordered BID
between meals.
3. Pediasure 1.0 with
fiber via Nocturnal feeds
@ 50 ml/hr x 10 hours,
advance as tolerated to
goal of 60 ml/hr x 12
hours
4. Continue to
recommend consideration
of peptide-based formula
Zofran, miralax,
phosnak TID,




Frequent emesis with full feeds but has been tolerating feeds at lower
rates the last two nights (30ml/hr, 40 ml/hr).
Team not yet ready to switch to peptide-based formula
Actual Intake: 10 kcal/kg, 0.43 g protein/kg, 10 ml/kg
Meeting 50% of nocturnal EN nutrition goals with remainder of
nutritional needs provided via PO diet
Qualitative Data – Interviews with Health Care Professionals
Introduction
In order to obtain basic information on the current nutritional support practices at
UVAHS, interviews were conducted with various members of the pediatric oncology health care
team to include a pediatric oncology nurse practitioner (NP), pediatric oncology bedside nurse
(RN), and a pediatric RD currently employed at UVAHS. The health care professionals provided
their perspectives on the optimal approach and challenges in the management of pediatric
oncology patients. A summary of the responses from the three healthcare professional interviews
can be found in Tables –16-18. Additionally, the full transcript of the interviews can be found in
Appendix C.
68
Table 18: Answer Summaries of Interview with Pediatric Oncology NP
Interview Question
What are the most common pediatric
cancers treated at UVA Children’s
Hospital?
Is there a protocol or guideline that
you follow regarding the nutritional
management of the pediatric
oncology patient?
At what point do you feel nutrition
support is indicated in this patient
population?
Answer
 ALL, AML , CNS brain tumors

No established guidelines but follow the
Children’s Oncology Group recommendations

The NP personally focuses on weight loss of 510% usual body weight to determine the
initiation for enteral nutrition or parenteral
nutrition.
UVA Children’s Hospital does not have a
determined number for weight loss as a
determinate initiating for nutritional support.
Advantages: Eliminates burden of caloric intake,
relieves tension between child and parent,
electrolytes are easier to maintain with TPN,
extra bolster of nutrition
Disadvantages: Higher risk for infection,
damaging to the liver
Advantages: provide oral medication through
tube, alleviate tension with child and parent, not
as expensive as TPN, easier to administer.
Disadvantages: “Children hate the NG tubes”,
tube dislodgement during emesis, source of
infection, g-tube requires surgical placement.
No barriers identified
Children often resistant to g-tube placement for
enteral nutrition

What are the advantages and
disadvantages to using parenteral
nutrition support?


What are the advantages and
disadvantages to using enteral
nutrition support (whether through
NGT or via GT)?

What are the biggest barriers or
complications associated with using
nutrition support in the inpatient
setting? Please note if you are
referring to EN and/or PN.


How do you feel nutrition
management of the pediatric
oncology patient could be improved?






Improved patient education handouts for clinic
Earlier initiation of nutritional support
RD to round consistently with oncology medical
team
RD to follow-up with patients in the outpatient
clinic
RD to provide nutritional support in-service to
pediatric oncology medical staff
69
Overall, as can be reviewed from the interview data, the oncology NP stated that the
UVA Children’s Hospital currently has no established guidelines regarding the nutritional
management of the pediatric oncology patient. The NP believed the pediatric oncology team
questions their nutritional management decisions retrospectively once the pediatric oncology
patient’s nutritional status has deteriorated for example: placing a g-tube sooner, different
placement of tube, or started TPN earlier. Currently the NP follows the supportive guidelines
provided by The Children’s Oncology group. The intervention of nutrition support should be
initiated when a child has lost 5% of body weight. In addition, she made the following
recommendations for improving the nutritional status of their outpatient pediatric oncology
population: implementing nutritional handouts to provide to the families during outpatient visits,
the appropriate timely initiation of EN, more consistent participation from the RD on medical
team rounds, nutritional education for the medical team, and the overall availability of an RD in
the outpatient clinic to follow-up with the pediatric oncology patients.
70
Table 19: Answer Summaries of Interview with Bedside RN
Interview Question
What are the advantages and
disadvantages to using parenteral
nutrition support?
What are the advantages and
disadvantages to using enteral nutrition
support (whether through NGT or via
GT)?
At what point do you feel nutrition
support is initiated in this patient
population?
What are the biggest barriers or
complications that you see associated
with using nutrition support in the
inpatient setting?
How do you feel nutrition management of
the pediatric oncology patient could be
improved?
Answer
 Advantages: symptom management for
mucositis or nausea
 Disadvantages: neutropenic, large fluid
volumes, more susceptible to inaccurate
recording of the input and out records
 Advantages: The ability to meet nutritional
needs if the patient refuses to take all calories
by mouth
 Disadvantages: The family and patient
adapting to meeting all calorie needs via
NGT/GT when the patient was previously
receiving via mouth
 Depends on the patient and which attending
is on service
 Depends on how the parents feel about the
lack of PO intake
 Enteral feedings: Formula availability
 Parenteral feedings: no barriers identified


Standard protocol not needed
Earlier initiation of enteral nutrition.
Overall, as can be reviewed from the interview data, the pediatric bedside nurse reported
one barrier to providing EN for the pediatric oncology patients is the availability of the enteral
formula in the units. However the beside RN identified no barriers to providing PN to the
pediatric oncology patients. In addition, she recommended earlier initiation of EN to improve
the nutritional status of their pediatric oncology population, and believed that factors
contributing to initiation of nutrition support were impacted by which attending was on service
and how concerned the parents were regarding lack of nutrition intake. However, she did not feel
that it would be feasible to develop standard protocols a UVA Children’s Hospital for the
management of nutritional support.
71
Table 20: Answer Summaries of Interview with Pediatric RD
Interview Question
What are the most common
pediatric cancers treated at UVA
Children’s Hospital?
Is there a protocol or guideline that
you follow regarding the nutritional
management of the pediatric
oncology patient?
What are the most common topics
of nutrition education that are
covered with this patient
population?
Answer


The Children’s Oncology Group’s algorithm
for the initiation of nutrition interventions and
nutrition support

Maximizing nutritional intake with protein and
calorie fortifiers
Making the most of the calories the children
are drinking
How to optimize intake despite severe nausea,
vomiting, or taste changes
Food safety practices



At what point do you feel nutrition
support is indicated in this patient
population? What are the factors
that influence your
recommendations for starting
nutrition support?

What are the advantages and
disadvantages to using parenteral
nutrition support?






What are the advantages and
disadvantages to using enteral
nutrition support (Whether through
NGT or via GT)?
ALL, AML, Wilm’s Tumor, Medulloblastoma,
Neuroblastoma, and Sarcomas



Begin nutrition support if a patient has lost >5
of their UBW
Consider upcoming treatments and anticipated
side effects when making recommendations
Anticipate PO intake in the interim, overall %
weight loss, nutrition status prior to diagnosis
to individualize when nutritional support
should be initiated
Family of patient may be more comfortable
with the use of TPN over EN
TPN is often used as a way to manage
electrolyte disturbances from chemotherapy
Greater risk for infection with the use of TPN
and higher dextrose infusion
TPN is less physiologic, doesn’t stimulate gut
mucosa like EN, and does not provide the
immune-stimulating benefits that using the gut
can provide.
EN is more physiologic and has improved
benefits in terms of maintaining the gut
mucosa.
Substantially less expensive than TPN and has
lower risks for infection
Disadvantages include: tube placement which
may require surgery, uncomfortable
72

What are the biggest barriers or
complications associated with using
nutrition support in the inpatient
setting?




How do you feel nutrition
management of the pediatric
oncology patient could be
improved?

nasoenteric tubes, and possible self-image
issues
For patients with active mucositis without prior
enteral access, it’s difficult to convince the
team to place a tube that might irritate the
mucositis or cause bleeding in a child with
thrombocytopenia.
Families/patients reluctant to using NG tubes
as part of their care plans.
Families often see weight loss as “expected”
given the nature of their child’s treatment and
IV nutrition may be seen as an “easier” fix.
TPN often utilized more than EN, even if EN
may be indicated.
“[Nutrition support] may affect quality of life,
and with other issues like mucositis and n/v,
unfortunately EN is often not started as
proactively as it could be. Once it’s started I
think the biggest barriers to optimizing nutrient
delivery are 1) tolerance, and 2) feeds being
held due to interruptions.”
“Proactive instead of reactive efforts in starting
nutrition support, particularly EN. I also think
it would be helpful to have more follow-up
from an RD in clinic, to allow for the
continuum of care, and to be able to identify
needs and adjust regimens in a timelier manner
(vs. only seeing these patients when they’re
inpatient).”
As can be reviewed from the interview data, the pediatric RD reported that nutrition
recommendations are made based on current standards provided by the Children’s Oncology
Group. The guidelines recommend initiation of nutrition support if a patient has lost >5% of their
Usual Body Weight (UBW). The UVAHS Children’s Hospital does not have current protocols
in place for the initiation of nutritional support in pediatric oncology patients. The RD provides
recommendations for nutritional support by considering upcoming treatments (chemotherapy,
surgery, or radiation), anticipated side effects of the treatments, and anticipation of appetite in
the interim, overall % weight loss, and nutrition status prior to diagnosis. Based on the interview
73
with the pediatric oncology RD, she feels that improvements to the nutritional management of
hospitalized pediatric oncology patients could be made by initiating nutrition support earlier, and
via the appropriate utilization of EN versus PN. In addition, more consistent follow up from the
pediatric oncology RD in clinic may help to provide optimal nutrition support, allowing for the
maintenance of the continuum of care, and to be able to identify needs and adjust regimens in a
timelier manner.
74
DISCUSSION
As suggested in the literature review, children with cancer have higher nutritional needs
requiring adequate nutrition to be provided by their oral diet, EN, or PN. Achieving adequate
nutritional intake is often difficult due to the symptoms that may arise from treatment that will
inhibit the ability to adequately meet the patient’s needs via the oral route. Children with cancer
are more susceptible to malnutrition due to altered metabolism and rapid weight loss.
Malnutrition was noted in two of three patients used in our case study upon their initial
admission of data collection as was noted in Tables 12-14. Furthermore, over the course of data
collection, each of the three patients experienced mild malnutrition during a hospital admission
in which patients did not have nutritional support initiated but were maintained on NPO with
intravenous fluids only.
The quantitative data collected within this study has shown that each of the three patients did
not receive adequate nutritional support with EN during their admissions at UVAHS Children’s
Hospital. Individualized nutrition care plans were recommended by the RD for each patient to
receive adequate nutritional support, but patients remained NPO or on a regular diet with no
additional nutritional support provided. Data also showed that when nutrition support was
initiated it was not advanced to the goal rate or was often delayed due to procedures during at
least one admission date recorded for each patient. According to the nutrition intervention
algorithm presented in Appendix D was developed by the Children’s Oncology Group to
establish guidelines for the process of nutrition support should be initiated when a patient has
incurred > 5% weight loss from their usual body weight or during therapy for the treatment of
their oncologic process. Additionally, a patient is identified as needing nutrition support if their
weight for length has crossed > 2% ile channels. During T.W.’s admission on August12th 2011,
75
the patient was identified as having a BMI < 5%, 76% of IBW, and a weight loss > 5% of usual
body weight. The physician had consulted the RD to provide recommendations for TPN.
Recommendations were made by the RD to provide adequate nutrition with TPN on the first day
of the admission and subsequently on a number of days following the initial assessment.
Unfortunately, the nutrition intervention was never implemented during this admission due to
central line infection.
However as evidenced by the algorithm, nutrition intervention should have been
implemented upon the first day of admission given that T.W. was at risk for moderate
malnutrition. Given that T.W.’s oncologic process warrants TPN or EN intervention based upon
poor PO intake > 4 days with average intake < 50% of estimated needs the patient was kept NPO
due to line infection, procedures, and fluid overload.. Per the algorithm, patients who cannot
meet adequate nutrition needs > 80% from an oral diet should begin on nutrition support.
However the diet was not advanced from NPO due to the barriers of developing a central line
infection and prior episodes of emesis during the admission. The optimal route of nutrition
intervention, whether EN versus PN, is dependent upon the patient’s ability to safely tolerate and
absorb nutrients into the GI tract. T.W. had a few episodes of GI intolerances due to emesis, but
these GI intolerances possibly could have been alleviated by appropriate formula selection or the
use of antiemetic or motility agents. If the intolerances can be eliminated by the use of antiemetic
agents then the patient is a candidate for EN. Given T.W.’s development of a central line
infection with the use of TPN, it only further supports the research indicating the overall benefits
of EN in pediatric oncology patients and validates that PN should only be used as a nutritional
intervention when EN is not indicated.33 The development of a central line infection inhibited the
medical team from optimally providing adequate nutrition support for T.W. during the admission
76
of October 12th, 2011. Retrospectively looking at the data collection, it presents the issue that if
there were protocols regarding the initiation of nutrition support. Would the appropriate nutrition
intervention have been chosen on the first day of admission thus preventing the barrier of
providing optimal nutrition support?
Another barrier to providing optimal nutrition support for the pediatric oncology patient is
the holding of EN for emesis and other side effects such as mucositis. For example, on August
12th, 2011, NG feedings were held due to emesis and concerns for mucositis. Given these
concerns, the medical team removed the patient’s NG tube. Consequently, the patient never
reached full EN feeds, with average feeds meeting only 67% of estimated EN goals. Ultimately,
the patient was made NPO, further preventing the achievement of optimal nutrition support.
However, prophylactic placement of a PEG tube before treatment may be beneficial to providing
additional nutrition support for the pediatric oncology patients with suspected concerns for
malnutrition during treatment.45 Patients often experience ulcerative oral mucositis and are likely
to suffer from nausea and vomiting, thus interfering with the ability to eat or have normal
swallowing function.45 The placement of the tube prior to beginning therapy in anticipation of
inadequate ability to meet nutritional needs may prevent dehydration, malnutrition, and weight
loss, further interrupting treatment and placing the patient at further risk for complications.45
A good example of placing a G-tube in anticipation of malnutrition exists in our third
case study patient, N.M. The patient presented to UVAHS Children’s Hospital on October 3rd,
2012 with a 17% severe loss of body weight within 3.5 months since diagnosis after undergoing
radiation therapy. The decision was made to place a G-tube in light of upcoming chemotherapy
treatments, severe weight loss, and minimal average intake as reported by a food diary. After Gtube placement, the patient’s weight significantly improved by 4.5 kg in December 2012 to a
77
weight of 30 kg. However, without standard protocols regarding the initiation of nutrition
support and appropriate nutrition intervention in place, optimal and consistent nutrition support
cannot be provided for the pediatric oncology patient population.
The qualitative data provided by the pediatric oncology NP, RD and bedside RN
provided additional perspectives from the various healthcare providers regarding the current
practices for implementing nutrition support at UVAHS Children’s Hospital. Each of the health
care professionals consistently identified the lack of protocols regarding the initiation of nutrition
support for the pediatric oncology patient at UVAHS as a problem and barrier to optimizing
nutritional support delivery and initiation. The RD and nurse practitioner both identified the
Children’s Oncology Group as a reference when providing recommendations for nutritional
management for the pediatric oncology patient; however; the data from our study suggests
nutrition management is not consistently being carried out per those guidelines despite timely
and repeated RD recommendations
The NP and RD also both identified the outpatient clinic as an area where nutrition
management is lacking, and that the patients and oncology team would benefit from the presence
of the RD in clinic as patients often experience side effects from their treatments that inhibit their
nutritional intake. The presence of an RD available in clinic would help with symptom
management and allow for proactive adjustments as needed to home nutrition support regimens.
Ultimately, both the quantitative and qualitative together identify a pattern of insufficient
nutritional support provided to the three patients reviewed for this case series study. The findings
from the qualitative and quantitative results suggest the need for quality improvement in
78
providing optimal nutritional support for our pediatric oncology patients at UVAHS Children’s
Hospital.
79
CONCLUSION AND RECOMMENDATIONS
The results of the qualitative and quantitative data obtained in this mixed methods case
series study further supports the need for an establishment of nutrition support protocols at
UVAHS Children’s Hospital. The quantitative data indicated inadequate provision of nutrition
support during the patients’ admissions. In a few circumstances, the appropriate route of
nutrition support, whether EN versus TPN, was utilized in an effective manner. However, this
was the exception rather than the norm. Establishment of nutrition support protocols would
uniformly provide pediatric oncology healthcare professions, with guidelines for the timely
initiation of appropriate nutritional support in our pediatric oncology patients. The optimization
of nutritional support for this patient population would allow for the provision of adequate
nutrition to support normal growth and development.
Furthermore, the qualitative data collection supported the need for uniform protocols in
providing nutrition support for pediatric oncology patients in the inpatient unit as well as
outpatient clinic. The qualitative data further supported the RD as being a key member of the
medical team and providing recommendations for nutrition support for the pediatric oncology
patients. However, having the RD on the pediatric oncology team is not beneficial to patient
outcomes if that individual’s timely and appropriate nutritional recommendations are not
implemented.
The RD is an important health care professional who provides proactive
recommendations for nutritional support in a timely and effective manner based on established
guidelines. The RD could play a vital role in improving the effectiveness of nutritional support
by educating the healthcare staff on the role of nutrition support in the pediatric oncology patient
80
population and appropriate nutrition recommendation, particularly if an RD is unavailable in the
outpatient clinics. Providing education on nutrition support to staff members will only reinforce
the importance of initiating nutritional support in a timely matter for the pediatric oncology
patient with increased nutritional needs. The UVAHS Dietitians have developed a Pediatric
Nutrition Support Handbook “Standards of Care” that could be utilized along with the existing
algorithm from the Pediatric Oncology Group presented in Appendix D to collaboratively
develop nutrition support protocols for pediatric oncology inpatients admitted to UVA Health
System. Furthermore, the availability of an RD in the outpatient clinic is important to having an
effective medical staff to provide recommendations for nutritional support and information on
symptom management in the pediatric oncology patient along the continuum of care.
81
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Future Research. American Association for Cancer Research Journal. 1982; 42: 721-725.
20.
Ward E, Hopkins M, Williams N, et al. Nutritional Problems in Children Treated for
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21.
Aseeri, M, Muhktar, A, Khansa, SA, et al. A retrospective review of antimetic use for
chemotherapy induced nausea and vomiting in pediatric oncology patients at a tertiary
care center. Journal of Oncology Pharmacy Practice. 2012.
22.
Arensmeyer, K RN. Nursing Management of Patients with Cancer-Related Anorexia.
Onco Link. 2012.
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Dahlin, C., Lynch, M., Szmuilowicz, E., & Jackson, V. Management of symptoms other
than pain. Anesthesiology Clinics of North America. 2006; 24: 39-60.
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Interventions: A Lives Saved Tool Analysis. PLOS Medicine. 2011; 8 (3).
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Cheng K, Chang A, Yuen M. Prevention of Oral Mucositis in Pediatric Patients Treated
with Chemotherapy: A Randomized Crossover Trial Comparing Two Protocols of Oral
Care. European Journal of Cancer. 2004; 40: 1208-1216.
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Baggott, C, Dodd, M, Kennedy, C, et al. Multiple Symptoms in Pediatric Oncology
Patients: A Systematic Review. Journal of Pediatric Oncology Nursing. 2009; 26 (6):
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85
Appendix A: Nutritional Assessment: UVAHS Pediatric Nutrition Standards of Care28
1. Food and nutrient intake (1)
a) Energy Intake (1.1)- kcal/kg
b) Food and beverage intake (1.2)
1) Fluid/beverage intake (1.2.1)- ml/kg
2) Food Intake (1.2.2)
c) Breast milk/infant formula intake (1.2.3)-ml/kg, Practice Guideline: note caloric
density
d) Enteral and parenteral nutrition intake (1.3)
1) Enteral nutrition intake (1.3.1)- kcal/kg, g pro/kg, ml/kg
2) Parenteral nutrition intake (1.3.2)- kcal/kg, g pro/kg, ml/kg, g fat/kg
c) Macronutrient intake (1.5)
1) Protein intake (1.5.2)- g/kg
d) Micronutrient intake (1.6)
2) Vitamin intake (1.6.1)
3) Mineral/element intake (1.6.2)
2. Food and Nutrient Administration (2)
a) Diet history (2.1)
1) Diet order (2.1.1)
2) Enteral and parenteral nutrition administration (2.1.4)
3. Medication and Herbal Supplement Use (3)
4. Medication and herbal supplements (3.1) Knowledge/Beliefs/Attitudes (4)
b) Food and nutrition knowledge (4.1)
86
c) Beliefs and attitude (4.2)
5. Behavior (5)
a) Adherence (5.1)
b) Avoidance behavior (5.2)
c) Mealtime behavior (5.4)- Practice Guideline: consider fatigue with feeding,
limited number of accepted foods, sensory preferences
6. Factors Affecting Access to Food and Food/Nutrition-Related Supplies (6)
d) Food/nutrition program participation (6.1)
e) Safe food/meal availability (6.2)
7. Physical Activity and Function
a) Breastfeeding (7.1)
b) Physical Activity (7.3)
87
Appendix B: Pediatric Oncology Nutrition Data Form 2012-2013: Barriers to Optimal
Nutrition Support
Name:
MRN #:
DOB:
Sex:
Admission Date:
Diagnosis:
Weight (kg): (___%ile)
Weight for length/BMI: (___%ile)
PMH: Length (cm): (___%ile) Reason for Admission:
PSH:
HC (cm): (___%ile)
Oncologic Treatments:
Data Collection
Day 1
Date/Hospital Day
Current Weight (kg)
1. Parenteral (Y/N)
% Dextrose (order)
PRO (g/kg or g/day)
20% IL (mL)
Actual Intake:
24 hr Volume (mL/day)
Dextrose kcal
PRO grams (g/kg)/PRO kcal
Lipid kcal
Kcal/kg (PN)a
2. Enteral (Y/N)
Formula & Density
Schedule
Route (NG, ND or G-tube)
Total Volume (mL/day)
Actual Intake:
24 hr Volume (mL/day)
Kcal/kg (EN)b
TOTAL kcal/kg/d (a+b)
3. Meeting Nutrition Goals (Y/N)
Nutrition Goals (kcal/kg, g/kg, ml/kg)
% of Goal (kcals, pro)
Barriers to Optimal Nutrition
# of Days Between RD Recs & Initiation of Nutrition Support
Relevant Medications
Comments:
88
Day 2
Day 3
Day 4
Day 5
Appendix C: UVA Health System Interview Guide
Interview 1:
The following questions were used to interview a pediatric oncology nurse practitioner. The
purpose of the interview is to obtain the nurse practitioner’s professional opinion regarding
pediatric cancer and its nutrition management.
1. What are the most common pediatric cancers treated at UVA Children’s Hospital?
The common pediatric cancers are childhood leukemia which accounts for 33% of all
pediatric cancers. About 75% of those are acute lymphoblastic leukemia and the other 25% is
acute myelogenous leukemia. The ALL requires treatment 2-3 years in treatment and AML
requires intense treatment where the children will be admitted for months in the hospital. The
children with ALL don’t require TPN although children with AML often require TPN. At UVA
there are several CNS brain tumor patients. Often hospitals will place a G-tube concurrent with
surgery for port placement or resection. The reason for this is due to the importance of adequate
nutrition needed for the children with brain tumors and the challenges they face with nutritional
adequacy. The brain tumor patients will often require a G-tube placement during the resection
process of the tumor. The lymphomas treatments are close to leukemia although not too intense
where they are NPO for long periods of time or require TPN. Some of the leukemia protocols
call for high doses of methotrexate which can cause Mucositis which requires IV fluids at night
for a week but almost never TPN. Bone tumors (Ewings or Osteo) depends on age but often
chemotherapy is very intense where there are infections in , Typhlitis and often require bowel
rest with TPN. Soft tissue tumors often can be a challenge with eating especially in toddlers
although no Mucositis and almost never g-tube placement. Neuroblastoma patients have long
difficult treatments with frequent placement of g-tubes and several rounds of chemotherapy,
surgery, and transplant .The neuroblastoma kids have a long difficult road with nutritional
management. The rare tumors hepatoblastoma and retinoblastoma don’t require g-tube
placement or the use of tpn and usually nutrition is not an issue. However adequate hydration
status can present problems. We ask parents to give IVF overnight and kids to provide adequate
hydration. A poor appetite is common among these patients and we often prescribe Marinol to
stimulate their appetite. Leukemia patients are often on high dose steroids and they “puff up”
with an increased appetite usually eating a lot. However the increased appetite doesn’t last very
long until it decreases again.
2. Is there a protocol or guideline that you follow regarding the nutritional management of the
pediatric oncology patient? If so, please specify the source.
We do not have a written guidelines established although we utilize the Children’s
Oncology Group recommendations. The Children’s Oncology group consists of hundreds of
different institutions that compile their data on treating oncology patients and publish supportive
care guidelines that discuss changing treatment or measures to take once a child has lost 5 % of
body weight. However we have nothing strict established at UV for our pediatric oncology
patients. Other institutions have specific guidelines or protocols for weight loss or caloric intake
especially if they have transplant units.
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3. At what point do you feel nutrition support is indicated in this patient population? What are
the factors that influence your decision for starting nutrition support?
From the get go the nutrition support is very important. I would consider it just as
important as infection control precautions. The child is still growing and having cancer increases
those needs for normal growth and development. We try to talk about eating high fiber foods to
combat the constipation from chemotherapy treatment. We educate the family on consuming
high protein shakes on days the children are not feeling well. We educate the parents on
increasing the calories in the foods by adding calorie dense foods during cooking. We are
fortunate that we can fall back on enteral nutrition, IVF, or TPN for additional nutritional
support. The type of chemotherapy may influence the type of nutritional support because of the
symptom management. The different types of chemotherapy treatment may cause mouth sores,
nausea, vomiting, the active level of the child, the tumor location. The tumor location can make
the nutritional support difficult like Wills tumor and neuroblastoma will affect the stomach.
These children often have several surgeries which may affect adequate nutritional intake. . The
weight loss will determine enteral nutrition versus parenteral nutrition. However weight loss
between 5-10% can determine the imitation of nutritional support. UVA does not have a set
number for weight loss as a determinate for nutritional support but we can take into
consideration the length of treatment. The maintenance therapy in leukemia with oral
chemotherapy has a lower emetic affect and we know the children will gain the weight loss back.
However with neuroblastoma or brain tumors the team tends to be more aggressive with
nutritional treatment because the nutritional status will worsen throughout the treatment course.
4. What are the advantages and disadvantages to using parenteral nutrition support?
We don’t have to “hound” the child to eat because a lot of times the child uses it as a
source of control. The nutritional support eliminates the burden of caloric intake and relieves the
tension between child and parent. Other advantages include the chemotherapy can cause the loss
of electrolytes excreted from the kidneys and this is easily corrected with TPN. We can use the
TPN to bolster the child for nutritional adequacy if going they are going to be on a long
treatment cycle. If the child hasn’t been eating but previously on TPN then the team will leave
the child on the TPN longer. The reasoning is to provide additional nutrition to bolster the child
through treatment if we know the next cycle will be tougher to provide additional nutrients. The
disadvantages are the TPN has a higher risk of infection due to the high glucose concentration.
The TPN can be harder on the child’s liver because of the lipid content and the overall
metabolism of the concentration of TPN. Parenteral nutrition is expensive and the labs to follow
the TPN daily are an added expense. When patients are discharged to home on TPN this can add
to another source of infection. The parents will administer the TPN through a central line. The
manipulation of the intravenous line puts the child at higher risk for infection.
5. What are the advantages and disadvantages to using enteral nutrition support (whether through
NGT or via GT)?
The advantages of the enteral nutrition are the ability to provide oral medication through
the tube. It can help to alleviate the tension between the child and parent. The parent will not
have to worry about asking child to finish every bite. The enteral nutrition is not as expensive as
90
TPN and easier for the family to administer feeds at home with a pump. Pediasure can be
purchased from a store but insurance doesn’t cover the cost of the product.
The disadvantages of enteral feeds are that the children hate the NG tubes. The tubing can
dislodge during episodes of emesis. The tubing can serve as a source of infection with Mucositis
or an irritant. The process of cleaning the tubing can cause issues for the parents. The tubing may
increase the anxiety for the parents or children and provide additional stress to the family. The
children often associate pain with the g-tube even if pain is due to the tumor. If the g-tube comes
out then it requires surgical placement.
6. What are the biggest barriers or complications associated with using nutrition support in the
inpatient setting? Please note if you are referring to EN and/or PN.
We don’t’ usually have barriers because the parents are usually on board with the idea of
nutritional support. However with the g-tubes children are usually hesitant but TPN is the option
children prefer. The oncology RD is a good supportive resource for when we are having
questions regarding nutritional support.
7. How do you feel nutrition management of the pediatric oncology patient could be improved?
We need better handouts to provide to the families and currently we follow a handout
made specifically for adult oncology patients. I am in the process of developing handouts to meet
UVA standards. A lot of the nutritional management we question in retrospective for example
placing a g-tube sooner, different placement of tube, or started TPN earlier. It is always a process
of trial and error because it is dependent upon the individual patient. We could improve the
nutritional management with the RD rounding with the team in the morning. The patients in
outpatient clinic are struggling with their nutritional support. I feel this may improve if they had
access to the inpatient RD they are familiar with during their admission. I feel it would be
beneficial to have follow-up with inpatients when they arrive for their outpatient clinic. It would
be beneficial to have more access to an RD in the outpatient clinic. The nurse practitioners would
benefit from knowing the options available for the different enteral products (flavors) via
resources provided (handouts).The pediatric nutritional support handbook provided to the staff
especially the nurse practitioners and attending’s would be beneficial as well. It would be helpful
for the nurse practitioners to receive an in-service from the RD on the nutritional support
information and guidelines.
91
Interview 2:
The following questions were used to interview a current RN at UVA Children’s Hospital. The
purpose of the interview is to obtain the bedside RNs professional opinion regarding use of
nutritional support in pediatric cancer patients.
1. What are the advantages and disadvantages to using parenteral nutrition support?
When an oncology patient is experiencing Mucositis or nausea, it is nice for them
to be provided with parenteral nutrition, so they do not have to have the increased stress
of eating enough to maintain proper nutrition. The downfall to getting parenteral
nutrition is that when a patient is neutropenic and receiving multiple antibiotics, they are
receiving large fluid volumes. So it is very important to accurately record input and
output.
2. What are the advantages and disadvantages to using enteral nutrition support (whether
through NGT or via GT)?
Some of our oncology patients are getting their calories via NGT/GT and they are
not eating by mouth. This is hard for some families to understand because they came into
the hospital with a child that was eating their meals and now they are refusing to eat. But
on the other side it is nice to be able to feed a patient even when they refuse to take all of
their calories by mouth.
3. At what point do you feel nutrition support is initiated in this patient population? (ie: after
X amount of days not eating, or a certain % weight loss, etc.)
I feel that this depends on the patient and which attending is on service. It can also
depend on how the parents feel about the lack of PO intake.
4. What are the biggest barriers or complications that you see associated with using
nutrition support in the inpatient setting? Please note if you are referring to EN and/or
PN.
For enteral feedings it is often difficult getting the proper formula. We have to
beg and borrow from other units when the store room states they are out of a certain
formula. This tends to happen more often than not. I do not feel that there are many
barriers with PN.
5. How do you feel nutrition management of the pediatric oncology patient could be
improved?
I know that every patient and their treatment vary so it would not be feasible to
have a standard protocol. I think that tube feeds should be started earlier than they are
sometimes. I know that it has to do with parent’s hesitation and wanting to see if the
92
patient’s intake will improve on its own. Overall I feel that the physicians and dieticians
are very involved in the management of nutrition for our oncology patients.
Interview 3:
The following questions were used to interview a current RD at UVA Children’s Hospital. The
purpose of the interview is to obtain the RDs professional opinion regarding use of nutritional
support in pediatric cancer patients.
1. What are the most common pediatric cancers treated at UVA Children’s Hospital?
I’m not sure of the official numbers, but the diagnoses that seem most prevalent include ALL,
AML, Wilm’s Tumor, Medulloblastoma, Neuroblastoma, and Sarcomas (osteo, Ewing’s, other)
2. Is there a protocol or guideline that you follow regarding the nutritional management of
the pediatric oncology patient? If so, please specify the source.
The Children’s Oncology Group has an algorithm for the initiation of nutrition interventions and
nutrition support. I typically follow these guidelines with my recommendations.
3. What are the most common topics of nutrition education that are covered with this patient
population?
We do a lot with maximizing nutritional intake, so using protein and calorie fortifiers, adding
dips, sauces, yogurt, cheese, peanut butter to foods, etc. I also work with the families a lot on
making the most of the calories the children are drinking, whether they use plain milk,
commercial oral nutrition supplements, or their own homemade milkshakes and smoothies.
We’ll also talk about how to optimize intake despite severe nausea or vomiting, or any taste
changes. Finally, we do talk about general good food safety practices, and if a patient is getting
ready for (or has recently had) a bone marrow transplant, then we’ll really hone in on this.
4. At what point do you feel nutrition support is indicated in this patient population? What
are the factors that influence your recommendations for starting nutrition support?
Based off of the guidelines, if a patient has lost >5% of their UBW, I think it’s worth starting
nutrition support. We also take into consideration their upcoming treatments, anticipated side
effects, how we think they’ll eat in the interim, overall % wt loss, nutrition status prior to
diagnosis to individualize when nutrition support might be indicated. With pediatrics especially,
I think it’s important to be proactive vs. reactive to try to ensure the best possible nutrition status,
not only to help support and maintain normal growth, but also for improved outcomes related to
their response to their treatment regimen.
5. What are the advantages and disadvantages to using parenteral nutrition support?
Patients/families seem a lot more comfortable using TPN over EN. I think a lot of this has to do
with the fact that the children already have central access, so it seems “easier” and less invasive
than a nasogastric or nasojejunal tube. The chemotherapy also often affects the child’s kidney
93
function acutely, and so we see a lot of electrolyte disarray. TPN can be a way to streamline
repletion of the electrolytes while still providing the nutrients that the child may be missing out
on.
Unfortunately, I think that too often we go to TPN as a first line of nutrition support, even if EN
may be better suited for the patient. There are significantly greater risks for infection with TPN
due to re-accessing their central lines, and the higher dextrose infusion. It’s also less physiologic
and does not stimulate the gut mucosa like EN can, and does not provide the immune-stimulating
benefits that using the gut can.
6. What are the advantages and disadvantages to using enteral nutrition support (Whether
through NGT or via GT)?
As previously mentioned using EN is more physiologic and has improved benefits in terms of
maintaining the gut mucosa. It’s also substantially less expensive than TPN and has lower risks
for infection which is such a big factor for this population, since their immune system is already
so compromised.
The disadvantages include the fact that a tube needs to be placed, and since it’s typically not a
PEG or G-button, which would require a surgery, the child would have to have the NG tubes
which are uncomfortable. We also see some issues with self-image due to the placement of the
tube. Finally, for a child with active mucositis without prior enteral access, it’s difficult to
convince the team to place a tube that might irritate the mucositis or cause bleeding in a child
with such low counts.
7. What are the biggest barriers or complications associated with using nutrition support in
the inpatient setting? Please note if you are referring to EN and/or PN.
I think there are two big issues that fall under that question: 1) barriers to starting nutrition
support, and then 2) barriers to optimizing nutrition support. As I’ve previously mentioned, I
think there’s a certain stigma patients/families associate with NG tubes which make them
reluctant to using them as a part of their care plans. Families often see weight loss as “expected”
given the nature of their child’s treatment and IV nutrition can be seen as an “easier” fix. This
also can affect quality of life, and with other issues like mucositis and n/v, often EN is not started
as proactively as it could be. Once it’s started I think the biggest barriers to optimizing nutrient
delivery are 1) tolerance, and 2) feeds being held due to interruptions.
8. How do you feel nutrition management of the pediatric oncology patient could be
improved?
I think we could be more proactive instead of reactive in starting nutrition support, particularly
EN. I also think it would be helpful to have more follow-up from an RD in clinic, to allow for the
continuum of care, and to be able to identify needs and adjust regimens in a timelier manner (vs.
only seeing these patients when they’re inpatient).
94
Appendix D: Algorithm for Nutritional Intervention in the Pediatric Oncology Patient15
Identify appropriate category:
 Age > 2 years choose either BMI or IBW
 Age < 2 years choose WT/LT (Weight for Length) or IBW
Underweight
Normal
th
< 5 % ile
< 10th % ile
< 70% severe
> 70-80% Moderate
> 80-90% Mild
BMI
WT/LT
IBW
Risk of Overweight/Overweight
th
5-85 % ile
10-90th % ile
> 90-110%
>85-95% ile
>110-120%
> 95th % ile
> 90th % ile
> 120%
> 5 % wt loss from Usual Body Weight or during therapy
Or
Crossing > 2 % ile channels
NO
Meeting >80% estimated nutritional needs through oral intake (food and
supplements)
YES
YES
NO
NO
Will impending treatment adversely affect nutritional
status and ability to meet needs orally?
YES
Encourage oral intake/ supplements and monitor
weight/ adequacy of diet once a month
NO
Oncologic prognosis warrants TPN or EN
YES
Can patient safely tolerate/absorb nutrients via GI tract
YES
NO
Is patient a candidate for EN?
NO
Is expected need for nutritional support > 5 days?
YES
NO
Can intolerance be alleviated by changing formula
or using antiemetic’s/motility agents
TPN until GI tract can be
safely used
YES
NO
Monitor and intervene as needed
YES
High risk of pulmonary aspiration or excessive emesis
NO
TPN
YES
Gastric feeds
Post-pyloric feeds
NO
EN required for > 3 months
NO
Can tolerance be alleviated by changing formula, method of
administration or adding medication?
YES
Nasoenteric EN:
Nasogastric
Nasoduodenal
Nasojejunal
YES
Implement necessary changes
NO
Provide EN as tolerated and wean when oral consumption is > 50% estimated needs
YES
95
Enterostomy EN
(PEG vs. G-tube):
Gastrostomy
Jejunostomy
Gastrojejunostomy
Can patient tolerate feedings in
strength and amounts necessary to
meet estimated needs?