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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 Natalie Navarre, Sodexo Dietetic Intern
Agenda • Cancer & Leukemia • Bone Marrow & Lymphatic System • ALL: • Diagnostic techniques • Treatments • Side effects • Common Medications • Medical Nutrition Therapy: ADIME • Presentation of case study patient
One in 300 Boys One in 333 Girls 13,400 Children Annually
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
Blood Cell Differentiation Myeloid Leukemia Lymphocytic Leukemia
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
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
Etiology & Risk Factors • NO KNOWN ETIOLOGY! • Risk factors of ALL: • Genetic risk factors • Lifestyle risk factors • Environmental risk factors
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
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
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
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
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
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!!!
Medical Nutrition Therapy Nutritional Management of Pediatric Acute Lymphocytic Leukemia
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
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
Assessment • Medical History • AnthropometricData • Physical Observations • Ins & Outs • Dietary History • Biochemical Data • Nutrient Requirements
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
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
BMT Nutrient Needs Source: The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010.
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
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
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
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
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
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
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
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
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
Case Study Patient J.B. – 13 year old male - Relapsed ALL
History & Recent Admissions • Initial admitting Dx: septic shock-N/V on admit • Bone marrow aspiration and flow cytometryDx 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
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
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
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
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
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
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
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
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
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!