In the name of God Nutritional Supportive Care Presenting by F.Malek Assistant Professor of Hematology & Oncology

Introduction The high prevalence of malnutrition in pediatric patients with cancer has been appreciated for decades and continues to be documented An increasing prevalence of obesity in the healthy pediatric population, combined with additional risks associated with cancer treatment, has prompted care providers to confront the potential for obesity-related chronic diseases among childhood cancer survivors

Definition of Cancer Cachexia Cachexia has been defined as a severe state of malnutrition characterized by anorexia, weight loss, muscle wasting, and anemia. Wasting is defined as involuntary weight loss, and is found in patients with anorexia nervosa, cancer, advanced HIV infection, and marasmus. Cachexia in contrast, is defined as involuntary loss of fat-free mass in the setting of minimal or no overall weight loss.

The pattern of weight loss and changes in body composition in patients with illness are important to be considered because differential loss of body fat versus fat-free mass implies a different etiology and prognosis of malnutrition.

Question A 16 year old girl with a disturbing body image about herself suffers from eating disorder and volunteering vomits How will be the pattern of her weight loss

Question A 9 y/m with ALL suffers from appetite loss and inevitable weight loss Describe the pattern of his weight loss

Question Which one has a greater risk for malnutrtion Stage 3 of Hodgkin Lymphoma Stage 5 of wilm’s tumor ALL in the 12 day of induction

Etiology and Pathophysiology In brief, weight loss or gain is due to energy imbalance, which ensues when energy intake differs from total energy expenditure (TEE). TEE in turn is considered to be the sum of several components of the energy equation. Energy intake = TEE = REE + Eactivity + Egrowth + Elosses + SDA

Weight loss will occur when any of the components of TEE are higher than expected and are not matched by a compensatory increase in energy intake. Weight gain occurs when energy intake exceeds TEE. Although an increase in energy intake is the most common reason for overweight, reduction in energy of activity has also been implicated in the development of obesity.

Decreased Nutrient Intake There are multiple reasons for decreased nutrient intake in the child receiving chemo- or radiotherapy. The most important etiology is …?

Mucosal damage is generally dose-related, with increased risk of mucosal toxicity with high-dose induction therapy and combination chemotherapy treatments. Psychological factors are also important to consider in evaluating the reasons behind inadequate dietary intake. Depression-related anorexia is probably underappreciated as a cause.

Alterations in Macronutrient Metabolism Children with cancer manifest changes in macronutrient utilization markedly different than that evident with starvation. The tumor itself seems to impose a pattern of perturbations that lead to catabolism

This may be due to the heterogeneity of tumor types and sizes, treatment protocols, and baseline nutritional status

Carbohydrate The changes seen in carbohydrate metabolism associated with malignancy generally include glucose intolerance, increased gluconeogenesis and Increased Cori cycling

This has been demonstrated with various tumors by documenting decreased glucose uptake under steady states of hyperinsulinemia induced during glucose clamp studies. The augmented conversion of lactate to glucose may be secondary to increased lactate production by selected tumors

Lipid Lipid metabolism is also affected by cancer. Alterations include increased free fatty acid turnover, free fatty acid oxidation, glycerol turnover, and lipolysis. Lipogenesis is reduced Treatment with chemotherapy is associated with decreased fat utilization in children newly diagnosed with ALL

Another salient derangement of macronutrient metabolism accompanying cancer is the presence of protein catabolism. Hypoalbuminemia is common while the synthesis of acute-phase proteins remains high. Some tumors such as hepatocellular cancer manifest very high rates of protein turnover and increased protein degradation

An increase in the muscle protein breakdown mobilizes amino acids that may afford tumor growth as well as fuel gluconeogenesis. This increased protein breakdown in pediatric patients with cancer may be related to falling levels of insulin-like growth factor 1 and insulin-like growth factor-binding proteins

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