Standards of nutritional care in pediatric oncology - Wiley Online Library

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Elena J. Ladas, MS, RD,1* Nancy Sacks, MS, RD, CNSD,2 Pat Brophy, MSN, CRNP,2 and Paul C. Rogers, MB, ChB. 3. INTRODUCTION. The prevalence of ...
Pediatr Blood Cancer 2006;46:339–344

Standards of Nutritional Care in Pediatric Oncology: Results From a Nationwide Survey on the Standards of Practice in Pediatric Oncology. A Children’s Oncology Group Study Elena J. Ladas, MS, RD,1* Nancy Sacks, MS, RD, CNSD,2 Pat Brophy, MSN, CRNP,2 and Paul C. Rogers, MB, ChB3 Background. The prevalence of malnutrition in children with cancer ranges between 8% and 60%. Malnutrition is strongly associated with the nature of treatment and increases an individual’s risk of infection. Clinical studies have suggested that nutrition intervention may decrease toxicity and improve survival in the oncology population. In order to identify the standards of practice in the nutritional management of a child with cancer, we conducted an international survey in institutions that are part of the Children’s Oncology Group (COG) consortium. Procedure. Surveys were submitted to 233 participating COG institutions. We requested one member in three disciplines complete the survey: physician, registered dietitian, and nurse or nurse practitioner. The survey was returned to the nutrition subcommittee of COG. Results. Fifty-four percent of institutions responded to the survey. We found no consistency in the provision of nutrition

services. Assessment of nutritional status does not routinely occur and different indices are employed to indicate the nutrition status of a patient. Institutions rely upon different guidelines when categorizing malnutrition. When nutrition intervention is clinically indicated, a variety of approaches are employed. Conclusions. This survey did not find standardized nutrition protocols being employed in the pediatric oncology population. The effect of varied nutrition practices on the quality of life, toxicity, and outcome in children with cancer is unknown. Prior to the initiation of clinical trials, uniform guidelines need to be developed and validated. Future clinical trials need to investigate the most efficacious method of nutrition assessment and intervention and its effect on quality of life, toxicity, and survival in children with cancer. Pediatr Blood Cancer 2006;46: 339–344. ß 2005 Wiley-Liss, Inc.

Key words: children; nutrition intervention; nutrition management; pediatric oncology; survival; toxicity

INTRODUCTION

The prevalence of malnutrition in children with cancer ranges between 8% and 60%, depending on diagnosis and treatment [1,2]. Malnutrition is strongly associated with the nature of treatment and increases an individual’s risk of infection [3–6]. Previous studies have found that children who are underweight or overweight at diagnosis have poorer outcomes compared to children who are well nourished at diagnosis [2,7,8]. A direct relationship between nutrition status and freedom from relapse has been observed in children with solid tumors [4]. Improved survival has also been observed in children with localized disease and who had good nutrition status at diagnosis [4]. Children with advanced disease had poor survival regardless of their nutrition status [4]. Clinical trials have found decreased frequency of dose reductions and therapy delays in children who maintain good nutrition status [9]. Investigators have also found the provision of nutrition support decreases the time to bone marrow recovery, suggesting nutrition support may help mitigate some toxicity associated with chemotherapy [10]. However, the ß 2005 Wiley-Liss, Inc. DOI 10.1002/pbc.20435

effect of nutrition intervention on overall survival is largely unknown. Guidelines for the nutritional management of a child with cancer have been previously published [11–13]. Unfortunately, there is not a consensus on the criteria that are utilized within the guidelines. This results in inconsistencies in the nutritional management of a child with cancer. Given the potential impact nutrition status and intervention can have on a child undergoing anticancer — ————— 1

Division of Pediatric Oncology, Columbia University, Children’s Hospital of New York, New York, New York

2

Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

3

Division of Pediatric Hem/Onc/BMT, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada *Correspondence to: Elena J. Ladas, Division of Pediatric Oncology, Columbia University, Children’s Hospital of New York, 161 Ft. Washington, Room 728, New York, NY 10032. E-mail: [email protected] Received 12 January 2005; Accepted 22 March 2005

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therapy, there is an increasing need for clinical research to determine the most sensitive indices of nutrition assessment and most effective methods of nutrition intervention. In order to identify the standards of practice in the nutritional management of a child with cancer, we conducted an international survey in institutions that are part of the Children’s Oncology Group (COG) consortium. The goal of this survey was to: (1) Identify current nutritional practices, (2) Identify the criteria utilized to assess nutrition status, and (3) Identify nutrition interventions that are most commonly employed so as to identify hypothesis-derived clinical research. METHODS

The survey was developed by the Nutrition, Nursing Clinical Practice, and Complementary/Alternative Medicine (CAM) sub-committees of COG and was distributed to all participating institutions in January 2003. Surveys were sent by e-mail from the COG corporate headquarters to the principal investigator at each COG-affiliated institution. We requested one member in three disciplines complete the survey: physician, registered dietitian, and nurse or nurse practitioner. The survey was returned to the nutrition sub-committee by mail, fax, or e-mail. Completed surveys were collected during the period of January 2003 to November 2003. Surveys that were received incomplete were resubmitted to institutions for completion. Incomplete data was documented accordingly. Members of the nutrition and nursing clinical practice sub-committees tabulated results. In order to obtain consistency amongst data evaluation, a detailed guideline was developed. If available, the results were categorized by institution and discipline. If only one discipline responded to the survey it was recorded as such. Results are presented as the percent distribution of the institution’s response. RESULTS

The survey was sent by e-mail to 233 institutions. At least one representative from 125 institutions (54%) responded to our survey. We investigated responses by discipline, however, the survey was not effective at retrieving responses from each of the three primary disciplines to extract meaningful comparisons. As a result,

the investigators evaluated differences in institutional responses. Sixty percent of the responses were from registered dietitians, 22% from physicians, 12% from registered nurse or nurse practitioners, 6% were combined responses, and 8% was unknown. Nutrition Assessment

Forty-six percent of the responding institutions completed a nutrition assessment on all newly diagnosed children with cancer (Table I). Seventy-seven percent of institutions reported that nutrition assessment is completed throughout therapy, however, most institutions (65%) conducted subsequent nutrition assessment only when clinically indicated. Institutions reported that the registered dietitian generally completes the initial nutrition assessment [n ¼ 98 (78%)]. Nutrition assessments were also completed by diet technicians [n ¼ 12 (10%)], physicians [n ¼ 11 (9%)], and nurses [n ¼ 10 (8%)]. Components of Nutrition Assessment

A diversity of criteria was used to categorize nutrition status (Table II). Most institutions reported that weight was the primary determinant in assessing nutrition status. Institutions reported additional criteria of height, problems with oral intake or recent dietary intake, head circumference and use of CAM contributed in the overall nutrition assessment of the patient. Body mass index was not routinely included as a component of nutrition assessment. Institutions reported the use of laboratory indices, such as albumin, pre-albumin, electrolytes, and liver function tests, however, there was not one laboratory indices that institutions universally reported as being the ‘‘gold standard’’ in determining nutrition status. Estimating Nutrition and Chemotherapy Requirements in Obese Patients

Institutions reported on the formula employed to estimate an obese patient’s nutrition and chemotherapy requirements (Table III). The majority of institutions based an obese patient’s nutrition requirements on ideal body weight or adjusted body weight [n ¼ 48 (38%); n ¼ 43 (34%)]. Institutions also reported the use of actual body weight [n ¼ 19 (15%)] or utilized combination of

TABLE I. Nutrition Assessment Question N (%) Is nutritional assessment completed at diagnosis? Is nutrition assessment completed at different time points in therapy? Does your institution have criteria for intervention? Are nutrition assessments done when clinically indicated? Does your institution have a screening tool that triggers a nutrition consult? a

Yes N (%)

No N (%)

Othera N (%)

57 (46) 97 (77) 65 (52) 81 (65) 70 (56)

16 (13) 22 (18) 49 (39) 35 (28) 38 (30)

52 (40.2) 6 (5) 11 (9) 9 (7) 17 (14)

Institutions in this category either did not respond, responded as unknown, or responded as ‘‘depends.’’

Standards of Nutritional Care in Pediatric Oncology TABLE II. Components of Nutrition Assessment Criteria Weight Height Problems with oral intake Laboratory indices Dietary intake Head circumference Complementary/alternative medicine Mid-arm circumference Triceps skinfold

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TABLE IV. Monitoring of Nutrition Intervention N (%) 125 (100) 121 (97) 122 (98) 107 (86) 105 (84) 58 (46) 37 (30) 6 (5) 6 (5)

formulas depending on the circumstance [n ¼ 2 (2%)]. Formulas for calculating chemotherapy requirements were not uniform among discipline or institutions. Criteria and Monitoring of Nutrition Intervention

Institutions utilized a range of criteria to assess the need for nutrition intervention. Most commonly, weight loss, weight for height, body mass index, and nutrient intake were included in health care providers’ nutrition assessment (Table IV). Most institutions reported that the registered dietitian monitors the effectiveness of the nutrition intervention, however, physicians and nurses also monitor the effectiveness of interventions, especially when total parenteral nutrition is indicated. Use of Enteral and Parenteral Nutrition

Institutions reported a wide range of practice on the use of enteral and parenteral nutrition. There are no standards of practice for the use of determining the most effective route of nutrition support. Institutions reported that nutrition support was initiated and monitored by various disciplines and departments within their medical center. Enteral feeds were not consistently the first form of nutrition support offered to the patients. We found the use of enteral and parenteral nutrition to be inconsistent between practitioners (physician, nursing, and dietetics), and varied by diagnosis. Nutrition Education

Sixty-seven percent of institutions reported that nutrition education is provided to all newly diagnosed patients. TABLE III. Criteria for Estimating the Nutrition Requirements of Obese Patients Criteria

N (%)

Ideal body weight Adjusted body weight Actual body weight Combined Unknown Not applicable

48 (38) 43 (34) 19 (15) 2 (2) 5 (4) 8 (6)

Criteria Weight for height 120% IBW for height