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

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

3. One in 333 Girls One in 300 Boys 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 Lymphocytic Leukemia Myeloid Leukemia

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

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 Sign/SymptomPossible Reasoning Fatigue/pale skin-Anemia (low red blood cells) Infections and fevers-Increased immature WBCs Headache, seizures, vomiting-Migration of leukemia cells into CNS Easy bleeding or bruising-Lack of blood platelets Bone or joint pain-Result of bone marrow being too “full” Loss of appetite/Weight loss, Abdominal Pain -Spleen and/or liver enlargement – pushing against stomach Swollen lymph nodes-Collection of lymphoblasts in lymph nodes Dyspnea-Migration of leukemia cells to middle of chest

11. Common Lab Values

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 1) Induction – goal to achieve remission 2) Consolidation – lingering leukemia cells 3) Maintenance Total Body Radiation High energy radiation  targets and destroys cancerous cells Chemotherapy Infusion of healthy blood stem cells into the bone marrow High risk ALL and relapsed ALL Bone Marrow Transplant

14. 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 >500mm 3 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 Nausea, vomiting, diarrhea, constipation Mucositis, decreased appetite Jaw pain, alopecia, fatigue, elevated glucose and triglycerides, hepatic insufficiency Total Body Radiation Nausea, vomiting, diarrhea Mucositis, dysphagia, altered taste/smell Malabsorption, ↓ saliva production, fluid/electrolyte imbalances Chemotherapy Poor intake  need for nutrition support Mucositis, diarrhea, vomiting, low blood counts C.Difficile – common Immunosuppression – viral, fungal, bacterial Exacerabtion of side effects Bone Marrow Transplant

16.  Donor stem cells reject recipients body  Increased risk with allogeneic transplants  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 Graft vs. Host Disease (GVHD)

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. Nutritional Management of Pediatric Acute Lymphocytic Leukemia

20. Role of the RD  MAIN GOALS: Identify malnutrition & growth failure o Direct correlation between malnutrition and intensified treatment regimens o 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 10 th or over 90 th %ile for wt. for age & wt. for ht. Height < 10 th %ile Weight < 90% of IBW TSF < 10 th %ile, MAMC < 5 th %ile BMI 85 th %ile Consuming less than 80% of needs

22. Assessment Medical, Surgical, Medication History Anthropometric Data Physical Observations -Past Procedures or diagnoses that may impact nutrition status -Medications that alter absorption of nutrients, cause GI upset -Track weight trends and growth velocity -% wt loss from UBW and % IBW -< 10%ile  growth impairment, inadequate nutrition -Fluid shifts -Signs of Wasting -Edematous -Dry skin, chapped lips -Wound healing -Pale, fatigued -Level of Pain -Frame size  Medical History  Anthropometric Data  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  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  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!

25. AGECALORIES PROTEIN (g/kg/d) 0-12 mo BMR* x 1.6-1.8 3 gm/kg/day 1-6 yrsBMR x 1.6-1.82.5-3 gm/kg/day 7-10 yrsBMR x 1.4-1.62.4 gm/kg/day 11-14 yrsBMR x 1.4-1.62 gm/kg/day 15-18 yrsBMR x 1.5-1.61.8 gm/kg/day > 19 yrsBEE** x 1.51.5 gm/kg/day BMT Nutrient Needs Source: The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010.

26. Diagnosis Inadequate oral intake Malnutrition Inadequate protein-energy intake Predicted suboptimal intake P roblem Side effects of treatments Treatments Side effects of diagnosis E tiology Intake less than x% of needs Stool output Dietary history Weight loss S igns/ Symptoms

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  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 Food Aversions  Association of food with unpleasant internal response  Interventions: Avoid favorite foods before treatments ‘Scapegoat’ – prevent changes from normal eating pattern

30. Taste Changes  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 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

31. Diarrhea  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  Triglycerides  Medication side effect  Monitor weekly  Interventions:  Omega-3 Fish oil supplement  Coromega

32. GVHD  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 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

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 Appetite Stimulant Method of Action Megace-Progesterone: increases appetite, causes weight gain Marinol -Cannabinoids class: Affects area of brain that controls nausea, vomiting, and appetite Periactin-Antihistamine: side effect of increased appetite

34. Nutrition Support 1. ORAL NUTRITION  Promotes normalized feeding  High calorie, high protein foods  Oral supplements (caution High osmolality)  Difficult to meet 100% of needs 2. ENTERAL NUTRITION  Indications: mucositis, intake <80% x 3-5 days  Shown to reverse malnutrition  Formula: -patient’s age -GI function -formula composition -cost/insurance  Semi- elemental & elemental formulas common 3. PARENTERAL NUTRITION  Failure to meet needs with EN and orally  Increased risk for infection – NOT recommended during chemo  TPN via central line  Complications: -gut atrophy -infections -cholestasis

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.  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 Monitoring & Evaluation

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, 2008July, 2012August, 2012

39. History & Recent Admissions 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 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 November 18, 2012: BMT prep

40. 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 11/26/12: Initial Nutrition Assessment Diagnosis: Inadequate oral intake related to chemotherapy as evidenced by patient report of no appetite today and not eating anything yet today. Intervention: 1)Continue regular diet and encourage PO intake 2)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 pkts Beneprotein by day 3 of feeds --To provide 2450kcal, 84 gm protein Food/Nutrient Delivery: PO Pre-BMT; PO + NGT day +1 Monitoring/Evaluation: 1.Monitor tube feeding tolerance post-transplant – goal to tolerate feeds and reach goal rate 100cc/hr 2.Monitor weight – goal of no weight loss greater than 2% in one week

41. 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 11/29/12: Nutrition Follow-Up Diagnosis: Inadequate oral intake related to chemotherapy/stem cell transplant as evidenced by PO intake of less than 25% of estimated needs. Intervention: 1)Continue regular diet and encourage PO intake as desired 2)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: 1.Monitor tube feeding tolerance post-transplant – goal to tolerate feeds and reach goal rate 100cc/hr – not met, discontinued for now. 2.Monitor weight – goal of no weight loss greater than 2% in one week – met, ongoing 3.Monitor TPN – goal to receive 100% of estimated needs from TPN

42. 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 12/04/12: Nutrition Follow-Up #2 Diagnosis: Altered GI function related to TBI and Cranial Radiation as evidenced by 7 days of loose stools and TPN dependence. Intervention: 1)Continue TPN at maintenance until PO intake improves and diarrhea is resolved – meeting 100% of needs from TPN 2)Encourage PO intake as able 3)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: 1.Monitor TPN – meeting goal rate and 100% of needs – met 1.Monitor weight – goal of no weight loss greater than 2% in one week – met, ongoing 2.Monitor Intake – goal to improve intake as able

43. 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 12/11/12: Nutrition Follow-Up #3 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 95 th percentile – however in view of diagnosis, not addressed at present. Intervention: 1)Continue maintenance TPN 2)Start trophic NG feeds of Peptamen Jr. PreBio at 3cc/hr for 24 hrs – monitor tolerance. 3)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 2.Monitor fish oil effects on triglycerides – goal to decrease triglyceride level 2.Monitor weight – goal of no weight loss greater than 2% in one week – met, ongoing

45. Basename12/10/1212/07/201212/04/201211/29/201211/26/201211/25/2012 WBC (K/UL) 0.1  <0.1  0.1  0.4  HGB (g/dL) 8.8  7.4  9.6  8.1  9.4  10.4  PLT (K/UL) 11  19  33  19  116  162 NEUTS (%) 0  0  0  7  1  60 LYMPHS (%) 2  100  --- 2  36 Mg (mg/dL) 1.7 1.4  1.5  ALP (u/L) 41  45  50  69  64  67  GGT (u/L) 93  110  154  160  179  Albumin (gm/dL) 2.4  2.7  2.8  3.0  Triglycerides (mg/dL) 305  435, 554  on 12/5 552  401  Zinc (mcg/mL) 0.44mcg/mL  on 12/1 Lab Trends: 11/25/12 - 12/10/12

46. 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

47. DateEN RegimenPN RegimenPO Intake 11/30/12DiscontinuedD19, AA5.3, IL0 =>2058kcal, 127gm protein, 4.9 GIR -- Maintenance Nothing 12/4/12 Coromega: 15gm lipid DiscontinuedMaintenance TPN D19, AA5.3, IL0 100% of needs -Poor -Some cheese puffs and Gatorade 12/7/12DiscontinuedMaintenance TPN D19, AA5.3, IL0 100% of needs -Poor -Slushies, Gatorade 12/11/12Peptamen Jr. PreBio 3cc/hrMaintenance TPN D19, AA5.3, IL0 100% of needs -Minimal intake 12/12/12Increased to 5cc/hrD17, AA1.8gm/kg, IL0 => ~90% of needs -Minimal intake 12/18/12Increased to 10cc/hrD17, AA1.8gm/kg, IL0 => ~90% of needs -Some cheese curls, crackers, and gatorade 12/20/1210cc/hrD17, AA1.8gm/kg, IL0 => ~90% of needs -Trialing Boost supplements -Megace started 1/2/13DiscontinuedProviding 700-900kcal (~40% of needs) -Continue weaning -Dry cereal, bowtie pasta, soft pretzel, 24oz fluids -Appx 1,000kcal 1/6/13Discontinued900ml overnight => 664kcal, 36gm pro -- (~32% of needs) -Improving with appetite stimulant 1/7/13Discontinued 100% of needs from PO intake

48. 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

49. 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

50. A very special Thank You to Michell Fullmer, 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!

51. Questions?

52. References Survival Rates for Childhood Leukemia. American Cancer Society Web site. http://www.cancer.org/cancer/leukemiainchildren/overviewguide/childhood-leukemia-overview- survival-rates. January 21, 2013. Accessed February 28, 2013. Be The Match: Parents and Families. National Marrow Donor Program Web site. http://marrow.org/Patient/Patients_and_Families.aspx. 2013. Accessed February 28, 2013. Cancer Facts and Figures 2012. American Cancer Society Web site. http://www.acco.org/LinkClick.aspx?fileticket=EcECXIUZyeA%3d&tabid=670. 2012. Accessed February 25, 2013. Childhood Leukemia. American Cancer Society Web site. http://www.cancer.org/acs/groups/cid/documents/webcontent/003095-pdf.pdf. January 18, 2013. Accessed January 20, 2013. Acute Lymphoblastic Leukemia. Leukemia and Lymphoma Society Web site. http://www.lls.org/content/nationalcontent/resourcecenter/freeeducationmaterials/leukemia/pdf/all. pdf. Accessed December 28, 2012. General Information About Childhood Acute Lymphoblastic Leukemia. National Cancer Institute Web site. http://www.cancer.gov/cancertopics/pdq/treatment/childALL/Patient /page1. Accessed January 3, 2013. Acute Lymphoblastic Leukemia. Boston Children’s Hospital Web site. http://www.childrenshospital.org/az/Site759/mainpageS759P0.html. Accessed December 28, 2012. Childhood Acute Lymphoblastic Leukemia. Children’s Hospital Cleveland Clinic Web site. http://my.clevelandclinic.org/childrens-hospital/health-info/diseases-conditions/cancer/hic-childhood- acute-lymphoblastic-leukemia.aspx. Accessed January 3, 2013. Selected Normal Pediatric Laboratory Values. Prentice Hall Web site. http://wps.prenhall.com/wps/media/objects/354/362846/London%20App.%20B.pdf. Accessed January 31, 2013. Sacks N, Wallace E, Desai S, et al. Oncology, Hematopoietic Transplant, and Survivorship. A.S.P.E.N. 2010: 349-373. Samour PQ, King K. Pediatric Nutrition. 4 th ed. Sudbury, Massachusetts: Jones & Bartlett Learning; 2012.