 |  |  | | | Why is good nutrition important for children with cancer? | | | | |
| |  | | In this first in the series of Nursing Leukaemia factsheets, we look at the importance of nutrition in young people with cancer. This article will also be relevant to nurses working with adults
 | Author biography |
|  | | Dawn Casey. MSc, PGCE, BN(Hons), RN(Child), qualified in 1996 having completed the Bachelor of Nursing certificate at the University of Wales College of Medicine in Cardiff. She has subsequently worked in medicine, surgery and for the last four years in paediatric oncology in Cardiff. She completed a PGCE in Cardiff and an MSc in public health/health promotion in Bristol. As part of her MSc, she carried out a nursing research study into the nutritional intake of paediatric oncology patients and its influencing factors.Dawn became a clincal teacher in 2002 with the Cardiff and Vale NHS Trust. She is responsible for the training and support of pre-registration nurses in the clinical area. She continues to work in oncology, maintaining her clinical skills. She also sits on a local research ethics committee and reviews research proposals from nurses, doctors and the pharmaceutical industry research. |
"Too often people don't consider nutrition until it is too late. We really need to be thinking about nutrition from the day the patient is diagnosed, even when they appear to be fit and well nourished. (Holmes, 2002, p10)"
 | Section 1 |
Children are particularly vulnerable to malnutrition because they have decreased calorie stores and need extra calories for growth and development (Han-Markey, 2000). The literature suggests that anything between 1-46% of paediatric oncology patients could be experiencing malnutrition (Pietsch and Ford 2000).
Malnutrition is a problem for all oncology patients people with leukaemia and lymphoma are no exception. There are several reasons why this is the case:
 | There is an increase in energy expenditure triggered by the bodys fight against cancer (Holmes, 2002). |
| The side effects of the cancer treatment can also affect dietary input by triggering nausea, vomiting and mucositis, for instance with the acute myeloid leukaemia (AML) protocols, or constipation with the acute lymphoblastic leukaemia (ALL) protocols. |
| ALL patients take steroids during their intensification block; this can cause an increased appetite and weight gain. This has been linked to the escalation of obesity in paediatric ALL survivors, which is four to five times more likely than expected (Reilly et al 2000). |
| The cancer itself can cause a severe form of malnutrition known as Cachexia. This is a progressive muscle wasting caused by a failure to meet protein or calorie requirements (Cunningham and Bell, 2000). Chemicals released by the tumour and the patients body cause them to lose both fat and lean body mass, namely skeletal muscle. Cachexia is linked to a decrease in response to treatment and death (Davis 2002). |
| Leukaemia and lymphoma patients can have an enlarged spleen. This encroaches on the patients stomach thus reducing their appetite. Patients with solid tumours of the gastrointestinal tract have a similar problem. |
| Hodgkins lymphoma patients may also suffer with shortness of breath, which can also cause a loss of appetite. |
Poor nutritional status has been shown to have an impact on several clinical outcomes, including treatment response, quality of life and cost of care. Malnutrition can lead to a decreased immune function, in already immuno-compromised patients; delay wound healing and reduce drug metabolism (Holmes, 2003). Also as mentioned earlier it can be a contributing factor to death and poor prognosis.
| Section 2 |
How can you tell if someone is malnourished?
The most accurate way of monitoring weight is using a nutritional assessment tool. This is particularly useful as it considers a combination of factors, and is completed regularly allowing observation of trends.
However, some general things to watch out for;
| General observations in young people (and adults) for signs of malnutrition |
| | Loss of appetite |
| Fatigue |
| Weight loss |
| Sore mouth/mucositis |
| Constipation |
| Uncontrolled vomiting |
| Blood results, particularly changes in. |
| Particularly intense courses of chemotherapy. |
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Loss of appetite
Poor appetite and weight loss are closely linked. Prolonged anorexia will lead to weight loss. There can be many reasons for a loss of appetite in oncology patients this includes fatigue, the child becomes too tired to eat. Depression can also reduce appetite and is especially common in adolescents (Moore and McLaughlin 2003). In lymphoma patients this can be caused by masses either in the spleen encroaching on the stomach, or in the chest restricting breathing.
Weight Loss
Another key sign is prolonged gradual weight loss or sudden large losses of weight. Cunningham and Bell (2000) have suggested that the criterion to identify weight loss varies, ie greater than 10% over six months or greater than 5% over one month. Consequently regularly weighing and documenting this on growth charts will help to monitor this weight loss and act as an early warning system. Remember it is easier to maintain current weight than regain lost weight.
Emesis
Children who have regular uncontrolled vomiting often loose their appetite, or lose weight as they are not absorbing anything. This is also the case with mucositis and sore mouths. They may also have electrolyte imbalance or dehydration due to excess fluid loss. Children with acute myeloid leukaemia (AML) often experience severe vomiting and mucositis
Specific cytotoxic agents
It is important to consider what protocol the child will follow, as this will help to predict which children are going to encounter mucositis or uncontrolled vomiting. Obviously, the side effects relate to the cytotoxic agents which are being used. For example, acute lymphoblastic leukaemia patients (ALL) often have constipation because of the vincristine in the intensification blocks.
Blood chemistry can also be an indicator of nutritional state, although the research would suggest that this is a late and unreliable sign (Attard-Monalto et al 1998).
| Section 3 |
How to improve nutrition/patients eating pattern
There are many ways of increasing the childs dietary input and no one solutions is fool proof. Most children need a combination of tactics.
| Try to offer children small amounts of food, frequently. Children find large plates of food overpowering and tend not to eat anything. Alternatively leave nibbles around for them i.e. nuts, cubes of cheese, crisps, pieces of fruit, sweets etc. |
| Trying to increase the calories provided in food is also useful, it allows the child to eat the same portion size but consume more calories. This can be done by using full fat products, adding cheese and butter/cream to things like mash potato. Encouraging dairy products or protein. Milkshakes made with fruit, full cream milk and ice cream, will increase calorie content. Bananas are a particularly good source of nutrients and energy. |
| Many children seem to suffer from cravings, particularly those on steroids. Offering the child what they want, when they want it seems to help with this. In view of the increasing number of obese ALL survivors, it may be advisable to only offer small amounts and try to focus on healthy food or a variety of food. |
| Dietary supplements can be used, following advice from the dietician. There are both savoury and sweet ones. They can be tried hot or cold to improve palatability. Alternately a plain flavour can be used as a basis for a milk shake, custard or soup etc and the family can add their own flavouring. |
| The research I carried out (And anecdotal evidence) would suggests that children do not eat spicier food, unlike their adult counter parts. They seem to enjoy bland food such as roast dinner. |
| NEVER hide medication in a childs favourite food. They will not take the medicine and it will probably put them off the only thing they will eat. It is also worth considering the RCN covert administration of medicines policy (RCN 2003). |
| If a child has a sore mouth soft foods and cold foods are particularly important i.e. jelly, mash, ice lollies, soup. |
| Egg dishes are also very useful as they are high in protein and soft. |
| Try not to make food an issue. Offer the child something to eat and if they decline leave it and try again later. |
| Also try to give the child a certain amount of control or choice. For instance what food item they will eat, or how many chips. |
| Some children will take milkshake etc from a syringe or supplements can be used as another medication. I interviewed one young man who took his daily tablets with a dietary supplement and then had a drink of water! |
Assessment of nutritional status should be an ongoing part of care and treatment. Early warning signs are vital in the fight against malnutrition. It is much easier to maintain weight than regain weight.
| References |
Holmes, S. (2002). Nutrition and cancer. Cancer Nursing Practice. 1(5), 31-38
Han-Markey, T. (2000). Nutritional considerations in paediatric oncology. Seminars in Oncology Nursing. 16 (2), 113-121
Pietsch, J. and Ford. C. (2000). Children with cancer: Measurements of nutritional status at diagnosis. Nutrition in clinical practice. 15 Aug. 185-188
Reilly, J. Ventham, J. Newell, J. Aitchison, T. Wallace, W. and Gibson, B. (2000). Risk factors for excess weight gain in children treated for acute lymphoblastic leukaemia. International Journal of Obesity. 24, 1537-1541)
| Section 2 Attard-Montalto |
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| Section 3 RCN (2003) Covert administration of Medicines. RCN |
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