Chapter 13: Pediatrics Flashcards
What is the leader cause of disease-related death in children aged 0-14?
Cancer
What is the 5-year survival rate for children with cancer?
84%
What is the most common childhood cancer?
Brain and Central Nervous System
What is the second most common childhood cancer?
Leukemia
Why are children at a high risk of malnutrition during cancer treatment, compared to adults?
Metabolic demand per kg body weight increases
Need to maintain appropriate weight gain and linear growth
What is Acute Lymphoblastic Leukemia?
Cancer of blood and bone marrow
Most common childhood malignancy
What is a long-term side effect of treatment for ALL?
Reduced bone mineral density
Why would a child with ALL need a hematopoietic stem cell transplant (HCT)?
Early relapse or refractory ALL
What is Acute Myeloid Leukemia (AML)?
2nd most common type of childhood leukemia
What is the initial treatment for AML?
Chemotherapy
Why would a child with with AML need an HCT?
High risk or relapsed disease
List 6 common nutrition related side effects of treatment for AML
Anorexia
Weight Loss
Malnutrition
Nausea
Vomiting
Mucositis
What is a late effect of treatment for AML?
Cardiomyopathy
Patients with a BMI below the 5th or above the 85th percentile have lower survival rates. True or False? Justify your answer.
TRUE
These children are prone to infections.
Primary Brain Tumor/CNS may be ______ or ______.
Benign or malignant
Why would a patient with PBT develop dysphagia? Hint: 2 reasons
Patients with posterior fossa brain tumors following tumor resection OR Patients with progressive disease that affects the cerebellum and brainstem areas.
What are some long term complications of treatment for PBT? List 4
Cognitive and motor skill deficits
Weight gain
Central adiposity
Feeding difficulties
Why would a patient with PBT, undergoing radiation, have an increased appetite?
Radiation may disrupt ghrelin & leptin cues.
These are hormones that control your appetite and sense of satiety.
What is ghrelin?
A hormone that increases your appetite.
It is made in the stomach and signals to the brain that you are hungry. Plays a role in short-term control of appetite.
Source: Cleveland Clinic
What is leptin?
A hormone that decreases your appetite. Leptin is produced by fat cells. Leptin sends signals to the brain letting you know that you are full. Leptin controls long-term weight control.
Source: Cleveland Clinic
Increased cardiovascular complications following chemotherapy are associated with what?
Central adiposity and overall fat mass
What is Hodgkin Lymphoma?
3rd most common type of childhood cancer
Includes Hodgkin lymphoma (HL) & non-Hodgkin lymphoma (NHL).
NOTE: Hodgkin lymphoma has also been historically called Hodgkin disease. You may see “HD” listed under medicine charts while studying for this exam!
What is an initial presenting nutrition related symptom of HL or NHL?
Weight loss
What is the survival rate of HL and NHL?
95%
What medication leads to weight gain in HL & NHL?
Steroids
Patients with HL and NHL receive mediastinal radiation. What 3 organs can this cause abnormal function in later?
Thyroid, heart, & lung
Survivors of HL and NHL are at an increased risk of secondary cancers. What are the 3 most common secondary cancers?
Breast
Thyroid
Skin
How is body composition altered after treatment for HL & NHL?
Decreased lean body mass
Increased body fatness
Non-Hodgkin Lymphoma encompasses all childhood lymphomas that are not HL. List 4 most common subtypes
Precursor lymphoblastic lymphoma
Burkitt or Burkitt like lymphoma
Diffuse large B-cell lymphoma
Anaplastic large cell lymphoma
List 4 nutrition symptoms associated with treatment for NHL
Nausea
Vomiting
Anorexia/loss of appetite
Constipation
Patients with NHL are usually on steroids. List 2 effects of steroids.
Fluid retention
Hyperglycemia
What are less common (but not unheard of) nutrition related symptoms of treatment for NHL?
Mucositis
Diarrhea
What are potential post-treatment effects for NHL? Hint: 4 listed in book
Obesity
Hypertension (HTN)
Impaired mobility
Reduced strength
What is neuroblastoma?
Solid tumor that commonly arises from cells in the sympathetic nervous system
Most common solid tumor in children
At what age is neuroblastoma typically diagnosed?
1 year or under
Older children may develop neuroblastoma. What is the concern with diagnosis at an older age?
Disease is usually more aggressive.
Metastatic disease usually present at time of diagnosis.
Intensive treatment is required.
Malnutition at time of diagnosis of neuroblastoma has been reported in ____ - _____ % of cases.
20-50%
List nutrition impact symptoms of neuroblastoma
Nausea
Vomiting
Dysgeusia
Anorexia
Abdominal discomfort
Why is abdominal discomfort a symptom of neuroblastoma?
Most neuroblastomas begin in the abdomen
Usually in an adrenal gland or in sympathetic nerve ganglia.
Source: American Cancer Society
Is HCT a common treatment for neuroblastoma?
Yes
Neuroblastoma is one of the most common indications for auto-HCT in pediatrics. It is often used in children with high-risk neuroblastoma who are unlikely to be cured with other treatments.
Source: American Cancer Society
Chemo for neuroblastoma usually includes a combination of drugs. The main chemo drugs used include:
Cyclophosphamide
Cisplatin or carboplatin
Vincristine
Doxorubicin (Adriamycin)
Etoposide
Topotecan
Melphalan (sometimes used during stem cell transplant)
Busulfan (sometimes used during stem cell transplant)
Thiotepa (sometimes used during stem cell transplant)
The most common combination of drugs includes cisplatin (or carboplatin), cyclophosphamide, doxorubicin, vincristine, and etoposide, but others may be used.
Source: American Cancer Society
Types of radiation used to treat neuroblastoma. Hint: 2
External beam radiation therapy
MIBG radiotherapy
What is rhabdomyosarcoma?
Soft tissue tumor
What are the common sites of rhabomyosarcoma?
Head and neck
Genital urinary tract
Extremities
Trunk (less common)
Common treatment side effects (list 3)
Anorexia
Jaw pain
Constipation
Late effects of treatment for neuroblastoma (list 4)
Small bowel obstruction
Esophageal strictures
Renal tubular dysfunction
Secondary malignancies
Radiation to the head and neck area may result in ____ _____ & ____ ____ _____.
Dental problems
Growth hormone deficiency
What is Wilms Tumor?
Most common kidney malignancy in children.
Note: may also be references as nephroblastoma.
At what age are Wilms Tumors most commonly diagnosed?
Under age 5.
Source: https://www.ncbi.nlm.nih.gov/books/NBK442004/
Overall 5-year survival rate for Wilms tumor?
92%
Source: https://www.ncbi.nlm.nih.gov/books/NBK442004/
Why might a pt with Wilms Tumor develop radiation enteritis?
Whole abdomen or flank radiation
List 2 late effects of treatment from Wilms tumor
Cardiotoxicity
Secondary malignancies
A patient with Wilms Tumor has bilateral disease. What condition may occur?
End Stage Renal Disease
What is osteosarcoma?
Most common bone tumor in pediatric patients
When does osteosarcoma typically develop?
During periods of rapid growth
Most common symptom of osteosarcoma at time of diagnosis?
Pain
What is the typical treatment for osteosarcoma?
Chemotherapy & Complete Resection
Surgery may include amputation or limb salvage surgery.
What are 5 common nutrition impact symptoms associated with treatment of osteosarcoma?
Nausea
Vomiting
Anorexia
Metallic taste
Mucositis
Which lab may be decreased due to treatment of osteosarcoma?
Magnesium
Late effects of treatment for osteosarcoma
Cardiotoxicity
Nephrotoxicity
What is Ewing Sarcoma?
2nd most common bone tumor in children
Most common sites of Ewing Sarcoma?
Lower extremities
Pelvis
Chest Wall
Can occur in almost any bone or soft tissue.
Typical treatment for Ewing Sarcoma?
Chemo
Surgery or radiation for local control
List 4 nutrition related side effects from chemotherapy for Ewing Sarcoma
Nausea
Vomiting
Anorexia
Weight loss
Pelvic radiation can lead to ____, ____, and _____.
Enteritis
Obstruction
Perforation
Surgery and radiation may affect ____, ____, and ____ ____.
Mobility
Growth
Functional status
What is hepatoblastoma?
Most common liver malignancy in children
At what age is hepatoblastoma typically diagnosed?
Under age 3
List 2 risk factors for hepatoblastoma
Prematurity at birth
Familial cancer syndromes
Why would a pt with hepatoblastoma have anorexia at time of diagnosis?
Abdominal tumor growth
Nutrition side effects of treatment for hepatoblastoma include? List 7
Anorexia
Nausea
Vomiting
Mucositis
Diarrhea
Renal toxicity
Electrolyte wasting
Treatment for hepatoblastoma typically includes?
Chemo & complete resection
What is chimeric antigen receptor T-cell therapy? Also called CAR T-Cell Therapy.
In CAR T-cell therapies, T cells are taken from the patient’s blood and are changed in the lab by adding a gene for a receptor (called a chimeric antigen receptor or CAR), which helps the T cells attach to a specific cancer cell antigen. The CAR T cells are then given back to the patient.
Source: American Cancer Society
Examples of CAR T-Cell Therapy include
Tisagenlecleucel, also known as tisa-cel (Kymriah)
Axicabtagene ciloleucel, also known as axi-cel (Yescarta)
Brexucabtagene autoleucel, also known as brexu-cel (Tecartus)
Lisocabtagene maraleucel, also known as liso-cel (Breyanzi)
Idecabtagene vicleucel, also known as ide-cel (Abecma)
Ciltacabtegene autoleucel, also known as cilta-cel (Carvykti)
CAR T-cell therapy has been approved for use in which childhood cancer?
Relapsed or refractory B-cell ALL
Infusion of CAR-T cells can cause cytokine release syndrome. What are some symptoms of CRS?
Fever
Nausea
Vomiting
Vascular leakage
Renal complications
Seizures
What is HIPEC (hyperthermic intraperitoneal chemotherapy) used for?
Used to treat extensive peritoneal disease
Includes administering heated chemo agents directly into the peritoneal cavity
Which cancer is HIPEC most effective for?
Desmoplastic small cell round tumors
At time of diagnosis, what percentage of children are malnourished? Hint: a range
5-21.5%
Malnutrition incidence increases by ____% during cancer treatment.
65%
Which cancer type is at a higher risk of malnutrition?
Patients with solid tumors
Obesity affects what percentage of children with cancer?
8-78% of children
Very large range. More research is needed.
What is SCAN?
Nutrition screening tool for childhood cancer.
Only validated tool to identify children at the highest risk for malnutrition
Best screening tool for hospitalized pediatric cancer patients?
Pediatric SGA.
Not validated for use in cancer.
Estimating calorie requirements
Indirect calorimetry = Gold Standard
WHO equation for REE can be used if this is not available or feasible. WHO equations change based on age and sex. Must be adjusted for stress factors.
Estimating protein needs
Non-stressed: RDA
Stressed: RDA x 1.5-2
Protein Needs (age 0-6 months) (g/kg)
Normo: 1.52
Stressed: 2.3-3.0
Protein Needs (age 7-12 months) (g/kg)
Normo: 1.20
Stressed: 1.8-2.4
Protein Needs (age 1-3 years) (g/kg)
Normo: 1.05
Stressed: 1.6-2.1
Protein Needs (age 4-13 years) (g/kg)
Normo: 0.95
Stressed: 1.4-1.9
Protein Needs (age 14-18years) (g/kg)
Normo: 0.85
Stressed: 1.3-1.7
Fluid Needs (Holliday-Segar method)
<10 kg: 100 mL/kg
10-20 kg: 1000 mL + 50 mL/kg for each kg over 10 kg
>20 kg: 1500 mL + 20 mL/kg for each kg over 20 kg
Which 2 micronutrients are typically low in pediatric cancer patients?
Vitamin D3
Calcium
3 appetite stimulants used in pediatric cancer patients
Cyproheptadine (Periactin)
Dronabinol (Marinol)
Megestrol acetate (Megace)
Conditions in which parenteral nutrition may be used?
Severe mucositis
Ileus
Neutropenic colitis or typhlitis (neutropenic enterocolitis of the ileocecal region)
GI hemorrhage
Penumatosis intestinalis
Intractable nausea, vomiting, diarrhea
Weight Percentiles (underweight, overweight, obese)
Underweight (< 5th percentile)
Overweight (85th to 94th percentile)
Obese (=/> 95% percentile)
7 factors are included in the SGNA
Height (stunting)
Weight (wasting)
Unintentional change in weight (increase or decrease)
Adequacy of dietary intake
GI symptoms
Functional capacity
Metabolic stress of disease
Sinusoidal obstruction syndrome (SOS)
- Formerly called veno-occlusive disease (VOD)
- Complication of hematopoietic stem cell transplantation
- Can occur with nontransplant-associated chemotherapy.
Source: https://pubmed.ncbi.nlm.nih.gov/33902061/
Why should lipase be monitored in pediatric patients?
Patients can develop pancreatitis from chemo, including steroids or asparaginase
What unique pediatric population is at higher risk for leukemia?
Down Syndrome
What could be the true cause of an elevated ferritin level?
Inflammation
What is a nutritional concern for Vitamin D levels? What is an appropriate minimum level for patients/survivors?
Often deficient in patients, supplement likely needed — important for bone health and immune health
30 mg/mL for 25-hydroxyvitamin D
What is the hallmark outcome of cachexia in pediatrics?
Growth failure
What % of cancers occur in children?
1%
DRI for vitamin D in children aged 1-12 months is ____ and for children age 1-18 years is ____
400 IU, 800 IU
Assess dynamic changes in growth over time and a decrease of more than ____ Z score is problematic.
1
Most children with leukemia have ____ needs at diagnosis and during anti-cancer treatment.
Near normal energy needs
BMI for age at or above ____ reflects obesity and _____ reflects overweight
95%, 85-95%
Because of research inconsistencies, what is the most appropriate tool for estimating energy needs in normal weight children with cancer?
DRI (EER)
Long-term effects of malnutrition in childhood cancer patients include which of the following
a. compromised bone health
b. stunted growth
c. compromised eating behaviors
d. reduced quality of life
e. all of the above
e. all of the above
Which would NOT be a part of pediatric nutrition assessment?
a. Comparison of height to the WHO or CDC growth charts
b. PG-SGA
c. Gastrointestinal tests (e.g., fecal fat test)
d. Triceps skinfold
b. PG-SGA
Rationale: the SGNA is the validated tool
Underweight is a common finding in all survivors of ALL, in particular, those who have received cranial irradiation.
True or False
FALSE
With increased stool output, what should be monitored and supplemented provided there’s a deficiency?
a. Potassium
b. Magnesium
c. Zinc
d. Sodium
c. Zinc
True or False. All HCT patients undergoing an allogeneic transplant should be placed on a neutropenic diet and avoid all restaurant and fast foods until after day 100.
TRUE
Protein needs may increase by how much during cancer treatment?
a. 25%
b. 33%
c. 50%
d. 100%
c. 50%
Latent side effects from radiation include which of the following (choose all that apply).
a. altered bone development
b. hearing impairment
c. neutropenia
d. secondary malignancies
a. altered bone development
b. hearing impairment
d. secondary malignancies
The following pediatric diagnoses would be classified as high nutrition risk
a. non-metastatic solid tumors
b. medulloblastoma
c. neuroblastoma
d. newly diagnosed AML
b. medulloblastoma
c. neuroblastoma
d. newly diagnosed AML
IC is the preferred method for estimating needs for which pediatric cancer population?
a. Wilms tumor
b. HCT
c. osteosarcoma
d. neuroblastoma
a. Wilms tumor
PN is indicated in children with GI dysfunction that has been present for how long
a. 7 days
b. 5 days or more
c. 10 days
d. 3 days or more
d. 3 days or more
What may alleviate the effect of PN associated liver disease in the pediatric population?
a. IV lipids that contain fish oil
b. increase amount of amino acids provided
c. increase total volume
d. combine the use of EN and PN
a. IV lipids that contain fish oil
d. combine the use of EN and PN
You are assessing the needs of a 12 y/o patient with AML who will be having HCT. What would their protein needs be?
a. 2 g/kg
b. 2.5 g/kg
c. 1.8 g/kg
d. 3 g/kg
a. 2 g/kg
Typically what happens to REE following HCT?
a. Increases
b. Decreases
c. Stays the same
b. Decreases
Which of the following pediatric diagnoses would be assessed within 24 hours?
a. Wt loss of 3-5% in the last month
b. Orders for nutrition support
c. modified diet orders
d. non-chemo induced nausea, vomiting, diarrhea
a. Wt loss of 3-5% in the last month
b. Orders for nutrition support
The Holliday Segar MEthod is the most common method for estimating fluid needs in children
True or False
True
What 2 micronutrients are a concern for pediatric oncology patient because a child’s bone health may be compromised during the course of cancer treatment?
a. calcium, vitamin E
b. calcium, vitamin D
c. calcium, iron
d. calcium, vitamin K
b. calcium, vitamin D
A z-score between -2 and -3 indicated which level of malnutrition?
Moderate malnutrition
A 10 y/o male, normal weight, is hospitalized and seen resting quietly in bed. What is the appropriate activity factor for estimated energy needs?
1.1-1.2 x BMR
True or False. Iron supplementation is always recommended for children undergoing multiple blood transfusions during treatment.
False
A child weighs 16 kg and does not have a fever. What are their fluid needs?
1300 mL using Holliday Segar method (1000 mL + 50 mL per every kg over 10 kg
