268 Puntis^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
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 PNETF 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
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