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Nutrition for children underdoing cancer treatment

Implementation

Supplementing/fortifying

Fortifying

  • No added vitamins, minerals, or trace elements 
  • Usually only fat, carbohydrates or protein, possibly a combination of fat and carbohydrates.

Breast milk from the child's mother or bank milk (milk from a donor) can be used as the only form of nutrition until the child is 4-6 months. Thereafter the child should have a more enriched diet to support the greater need for energy. Unpasteurized bank milk or biologically active milk should not be used for children with cancer.  

Nutritional drinks

There is an assortment of ready-made nutritional drinks available on the market.  Some of these products are complete.  They contain carbohydrates, protein, fat, and all of the necessary vitamins, minerals, and trace elements are added. Fiber is also added in some. The energy content varies from 85-200 kcal /100 ml and certain products have a high protein content.

These products are age appropriate and dose is determined individually by a clinical nutritionist/doctor.

Most children prefer homemade nutritional drinks based on whole milk, cream, ice cream, fruit, and flavorings. These are free of additives and taste more fresh. The energy and protein content are close the commercial products and are much less expensive. Homemeade nutritional drinks are, however, not complete and should not be used as the only source of nutrition, but as a supplement to other nutrition.

Enteral feeding (tube feeding)

Choice of product

The choice of product is based on:

  • energy and protein need
  • age and condition of the illness
  • existing nutritional intolerance/allergy 
  • gastrointestinal function
  • the location of the tube
  • the characteristics of the product, for example, osmolality, nutritional content, protein type, user friendliness, and cost

Administration

Continual administration is recommended at the start of tube feeding to reduce the risk of diarrhea. When the child is established on full volume, he/she may change to bolus meals, and eventually intermittent administration. 

The tolerance for the volume of tube feeding and the different products varies from child to child. It may be necessary to change pruducts as well as assess the position of the tube. The tolerance for tube feeding during a course of chemotherapy is often reduced. The child's appetite is usually reduced for 1-5 days. Tube feeding must often be reduced or stopped for a few days and carefull resumed 2-3 days after ending a course with about 1/3 of the normal volume.

Food can be fed by tube feeding in three different ways:

  • Continual: Infusion with pump for 24 hours. The tube should be rinsed every 4-8 hours. It is recommended to take a break for 4 hours which will lower pH in the stomach. This has an antibacterial effect.
  • Bolus: Enteral formula given in small portions at the mealtimes the child normally eats. This is divided into 5-8 meals. Each meal is given over 15-60 minutes depending on the volume. Bolus can also be given after other food. The tube should be rinsed before and after each meal. 
  • Intermittent: The formula is given using a pump. For example, the child is given food continually through a tube at night and is able to eat normally during the day. The tube should be rinsed before and after each meal. 

Hygienic precautions during administration

  • The expiration date on the package should always be checked before use. 
  • The nutrition set should be changed after 24 hours.
  • Unopened packages of tube food should be stored at room temperature.
  • Opened packages that are not attached to the nutrion set should be stored in the refridgerator and used within 24 hours.
  • Enteral nutrition in a closed system may hang for 24 hours at room temperature, provided it is connected to the feeding set.
  • Enteral feeding solution in a glass may hang for 8 hours in room temperature.
  • Enteral feeding solution poured into a feeding bag may hang for 8 hours at room temperature.
  • Feeding solution mixed from powder may hang for 4 hours at room temperature.
  • The tube should always be sealed when disconnected.
  • The tube should be rinsed with water between meals. For immunosuppressed patients and babies, sterile water should be used.

Diarrhea

For persisting diarrhea, enteral feeding should be stopped for 24 hours and oral rehydration fluid given. The enteral formula can then be gradually increased again.

The are multiple causes of diarrhea during treatment

Case

Measure

Bacterial contamination

Use a closed system

Volume of feeding solution given as bolus is too large

Reduce the volume or rate

Feeding solution is given to quickly

Administer the formula continually

Feeding solution is too cold

Temperate the formula

Osmolarity of feeding solution is too high and is not well tolerated

Switch to an isotonic product

Intolerance for content in feeding solution

Use another product

Tube has reached the duodenum

Check the position of the probe

Parenteral nutrition

Administration

  • TPN mixtures last for 24 hours at room temperature. 
  • The infusion set is changed every day.
  • TPN bag is taken out of the refridgerator 2 hours before use.
  • The TPN infusjon should be stopped 3 hours before taking blood tests.  
  • The central venous catheter should be rinsed daily with 1 ml 45% ethanol to prevent accumulation in the catheter. The ethanol is aspirated after 1 minute. 
  • TPN should last as many hours as possible so the child is able to absorb as much of the nutrition as possible.  
  • A drug can be administered with TPN if it is documented that they will be mixabler. The documentation must apply to the relevant TPN formula.

Transfer from TPN to enteral feeding

It is important that TPN is not stopped too early. The transfer to enteral feeding should occur gradually. When the child is able to cover 25% of the calculated energy need required by enteral nutrition, a corresponding reduction of TPN can be made. TPN should not be stopped before the child has reached at least 75% of its nutritional need enterally.

Prednisolone treatment

Prednisolone treatment over a longer period of time leads to increased appetite and weight, both during and after concluded treatment. To prevent the child from becoming overweight, the amount of calories should be adjusted according to the consumption. If tube feeding is used, it is very important to reduce this to avoid to high calorie intake. Intake of calcium and vitamin D should be monitored during prednisolone treatment. Supplements should be given if the need is not met by diet or tube feeding.

Nutrition associated with bone marrow transplant (BMT)

Nutritional status for children who have bone marrow transplants must be assessed in advance before the transplantation. The nutritional condition must be optimized so the child is well nourished. Nutritional intake should be intensified. Some children may need tube feeding for a period before the transplantation.

The child should also have close follow-up of their nutritional status after the transplantation. Many children have a poor appetite for a long period after the transplantion and require tube feeding/supplementation. More children are bothered by sore mouth and nausea and require tube feeding due to this.

During the period right after the transplantation, the child will have neutropenia and be susceptible to gastrointestinal infections from foodborne pathogens.

According to the "Nordic guidelines for nutrition during BMT" the child should avoid the following foods while in isolation:

  • fresh fruit that cannot be peeled
  • raw berries and vegetables
  • cured or smoked salmon
  • candy in loose weight
  • McDonalds and other fast food
  • unpasteurized milk and milk products including unpasteurized bank milk

There is no consensus on whether Biola (probiotic milk) should be avoided by immunosuppressed patients.

Products with a high risk for high amount of listeria to be avoided:

  • fermented fish
  • cheese and sour cream of unpasteurized milk
  • soft cheesese, both pasteurized and unpasteurized
  • smoked fish
  • raw fish products
  • sprouts
  • raw meat
  • mildly preserved or long-lasting products 

 

Reference

Ernæring til barn med kreft – Veileder for helsepersonell [Online]. Mars 2004 [hentet 1. desember 2007]; Tilgjengelig fra: URL:http://www.kreftforeningen.no/vp/multimedia/archive/00001/Ernaering_til_barn_me_1627a.pdf

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