Hi.

I am very happy to introduce a special guest to you.

This is Nina van der Linden.
She is a trained nutritionist and a registered dietitian
and she is currently working as a clinical dietitian in our national hospital
for paediatric oncology.
Nina and I met each other in a working group for childhood cancer research
and I am delighted that she is willing to tell us something
about the nutritional care of cancer patients.
Hi Nina, welcome.
Thank you.
It is very good to have you here,
so I would love to learn more about your work.
Would you be able to tell us something about the work you are currently doing?
Yeah sure. As you said earlier, I'm working at the
Princess Maxima centre for paediatric oncology.
And I'm working there as a clinical dietitian,
doing both in-patient and out-patient work.
So the kids that come and are admitted to the hospital,
but also the kids that are just coming for
a visit with the doctor or physiotherapist.
I see them as well.
And there I work with the kids like I said, but also...
with a kid always comes a parent
So you always have to deal with the families as well,
which makes it an interesting group to work with.
Okay, so what sort of problems do these children have
when they are referred to you?
It can be actually anything to do with nutrition.
Some of the big ones that we see a lot are weight loss,
malnutrition because they can't eat anymore or don't want to eat,
because of decreased appetite, but we also see weight gain due to medication use.
A lot of the times, also an influence is mucositis,
and that can be anything from the mouth all the way to the anus
that's disturbing their digestion problems.
We also see a lot of smell and taste changes
which influence their appetite and their eating habits.
Behavioural changes as well,
that they don't want to eat or want to eat a whole bunch
because of medication or just because they're not feeling well, because of pain.
And then also the whole aspect of the food hygiene plays into there as well,
because they're all immunocompromised patients.
Okay, so you said that the medication and also pain
may have an impact on nutritional behaviour and nutritional status.
So most of the common problems that these patients have,
are these caused by the cancer itself or rather by the cancer treatment?
It can be both.
If they're caused by the tumour itself or the cancer itself
that could be if there's a tumour in the stomach that's pushing on the stomach
that makes them not feel well and they're not able to eat.
Or if they have a tumour in their throat and they're not able to swallow.
So that would be the causes of the tumour itself,
but most of the time it's because of the treatment
or the complications that come along with treatment.
So because of the chemotherapy they're really nauseous,
or they're vomiting, they're not feeling well.
Or because some of the medications they have to take next to the treatment,
that cause constipation or diarrhoea, that could also be causing some problems.
And then there's also the kids that take prednisone,
and that really influences their behaviour and their eating habits,
so that also plays a role.
When should a patient actually be referred
to a dietitian, is there a specific guideline or recommendation for that?
There's not really anything for us, in our centre, right now on paper.
We're working on protocols so that the doctors know exactly when they should refer
to us.
But right now it is actually...
we're referred to when a doctor signals
that there may be a compromised nutritional status of the child.
So if they anticipate that, which is what we usually want,
because then we can kind of nip the problem in the bud before it gets too big.
Or if there's already weight loss or weight gain, then we're usually called to
come...
come into referral.
Could you also tell us something about the sort of advice that you can give to
these patients?
So what can you recommend to these patients? - Yes for sure.
So usually we start with... we always do individual advice that's
based on the symptoms of the child or what they're experiencing at that time.
Because the children go through a lot of changes in chemo and a lot of different
regimes
our advice also changes really quickly, from week to week,
because one week they're feeling really good and the next week
they're admitted to the hospital with fever, diarrhoea, whatever, you could name
it.
But usually we start off with trying to...
I guess not really fix the problem, but we advise them dietary changes with normal
foods
that they can do at home.
So that could be things like if the child has a decreased appetite and they've lost
a lot of weight,
that we would advise to consume more protein but also more calories, more energy.
And that could be simple things like changing all your products or making product
choices to
full-fat products, adding an extra layer of butter to your bread
royally using sauces or condiments like mayonnaise, something that has a lot of
calories.
So simple tips like that to increase the amount of calories in the diet of the
child.
So that every calorie counts to their weight of course.
If that doesn't work, we usually step over to oral nutritional supplements,
so beverages that the children can drink
to boost their weight again.
Sometimes drinking is a little bit easier than physically eating for the kids.
So that can sometimes be a solution.
But sometimes that's not the solution, they can't eat, they can't drink,
everything is really difficult at that time,
then we step over to enteral feeding, tube feeding.
Unfortunately, most of the kids that go through
chemotherapy or a cancer treatment journey
will have tube feeding at some point in time,
so usually we resort to tube feeding.
With children it's a lot easier, also with the young ones of course, to start tube
feeding
because they already have a nasogastric tube for medication,
because they can't swallow all their medication, so that
step to start tube feeding is a little bit easier than for adults.
And then, in the cases of really severe mucositis, you can always turn to
parenteral nutrition
that's again... a more intense step I guess.
And then kind of stepping away from that, when the children are done
with their treatment or their chemotherapy
or if they can eat again,
then we usually tailor our advice to try to get them back into a normal eating
pattern
or healthy eating lifestyle.
So actually during the treatment, the major concern is weight loss?
That's probably the biggest one that we come across, yeah.
So is there also a specific moment during or after treatment that
you're mostly concerned about weight gain,
is that also something that you see in clinic?
Yeah, but that is usually linked to medication use,
so the prednisone...
Sometimes how the kids take their medication, or their whole regime
they always have a period where there's weight gain and then a lot of periods with
weight loss.
So the weight loss is usually larger... or the
decreased appetite than the increased appetite.
But with a lot of kids, there's a period of both.
Okay. And I was also wondering: how's the referring organized? Can...
a patient or a parent decide by themselves
that they want to seek for nutritional support
or is there always a medical team or a medical specialist involved in that?
Yeah, right now it always comes from the doctor.
So either the doctor that's in charge of the patient
or one of the subdoctors under that one.
But it's pretty easy that if a parent says:
I have some questions, I'd like to speak to a dietitian, they'd refer to us
automatically,
those lines are pretty open and the communication is pretty open.
But unfortunately, right now the parents can't seek advice just by themselves.
Okay, as you're working specifically with young children, young patients...
Do you think that there are any differences in nutritional complications and
nutritional care
that you see in these children as compared to adults with cancer?
Yeah definitely.
I think the biggest one is...
because you have growth as a factor in children,
you don't have that as an additional factor with adults.
The base of all nutritional care is trying to keep their growth on track,
because of the therapy they're going through, they could have a stunted growth in
height
or they could lose weight, which also impacts their growth.
So that's kind of an added aspect that you don't have with adults.
And also a big difference is that
kids primarily react to what they're feeling in their symptoms.
And if you tell an adult: you need to eat
even when you're not feeling well, but you need to eat because you need to gain
weight,
to become stronger and to withstand your treatment,
a kid doesn't understand that, they only understand:
I have that pain in my stomach, so I'm not going to eat... you can't tell them to
eat.
So in that way, the parents play a huge role in motivating their children
but the parents also have a huge role in steering that, that we can't control.
So that's also one of the really big differences between adults and kids.
So I guess that you as a dietitian also play a major role in that motivating
process?
Yeah. - I was wondering, what is actually... what do you love most about your job?
I think that I love most the contact that I have with families.
Because the kids are in the hospital so often,
every couple of weeks they come for a new chemotherapy
sometimes they stay five days, they go home for two weeks, they come back for five
days...
you see the same families a lot.
So you build a relationship with the families and the kids.
And you have your patient, the kid, but also brothers and sisters that are
involved,
the grandparents that sometimes come along.
So you really get to know the families, and I really like that aspect of it a lot.
I think that is a beautiful answer.
So I'd like to thank you very much for your inspiring information and your come
to this place.
And I'd like to thank you
and I hope that we can continue in research together
and I hope that you'll be able to help many more cancer patients in the future.
Thank you. - Thank you.