Peds Flashcards
Peds Stats
leading cause of death in kids 0-14
84% of kids live 5+ years
top cancer is brain and CNS cancer and the leukemia
Every year there are more survivors than the year before
Acute Lymphoblastic Leukemia
ALL is cancer of blood and bone marrow, most common childhood malignancy.
Malnutrition can affect disease response, infection risk, toxicities and tx delays
Kids are at risk for developing obesity during the maintenance and continuation phases but this can be prevented.
Studies show RD intervention is key
reduced bone mineral density may be caused by tx, relapses may require HCT
Acute Myeloid Leukemia (peds)
2nd most common childhood cancer
tx initially with chemo, but kids may need HCT.
Nutritional status affects outcome- kids with BMI at either end of the percentiles have lower survival rates
pts are more prone to anorexia, wt loss, N/V, mucositis, and malnutrition due to intense chemo
cardiomyopathy is a late effect of tx
Peds- CNS tumors side effects
dysphagia is a common potential complication for patients with posterior fossa tumors after resection, or those with progressive disease that effects the cerebellum or brainstem
long term complications include cognitive and motor skill deficits, wt gain, central adiposity, or feeding difficulties
RT may interrupt grehlin and leptin cues causing excessive intake.
Hodgkin Lymphoma
lymphoma is 3rd most common- can be HL or NHL. Significant weight loss may be a presenting symptom - great supportive care helps mitigate malnutrition risk.
frequent steroid use may lead to wt gain.
overall survival is 95%, but significant late effects. mediastinal RT can cause abnormal thyroid, heart, and lung function. anthracyclines further inc cardiac risk. Also increased risk for secondary primary cancers
Kids can have inc fat mass and dec LBM after tx
Neuroblastoma
most common solid tumor in kids, usually diagnosed in 1st yr of life, often observation for kids <6 months. Typically much more aggressive in older kids- often includes hard tx like myeloablative chemo and allo stem cell rescue
20-50% are malnourished which persists through tx r/t NIS like N/V, taste changes, anorexia and abdominal discomfort
late effects include underweight status, decreased growth and development after HCT, musculoskeletal complications, neuro complications and endo complication
Rhabdomysosarcoma
soft tissue tumor- often occurs in H&N area, genitourinary tract, extremities and occasionally in the trunk
short terms side effects: anorexia, constipation and jaw pain, high risk disease has higher risk of malnutrition
late effects may include SBO, esophageal strictures, renal tubular dysfunction, and secondary malignancies. RT to the H&N can lead to dental issues and growth hormone deficiency
Wilms Tumor
most common kidney malignancy in kids. pts present with large abdominal masses and sometimes HTN. malnutrition comes from early satiety and anorexia. mid upper arm circumference may be better than wt or BMI
surgery, chemo and RT are tx. side effects include constipation, jaw pain, N/V/D. RT might lead to radiation enteritis
late effects: cardiotoxicity and secondary malignancies . ESRD may happen in pts with bilateral disease
Osteosarcoma
most common bone tumor in kids- commonly occurs in periods of rapid growth. pain is the common presenting symptoms
Tx inc chemo and complete resection
common NIS: N/V, anorexia, hypomagnesemia, metallic taste changes and mucositis
late NIS: cardiotoxicity and nephrotoxicity
Ewing Sarcoma
2nd most common bone tumor. most often occurs in lower extremities, pelvis and chest wall
tx includes chemo, RT or surgery. NIS: N/V, anorexia, and wt loss.
Surgery and RT may significantly effect functional status, mobility, and growth
Hepatoblastoma
most common liver malignancy in children, usually occurring in kids <3 yo. Risk factors includes prematurity and familial cancer syndrome.
Tx includes chemo and complete resection if possible. Chemo may cause anorexia, N/V, mucositis, diarrhea, renal toxicity, and electrolyte wasting
CAR-T therapy
approved for tx of kids with relapsed or refractory B-cell ALL.
can cause cytokine release syndrome which includes fever, nausea, vomiting, vascular leakage, renal complication, and seizures
Hyperthermic intraperitoneal chemotherapy (HIPEC)
an approach to treating extensive peritoneal disease and involving administering heated chemo into the peritoneal cavity.
Post-op pts may require nutrition support because of the difficulty of feeding after extensive debulking surgery
Low nutritional risk for malnutrition (peds)
Nonmetastatic tumors
favorable prognosis at diagnosis
Adv diseases in remission during maintenance treatment
High nutritional risk for malnutrition (peds)
Depletion of body stores at diagnosis adv disease at diagnosis solid tumor w/ unfavorable histology stages III and IV neuroblastoma, especially with unfavorable biology adv stage at diagnosis acute leukemias during induction multiply relapsed leukemia HCT especially with GVHD
Nutrition Screening (peds)
every kid should be screened at diagnosis and periodic reassessment
Only 1 validated tool: SCAN (nutrition screening tool for childhood cancer)
SCAN
out of 10, >3 at risk, refer to RD
Does the pt have a high-risk cancer?
is the pt undergoing intensive tx?
Does the pt have any symptoms r/t to the GI tract?
Has the pt had poor intake over the past week?
Has the pt had any wt loss over the past month?
Does the pt show sign undernutrition?
Kids with amputations
some children with osteosarcoma and Ewing sarcoma may require amputation and require adjusted BMI and IBW
Foot: 1.3% BW below knee: 3.26% BW above knee: 9.96% BW hemipelvectomy or hip disarticulation: 11.83% BW shoulder disarticulation: 5% above elbow: 3.55% below elbow: 1.45% hand: 0.7%
Energy requirements (peds onc)
controversial- needs vary based on disease, clinical status, tx intensity, nutritional status and activity level
predictive equations may overestimate needs in peds onc pts
gold standard is always IC, but in place, equations to estimate EER are ok. In critically ill pts wHO equation for REE can be used.
Anthropometric measures
Growth charts (WHO 2006 0-24 months OR 2000 CDC 2-20 ys)
Wt (admission wt, track over time to see trends)
length and ht (investigate z-scores more than +/- 2)
Wt for length or BMI (investigate Z-scores less than -1)
Mid-upper arm circumference (accounts for tumor burden/ ascites)
MUAC and triceps skin fold
Biochem data
CBC- more r/t chemo than nutrition
ANC (absolute neutrophil count)
glucose level- monitor with steroids, insulin may be warranted to prevent rapid wt loss
Ferritin level: often falsely elevated due to inflammation
Vit D
Lipase level: pts may develop pancreatitis from chemo, including steroids or asparaginase
Clinical and medical history
- Assess history for medical conditions or personal circumstances
- inquire about family hx of diet related chronic illnesses
- assess current medical status for neutropenia, fever and infection
- individuals with Down syndrome more likely to develop leukemia
- Review cancer treatment and anticipated nutrition- related side effects
Dietary and activity assessment
assess the patient for the following:
total dietary intake (quality and quantitiy)
use of dietary supplements
baseline and recent physical activity level
tx side effects like anorexia, nausea, vomiting, hyperphagia
Nutrition-focused physical findings
Assess the patient for the following:
- fluid status: edema, ascites, hydration status
- presence of hepatosplenomegaly (leukemia) or large solid tumors
- GI tract issues (mucositis, esophagitis, gas, diarrhea, colitis, pancreatitis, etc)
- skin condition: dry skin, integrity, wounds
- muscle condition
- fat distribution
Adjusting body wt for amputations
adjusted wt: actual wt (kg) x100/ (100- % body weight amputation limb)
Adjusted BMI (adjusted wt in kg)/ (Height in m2)
Adjusted IBW (IBW in kg x 100)/ (100- % BW of amputated limb)
EER equations
0-3 mo (89 x wt in kg-100) +175
4-6 mo (89 x wt in kg-100) + 56
7-12 mo (89 x wt in kg-100) + 22
13-36 mo (89 x wt in kg-100) + 20
3-8 y:
M- 88.5- (61.9 x age in yrs) + phy activity factor x (26.7 x wt in kg +903 x ht in M) + 20
F- 135.3- (30.8 x age in yrs) + phy activity factor x (10x wt in kg +394 x ht in M) + 20
9-18 y
M- 88.5- (61.9 x age in yrs) + phy activity factor x (26.7 x wt in kg +903 x ht in M) + 25
F 135.3- (30.8 x age in yrs) + phy activity factor x (10x wt in kg +394 x ht in M) + 25
EER equation phys activity factors
sedentary M 1.0 F: 1.0
Low active M 1.13 F: 1.16
Active M 1.26 F: 1.31
Very active M 1.42 F: 1.56
Protein
fundamental for proper growth and development although no data exists regarding specific protein needs for peds cancer pt
protein needs are elevated - may be up 150-200% of the RDA
RDA stressed (RDA 1.5-2)
0-6 mo 1.52 2.30 - 3.0
7-12 mo 1.20 1.8- 2.4
1-3 y 1.05 1.6- 2.1
4-13 y 0.95 1.4- 1.9
14-18 y 0.85 1.3- 1.7
Determining Fluid needs
Holliday-segar method should be used and adjusted for lytes, organ dysfunction, or tx side effects
Wt <10 kg: 100 mL/kg
Wt 10-20 kg: 1000 mL + 50 mL/kg for ea kg over 10 kg
Wt > 10 kg : 1500 mL + 20 mL/kg for each kg over 20 kg
Micronutrients
Calcium and vit D: likely need to supplement, critical for bone health
