I remember when my children were little, I was consumed with feeding them well. I made sure they had well-balanced meals, snacks, and drinks. I made sure their friends were well fed. I guess it's the way of my people.
But I had healthy kids and a plethora of resources available to me to properly feed my children; they weren't fighting cancer, being treated with chemotherapy and/or radiation, and fighting for their lives. And it got me thinking: how does the cancer care team handle nutrition in the pediatric cancer patient?
A recent article highlights the nutritional issues in children with cancer. The authors note that according to the literature, 46 percent of pediatric patients with cancer experience malnutrition due to several tumor- and treatment-related factors. And while it may seem like commonsense that children with cancer are more vulnerable to malnutrition, the lack of a "gold standard definition for undernourishment in children" (or even concise definitions) can cause confusion in institutions trying to put preventative policies in place.
The World Health Organization (WHO) recommends that a child's nutritional status be assessed by finding the weight for height index; a loss in body weight of approximately 5 percent signifies acute malnutrition, and a height-for-age value below the 5th percentile may reflect chronic undernourishment in children.
However, this system often does not work for children with cancer because of their cancer type (embryonal neoplasm) or treatment side effects (edema from steroids). While their "numbers" may read "normal," they are actually in a state of "nutritional depletion."
"She's just wasting away"
Pediatric cancer patients experience anorexia issues as well as energy loss, just like adult cancer patients. However, children with cancer often experience cachexia, a "profound and progressive wasting of lean tissue and body fat" often seen in individuals with acute sepsis, burn injuries, or AIDS.
The frustrating issue with cancer cachexia versus simple starvation is that an increase in "nutrient ingestion" isn't necessarily enough to "prevent, reverse or retard" it. Also, currently there are no drugs approved for the prevention or treatment of cancer cachexia. So how do we address the nutritional needs of children with cancer?
The strategy
First, children must be assessed for nutritional status, energy intake, and energy expenditure before therapy begins. Second, assess the cancer type. Third, if a child can eat her food, that is preferable, but if there are issues such as gastrointestinal obstruction, severe diarrhea, vomiting, or chronic malabsorption, a nasogastric feeding tube, PEG jejunostomy, or parenteral nutrition strategy should be immediately used.
To quote the authors, "Malnutrition in children with cancer should not be accepted at any stage of the disease or tolerated as an inevitable process." Children with cancer should have a nutritional plan in place that is discussed with everyone on the cancer care team -- from the oncologist to the nurse to the parents -- so the expectations for success are established.
In your practice, how do you meet the unique nutritional needs of children with cancer?
References:
Bauer, J. et al. Important Aspects of Nutrition in Children with Cancer. Adv Nutr March 2011 Adv Nutr vol. 2: 67-77, 2011.
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