3 Nutritional Challenges in Special Conditions and Diseases
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 266–270
DOI: 10.1159/000360349
3.23 Haemato-Oncology
John W.L. Puntis
Key Words
Malignant disease · Bone marrow/stem cell
transplantation · Mucositis · Enteral tube feeding ·
Parenteral nutrition
Key Messages
• Malnutrition is a common complication of malig-
nant disease and its treatment, and is most likely to
occur in advanced-stage solid tumours, acute my-
eloblastic leukaemia and bone marrow/stem cell
transplantation
• Nutritional support is a major part of therapy; there
is no evidence that extra nutrients promote tumour
growth
• The aims of nutritional support are to reverse mal-
nutrition if present at diagnosis, to prevent deterio-
ration in nutritional status during treatment, and to
promote normal growth
• Children at low nutritional risk require high-energy
supplements that can be taken by mouth; they ben-
efit from flexibility in mealtimes and menus
• When oral energy intake is inadequate, enteral tube
feeding should be used; this is usually well tolerat-
ed and improves wellbeing even in children under-
going intensive chemotherapy
• Parenteral nutrition is reserved for those children
with severe gastrointestinal symptoms related to
underlying disease, chemotherapy or radiotherapy
© 2015 S. Karger AG, Basel
Introduction
Nutritional status influences prognosis in chil-
dren with cancer and affects treatment tolerance
and susceptibility to infection. Patients often have
significant difficulties with eating during long pe-
riods of treatment and recurrent admissions to
hospital, and have particular nutritional needs
[1]. Malnutrition is common, with estimates of
prevalence ranging up to 50% depending on the
type, stage and metastatic status of the disease as
well as the toxicity of various cancer therapies [2].
Children with large, solid abdominal masses (e.g.
neuroblastoma, hepatoblastoma, Wilms’ tu-
mour) may present with normal weight despite
severe nutritional depletion, so that simple an-
thropometric assessment can be misleading [3].
The highest risk posed to nutritional status comes
from advanced-stage solid tumours, acute my-
eloid leukaemia, multiple-relapse leukaemia,
head and neck cancer, medulloblastoma and
bone marrow or stem cell transplantation. The
pathophysiology of malnutrition is multifactorial
and includes complex interactions between ener-
gy and substrate metabolism, hormonal and in-
flammatory components, and alterations of met-
abolic compartments. These result in accelerated
198.143.38.1 - 1/27/2016 8:25:11 AM
Downloaded by:
UCONN Storrs
 Table 1. Risk factors for nutritional compromise

Decreased food intake

Inadequate amount of food offered
Unappetising food; lack of flexibility in meeting a child’s preferences
Too much food
‘Forced’ feeding
Reduced appetite from illness
Symptoms associated with disease or treatments,
e.g. nausea, vomiting, sore mouth, pain, diarrhoea and breathlessness
Repeated fasting for treatments or procedures
Mucositis, swallowing or chewing difficulties
Difficulty self-feeding
Poor child-carer interaction at meal times
Impaired conscious level
Increased nutritional requirements
Illness/metabolic stress
Wound or fistula losses
Impaired ability to absorb or utilise nutrients
Due to disease or treatment, e.g. chemotherapy causing enteropathy or
pancreatic exocrine impairment
Infection as a consequence of immunosuppression

mobilisation, oxidation of energy substrates and
loss of body protein [4].
General risk factors for malnutrition are
shown in table 1. Learned food aversion associ-
ated with nausea-inducing treatment sometimes
leads to anticipatory vomiting. Chemotherapy
may adversely affect food intake and gastrointes-
tinal function by causing oral or oesophageal ul-
ceration, altered taste perception, anorexia, nau-
sea, vomiting, and enteritis with malabsorption
and diarrhoea. Serving food cold or at room tem-
perature and covering drinks (taken through a
straw) can decrease tastes and smells and make it
easier for children to eat. Radiation therapy to the
head and neck can cause mucositis, anorexia,
nausea, vomiting, dysphagia, dry mouth and al-
tered taste, while radiation to the abdomen may
cause enteritis and bowel stricture.
Bone marrow transplantation (BMT) or stem
cell transplantation is indicated in children with
a range of malignant and non-malignant condi-
tions. Chemotherapy and/or radiation therapy
are used to reduce host cells to the point that do-
nor stem cells will engraft (allogeneic BMT), or
to reduce the tumour burden and rescue the pa-
tient with his/her own stem cells (autologous
BMT). Priming chemotherapy causes severe
nausea, vomiting and oral ulceration, and is of-
3
ten associated with diarrhoea, protein losing en-
teropathy, and depletion of zinc and electrolytes
[5, 6]. Most children undergoing BMT stop eat-
ing either as a result of these side effects or be-
cause eating becomes one of the few areas over
which they can exercise some control. Impair-
ment of gastrointestinal barrier function in-
creases the risk of viral, bacterial and fungal in-
fections. Episodes of sepsis are associated with
protein catabolism and negative nitrogen bal-
ance. Enteral feeds should be prepared in a man-
ner that renders them low in bacterial load (‘clean
feeds’); parenteral nutrition (PN) may be neces-
sary, but enteral tube feeding (ETF), if tolerated,
is associated with better nutritional response
and sense of wellbeing.
198.143.38.1 - 1/27/2016 8:25:11 AM

Haemato-Oncology 267
Downloaded by:
UCONN Storrs

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 266–270
DOI: 10.1159/000360349
Provision of Nutritional Support
A nutritional care plan for each patient should be
developed by the multidisciplinary haematology-
oncology team (including an expert dietitian).
The goals of nutritional support are to reduce
morbidity and minimise or prevent complications
such as infection and growth failure; there is no
evidence that nutritional support promotes tu-
mour growth. Baseline nutritional status should
be established, including eating habits and any
family perceptions of problems around eating.
Weight measurement is inaccurate as an indicator
of nutritional status in children with a large tu-
mour mass, and mid-upper-arm circumference
and skinfold thickness measurements are more
reliable methods of assessment and monitoring
[7]. Neutropenic patients must avoid food that
may carry a high microbial load, such as poorly
cooked meats, soft cheeses, pâté, shellfish, and raw
or soft-cooked eggs; however, most infections are
hospital acquired and not food borne, so over-
restriction of food choices may be counterproduc-
tive. Mucositis (painful mouth ulcers ± superin-
fection), vomiting and anorexia often limit oral
intake. Routine saline mouthwashes are used, to-
gether with adequate pain relief (opiates if neces-
sary). Frequent small meals of appetising food are
more likely to be accepted, and advice with regard
to the use of high-calorie foods should be given
routinely. There should be flexibility with regard
to menu choice, mealtimes and parental involve-
ment; children on the ward should be encouraged
to eat together at mealtimes. Tastes may be bitter
or metallic with some drugs (e.g. procarbazine
and cyclophosphamide) or food may have no taste
at all. Some children develop a liking for strong
flavours (pickles, spices). Serving food with sauces
and gravies will increase moisture and help swal-
lowing if the mouth is dry. Food can be purchased
from the shop/canteen or brought in from home
if tempting meals cannot be provided in hospital.
Ideally, a hospital cook should prepare meals on
demand from a ward kitchen, or meals be ordered
268
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 266–270
directly from the catering service as required
throughout the day and not just at mealtimes [8].
The use of a reward system (star chart) may moti-
vate some younger children to eat, but rewards
need to be appropriate to the child’s age and goals
must be achievable and relevant.
ETF and PN
ETF or PN is likely to be needed when:
• the child is malnourished at diagnosis;
• there is loss of >5% body weight during treat-
ment;
• weight-for-height is <90%;
• there is a drop in weight across 2 centiles;
• food intake is <80% of the estimated require-
ment;
• triceps skinfold thickness is <5th centile, or
• the child is a BMT patient.
Long-term use of ETF in infants often leads to
later feeding difficulties, and early advice should
be sought from a speech and language therapist.
Gastrostomy may be considered if tube feeding is
required for more than 4 weeks or if the nasogas-
tric tube is not tolerated (e.g. severe mucositis;
vomiting). Older children should be allowed to
choose between a nasogastric tube and percutane-
ous endoscopic gastrostomy. Tube feeds are gener-
ally given overnight to allow for normal activities
and oral intake during the daytime. Tube feeding
[9] may result in a number of complications in-
cluding vomiting, regurgitation/aspiration and
diarrhoea (see table 2 for potential problems and
solutions). Whereas the enteral route should be
used for nutritional support whenever possible,
PN must be considered when gut dysfunction pre-
cludes enteral feeding for more than 5 days. This
may occur when there is severe mucositis and en-
teritis, neutropenic enterocolitis, ileus, bowel ob-
struction, chylous ascites following surgery, and
severe graft-versus-host disease. Standard PN reg-
imens can be used, although refeeding syndrome
is a risk in malnourished patients, and careful
198.143.38.1 - 1/27/2016 8:25:11 AM
Puntis
Downloaded by:
UCONN Storrs
DOI: 10.1159/000360349
Table 2. ETF: problems and potential solutions

Symptom Cause Possible solution

Diarrhoea Unsuitable feed for a child with Change to hydrolysed formula or modular feed
impaired gut function
Excessive infusion rate Slow rate, increase as tolerated
Intolerance of bolus feeds Frequent, smaller feeds, or change to continuous feeds
High feed osmolarity Build up strength of feed slowly and give by continuous
infusion
Microbial contamination of feed Use sterile, commercially produced feeds if possible;
prepare other feeds in a clean environment
Drugs (e.g. antibiotics, laxatives) Review drug prescription
Nausea/ Excessive infusion rate Slowly build up feed infusion
vomiting Slow gastric emptying Encourage lying on right side; prokinetics
Constipation Maintain regular bowel habit with adequate fluid intake,
fibre-containing feed and/or laxatives
Medicines given at the same time as Allow time between giving medicines and giving feed,
feed or stop continuous feeding for a short time
Psychological factors Review feeding behaviour; consider referral to
psychologist
Regurgitation/ Gastro-oesophageal reflux Correct positioning; feed thickener; drugs; continuous
aspiration feeds; jejunal tube (consider fundoplication)
Dislodged tube Secure tube adequately and regularly review position
Excessive infusion rate Slow infusion rate
Intolerance of bolus feeds Smaller, more frequent feeds, or continuous infusion

monitoring is required [10]; regimens also require

modification in the light of nutritional response. It
is important to consider and regularly review the
objectives of nutritional support in individual pa-
tients. Monitoring will include assessment of nu-
tritional intake, anthropometry, biochemical and
haematological parameters, general clinical state,
gastrointestinal function and feeding tube/central
venous catheter integrity.
dren with brain tumours, especially craniopha-
ryngioma survivors [11]. Late nutritional compli-
cations also include a reduction in lean body mass
3
in some patients [12]. Reduced bone mineral den-
sity can result from decreased physical activity,
reduced calcium intake and the effects of cortico-
steroid treatment; undermineralisation may per-
sist in a small proportion of patients. Growth and
nutritional status should be monitored during
long-term follow-up.

Late Nutritional Complications

Conclusions
Survivors of common paediatric malignancies are
at risk of obesity, which in turn is associated with Always try to:
cardiovascular and endocrine diseases. Increased • identify a child’s favourite foods – these are
BMI (>25) was found in survivors of acute lym- best avoided whilst having chemotherapy so
phoblastic leukaemia <4 years of age at diagnosis that aversion does not develop;
receiving cranial radiation therapy, and in chil- • offer small, frequent meals;
198.143.38.1 - 1/27/2016 8:25:11 AM

Haemato-Oncology 269
Downloaded by:
UCONN Storrs

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 266–270
DOI: 10.1159/000360349
• encourage dietary supplements;
• provide skilled dietetic supervision;
• manage side effects of chemotherapy effective-
ly (nausea, vomiting);
• consider the need for tube feeding early, espe-
cially in high-nutritional-risk patients;
References
1 Capra S, Ferguson M, Ried K: Cancer:
impact of nutrition intervention out-
come – nutrition issues for patients.
Nutrition 2001;17:769–772.
2 Bauer J, Jürgens H, Frühwald MC: Im-
portant aspects of nutrition in children
with cancer. Adv Nutr 2011;2:67–77.
3 Skipworth RJ, Stewart DFG, Dejong CH,
Preston T, Fearon KC: Pathophysiology
of cancer cachexia: much more than
host-tumour interaction? Clin Nutr
2007;26:667–676.
4 Murphy AJ, White M, Davies PSW: The
validity of simple methods to detect
poor nutritional status in paediatric on-
cology patients. Br J Nutr 2009;101:
1388–1392.
5 Papadopoulou A, Williams MD, Dar-
byshire PJ, Booth IW: Nutritional sup-
port in children undergoing bone mar-
270
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 266–270
• remember that a child may eat better at home,
and
• use parenteral nutrition when appropriate (i.e.
when enteral feeds are precluded by gastroin-
testinal dysfunction).
row transplantation. Clin Nutr 1998;17:
57–63.
6 Papadopoulou A, MacDonald A, Wil-
liams MD, Darbyshire PJ, Booth IW:
Enteral nutrition after bone marrow
transplantation. Arch Dis Child 1997;77:
131–136.
7 Smith DE, Stevenson MCG, Booth IW:
Malnutrition at diagnosis of malignancy
in childhood: common but mostly
missed. Eur J Pediatr 1991;150:318–
322.
8 Royal College of Nursing: Nutrition in
children and young people with cancer.
London, Royal College of Nursing, 2010.
http://www.rcn.org.uk/_data/assets/
pdf_file/0010/338689/003805.pdf.
9 Smith DE, Handy DJ, Holden CE, et al:
An investigation of supplementary na-
so-gastric feeding in malnourished chil-
dren undergoing treatment for malig-
nancy: results of a pilot study. J Hum
Nutr Dietet 1992;5:85–91.
10 Afzal NA, Addai S, Fagbemi A, Murch S,
Thomson M, Heuschkel R: Refeeding
syndrome with enteral nutrition in chil-
dren: a case report, literature review and
clinical guidelines. Clin Nutr 2002;21:
515–520.
11 Meacham LR, Gurney JG, Mertens AC,
et al: Body mass index in long-term
adult survivors of childhood cancer: a
report of the Childhood Cancer Survival
Study. Cancer 2005;103:1730–1739.
12 Oeffinger KC, Mertens AC, Sklar CA, et
al: Obesity in adult survivors of child-
hood acute lymphoblastic leukemia: a
report from the Childhood Cancer Sur-
vivor Study. J Clin Oncol 2003;21:1359–
1365.
198.143.38.1 - 1/27/2016 8:25:11 AM
Puntis
Downloaded by:
UCONN Storrs
DOI: 10.1159/000360349