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The Role of the RD in the Treatment of Pediatric Acute Lymphocytic Leukemia

The Role of the RD in the Treatment of Pediatric Acute Lymphocytic Leukemia. Natalie Navarre, Sodexo Dietetic Intern. Agenda. Cancer & Leukemia Bone Marrow & Lymphatic System ALL: Diagnostic techniques Treatments Side effects Common Medications Medical Nutrition Therapy: ADIME

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The Role of the RD in the Treatment of Pediatric Acute Lymphocytic Leukemia

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  1. The Role of the RD in the Treatment of Pediatric Acute Lymphocytic Leukemia Natalie Navarre, Sodexo Dietetic Intern

  2. Agenda • Cancer & Leukemia • Bone Marrow & Lymphatic System • ALL: • Diagnostic techniques • Treatments • Side effects • Common Medications • Medical Nutrition Therapy: ADIME • Presentation of case study patient

  3. One in 300 Boys One in 333 Girls 13,400 Children Annually

  4. Cancer & Leukemia • Cancer: Abnormal cell proliferation and growth • Malignant vs. Healthy cells • Containing damaged DNA • Invasion of tissues and organs • Leukemia: Cancer of the blood and bone marrow • Sub-types: ALL, CLL, AML, CML • Rapid invasion of the blood, tissues, and organs

  5. Cancer Incidence Statistics

  6. Blood Cell Differentiation Myeloid Leukemia Lymphocytic Leukemia

  7. Lymphatic System T-Cells B-Cells • Proper immune function • T-cells & B-cells reside in lymph nodes • Filters lymph of toxins, dead cells, debris, infectious organisms

  8. Acute Lymphocytic Leukemia (ALL) • Most common form of childhood leukemia • White blood cells  only affects lymphocytes • Includes T-lymphocytes and B-lymphocytes • Acquired genetic injury to a single cell in the marrow • Presence of damaged DNA leads to over production of lymphoblasts • Poor immune function • Immature and abnormal lymphoblasts not able to fight infection • Rapid influx of leukemic blasts  Decreased healthy blood cells

  9. Etiology & Risk Factors • NO KNOWN ETIOLOGY! • Risk factors of ALL: • Genetic risk factors • Lifestyle risk factors • Environmental risk factors

  10. Signs & Symptoms

  11. Common Lab Values WBC value on CBC determines risk groups Low/Standard Risk: 1-10yrs old + WBC less than 50,000mm3 High Risk: Less than 1yr or older than 10yrs + WBC greater than 50,000mm3 • CBC Hematological lab values • White blood cell count  • Red blood cell count  • Platelets  • Hemoglobin  • Hematocrit

  12. Diagnosing ALL • CBC & blood smear • Bone marrow biopsy & aspiration • Lumbar puncture – cerebrospinal fluid • Flow cytometry – type of leukemia • Cytogenic analysis – presence of genetic abnormalities • May help determine prognosis Healthy Lymphocytes ALL Lymphoblast Cells

  13. Treatments

  14. Bone Marrow Transplant • PRE-Bone Marrow Transplant: 4-10 days • High-dose chemotherapy + Total body radiation • Destroys blood forming cells in bone marrow & leukemia cells • Purpose make room for new, healthy cells and destroy immune system • POST-Bone Marrow Transplant: Days +0 to +30 • Signs of engraftment – Days 10-20 usually • ANC >500mm3 x 3 days • Platelets 20,000-30,000 per microliter • Pancytopenia – high risk for infection • POST-Bone Marrow Transplant: Days +31 to +100 • Increased risk for complications up to day +100 • Blood cell counts increase and immune system gets stronger

  15. Side Effects of Treatment

  16. Graft vs. Host Disease (GVHD) • Donor stem cells reject recipients body • Increased risk with allogeneictransplants • Acute GVHD  within first +100 days • Abdominal pain, N/V/D, jaundice, skin rash • Chronic GVHD  after first +100 days • Dry mouth, dry eyes, chronic pain, weight loss, muscle weakness • Prevention: prophylaxis and immunosuppressive drugs • Treatment: steroids and immunosuppressive drugs GVHD – stage I

  17. Common Medications • Motility agents gastroparesis, GERD, feeding intolerances • Proton Pump Inhibitors  ulcers, GERD • Anti-Emetics  nausea and vomiting • Medicated mouth wash mucositis • Chemotherapeutic Agents methorexate, cisplatin, PEG-Asparaginase • Immunosuppressive Agents  prevent transplant rejection • Prophylactic Agents prevention medications; GVHD, infections

  18. Emerging Research • Children’s Oncology Group (COG) and National Cancer Institute (NCI) • Targeted chemotherapy and high-dose chemotherapy • COG-AALL1131: combination chemotherapy with different dosages and combinations • COG-ACCL0934: giving specific antibiotics post-transplant prophylactically to prevent infection • Survival Rates are INCREASING! • 1976-2006 increased from 41%-67% • Currently more than 85%5 year survival rate!!!

  19. Medical Nutrition Therapy Nutritional Management of Pediatric Acute Lymphocytic Leukemia

  20. Role of the RD • MAIN GOALS: • Identify malnutrition & growth failure • Direct correlation between malnutrition and intensified treatment regimens • Cancer cachexia • Manage nutrition related side effects • Ensure meeting 100% of needs PO, enterally, or parenterally • Improve patients nutritional status through interventions

  21. Nutrition Screening • Screening criteria for oncology patients at nutritional risk: • Total weight loss greater than 5% over past month • Under 10th or over 90th %ile for wt. for age & wt. for ht. • Height < 10th %ile • Weight < 90% of IBW • TSF < 10th %ile, MAMC < 5th %ile • BMI < 5th or >85th %ile • Consuming less than 80% of needs

  22. Assessment • Medical History • AnthropometricData • Physical Observations • Ins & Outs • Dietary History • Biochemical Data • Nutrient Requirements

  23. Assessment: Biochemical Data • Vitamin D & Calcium: • Transplants patients – steroids & TBI alter bone metabolism • Decreased absorption of Calcium and associated with low vitamin D • Vitamin K: measured with Prothrombin time • Multiple antibiotics  decreased absorption • Zinc: low levels related to diarrhea • Electrolytes: fluid retention, third spacing, increased excretion • Hyperglycemia & Hypertrygliceredemia • LFTs

  24. Assessment: Nutrient Requirements Children > 1 year Basal Metabolic Rate (BMR) x Stress Factor Children < 1 year Estimated Energy Requirement Equations can be found on last page of packet! • No specific nutrition protocols for pediatric oncology • Goals of nutrient requirements: 1) Promote growth, prevent catabolism 2) Identify/Prevent protein-energy malnutrition 3) Continuous re-evaluation

  25. BMT Nutrient Needs Source: The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010.

  26. Diagnosis

  27. Example PES Statements • (P) Inadequate oral intake related to (E) decreased appetite as evidenced by (S) oral intake meeting only 25% of estimated needs. • (P) Atered gastrointestinal function related to(E) radiation therapy as evidenced by (S) stool output exceeding 2,000mL/day

  28. Interventions • Purpose & Goals: • Manage treatment related side effects • Prevent weight loss and malnutrition • Preserve lean body mass • Common side effects requiring intervention: • Nausea/Vomiting • Mucositis • Changes in taste • Diarrhea • Loss of appetite • Triglycerides • Neutropenia • Nutrition Support

  29. Nausea/Vomiting Food Aversions Association of food with unpleasant internal response Interventions: Avoid favorite foods before treatments ‘Scapegoat’ – prevent changes from normal eating pattern • Cytotoxic effect on CNS • Complications: weight loss, dehydration, electrolyte imbalance, food aversions • Interventions • Anti-emetics • Avoid high fat, high sugar food/drinks • Small, frequent feedings

  30. Taste Changes Mucositis Inflammation and breakdown of oral mucosa Severely inhibits oral intake &  quality of life Interventions Soft, pureed foods Avoiding spicy/salty foods Enteral/Parenteral nutrition • Alteration of taste buds • Metallic, chemical, or burnt taste in mouth • Increased/Decreased sensitivity to bitter, salty, sweet • Interventions: • Bitter/Metallic  add sugar, vinegar, citrus juice • Sweet add salt or water • Add spices/seasonings • Trial different temperatures • Aromatic foods

  31. Diarrhea  Triglycerides Medication side effect Monitor weekly Interventions: Omega-3 Fish oil supplement  Coromega • May decrease appetite & inhibit intake • Dehydration, electrolyte imbalances, malabsorption, altered GI motility • Interventions: • Low-fat, low-lactose diet • Avoiding caffeine, high sugar, high osmolality beverages • Provide education • Increase fiber intake • Change formula

  32. GVHD Neutropenia Compromised immune system  high risk for infection Neutropenic diet first 100 days post-transplant Intervnetions: Neutropenic diet education Safe food handling Safe eating techniques • Most commonly affected in acute GVHD: skin, gut, liver • May lead to mucosal breakdown, malabsorption, protein catabolism • May require bowel rest & PN • Interventions: • Guide food intake progression back to regular diet • Bowel rest (TPN)  Oral feeding  Solids  Expand diet  Resume regular diet • Wean TPN when PO meets 50% of needs

  33. Loss of Appetite/Early Satiety Culmination of side effects & treatment Interventions: • Small frequent meals • Liquid oral supplements • Appetite Stimulant • Providing favorite foods • between treatment • Calorie count

  34. Nutrition Support

  35. Enteral & Parenteral Nutrition Post-Bone Marrow Transplant: Combination of EN and PN  acceptable and cost-effective option Candidates: reduced-intensity conditioning regimens, anticipated mucositis, poor nutritional status prior to transplant Enteral Nutrition: Start at 10cc, increase 10cc every 8 hours to goal Trophic feeds of 3-5cc/hour for gut integrity Total Parenteral Nutrition: D: start 5-6mg/kg/min advance by 1-2mg/kg/min every 24hr to max 15mg/kg/min AA: Start at DRI IL: 20-60% kcals

  36. Monitoring & Evaluation Meeting 100% of estimated needs for growth & development Growth chart trends Intake/Output Management of nutrition related side effects Prevent malnutrition Weight maintenance Route of nutrition support adjusted as needed

  37. Case Study Patient J.B. – 13 year old male - Relapsed ALL

  38. History & Recent Admissions • Initial admitting Dx: septic shock-N/V on admit • Bone marrow aspiration and flow cytometryDx ALL with AML1 gene amplification • Tx Plan: COG AALL0331 • Oncology f/u • Treatment finished • July, 2011 • -ALL in remission • Bone scan  • Osteopenia • Learned food • aversions since • chemo • Outpatient weight mgnt clinic • Wt: 66.8kg • Ht: 166.2cm • Primary focus: food aversions February, 2008 July, 2012 August, 2012

  39. History & Recent Admissions • Admitted for BMT prep – TBI • Completed induction phase 3 per AALL1131  increased fatigue, decreased PO intake • Day -12 to Day +0: • -Cranial radiation, TBI, Chemotherapy, Imunnosuppressive agent • Medications: Anti-emetics, PPI, Swish & Swallow, Anti-depressant, BP 2/2 to meds • Diet Order: Regular Diet • Seen by nutrition day -7  nutritional status intact – expect decline with therapy regimen • 9/10-9/21/2012 • Presenting with headache • Relapsed ALL • 9/30-10/12/2012 • Presenting with mucositis related to chemotherapy • 10/23-10/23/2012 • Chemotherapy – induction 3 per AALL1131 November 18, 2012: BMT prep

  40. 11/26/12: Initial Nutrition Assessment • J.B. – 13y.o. male with relapsed ALL admitted for TBI/chemo in prep for BMT (Day +0) • Active problems: Osteopenia, food aversions, overweight, relapsed ALL, mucositis 2/2 chemo, vitamin D deficiency • Height: 11/18/12: 165 cm (64.29%ile) • Weight: 11/26/12: 64.8 kg (89.06%ile) – 127% IBW • Biochemical: low hematological labs, low Mg, ALT and GGT, fibrinogen and PTT • Medications: prophylaxis, antibiotics, anti-emetics, Swish & swallow, anti-depressant, pain meds, BP • Estimated Requirements: • 2320 calories (WHO REE x 1.3 stress factor) • 97-130 gm protein (1.5-2 gm protein/kg) • 2400 ml fluid normal maintenance • (needs based on weight at admission of 65kg) • Diet: Regular diet • Medical Course: (+) C. Difficile, asymptomatic HTN 2/2 to medications, 10/10 allogeneic BMT scheduled for today • Diagnosis: Inadequate oral intake related to chemotherapy as evidenced by patient report of no appetite today and not eating anything yet today. • Intervention: • Continue regular diet and encourage PO intake • Start enteral feeds Day +1 of: Peptamen Jr. PreBio – start at 10cc and increase 10cc every 8 hours to goal of 100cc/hr--Add 2 pktsBeneprotein by day 3 of feeds--To provide 2450kcal, 84 gm protein • Food/Nutrient Delivery:PO Pre-BMT; PO + NGT day +1 • Monitoring/Evaluation: • Monitor tube feeding tolerance post-transplant – goal to tolerate feeds and reach goal rate 100cc/hr • Monitor weight – goal of no weight loss greater than 2% in one week

  41. 11/29/12: Nutrition Follow-Up • Height: 11/18/12: 165 cm (64.29%ile) • Weight:11/28/12: 63.9 kg • 11/26/12: 64.8 kg (87.8%ile) – 125% IBW • Biochemical: hematological labs still low, Mg remains low, ALP and GGT, IgG, consistently albumin, Triglycerides • Medications: prophylaxis meds, antibiotics, anti-emetics, Swish & swallow, anti-depressant, pain meds, BP +IVIG, neupogen, additional antibiotics • Estimated Requirements: • Remained the same • Diet: Regular diet-Peptamen Jr. PreBio at 3cc/hr • Medical Course: DAY +3 -Presenting with rash on face, back, and arms-Transfusions: IVIG-C.diff negative • Diagnosis: Inadequate oral intake related to chemotherapy/stem cell transplant as evidenced by PO intake of less than 25% of estimated needs. • Intervention: • Continue regular diet and encourage PO intake as desired • TPN to meet 100% of needs – 2400ml, D19%, AA5.3%, IL0%2058kcal, 127gm protein, 4.9mg CHO/kg/min • Food/Nutrient Delivery:PO ad lib + TPN • Monitoring/Evaluation: • Monitor tube feeding tolerance post-transplant – goal to tolerate feeds and reach goal rate 100cc/hr – not met, discontinued for now. • Monitor weight – goal of no weight loss greater than 2% in one week – met, ongoing • Monitor TPN – goal to receive 100% of estimated needs from TPN

  42. 12/04/12: Nutrition Follow-Up #2 • Height: 11/18/12: 165 cm (64.29%ile) • Weight:12/04/12: 69.5 kg • 11/28/12: 63.9 kg (93.6%ile) – 136% IBW • Biochemical: hematological labs still low, Mg remains low, ALP and GGT, consistently  albumin,  Triglycerides, BUN, Na and Cl,  K, zinc • Medications: prophylaxis meds, antibiotics, anti-emetics, Swish & swallow, anti-depressant, pain meds, BP, IVIG, neupogen, additional antibiotics • Estimated Requirements: • PO&EN: 2320 calories • LESS 10% for TPN = 2070kcal • Diet: Regular diet • PN: 2400ml – D19% (456gm, 1550kcal), AA5.3% (2gm/kg, 508kcal). TV= 2058kcal 127gm protein, 4.9mgCHO/kg/min. *IL held due to high triglycerides • Medical Course: DAY +8-rash improving – unknown etiology - Triglycerides – unknown etiology • -platelet transfusion • Diagnosis:Altered GI function related to TBI and Cranial Radiation as evidenced by 7 days of loose stools and TPN dependence. • Intervention: • Continue TPN at maintenance until PO intake improves and diarrhea is resolved – meeting 100% of needs from TPN • Encourage PO intake as able • Lower CHO containing beverages to help control diarrhea. Spoke with mom about foods to avoid with diarrhea • Food/Nutrient Delivery:PO ad lib + TPN • Monitoring/Evaluation: • Monitor TPN – meeting goal rate and 100% of needs – met • Monitor weight – goal of no weight loss greater than 2% in one week – met, ongoing • Monitor Intake – goal to improve intake as able

  43. 12/11/12: Nutrition Follow-Up #3 • Height: 11/18/12: 165 cm (64.29%ile) • Weight:12/11/12: 74.8 kg • 12/06/12: 70.2 kg (96.56%ile) – 146% IBW • Biochemical: hematological labs still low, Mg remains low, ALP and GGT, consistently  albumin,  Triglycerides, zinc, PTT • Medications: prophylaxis meds, antibiotics, anti-emetics, Swish & swallow, anti-depressant, pain meds, BP, IVIG, neupogen, additional antibiotics, +methotrexate, lasix • Estimated Requirements: • PO+EN: 2320 calories • LESS 10% for TPN = 2070kcal • Diet: Regular diet • PN: 2400ml – D19% (456gm, 1550kcal), AA5.3% (2gm/kg, 508kcal). TV= 2058kcal 127gm protein, 4.9mgCHO/kg/min. *IL held due to high triglycerides • Medical Course: DAY +15-Changing nature of rash – sign of engraftment • -platelet transfusion-Hypertriglyceredemia – normal lipid panel – 2/2 to medications • Diagnosis:Inadequate oral intake related to mucositis secondary to chemotherapy as evidenced by receiving 100% of needs from TPN. • Obesity related to fluid retention and steroids as evidenced by BMI/age above the 95th percentile – however in view of diagnosis, not addressed at present. • Intervention: • Continue maintenance TPN • Start trophic NG feeds of Peptamen Jr. PreBio at 3cc/hrfor 24 hrs – monitor tolerance. • If tolerating NG feeds x 24 hrs – increase to 5cc/hr for next 24 hours • Food/Nutrient Delivery:PO ad lib + TPN + NG Trophic feeds of Peptamen Jr. PreBio • Monitoring/Evaluation: • 1. Monitor ability to transition to NGT feeds – goal to tolerate without nausea, vomiting, diarrhea • Monitor fish oil effects on triglycerides – goal to decrease triglyceride level • Monitor weight – goal of no weight loss greater than 2% in one week – met, ongoing

  44. Lab Trends: 11/25/12 - 12/10/12

  45. Continuation of JB’s Hospital Course • December & January Inpatient: • Acute Grade 2 GVHD  rash > 50% of body + average 500-1000cc diarrhea/day  started on high dose steroids • 12/18/12: Concern for EFAD due to ~3 weeks TPN without lipids and minimal lipids in diet • 12/20/12: Appetite stimulant started – Megace • Discharged home on 12/31/12 • Most recently seen by nutrition on 2/18/13: • Reverted back to food aversions – only eating chicken nuggets, macaroni and cheese, and grilled cheese • Goal to try two new foods a week • Will be seen weekly by AIDHC nutrition

  46. Critical Comments • Current research in line with interventions • Hospital protocol – allowed for early intervention • Anthropometrics: • Consider TSF and MAMC to get better assessment of dry weight • Nutrition Counseling – developing relationship with patient; interaction with mom

  47. Key Points • Meet 100% of patients estimated needs • Prevent malnutrition • Promote growth and development • Anticipate side effects – intervene early • Manage side effects associated with treatment • Promote quality of life to best of our ability

  48. A very special Thank You to MichellFullmer, the pediatric oncology dietitian at AIDHC, for her guidance and support through this case study! & Thank you to ALL of the dietitians at AIDHC for your endless support!

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