Nutrition

If you require further advice or would like to discuss an individual child or young person, please contact the patient’s treatment centre or Paediatric Oncology Outreach Nurse Specialist (POONS: Key Worker) directly.

Importance of good nutrition

The nutritional status of a child or young person with cancer is an important factor to consider both at diagnosis and throughout treatment. Studies have shown that a well-nourished child or young person with cancer is more likely to cope better with treatment, have reduced complications and is more able to fight infection [1]. Malnutrition may be present at diagnosis or develop during therapy secondary to side-effects of treatment [2]. It is for this reason that the nutritional status of all children and young people with cancer should be assessed at diagnosis and their weight and height closely monitored and plotted on an age appropriate centile chart throughout their treatment. The child or young person may lose or gain weight throughout their treatment which may lead to a reduction in drug doses. It may also have an adverse effect on their emotional and physical wellbeing.

Malnutrition

Malnutrition is a term used to define an imbalance of nutrients. It is often associated with weight loss, however, it should be noted that a child or young person with cancer may be of a normal weight or be overweight and still be malnourished. Malnutrition may be masked in patients with an abdominal mass as they may have a falsely elevated body weight [3]. Malnutrition can occur due to an inadequate diet or the inability to utilise the nutrients effectively [4].

Identifying those at risk

At diagnosis there should be a multi-disciplinary team (MDT) approach to maximise the nutritional status of the child or adolescent with cancer. Assessment of nutritional status and subsequent monitoring is essential in highlighting when and if any nutritional intervention is required. When considering the nutritional status of an individual it is not only the weight and height history and adequacy of the diet that need to be taken into account but also the diagnosis, subsequent therapy and anticipated toxicity. By considering the treatment protocol and drug toxicity, patients likely to require nutritional support can be identified early. Regularly carrying out a nutritional screening tool will highlight when a referral to the dietitian is required. A Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) is a validated nutrition screening tool for use in hospitalised children aged 2 to 16 years. [5] It has been especially adapted by Royal College of Nursing (RCN) Children & Young People nursing group for use in Paediatric Oncology.[6] In most centres the dietitian is only able to see patients who have been referred to them and therefore STAMP is an excellent resource for all healthcare staff it is important to identify individuals at nutritional risk and conditions and therapies that expose the child or young person with cancer to a greater risk. In some cases it may be beneficial to introduce nutritional support at the beginning of treatment and consider, for example, early placement of a gastrostomy.

Diagnoses / treatment most likely to require additional nutritional support via the enteral or parenteral route

High risk/Stamp score 3 [6]

Neuro-oncology patients, especially medulloblastoma
Osteosarcoma
Stage III and IV Wilms’ tumour
Ewing’s sarcoma / PNET (Primitive Neuro Ectodermal Tumour)
Nasopharyngeal tumours
High risk rhabdomyosarcoma
High risk neuroblastoma
Patients with abdominal disease which may respond poorly or slowly to treatment
B cell Non Hodgkin’s Lymphoma
Acute Myeloid Leukaemia
Some Acute Lymphoblastic Leukaemia (ALL) – Infant ALL, those on protocol A receiving a short dose of dexamethasone, regimen A protocol randomised to Methotrexate, B and C protocols, relapsed ALL
Bone marrow transplant
Peripheral Blood Stem cell Transplant (PBSCT).

Weight loss

There are many reasons why a child or young person with cancer loses weight. 60% of children with cancer are reported to suffer weight loss [8]. Understanding the predisposing factors leading to inadequate nutrition will enable healthcare professionals to support the patient and family [8]. Some individuals can present with a long history of poor intake that is easily reduced further with treatment.

There may be many reasons for weight loss and malnutrition. It may be due to catabolic (chemical energy) effects of the tumour; presence of the tumour resulting in, early satiety (feeling full), dysphagia (difficulty swallowing) or bowel obstruction. Reduced food intake can also occur secondary to the side-effects of treatment, such as nausea, vomiting, anorexia, altered taste/smell, mucositis, diarrhoea, constipation and pain. Psychological factors may also affect intake, such as the realisation of the diagnosis itself, fatigue, depression and anxiety [8]. The younger child can also refuse food as a way of taking control and for attention.

Prolonged hospital admission can also have an adverse effect on a child or young person’s food intake and overall nutritional status. Mealtimes are generally very structured with few options out with these times. Meals not looking appetising or familiar can all reduce the child or young person’s willingness to eat.

Weight gain

It should be noted that children and young people presenting with a large tumour burden may have a falsely elevated body weight. Consideration of this will be taken into account especially when calculating drug dosages and when tumour (or limb in some cases) is removed / shrunk.

Rapid weight gain in children and young people undergoing treatment for cancer is frequently linked to steroids. The child, young person and parents/carers should be reassured that, if healthy eating guidelines are followed, the child or young person should lose the weight once the steroids are stopped [9]. A balanced diet following healthy eating principles, including five fruit and vegetables a day and limiting intakes of foods high in salt, sugar or carbohydrates, can help limit excessive weight gain. Protein and healthy fats are fine and are a good source of calories. Once intensive treatment is finished, these principles should also be encouraged with the whole family becoming involved.

Steroid related weight gain

Advice for parents/carers, children and young people

It is important that the child, young person and family are made aware of the impact that the treatment may have on the patient’s weight and nutritional status. It is important that they are involved in the decision-making process. The verbal communication regarding nutrition is enhanced by written information in the form of booklets [8] [10]

Foods to avoid

Generally it is important not to restrict the food intake of any individual with a reduced intake. There are some foods, however, that should be avoided as they may cause harm. These are listed below.

Raw or lightly cooked eggs
Probiotic or bio foods, drinks or supplements
High energy drinks and those loaded with high dose caffeine are not suitable for children and adolescents
All unpasteurised dairy products, e.g milk sold on local farms
Soft, ripened cheese, e.g. brie, camembert, blue veined cheese such as stilton, goat’s cheese
Soft cheese made with unpasteurised milk, e.g. feta, parmesan
Pate
Shellfish
Raw / undercooked meat, poultry or fish, e.g meat that is still pink, sushi.

Patients undergoing a stem cell or bone marrow transplant will be advised to avoid additional foods as well as those mentioned above. A full list of foods to avoid can be found in the Leukaemia and Lymphoma Research patient information booklet: Dietary advice for Haematology patients with neutropenia.

Nutritional support

The aim of nutritional support for the child or young person with cancer is to correct malnutrition at diagnosis, prevent malnutrition due to treatment and to promote normal growth and development throughout treatment [2].

Enteral nutritional support

The first line of nutritional support for all patients would be advice on eating problems associated with side-effects of treatment. For individuals with a reduced intake, advice on energy dense foods, suggestions on how to maximise the nutrient density of food and the inclusion of small regular meals and snacks over the day should be provided.

For those patient’s still unable to improve their nutrient intake through diet alone, age appropriate oral nutritional supplements should be considered. These are frequently in a drink form providing extra kilocalories, protein and micro-nutrients. Supplements can be milk or juice-based. Not all supplements are nutritionally complete but the dietitian will offer advice on the most appropriate supplement. Advice should be given on how best to take them to improve their palatability and advice on dosage.

Children and young people unable to take adequate fluids and diet orally, e.g. due to mucositis, nausea or taste changes, may require enteral feeding via a nasogastric or gastrostomy tube to supplement their oral intake. Using this route helps to maintain the function and integrity of the gut. It can be pre-empted in some cases where additional support via this route will be required. In those with prolonged gut dismotility (Slow or absent gut movement) /prolonged vomiting, the nasojejunal (NJ) or gastrojejunal (GJ) route may need to be considered.

Parenteral nutritional (PN) support

Parenteral nutritional support would be considered if it is anticipated that the child or young person will have gut dysfunction for more than five days, e.g. due to severe mucositis, enteritis, typhlitis, neutropenic enterocolitis, ileus or bowel obstruction [6]. Parenteral nutrition is administered via a central venous access device. Risks associated with parenteral nutrition are sepsis, fluid overload and metabolic complications [1].

Where possible, small amounts of enteral feeds would continue to be given alongside the PN to help maintain gut integrity and reduce the risk of bacterial translocation.

Any further enquiries regarding specific nutritional advice should be directed to the patient’s dietitian, doctor or nurse.

Complementary Therapies

Parents/carers may ask about complimentary therapies in order to help a child or young person cope with the side effects of treatment or generally improve their well-being . If a parent/carer discusses this with you, it is important to stress they discuss it with their consultant and the child or young person (as appropriate).