Supportive nutritional intervention in pediatric cancer.

Nutritional support of the child with cancer now is recognized as an important adjunct to cancer treatment. Protein-energy malnutrition frequently accompanies the diagnosis and treat ment of children with neoplastic diseases. Common risk factors for the development of protein-energy malnutrition include ad vanced stages of disease, lack of tumor responses, intense treatment with curative intent (including chemotherapy cycles at <3-week intervals, abdominal operative procedures, or ab dominal and pelvic irradiation), and the absence of a supportive health care team which implements effective nutritional sup port. The impact of malnutrition may be reflected in tolerance of treatment, tumor response, and survival as well as in the incidence of complications. The risks and benefits associated with enterai and parenteral nutritional support are reviewed. Preliminary data from our institution document the severity of alterations in nutritional status and the ¡mmunological compe tence associated with multimodal treatment of children with advanced cancer. The effectiveness of enterai and parenteral nutrition in supporting a satisfactory nutritional status and/or reversing protein-energy malnutrition was evaluated in 28 chil dren, ages 1 to 19 years, with a variety of neoplasms (21 solid tumors, 7 leukemia-lymphoma). A comprehensive enterai nu trition program which included intense nutrition counseling and oral supplements was found to be ineffective in preventing nutritional depletion during initial intense treatment of most children. Sixteen of 21 patients who received a comprehensive enterai nutrition program had a decreased kilocalorie intake [48 ± 24% (S.D.) of the Recommended Dietary Allowance] and significant weight loss (16 ±6%). On the other hand, total parenteral nutrition provided at a kilocalorie intake of 100% of the Recommended Dietary Allowance and 2.5 to 3 g amino acids per kg for 28 or more days effectively restored muscle and fat reserves, increased serum albumin and transferrin to normal concentrations, and, in most patients, reversed anergy to recall skin test antigens. A shorter period of total parenteral nutrition (9 to 14 days) did not restore appropriate weight for height, fat reserves, and albumin concentration, although trans ferrin concentration was normalized and quality of life was improved. Of the group of 28 patients, 9 children (ages 1 to 7 years) with Wilms' tumors had the most severe and predictable malnutrition. A dramatic loss of weight (22 ±7% by 26 ±17 days from the beginning of treatment) was associated with initial intense treatment in children who received enterai nutri tion. Every patient who received parenteral nutrition gained weight despite continuing treatment. These data suggest that most children with advanced Wilms' tumors will benefit from early and continued provision of adequate nutrition, such as that provided by total parenteral nutrition. Once patients com pleted the initial phase of treatment, however, enterai nutrition was effective in restoring or maintaining muscle and fat re serves in patients who had no evidence of tumor. Further research is needed to determine the roles of enterai and parenteral nutritional support in children with specific tumor types, when and how to implement effective enterai nutrition programs, and the value of parenteral nutrition in the support of the nourished child. Nutritional support of the patient with cancer is attracting considerable attention as an important adjunct to cancer treat ment. Effective nutritional support has been one of the most important and potentially beneficial advancements in patient care in the last 10 years. This report identifies children at high risk for nutritional depletion, discusses the significance of nutritional support, reviews the risks and benefits of enterai and parenteral nutritional support, provides data regarding the effectiveness of these modes of nutritional support in selected populations of children with neoplasms, and summarizes con clusions regarding the use of enterai and parenteral nutrition in the clinical management of children with cancer. Childhood Neoplasms with High Risk for PEM PEM2 is frequently observed at the time of diagnosis and during treatment of childhood cancer (54, 59, 70). The inci dence of PEM at diagnosis of childhood neoplasms varies from 6% to as high as 50% (Table 1), depending upon tumor type, stage of disease, and criteria for PEM. Although data regarding the incidence of malnutrition associated with specific tumor types of childhood neoplasms and their treatment are sparse, some generalizations can be made which are consistent with clinical observations previously noted at this institution. At initial diagnosis or at the time of relapse, children with advanced stages of solid tumors have a higher incidence of PEM than do children with localized disease or children with leukemias. Although PEM may not be present at diagnosis, it may occur frequently during treatment. A number of factors may signifi cantly increase the risk of development of PEM in children with neoplasms (Table 2). The extent of disease at diagnosis or the intensity and mode of treatment designed to eradicate the neoplasm and tumor response are determinants for the devel opment of PEM. In addition, the absence of a supportive health care team and lack of attention to enterai nutrition increase the 1 Presented at the Pediatrie Cancer and Nutrition Workshop, December 11 and 12, 1980, Bethesda, Md. Supported in part by Grants RO1 CA28005 and RO1 CA28531 from the National Cancer Institute, NIH, Bethesda, Md. 20205. 2 The abbreviations used are: PEM, protein-energy malnutrition; TPN, total parenteral nutrition; RDA, recommended dietary allowance. 766s CANCER RESEARCH VOL. 42 on April 13, 2017. © 1982 American Association for Cancer Research. cancerres.aacrjournals.org Downloaded from Supportive Nutritional Intervention