Anorexia- Cachexia:

in Pediatric Palliative Care

Dr Endang Windiastuti SpA(K)
Hematology-Oncology Working Group
Indonesian Pediatric Society
Learning Objectives
• Identify reversible causes of anorexia
• Learn management of anorexia
• Know the features of cachexia
• Understand that cachexia is often caused
by same factors that cause anorexia
Definitions
• Anorexia: loss of appetite and reduced
caloric intake
• Cachexia: involuntary loss of more than
10% of premorbid weight and loss of
muscle, visceral protein and lipolysis
• Starvation: loss of weight and loss of
needed calories
Anorexia
• Anorexia = poor appetite

• Anorexia-cachexia occurs > 50% adult

patients with cancer
Anorexia = poor appetite
Cachexia = catabolic state
Inui A, “Cancer Anorexia‐Cachexia Syndrome: Current Issues in Management and Research.”
Cancer J Clin 2002; 52:72‐91
Anorexia - Cachexia
• Anorexia occurs in 25% patients in palliative
care
• Cancer and other diseases, such as
HIV/AIDS, can often cause a lack of appetite
(anorexia) and weight loss with muscle
wasting (cachexia)
• These are often accompanied by fatigue
• The process of anorexia/cachexia is complex
and involves numerous metabolic changes
Assessment
 A good history and clinical assessment is
important to try and identify any reversible
cause of the anorexia/cachexia
 Assess appetite
 Assess ability/difficulty in swallowing and chewing
 Identify any other symptoms such as pain,
constipation, depression, or nausea and vomiting
that may be causing decreased appetite
 Examine the mouth for any sores, lesions or
infection
…Assessment
 Treatable causes of anorexia/cachexia include:
 Ongoing pain
 Nausea and vomiting
 Depression
 Oral problems, Dry mouth
 Mucositis secondary to chemotherapy
 Thrush/candidiasis
 Gastrointestinal motility problems
 Reflux oesophagitis,
 Constipation
Todays’ Theory
Cytokines

Neurohormonal
Metabolic Abnormalities
Alterations
 Anorexia . . .
• Common treatable causes of anorexia
• Xerostomia, mucositis, esophagitis, GER,
pain, dysphagia, early satiety, bulky
organomegaly, intestinal obstruction
• Cancer treatment related anorexia:
• Anorexia, nausea, vomiting, decreased
oral intake, and weight loss during
cancer treatment
Contributing Factors
 Cancer Related:
 Cancer head-neck, lung cancer, GI tract, liver
 Cancer Treatment Related
 Diarrhea, constipation, mucositis, taste/smell
changes, nausea
 Others
 Medicamentosa (opioid), end-stage disease,
neurological disease
 Depression, anxiety
 Treatment strategies
• Provide effective cancer-directed therapy
• Treat reversible causes
• Increase appetite and nutritional intake
• Improve functional status
• Provide interdisciplinary care to address
nutritional, functional and psychological
issues
Management
• Non-pharmacological Approaches
• Patient and family education
• Eliminate dietary restrictions
• Encourage patient to eat their favourite foods

• Pharmacological Approaches
• Ensure good pain and nausea/vomiting
control, treat constipation
• Stimulate appetite
 Nutrition for Children
in Palliative Care
• Food is not only important for
nourishment, but also as a source of
pleasure and comfort.
• Parents of children are often worried
about making sure their child’s nutritional
needs are met.
• Food is important for improving quality of
life, relieving symptoms and to provide
pleasure and comfort.
Minimizing Wight Loss
• It is very difficult for family and carers to watch
their child lose weight.
• Reasons for weight loss including nausea and
vomiting, anxiety and decreased food intake.
• It is important to understand that your child’s
reluctance to eat is not a reflection of the foods
you are offering.
• Let your child eat the foods that they feel like.
• It is better to eat and enjoy rather than struggle
to maintain a balanced diet.
… Minimizing Wight Loss
• Create a positive eating environment - share
meals and eat together.
Try not to comment if food goes uneaten.
Try to offer past favorite foods.
Small frequent meals may be easier to eat. Offer
food every couple of hours if your child has no
appetite.
• Small meals and soft foods that are easy to chew
and swallow may be easier to eat
Palliative Tips
• Increasing calorie intake is unlikely to
increase body weight and quality of life in
advanced cancer.
• Aggressive feeding can often make symptoms
such as nausea, vomiting and pain worse
• Educating the family
• Wasting is a part of the disease process and
• Not the result of the family not providing enough
nutrition for the patient is important
 Family support
• Minimize symptoms and distress as possible
• Note the meaning attached to feeding
• Encourage alternatives to feeding
• Affirm comfort provided through family bonds

Integrative approaches
• Hypnosis
• Acupuncture/ Acupressure
• Aromatherapy
• Relaxation
• Massage
• Music Therapy
Supplements and Medications
• Nutritional supplements
– Oral protein shakes, protein powders
• Take in ADDITION to food not instead of meals
– Calorie dense supplement
• Add to pureed foods, adds calories, no nutrition
• Appetite stimulants
– Dexamethasone
– Megesterol acetate
 Megesterol acetate (Megace)
in Adults
• Improves appetite and weight gain
– Most of weight gain is from fat not lean muscle
– Best absorbed when taken with high-fat meal
• Takes a few weeks to take effect but longer
duration of benefit than steroids
• Side effects: Increase risk of venous
thromboembolism, fluid retention
 Roles of Megesterol acetate
(Megace)in Children
Study aim: effect of Ma & implication adrenal suppresion
Conclusions:
• Although the results of this study support the ability of MA
to improve nutritional status, its use was complicated by
severe adrenal suppression in almost all patients tested,
with a serious clinical adverse event occurring in one
patient. Routine hydrocortisone supplementation
throughout MA treatment should be considered as well as
larger doses for patients with acute illness and patients
who undergo surgery.

Orme et al. Cancer 2—3;98:397-405

Corticosteroids
• Stimulates appetite short-term
• Dexamethasone preferred over others due to its
relative lack of mineralocorticoid effect
• Rapid effect, long half life but effect limited 2-6
weeks
• Doses of 2-16 mg/day dexamethasone
• Many side effects
• Consider 1 week trial
– If no improvement, then discontinue
– If helps, then reduce to lowest effective dose.
– Reassess need frequently; discontinue when no longer
effective
 Treatment Goals for Anorexia
• Prolong survival
• Improve quality of life
• Improve performance status
• Reduce fatigue
• Improve pleasure associated with eating
• Increase lean body mass
• Reduce family conflict
• Increase treatment options
Why not TPN/EN?
• Complications (ie: mechanical, metabolic and
infection)
• Expensive
• Does not improve survival
• Does not cause weight gain
• How does one make the decision to discontinue
TPN – very hard for family
 Nutrition and Hydration :
Autonomy
• Parents/ families have a right to choose
whether or not to receive artificial
nutrition or hydration
• Social reasons
• Religious reasons
• Health care staffs and facilities have a right to
whether they want to care for patients who
decide artificial feeding / hydration
Tube Feeding
•When your child is not able to eat or drink
enough.
•Another way to provide food and fluid is via
a gastric tube.
•Help your child feel more comfortable, and
increase their energy and strength to play or
activities.
•A gastrostomy can be used if a child requires
tube feeding for a long period of time.
 Food taste better when you eat it with
your family
• Sharing
• Togetherness
• Social attachment
• Love & caring
• Normality

Emotional binding during

eat together
29
Summary
• Feeding should start immediately
when the patient is medically stable
• Do not feed or stop feeding if
medically contraindicated
• Support the medical, psychological
and spiritual needs of the patient and
family
Th an k
You