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Volume 23, Number 3, 2016ISSN 1545-9896

Oncology Nutrition

ConnectionTable of Contents

• Message from the Chair: Kelay Trentham, MS, RDN, CSO page 1

• Breastfeeding the Baby with Cancer page 2

• Pediatric Oncology Nutrition Corner: Seeing the Community Healing Garden at Mercy Cancer Center Take Root page 8

• CPE Article: Pediatric Nutrition Oncology Primer: Not just smaller adults! page 11

• Eat Right to Fight Cancer: Butternut Squash page 17

The successful completion of this workshop represents a stellar coordination between the ON DPG Executive Committee, under the leadership of Elaine Trujillo, MS, RDN, ON DPG Past Chair, and the Institute of Medicine’s (IOM) Ann Yaktine, PhD, RD, Director of the Food and Nutrition Board (FNB). As always, we have so many important projects going on for the upcoming year. The IOM workshop has spawned the next phase of ON DPG’s benchmarking work, starting with renaming the subcommittee “Nutrition Access for Cancer Health Outcomes,” a.k.a. “NACHO.” This reflects a new focus on activities which support and demonstrate the need for outpatient oncology nutrition care, including submission of nutrition supportive care recommendations for inclusion in National Comprehensive Cancer Network (NCCN) guidelines, and publishing clinical pathways for the nutrition management of various cancer diagnoses.

This summer, ON DPG committee members are beginning work on updating our Standards of Practice/Standards of Professional Performance (SOP/SOPP) document. The SOP/SOPP defines the scope of practice for oncology medical nutrition therapy, and the characteristics of competent, proficient and expert levels of practice. Our immediate past-Chair, Tricia Cox, RDN, CSO, LD, CNSC will lead a research feasibility project coordinated with the Commission on Dietetic Registration (CDR) and The Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) to evaluate the use of ANDHII for outcomes research in oncology. ON DPG also will have an active presence at FNCE© this year with our Oncology Spotlight Session “Plant-based or Low-carb: personalized approaches for obesity, diabetes and cancer”; a session highlighting results of the IOM workshop “Access to Nutrition Care in Outpatient Cancer Centers: Moving the Conversation

ON DPG Message from the ChairHello and happy summer to all! As your 2016-2017 ON DPG Chair, I am excited to welcome our new members and express appreciation to those who’ve renewed their membership this year. This past year saw the continued development and growth of our Pediatric Subunit, our well attended and third biennial Oncology Nutrition Symposium in Arizona, and our workshop with the Institute of Medicine: “Examining Access to Nutrition Care in Outpatient Cancer Centers.”

(Continued on next page)

2 ❙ Oncology Nutrition Connection ❙ Volume 23, Number 3, 2016

Oncology Nutrition ConnectionA publication of Oncology Nutrition (ON), a dietetic practice group of the Academy of Nutrition and Dietetics. ISSN 1545-9896.

Visit the ON DPG website at www.oncologynutrition.org

Editor: Suzanne Dixon, MPH, MS, RDN [email protected]

Associate Editor: Jodie Greear, MS, RD, LDN [email protected]

Renee Stubbins, PhD, RD, LD, CSO [email protected]

Oncology Nutrition Connection (ONC) ISSN 1545-9896, is the official newsletter of the Oncology Nutrition Dietetic Practice Group (ON DPG), a practice group of the Academy of Nutrition and Dietetics, and is published quarterly. All issues of ONC are distributed to members in electronic format only.

Articles published in ONC highlight specific diseases or areas of practice in oncology nutrition. Viewpoints and statements in each newsletter do not necessarily reflect the policies and/or positions of the Academy of Nutrition and Dietetics or ON DPG.

Oncology Nutrition Connection is indexed in the Cumulative Index to Nursing and Allied Health Literature. For inquiries regarding copyright, single-issue sales and past issues, contact the editor. Individuals interested in submitting a manuscript to ONC should contact the editor or check the ON website for author guidelines. Individuals who are ineligible for membership in the Academy of Nutrition and Dietetics can order yearly subscriptions to ONC for $35.00 (domestic fee) and $40.00 (international fee), payable to the Academy of Nutrition and Dietetics/ON DPG. Institutions can subscribe to ONC for $50.00 (domestic yearly fee) and $65.00 (international yearly fee). ON DPG members have access to archived back issues in pdf format. Non-members can order printed copies of back issues (contact editor for availability) at a cost of $10.00 each if mailed domestically and $20.00 each if mailed internationally. Send requests for subscriptions or back issues to the editor. All ON DPG member mailing address changes and email address changes should be sent to the Academy using the address change card in the Journal of the Academy of Nutrition and Dietetics or at eatright.org in the members-only section.

©2016. Oncology Nutrition Dietetic Practice Group. All rights reserved.

Many aspects of therapy may threaten the ability to breastfeed, and the oncology dietitian must be prepared to offer creative alternatives so that while treatment progresses, optimal breastfeeding is maintained. When breastfeeding as sole source of nutrition is jeopardized, there are ways to overcome problems and to provide guidance to the nursing mother so that breastfeeding can resume as soon as the baby’s condition improves. This article discusses the benefits of breastfeeding during an infant illness, the special considerations needed for infants with cancer, and emphasizes the importance of care for both members of the nursing couplet in order to assure successful breastfeeding is supported and preserved. The oncology dietitian must serve as an advocate for the breastfeeding dyad during therapy for a baby with a cancer diagnosis.

The news of a baby’s cancer diagnosis can trigger many feelings for the breastfeeding mother. Shock and denial are often the first emotions that any mother may feel, followed by worry and even depression. The breastfeeding mom may feel guilt that somehow her milk has caused this illness in her nursing infant. She first needs reassurance that breast milk is certainly the best nutrition she can provide for her child, and in fact, her milk may have prevented, and may continue to prevent other infections in her baby which could complicate the illness and its treatment. Further, studies have suggested that compared with formula-fed infants, infants who have been exclusively breastfed for at least 4 months experience decreased incidence of acute lymphoblastic leukemia, Hodgkin’s disease, and neuroblastoma. A meta-analysis of 18 studies indicated that compared with no or shorter breastfeeding, any breastfeeding for

Breastfeeding the Baby with CancerBy Ginger Carney, MPH, RDN, IBCLC, RLC

Introduction Meeting the nutrition needs of infants undergoing cancer therapy is challenging, but working with this population can be very rewarding for the oncology dietitian. Because exclusive breastfeeding is accepted as optimal nutrition for the first 6 months of life and throughout at least the first year of life with the addition of age-appropriate foods, the dietitian must support both mother and child to assure that the breastfeeding relationship is preserved, whenever possible. Successful breastfeeding allows superior nutrition for the infant, secures the vital mother-baby bond during early life, and provides comfort while the baby receives cancer therapy.

Forward”; and our Member Appreciation Breakfast featuring Dr. Walter Willett speaking about nutrition for cancer prevention and survival. We will continue to offer CEUs via our quarterly webinars and our newsletters, to add and update nutrition education content on our website, and to promote the CSO credential and ON DPG via our social media outlets. It’s going to be a busy year and we are always looking

for volunteers. If any of the above goings-on spark your interest in volunteering with ON DPG, please CONNECT with us! We’d love to hear from you!

Warm regards,

Kelay Trentham, MS, RDN, CSOChair, Oncology Nutrition Dietetic Practice Group

Oncology Nutrition Connection ❙ Volume 23, Number 3, 2016 ❙ 3


6 months or longer was associated with a 19% lower risk for childhood leukemia (1). A separate meta-analysis of 15 studies indicated that compared with never breastfed infants, those who were ever breastfed had an 11% lower risk for childhood leukemia, although the definition of never breastfed differed between studies, making results challenging to interpret. The authors concluded that 14-19% of all childhood leukemia cases may be prevented by breastfeeding for 6 months or more (2).

The research is promising, however, the reality is that we are still faced with infants who present with malignancies during a time when the bonding process between mother and child is of utmost importance, and despite needed therapy, must be protected. An illness in the child can disrupt many aspects of family life. Mothers who experience this situation may feel breastfeeding is the only normal activity they can share with their infant. In many cases, this special relationship between the mother and her baby is threatened. This is a serious concern because breastfeeding is much more than nutrition—it also provides comfort and love for both mother and child. Members of the healthcare team, including the oncology dietitian, can help families through this difficult time by providing both practical and emotional support and encouragement to establish or maintain lactation, facilitate direct breastfeeding when possible, and prevent unnecessary weaning.

Benefits of breastfeeding for the infant with cancerIn addition to respecting the mother-baby bond, there are other reasons for supporting and preserving breastfeeding while an infant is undergoing cancer therapy. Breastfeeding may help protect the infant from other illnesses. Since young infants are prone to infections, breast milk is essential to provide the antibodies and other antimicrobial factors that offer protection against many common illnesses. Breastfeeding is well documented to protect against gastrointestinal (GI), upper and lower respiratory system, and urinary tract infections (3,4). Compared with bottle-fed

infants, breastfed infants have significantly reduced risk of otitis media (5,6), and the longer the breastfeeding, the more prolonged the protection (3). For an infant in cancer therapy, contracting these infections may complicate the course of care.

The nutritional benefits of mother’s milk for her infant cannot be matched by a breast milk substitute. The perfect blend of macronutrients, vitamins, minerals, and water in breast milk supports a baby’s nutritional needs exclusively for the first 6 months and beyond, when combined with age-appropriate, and properly introduced solid foods. The maximum bioavailability of essential nutrients in human milk means that digestion and absorption are highly efficient. Human milk is species specific, and provides essential nutrients in the optimal combination for a human baby. Breast milk also contains hormones, growth factors, and beneficial microbes, oligosaccharides, lactoferrin, and lysozymes, which support robust microbiome and immune system development (7). When the baby consumes mother’s milk, the infant’s gut is colonized with microbes which support an intact mucosal barrier; this in turn provides protection against antigen invasion through the intestinal wall. Minimizing antigen exposures via the gastrointestinal tract can ward off immune response to antigens in the environment, and may minimize exposure to antigens associated with later development of food allergies (7). The mother’s mature immune system is active in providing specific protection to the antigens detected in her (and her baby’s) environment. The mother’s gut-associated B-cells are activated and produce secretory antibodies in response to antigens detected (7). These are then transferred to the baby during breastfeeding. This system also works in reverse. The baby will transfer antigens from its environment to the mammary glands, where the mother again can produce specific antibodies that will be transferred back to the baby during breastfeeding. In this way, the baby will enjoy additional protection from environmental pathogen exposure independent of the mother’s pathogen exposures (7).

A maternal benefit to continued breastfeeding during infant illness is a boost to self-esteem by providing total nutrition to her new baby. Breastfeeding empowers a woman to do something for her infant that no one else can do. Being able to hold and nurture a baby at the breast, and to provide total nutrition from her own body is a powerful experience for a mother. This helps create the strong bond of interdependence between the nursing couplet, as well. This bond is important for creating trust and love between mother and infant, and provides a solid foundation for the child’s development. A lactating mother releases the hormones oxytocin and prolactin, which may provide a sense of calm and contentment. These “natural anxiety-relieving substances” can be extremely beneficial to the mother in a busy, chaotic hospital or clinic environment.

ChallengesThe breastfeeding mother-baby pair should be assured that every effort will be made to preserve breastfeeding after a cancer diagnosis. At diagnosis, the dietitian should complete a thorough assessment to elucidate the existing breastfeeding relationship. A sample of an admission screen is outlined in Box 1.

For the infant, cancer therapy may cause poor appetite, nausea/vomiting, or infection with fever, malaise and a general disinterest in feeding. Mucositis secondary to chemotherapy, or thrush as a side effect of multiple or prolonged antibiotic therapy, will cause discomfort and pain in the baby’s mouth. This may compromise effective breastfeeding. Nonetheless, because breastfeeding is more than simply provision of nutrition for the nursing infant, the baby may want to go to the breast simply for comfort. Although these “non-nutritive” feedings should be supported, ongoing assessment of the baby’s weight is warranted; intake may be poor during these times. The Registered Dietitian Nutritionist (RDN) should observe a breastfeeding session to assess the baby’s effectiveness at the breast, and to determine if milk transfer is occurring. Milk transfer is crucial to assure


that adequate nutrition is being obtained. This can be done by watching and listening for suck/swallows and through the use of test weights. Test weights are taken before and after a nursing session (weigh in same clothing/diaper) to measure the exact quantity a baby ingests at the breast (1 gram weight = 1 cc milk). This allows an assessment of feeding efficacy with minimal disruption of breastfeeding to request milk expression and bottle feeding.

The infant must obtain adequate fluids and calories to support ongoing growth and development. When the expected weight gain does not occur, or the baby loses weight, RDN intervention is necessary. Failure to meet the infant’s nutrition needs may result from poor intake, a low maternal milk supply, or both. The RDN should work with an International Board Certified Lactation Consultant (IBCLC) to address the root cause of failure to obtain adequate nutrition. The goal is to have breastfeeding continue, with nutritional support from other sources as necessary. The information in Table 1 can be used to assist in determining the reasons for inadequate breast milk intake by the infant, and provide guidance for identifying solutions to feeding issues. Box 2 identifies breastfeeding problems related to latching onto the breast, which can lead to inadequate milk intake for the infant as well.

Hectic schedules for clinic visits, medical procedures and hospitalizations, long periods of time when the baby is away from the mother, or procedures for which the baby is held NPO may lead to breastfeeding interruptions, necessitating increased support for the lactating mother for continued success. A baby who has to be held NPO for a period of time may be distressed and may be better comforted by someone other than mother so that the desire to breastfeed is reduced. A hungry breastfed infant can smell and sense that mother is near and become increasingly agitated if not allowed to be put to the breast. After surgery or other medical interventions the baby may not be able or desire to nurse effectively, which may increase the mother’s distress and discomfort. In these situations, the RD should initiate support for milk expression (e.g., use of a breast pump). It is important that the mother has the education and equipment needed to maintain her milk supply. Hospital grade breast pumps are effective for stimulating a letdown for the mother; she can maintain her milk supply and collect expressed milk for later bottle or enteral feedings. Access to a refrigerator is essential for safe milk storage. During hospitalization or after a medical procedure, if the infant has an intravenous (IV) line or other medical devices attached to his body,

Box 1. Initial Screen for the Breastfed Patient

If baby is ≤ 6 months, is baby exclusively breastfed?

• If not, what else does baby take?

• Does baby take bottles readily? From anyone?

• What other feeding devices are used?

If baby is ≥ 6 months, does baby take solid food?

• If so, when, what, & how much?

What is baby’s normal feeding routine?

• How often does baby nurse?

• How long does baby nurse at a feeding?

• Does baby only take feedings at breast?

• Is expressed breast milk used? How much/how often?

Does mother express milk on a regular basis?

• Does she have her own breast pump?

Does mother have immediate concerns or supply/equipment needs?

• Consult IBCLC (International Board Certified Lactation Consultant)

St. Jude Children’s Hospital, Memphis, TN

Table 1. Inadequate Nutritional Intake for the Breastfed Infant

Maternal Causes Infant Causes

Poor letdown Poor production High energy requirement Low net intake Poor intake

Stress, anxiety Retained placental fragment Central nervous Nausea/Vomiting/ Poor latch (immediate postpartum) system defect Diarrhea (see Box 2)

Certain drugs Hyperthyroidism Congenital heart disease Malabsorption Content/sleepy

Hypertension Unnecessary supplementation Small for gestational age Infection/illness Infrequent feeding

Cigarette smoking Excessive antihistamine use Congenital defects Craniofacial (mouth/face) abnormalities

Sore nipples Insufficient development of Ineffective emptying alveolar tissue of breasts

Engorgement Excessive alcohol intake Cigarette smoking Illness

Past breast surgery Poor diet Inadequate emptying of breasts Pregnancy Past breast surgery

Adapted with permission from Krause’s Food, Nutrition, & Diet Therapy, 14th Edition (in press)


assistance should be provided to the mother to ensure both mother and baby are in a comfortable position for breastfeeding. The dietitian should solicit assistance from the IBCLC who can play an instrumental role in these situations.

The provision of breast milk for nearly all infants is the gold standard for nutrition, and should be maintained if at all possible, at least throughout the baby’s first year of life (8). A pediatric unit is best equipped to support breastfeeding with a supportive environment in place. Box 3 provides recommendations for a breastfeeding-friendly pediatric unit.

Interventions for infant weight lossAn infant undergoing cancer therapy is at risk for weight loss, and the dietitian must anticipate ways to mitigate this so the baby does not become malnourished and fail to thrive. An infant’s first year is normally a time of rapid weight gain and brain growth. Nutrition is of utmost importance during this time and every effort should be made to see that this growth and development is not compromised. If adequate nutrition to support growth and development is not provided, the baby may experience permanent stunting and cognitive deficits despite surviving cancer.

A proactive nutritional care plan may include storing extra breast milk for use if the baby is unable or unwilling to nurse effectively during treatment. Expressing milk in between feedings or just a few times each day when a baby is feeling and nursing well could help to establish an overflow supply for later use, and also provide extra stimulation for the mother who may be stressed or exhausted from her

baby’s illness. This will help her to maintain or increase her milk supply as well. When using a breast pump, it is of extreme importance for the mother to use clean technique to collect her milk. Scrupulous hand washing, cleaning pump parts after every pumping session, and sterilizing the pump parts at least once a day to prevent bacterial contamination of milk is particularly important when expressing milk for an immunocompromised infant. Excess milk must be refrigerated, or if storage time is expected to be longer than two days, frozen.

If there is a need for expressed milk, this may be given via bottle, oral syringe, cup, or nasogastric tube for extra nutrition. Information on cup feeding infants is readily available from reputable online resources (9). These feeding methods may be useful when mucositis or thrush is present in the baby’s mouth. If the baby will not accept other methods of feeding, a mother may employ a supplemental device worn at the breast so that the baby is supplemented while latched. Figure 1 illustrates this device in use during a breastfeeding session. If concentrated calories are desired, hindmilk can be separated out from the expressed milk, if the mother has a copious supply (see Box 4). Hindmilk is the breast milk expressed toward the end of the feeding, may be higher in fat than foremilk, and may yield up to 30-35 kcals/ounce.

If hindmilk is not possible or available, whole breast milk can be fortified with concentrated formula or a modular component, depending on the nutritional needs of the baby. With older infants, fortified milk or the use of a supplemental feeding device can present challenges. Older infants have a keener sense of the world around them and are familiar with the act of breastfeeding; they may reject the supplemental device since they are used to nursing without it, or recognize the unfamiliar taste of something other than their mother’s milk. If the baby’s nutrition


Box 2. Signs of Poor Latch

• Maternal pain

• Trauma to breast or nipple tissue

• Frequent moving of infant head

• Indentation of infant’s cheeks

• Infant lips not flanged

• Poor infant weight gain

Breastfeeding and Human Lactation, 5th Ed., 2016

Box 3. Characteristics of a Breastfeeding- Friendly Pediatric Unit

• Written breastfeeding policies in place

• Staff trained in skilled breastfeeding assessment and breastfeeding intervention when needed

• Provides parents with written and verbal information about the benefits of breastfeeding and breast milk

• Facilitates unrestricted breastfeeding

• Facilitates milk expression by mothers who want to provide milk for infants who are unable to breastfeed; the following are accessible: breast pump and privacy for pumping, storage place for expressed milk, referral to lactation services and pump rental sources if needed

• Provides breastfed children only age-appropriate or medically indicated supplementation of food or drink

• Uses alternative feeding methods most conducive to successful breastfeeding and appropriate weight gain

• Provides 24-hour rooming-in of parents and their children

• Provides meals and snacks for the breastfeeding mother

• Plans medication schedule and procedures to avoid interfering with the breastfeeding relationship

• Provides information about breastfeeding support available in the hospital and the community

• Assesses compliance with policies through quality assurance activities and research

Adapted from Breastfeeding and Human Lactation, 5th Edition

Figure 1.

apted from Breastfeeding and Human Lactation, 5th Editi

Medela© Supplemental Nursing System™ Used with permission


needs must be supplemented by any means, the mother should be encouraged to provide frequent, infant full-body skin-to-skin contact against the mothers chest, between the breasts. The baby should be put to the breast ad lib, as well, so the baby can feel close, and the mother can maintain her milk supply.

A mother may show disappointment and defeat if she is not able to completely sustain her infant nutritionally, even when extra pumping is allowing her to provide extra expressed milk for supplementation. She may refuse artificial milk for her baby, and/or a breastfed baby may refuse anything but human milk because of taste preference. In this situation, one option is the utilization of donor human milk. Despite the cost and potential inconvenience, donor milk is recommended for infants who do not have their own mother’s milk available (10). An added advantage is that many banks regulated by the Human Milk Banking Association of North America (www.hmbana.org) can provide a higher calorie milk if requested. In addition, feeding donor human milk sometimes allows the family to relax knowing that the baby is still receiving the next best thing to the mother’s milk. If the family asks about or requests donor milk, they should be given information about securing donor milk for their infant, and the RDN should educate the family on obtaining milk only from a HMBANA-regulated milk bank. This is to ensure the milk is from a safe, well-screened supply, and will not expose the infant to bacteria, viruses or other pathogens. They should know beforehand if they will be charged

for this milk or if it is simply a matter of coordinating the pick up or delivery of the milk. If institutions are unable or unwilling to obtain donor milk when it is specifically requested by the parents, the family may choose to bring in other donor milk from a friend, relative, or from online sources. If the family is discouraged from doing this, the mother may simply use a label stating the milk is her own. This practice could be extremely dangerous to the infant’s health. As an example, if the mother is cytomegalovirus (CMV) positive, the healthcare team may advise the mother to refrain from breastfeeding when the infant is experiencing significant immunosuppression. If, on the other hand, the mother is bringing in outside donor milk, and the team is unaware of this, this important issue is not addressed properly. This may put the infant at risk for a potentially serious infection.

Support for the nursing motherTo properly support a breastfeeding infant, the dietitian also must support the mother; the interaction between the two can affect the quality and quantity of human milk, so minimizing the mother’s stress is important. If the baby is very young, the mother herself still may be gaining strength from her recent childbirth experience. She may need extra rest and nutrition to help her return to her pre-pregnancy health status. The IBCLC should work closely with the mother to ensure she has needed breastfeeding supplies. In addition to her physical needs, the mother of the sick baby will need plenty of emotional support. The family may include older children, and spending quality time with them can be a source of comfort and normalcy for the mother, and help to maintain a healthy state of mind. Without this, her milk supply will suffer. In summary, because the nutrition of the baby depends on a good maternal milk supply, the dietitian should assist in assuring that the lactating mother’s needs are met.

Maternal medicationsIf a breastfeeding mother is taking prescription or over-the-counter medication, she should discuss with the pharmacist that her baby is undergoing

cancer treatment. A compatible drug can be selected by the provider to avoid potentially dangerous drug-drug interactions. She should inform the baby’s care team about what medications she is taking as well. It is generally accepted that all medications transfer into human milk to some degree, although concentrations in milk tend to be quite low. Ingested breast milk, must travel through the infant’s GI tract prior to absorption. Some drugs are poorly stable in the environment due to the proteolytic enzymes and acids in the infant’s stomach. Other drugs are poorly absorbed by the infant’s GI tract or are captured by the liver and never enter the infant’s blood stream. Additionally, many drugs, including vancomycin, cephalosporin antibiotics, and large protein drugs (heparin), are so poorly absorbed from breast milk that it is unlikely the infant will be exposed to significant quantities (11). Despite this, caution must still be used, because the action of a drug the mother is taking may act in the infant’s GI tract and cause diarrhea, constipation, or other problems.

Medications such as anticonvulsants, antidepressants, and antipsychotics frequently penetrate milk in higher—but not necessarily “high”—concentrations due to their physiochemistry . If a mother has been prescribed any of these medications, the baby should be monitored closely for side effects, such as sedation or other neuroleptic effects (9). It is always advisable to use caution when considering the effect a maternal medication has on a sick infant. Another consideration is the potential outcome when the mother’s milk is faltering because of stress, worry, or lack of effective emptying of milk from her breasts. In these cases, the infant will likely be exposed to much lower concentrations and total quantity of the mother’s medications.

Mothers should be encouraged to avoid using unnecessary over-the counter medications, herbal supplements, high dose vitamins, and other dietary supplements, because these substances may complicate cancer therapy for the infant. If the mother feels she needs any of these substances, she should consult with her physician and

Box 4. Collecting hindmilk (calorically dense human milk)

• Begin pumping with the breast pump. About two minutes after the milk starts flowing steadily, turn the pump off, pour this milk into a separate container and label it “foremilk.” This should equal about one-third of the usual amount expressed.

• Continue pumping until milk flow stops, then for two more minutes. Label these bottles “hindmilk.”

Children’s Hospital of Philadelphia

http://www.hmbana.org




lactation consultant for guidance. Fortunately, it is rare that breastfeeding needs to be discontinued because of maternal medications. This should never occur due to a clinician’s anxiety or ignorance about how a medication may affect the infant. The risks of formula feeding are significant and the importance of human milk and breastfeeding should be a priority in the care of all sick infants. If a maternal medication may lead to safety issues for the breastfed infant in cancer treatment, the medical team should conduct further research into the pharmacology of the drug and the physiology of lactation relative to that medication (10). A PharmD experienced in maternal-fetal medicine is the ideal resource for assistance regarding the suitability of maternal medications during lactation.

Infant lossIf a baby does not survive, this will be devastating to the entire family, but a breastfeeding mother also will feel the physical effects because of the physical nature of lactation. Losing an infant means a mother also loses her identity of being a mother, especially if there are no other children in the family. The mother should be given options about how to cope with this loss. Providing a mother the choice about how to handle her lactation often empowers the mother and allows her to take control when other things are out of control. Some mothers may want to suppress lactation right away because it is a reminder of their loss. Other may choose to continue lactation to find some meaning in the experience of their baby’s death and as a means of comforting themselves (11). Mothers may feel that by prolonging milk expression and production they can continue to identify as a mother. Many times when mothers have expressed their milk for long periods, this serves as a comforting ritual, and can be used as a tool for grieving their loss (12).

If the mother chooses to discontinue lactation, she should receive guidance from the IBCLC on ways to do this comfortably, without engorgement, plugged ducts, or mastitis. For the baby who received donor milk as part of their nutrition therapy, a

mother may feel she can “pay back” the milk bank so that another baby can benefit from her milk. In this case, the mother may choose to continue her lactation and she will need to continue to regularly express her milk. This may serve as a source of comfort and allow something positive to come out of a tragedy. If the mother is considering this, she should be provided with information on milk banks regulated by the Human Milk Banking Association of North America-HMBANA (www.hmbana.org) to arrange for donation (see Table 2). A mother who donates to a HMBANA milk bank will be required to participate in a medical and lifestyle history review and complete a medical release form signed by her and the baby’s physician. She will need to agree to blood screening for HIV, HTLV, Hepatitis B & C, and syphilis. If the mother does not want to go through these steps, she can donate her stored milk to research. Any stored milk left behind at the hospital can be poured in a sink, as it is not considered a biological hazard. The dietitian and the IBCLC can work together to finalize and execute plans for milk donation or disposal. Finally,

families should be referred to social services and bereavement groups in their community for ongoing emotional support.

Implications, conclusions, and applications for oncology dietitiansThe oncology dietitian has a unique role in the care of a baby with cancer. With the knowledge of nutritional care during cancer therapy, along with the understanding of the importance of breastfeeding to an infant and mother, the dietitian plays an instrumental role in preserving the important relationship between mother and child. Many things must be considered in this special situation, and the oncology dietitian should take responsibility for helping to coordinate the needs of both mother and baby with the prescribed nutritional therapy. The RDN should be the advocate with the rest of the healthcare team for continued breastfeeding. When a baby who is being breastfed begins cancer treatment, the RDN must assure the mother that breastfeeding will provide the best nutrition for her baby. Support should be

Table 2. Current HMBANA Milk Banks in the U.S.

Mother’s Milk Bank of Alabama

Mothers’ Milk Bank

Mothers’ Milk Bank

Mothers’ Milk Bank of Florida

Mothers’ Milk Bank of the Western Great Lakes

The Milk Bank

Mother’s Milk Bank of Iowa

Bronson Mothers’ Milk Bank

Mothers’ Milk Bank of Mississippi

Heart of America Mothers’ Milk Bank

Mothers’ Milk Bank of Montana

Mothers’ Milk Bank Northeast

WakeMed Mothers Milk Bank and Lactation Center

OhioHealth Mothers’ Milk Bank

Oklahoma Mother’s Milk Bank, Inc.

Northwest Mothers’ Milk Bank

CHOP Mothers’ Milk Bank

Mothers’ Milk Bank of South Carolina

Mothers’ Milk Bank at Austin

Mother’s Milk Bank of North Texas

The King’s Daughters Milk Bank

Birmingham, AL

San Jose, CA

Arvada, CO

Orlando, FL

Grove Village, IL

Indianapolis, IN

Coralville, IA

Kalamazoo, MI

Flowood, MS

Kansas City, MO

Missoula, MT

Newton Upper Falls, MA

Raleigh, NC

Columbus, OH

Oklahoma City, OK

Portland, OR

Philadelphia, PA

Charleston, SC

Austin, TX

Fort Worth, TX

Norfolk, VA




offered so she can continue to breastfeed, and if necessary, help coordinate provision of supplies for milk pumping and safe storage for later use.

The dietitian and the nursing mother should consult with an IBCLC to provide clinical lactation care, and the maternal-fetal PharmD who can provide advice and guidance on maternal medications. In cases of infant loss, the oncology dietitian will need to assist the nursing mother in making decisions about what to do with any expressed breast milk that may be stored in the institution or clinic. There are options for donation to a milk bank, if desired. Referral to an IBCLC for management of lactation at this stage is appropriate.

References 1. Kwan ML, Buttler PA, Abrams B, et al:

Breastfeeding and the risk of childhood leukemia: a meta-analysis. Public Health Rep. 2014;119:521–535.

2. Amitay EL, Keinan-Boker L. Breastfeeding and childhood leukemia Incidence: A Meta-analysis and Systematic Review. JAMA Pediatr. 2015;169(6):e151025. doi: 10.1001/jamapediatrics.

3. Ip S, Chung M, Raman G, et al: Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: Agency for Healthcare Research and Quality; 2007. AHRQ publication no. 07-E007.

4. Piscaine A, Graziano L, Zona G, et al. Breastfeeding and acute lower respiratory infection. Acta Paediatr. 1994;83:714–718.

5. Alho OP, Koivu M, Sorri M, et al. Risk factors for recurrent acute otitis media and respiratory infection in infancy. Pediatr Otorhinolaryngol. 1990;19:151–161.

6. Aniansson G, Alm B, Andersson B, et al. A prospective cohort study on breastfeeding and otitis media in Swedish infants. Pediatr Infect Dis J. 1994;13:183–188.

7. Hurd L. Optimizing the microbiome and immune system with maternal diet in pregnancy and lactation may prevent food allergies in infants. ICAN. 2015;7:212–216.

8. Section on Breastfeeding Medicine. Breastfeeding and the use of human milk. Pediatrics 2012; 129(3):e827–841.

9. Australian Breastfeeding Association. Cup-feeding. Accessed July 18, 2016: https://www.breastfeeding.asn.au/bfinfo/cup-feeding.

10. Hale T, Rowe, HE. Medications & Mothers’ Milk. Plano, TX: Hale Publishing, L.P; 2014:7–12.

11. Cole M. Lactation after perinatal, neonatal, or infant loss. Clin Lactation. 2012;3:94–100.

12. Welborn J. Lactation support for the bereaved mother—a toolkit: Information for health care providers. Human Milk Banking Association of North America; 2012.

Oncology Nutrition Corner: Seeing the Community Healing Garden at Mercy Cancer Center Take RootBy Crystal Tallman, MFCS, RD, CSO, LD and Barb Wisnieski, RD, LD

This month, as part of our Pediatric Oncology special issue, our Peds Corner is featuring an article on a topic of broad interest to all of our readers. We hope you enjoy our entire pediatric-focused issue, and this special column about an inspiring healing garden project in an Iowa cancer center.

The warm sun on your back, the earthy smell of freshly tilled soil under your fingertips, and brightly colored and scented flowers. Spring and gardening go hand in hand—a true pleasure for the senses. Gardening goes much further than simply appealing to the senses; it is beneficial to health! This message was the platform we used to launch the Community Healing Garden at Mercy Cancer Center in 2013.

Our community cancer center spans two campuses; our main campus is in downtown Des Moines, Iowa, and our satellite facility is in the suburb of Clive, a fifteen minute drive from our downtown campus. The Clive Cancer Center has an open grassy lawn directly south of the building, which we envisioned as being the perfect space for a garden. As dietitians, we thought having a garden on-site would help us to “walk the walk” with our patients and further our message of the benefits of a plant-based diet and its cancer protective properties.

Our medical center uses a local landscaping company for lawn maintenance at its facilities, so we were connected with them to partner with us on this project. Within that company, we were put in touch with one of the landscape architects and a project manager who both encouraged us to dream big. They translated our garden wish list into a visual schematic that was much better than we ever could have created. This beautiful plan came with a jaw-dropping price tag of nearly $150,000, and we immediately felt defeated. For two dietitians who had no experience raising

money, we were overwhelmed with the idea of fundraising this amount of money!

We began applying for small grant opportunities and were connected with our medical center’s Foundation. They brainstormed potential donors and fundraising opportunities that would raise awareness of our garden. These efforts paid off, and our garden officially sprung to life in October 2013 after we received a $5,000 grant from the Mercy Auxiliary. We used this

The future site of our Garden

Build Day, October 2013

http://www.ncbi.nlm.nih.gov/pubmed/26030516





“seed money” to buy cedar lumber to build raised garden beds and soil.

On a beautiful, sunny October day that year, we hosted a “Garden Build Day” and were fortunate to have forty volunteers show up to help our garden take root. Volunteers that day included cancer center staff, patients and their family members, and people affiliated with our partnering landscaping company. Volunteers built eight raised beds to a height appropriate for patients in wheelchairs, put four beds into place and filled them with soil, and planted mums and bulbs. We initially filled only four of the eight beds because our garden space is on a slope; the land had to be graded before placing and utilizing the other four beds. Everyone had a wonderful time at our Build Day, with many asking to be put on the list of people to contact for similar future events.

In 2014, our main goals were to continue to apply for grants and to plant our garden for the year. We had a great start to the year after winning a $5,000 grant from a new grant opportunity entitled “Gardens to Hospitals.” Among other things, this provided money to buy seeds, starter plants, and a coupler for the irrigation system, to allow easier garden watering.

We opted to plant easy-to-grow, edible favorites that year, such as lettuces, tomatoes, carrots, and green beans, as well as some less commonly eaten produce items like dark greens, Brussels sprouts, and a variety of herbs. The two of us have done the majority of the produce harvesting ourselves, but we will increase efforts to get patients and their family members involved as our garden grows in size. All of our produce is organically grown and distributed free of charge to our patients at both clinics. Alongside the produce in our clinics, we provide recipes and tips on how to prepare these foods to encourage patients to try items they may not have tried before. We estimated we distributed over 400 bags of produce in each of the first two years of our garden.

The start to our Garden, October 2013

Our first harvest, June 2014

We had some exciting developments over the past year. We have gotten a few additional small grants through companies supportive of the project, and our Foundation has offered to cover the rest of the bill, with the intention of future fundraising going back to paying off this

loan. Additionally, our project manager from the landscaping company has been a significant advocate for our project, and he has managed to get tens of thousands of dollars of donated labor and materials from local companies to help us cut down on our costs.


Our healing garden, May 2016

What started off as a four raised bed garden in 2013 now has eight raised beds, a central water feature—donated by one of our radiation oncologists in memory of one of his patients/friends, six in-ground garden beds, a paved walkway, tables and chairs, and three large metal panels with the words “faith,” “hope,” and “love” on them.

We had a garden grand opening in late May 2016 and planted all of this year’s crops at the event. All of our raised beds have vegetables (Brussels sprouts, green beans, carrots, parsnips, cherry tomatoes, lettuce, spinach, kale, broccoli, cauliflower) and herbs (rosemary, cilantro, parsley, oregano, basil) in them, and we have planted raspberry bushes, trellised cucumbers and zucchini, asparagus, and flowers in the in-ground beds. Getting to this point has truly been a team effort, and one we couldn’t be prouder of. Our patients have given us very positive feedback, and we’re excited to be able to offer a healing space on our campus for our patients and their loved ones. While we’ve been fortunate to partner with people locally who have greatly supported our garden, we’re also truly grateful for the ON DPG, which has been a resource and connected us with others who have on-site gardens. If you are interested in starting a garden at your facility and have questions, please don’t hesitate to contact Barb Wisnieski ([email protected]) or Crystal Tallman ([email protected]) with any questions you may have.

IOM WORKSHOP REPORT Now Available!The report from the ON DPG IOM workshop is now available!

Download your free copy at:

http://www.nationalacademies.org/hmd/Reports/2016/Examining-Access-to-Nutrition-Care-in-Outpatient-Cancer-Centers-Proceedings-of-a-Workshop.aspx

mailto:[email protected]






Pediatric patients often present with different cancers than adults. Common pediatric cancer diagnoses include, but are not limited to, leukemia, medulloblastoma, neuroblastoma, Wilm’s tumor, Ewing’s and osteosarcomas, and other bone and soft tissue sarcomas, such as rhabdomyosarcoma (1). The treatment of these cancers is different in the pediatric population. Most adult cancer patients are administered chemotherapy in an outpatient infusion center and are only admitted to the hospital when complications arise. The pediatric cancer patient typically spends more time in the hospital because many chemotherapy protocols require frequent and long hospital admissions due to the consequences of treatment. The majority of children with cancer are treated as part of clinical trials. Ninety percent of these trials are affiliated with the Children’s Oncology Group (COG). COG is the world’s largest organization that performs clinical research to improve the care and treatment of children and adolescents with cancer (1). Research on nutrition is limited in this population and this article will attempt to provide evidence-based information whenever possible. In the areas for which there is no objective evidence at this time, the author’s experiences will be noted. In general, the provision of MNT in the pediatric population, including assessment and intervention,

should involve the patient, family, and caregivers. The caregiver(s) may include one or both parents, foster or adoptive parent(s) and grandparent(s) or other extended family. The RDN should be mindful of where and how to direct questions and information.

Assessment of Growth and AnthropometricsPediatric cancer patients can range in age from birth to 21 years, depending on age delineations for pediatric vs. adult patients at the treating facility. As in adults, screening for nutritional risk is the first step in determining the need for nutritional assessment and intervention. The Pediatric Subjective Global Assessment is one method of screening for nutritional need; although, nutrition screening may be institutionally based (2,3). There are many necessary components of nutrition assessment of the pediatric cancer population including, but not limited to, social dynamics, family beliefs regarding feeding, cultural food practices, financial limitations, anthropometrics, laboratory parameters, nutritional requirements, nutrient intake, and growth. Unlike adults who may have significant comorbidities prior to diagnosis, pediatric patients tend to be healthy until just prior to presentation. One exception is the higher prevalence of leukemia in children with Down’s syndrome

CPE Article: Pediatric Nutrition Oncology Primer: Not just smaller adults!By Michelle Fullmer, RD, LDN, CSP, CNSC and Corinna Schultz, MD, MSHP

Intro/background Childhood cancer is the leading cause of death for children past infancy in the United States (1). The role of the Registered Dietitian Nutritionist (RDN) in the care of the pediatric oncology population is to ensure nutritional needs are met and optimized. At times, an adult oncology RDN is asked to provide Medical Nutrition Therapy (MNT) to the pediatric cancer patient. This article is intended to provide basic information regarding the provision of MNT to the pediatric cancer patient, and to describe the particular challenges that arise when treating this population, in comparison with adults. The differences between treating the adult and pediatric patient will be highlighted.

(4). Even prior to diagnosis, a child with Down’s syndrome can present with cardiac issues and low oral tone, which can affect the types of foods consumed.

The nutrition assessment begins with a review of the medical record and growth chart. Accurate weights, heights, and head circumference (for the child under two) measurements are essential, though in the author’s experience can be difficult to obtain in younger children who may have trouble remaining still for measurement. Despite the challenge of obtaining accurate measurements, this is essential and the RDN should re-measure, as needed, to ensure this goal is met. The RDN should plot weight, length/height, and head circumference on the WHO growth chart for those under 2, and on the CDC growth chart for children aged 2 to 21 (5). For the patient with Down’s syndrome, data points should be plotted on the Down’s syndrome-specific growth chart (6). In the adult population, weight loss alone can be an indicator of malnutrition; in the pediatric patient weight change velocity rather than weight stability alone is a critical nutritional indicator. Utilization of a z-score can assist with the diagnosis and assessment of malnutrition at presentation and at subsequent visits. The z-score represents the standard deviation from the mean and is a more sensitive indicator than “weight-for-age” percentiles (7,8). Most computerized electronic medical records allow the z-score to be displayed on the growth chart or can be found on the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) website (http://www.cdc.gov/growthcharts/), as well as Pedi-tools.org. Changes in z-score are useful for assessing the patient for malnutrition and risk for obesity. Other indicators for malnutrition in the pediatric patient are weight gain velocity and mid-upper arm circumference. Expected weight gain velocities for age are found in Table 1 (9).

The RDN should measure mid-upper arm circumference (MUAC) in pediatric patients, as this has been shown to be a more sensitive indicator for diagnosing


malnutrition than weight-for-height parameters as discussed later (10). In addition, chemotherapy is often administered with a significant amount of intravenous fluid, which can result in misrepresentation of true weight loss or gain. The MUAC measurement is less likely to be affected by the patient’s fluid status, making it an especially useful marker of nutrition status in the pediatric oncology population (11). A combination of these measurements can be utilized to define severity of malnutrition in the pediatric population (Table 2) (7,8). Both in the pediatric and adult populations, a nutrition focused physical exam should be performed, and should include a review of muscle wasting, loss of subcutaneous fat, and severity of edema (12).

While malnutrition can be a significant concern, an upward trend on the BMI-for-age or weight-for-length growth charts are concerning as well. This is most common in children receiving chemotherapy regimens that rely on steroid therapy and cranial radiation (13). Overweight is defined as a BMI at or above the 95th percentile for children and teens (14). Obesity is not yet defined by z-score. Knowledge of the type of nutritional risk (obesity or malnutrition) most commonly associated with specific diagnoses can guide the RDN in providing the most appropriate therapy and food choices. The diagnoses which tend to be associated with a higher risk of malnutrition include Wilm’s tumor, rhabdomyosarcoma, neuroblastoma, high risk Ewing’s sarcoma,

relapsed leukemia, head and neck tumors, and tumors that require abdominal surgery, radiation, or stem cell transplant. The diagnoses associated with higher risk for excess adiposity are acute lymphoblastic leukemia (ALL) (especially Hispanic males under the age of 10), central nervous system tumors, lymphomas, and those undergoing brain surgery (15).

Diet and Feeding AssessmentAn integral next step of the assessment is a review of the patient’s diet and feeding history. The same questions that are asked of the adult patient would apply to the pediatric patient. Questions should be phrased to elicit vital information such as typical intake, current intake, who prepares food, food allergies, religious considerations, economic constraints with food, eating patterns throughout the day, food and taste aversions, foods a child may tend to overeat, whether family meal times are a regular component of the family’s habits, and barriers the parents feel they face in helping the child make appropriate and healthy food choices. It is important to note the feeding environment of the pediatric patient with questions that address seating position (high chair, caregiver’s lap, walking), location (table, living room, with television), tools (bottle, cup, utensils), as well as any other feeding behaviors or picky eating habits. This information is critical to understand the development of the child and challenges there may be with previous eating tendencies. Developmental stages,

Table 1. Adapted Expected Weight Velocity to Maintain Growth at 50th percentile (9)

Age Weight gain average (in grams)

0-3 months 23-39 grams per day




2-3 years 138-151 grams per month








Table 2. Recommendations for Defining Malnutrition (7,8) Reprinted with permission

Primary Indicator Mild Malnutrition Moderate Malnutrition Severe Malnutrition

Weight-for-height z score -1 to -1.9 z score -2 to -2.9 z score -3 or greater z score

BMI-for-age z score -1 to -1.9 z score -2 to -2.9 z score -3 or greater z score

Length/ height-for-age z score No data No data -3 or greater z score

Mid–upper arm circumference Greater than or equal to Greater than or equal to Greater than or equal -1 to -1.9 z score -2 to -2.9 z score to -3 z score

Weight gain velocity <75% of the norm for <50% of the norm for <25% of the norm for (less than 2 years of age) expected weight gain expected weight gain expected weight gain

Weight loss (2-20 years of age) 5% usual body weight 7.5 % usual body weight 10% of usual body weight

Deceleration in weight- Decline of 1 z score Decline of 2 z scores Decline of 3 z scores for-length z score

Inadequate nutrient intake 51% to 75% estimated 26% to 50% estimated <25% estimated energy/protein need energy/protein need energy/protein need


including feeding behaviors, change and evolve between the ages of birth to 21 years. In the author’s experience, diet history and nutritional adequacy of the diet need to be continually reviewed as eating behaviors often change during chemotherapy and prolonged hospitalizations, as well as with developmental stage.

Typically, questions and education would be directed at the caregiver from birth to approximately 8-10 years old. From ages 10-16 years, it is suggested questions and education be directed at both the caregiver and patient, as both often are involved in the decision-making process regarding food choices. From ages 16-21 years, the questions and education should be directed to the patient as they are in charge of their own health at that point.

Laboratory Assessment The oncologist and RDN monitor laboratory parameters, such as electrolytes, liver enzymes, pre-albumin, and albumin. Their relevance of these values typically is similar to adult patients (16). In reviewing labs for the pediatric patient, the RDN should ensure that the laboratory parameters reflect normal pediatric reference ranges for an accurate assessment. Vitamin D and calcium are micronutrients of particular concern in the pediatric population. Important benefits of achieving adequate vitamin D intakes for the pediatric oncology patient include improved bone growth, immune function, mood, and cognition (17). Ensuring adequate calcium intake can help optimize bone health and limit risk of osteopenia (17). Osteopenia is common in children who have completed therapy for ALL (39.5%) (18), and as with adults, is a concern in children receiving steroid therapy. Because of this, the RDN may consider checking 25-OH Vitamin D at diagnosis and throughout therapy. RDNs may want to consider checking vitamin D for all cancer diagnoses as well; these patients often spend more time indoors and in bed than their peers. At this point, there is no consensus on the best protocol to replete children presenting with deficient Vitamin D levels (18). At Alfred I. DuPont

Hospital for Children we utilize Stoss therapy, providing 50,000 international units of vitamin D weekly for 1 to 8 weeks (17,19). This preparation is available by prescription and, in the author’s experience, is covered by more insurance companies than over-the-counter supplements. This is helpful if purchasing vitamin D is a financial hardship for the family. Additionally, Stoss therapy allows for a weekly dosage, which may be given during clinic visits or hospital admissions; this increases likelihood of adherence to vitamin D repletion protocol, and is helpful for patients who are on multiple medications. Supplementation of calcium is indicated if intake does not meet the RDA/DRI. Table 3 provides the RDA/DRI needs by age (20). Calcium supplementation is not suggested until tumor lysis syndrome is no longer a risk, which is generally about 2 weeks after completion of induction chemotherapy, and/or as determined by the medical team.

Assessment of Energy Requirements Overall, nutrient needs are often increased due to high metabolic demand placed on the child due to cancer therapies, and the ongoing need for growth and development (21). It is estimated that macronutrient needs are 15-50% higher than prior to diagnosis for many children (3). Calculation of energy requirements should be based on Estimated Energy Requirements (EER) until one year of age, and based on the WHO calculation for those over one year of age (5). Calculation for basal energy needs and protein for children over age one are provided in Table 4, and are intended to be utilized as a general guideline for energy

requirements at diagnosis (3,22). Depending on weight status and severity of illness, an activity/injury factor of 1.2 (for the patient who presents with obesity at diagnosis) to 1.5 may be added (16). If nutrition support is based on these energy and protein requirements, it is imperative to continually review their impact on appropriate growth. This can be accomplished by a review of the growth chart or assessment of appropriate weight gain and growth.

Subjective areas to assess in the pediatric patient are alertness, playfulness, and lethargy. While decreased alertness and playfulness can have multiple etiologies, they also can reflect diminished nutritional intake in the author’s experience. Children may not be able to verbalize nausea as a reason for decreased intake, so observation is integral to the assessment.

Intervention, Diet, and Supportive CareNutrition interventions, including dietary manipulations, oral nutrition supplements, tube feeding, and TPN, should promote growth and development and maintain an appropriate relationship with food, as much as possible. An individual’s relationship with food is forming during childhood and adolescence. For those who have nausea and/or vomiting from chemotherapy, eating can become a source of stress and difficulty, especially if a parent or clinician attempts to force eating.

The provision of nutrition interventions in the pediatric population can be challenging due to multiple factors influencing the ability to intervene. In contrast to an adult patient, who is often responsible for his or her own nutritional status, there are typically multiple caregivers in the pediatric setting including immediate and extended family, baby sitters and nannies, and daycare or school providers. Legally, parents or guardians can make decisions for the child until age eighteen. For children from birth to school age, most choices and decisions are made solely by the caregiver. From elementary school age to high school,


Table 3. Recommended Dietary Allowances for Calcium by age (20)

Age RDA (in milligrams)

0-6 months 200

7-12 months 260

1-3 years 700

4-8 years 1000

9-18 years 1300

19-50 years 1000


child during mealtimes, whenever possible. Without this reminder, parents are often left to sit and literally “watch” their child eat instead of engaging in the activity with them. At times, the RDN may want to consider non-threatening food activities such as playing with food, tea parties, or even cooking, but without having to actually eat the food. This can remind children of the social and fun aspect of eating, as shown in Figure 1 above, in which I play with one of my patients making a gingerbread house. We made sour faces in response to tasting sour candies, which later encouraged him to try other foods. In the author’s experience, this investment of time with patients and their families gives positive reinforcement with eating and builds trust. This trust improves the likelihood that more invasive interventions, nutrition or otherwise, are more readily accepted by the patient, and therefore, more successful.

Between chemotherapy treatments, nutritional status should be maximized to offset intervals when oral intake is poor. This may be accomplished by providing the family with high calorie food suggestions or oral supplementation. In the author’s experience, there will be greater success with initiation of supplementation when introduced at home (after discharge), as often anything “medical” is refused by the child. Using milkshakes and smoothies can

decisions are generally shared between the child and caregiver. From high school to adulthood, the patient typically makes decisions with some influence by caregivers (23). Unlike adults, pediatric patients often lack the maturity to comprehend the necessity of nutritional interventions and therefore often easily reject them. Additionally, pediatric cancer treatment often results in one family member limiting their working hours or withdrawing from the work place to support and transport the child throughout the course of treatment. This can place an additional financial and time management burden on the family, which can influence food availability. Throughout treatment, the pediatric patient may have limited choices in many areas of care, including when to sleep, take medications, have vital signs taken, or have other medical testing completed. Oftentimes, eating or not eating is a way of trying to exhibit control over their circumstances, in the experience of the author.

Unlike adults, young children are less likely to communicate that they feel nauseated, have dysgeusia (altered tastes) or are experiencing early satiety. Young children often do not know how to describe these symptoms. Instead, they may present with decreased intake or weight loss but no complaints of nausea. Inquiry as to why the child is not eating is required. A trial of scheduled antiemetic medications in a preverbal child is sometimes indicated to determine if inadequate intake is a result of

untreated or undertreated nausea.

Pediatric patients with cancer often require prolonged hospitalizations, which can lead to taste fatigue with hospital food, and limited intake. It is not unusual for the patient to refuse a food item because it is presented in the hospital. This may result in parents relying on takeout food or foods brought from the family home. In this situation, the RDN’s role is to emphasize the importance of food safety with the use of restaurant foods and transporting foods, especially during times of neutropenia. Information on food safety during chemotherapy is readily available from reputable online resources (http://www.cancer.net/survivorship/healthy-living/food-safety-during-and-after-cancer-treatment). Additionally, review of food menus in advance may be beneficial if there is a need for special dietary restrictions.

While hospitalized, the pediatric patient’s normal schedule, including mealtimes, is disrupted. As stated previously, mealtimes can be stressful for a child if the parent focuses excessively on their eating, or lack of eating. When able, it is important that the child maintain structured mealtimes; children tend to thrive with structure. The RDN’s role is to remind parents and caregivers that mealtimes provide nutrition but are social encounters, as well. Because the social aspect of eating should be maintained, the parent should eat with the

Table 4. Energy Requirements by age (3,22)

Age Energy Equation for Basal Metabolic rate Protein Needs (W=weight in kilograms) (Grams per kilogram)

0-6 months Utilize EER 3

7-12 months Utilize EER 2.5-3

1 -3 years Male: 60.9 x W -54 1.5-2 Female: 61 x W -51

3-10 years Male: 22.7 x W +495 1.5-2 Female: 22.5 W +499

10-18 years Male: 17.5 x W +651 1.5-2 (age 10-13 years) Female: 12.2 x W + 746 1.5 (age 14-18 years)

18-20 years Male: 15.3 x W +679 1.5 Female: 14.7 x E +496

EER: Estimated Energy Requirements

Figure 1.

Reprinted with permission.


be helpful. Additionally, providing moments in which children can play with or cook food without pressure to eat can help them to regain interest in food.

If nutritional status and intake continue to falter, use of an appetite stimulant may be indicated. Typically, the three appetite stimulants utilized in the pediatric population are megestrol, dronabinol, and cyproheptadine. Megestrol and cyproheptadine have been studied and shown to promote weight gain in pediatric patients (16). Marinol has been shown to promote weight gain in adults, but is not proven to promote weight gain in pediatric populations (16).

Nutrition SupportIf appetite stimulants are not successful in maintaining adequate intake, enteral tube feedings should be considered. Parenteral nutrition should be limited to children without a functioning gastrointestinal tract (16). Enteral feedings may be seen by the child as a failure to please the parent or by the parent as a failure to feed their child, and can be a very emotional decision for a caregiver. Because of this, it is important to emphasize that maintaining nutrition during cancer treatment can be very difficult and utilizing enteral feedings is not a failure, but is often needed to support the patient during treatment. Also emphasizing the benefits of tube feeding, including better tolerance to treatment, energy to play, less stress to eat when appetite is poor, and prevention of malnutrition may aid the family in making this decision. Adolescents can be a particular challenge in the area of nutrition support, because they may refuse feeding tube placement. Additionally, a pediatric patient can impact the RDN’s ability to provide nutritional interventions by pulling out a nasogastric (NG) tube or refusing to consume oral nutrition supplements; due to their age, it may be more difficult to rationalize the need for feeding tube placement than it is with an adult patient. The RDN is an essential member of the medical team in the decision making of feeding tube placement, and can work with children and families

around attitudes regarding enteral feedings. Often a significant benefit of tube feeding for the pediatric patient is not needing to take most oral meds by mouth; most medication can be taken via the feeding tube instead. As the patient’s intake improves, it may be helpful to allow them more control over decreasing feedings, such as what hours the enteral feeds can be turned off. During this time, foods of any type are encouraged, including less healthy options. However, childhood is a time in which lifetime feeding behaviors are established; it is important to have ongoing discussions including the importance of healthy foods, especially if immune suppressed due to cancer treatments. It can be challenging for children and family to understand that during times of nutritional inadequacy, any food is a “good” food, but that after treatment, healthy eating should be the priority for long term well-being. The ongoing conversation can help clarify these issues, as can providing healthy alternatives and nutrition education during treatment.

For cancer therapies with a high risk of adiposity, healthy eating should be strongly encouraged from diagnosis. Family members may have difficulty restricting intake due to the child’s cancer diagnosis, which may require use of appetite-inducing steroids for treatment. Families often feel that if the child is eating well, then the child is doing well overall. Discussions should be based around healthy eating and healthy behaviors instead of weight. Discussions focused on weight alone can result in negative outcomes in the childhood/adolescent periods, including an unhealthy preoccupation with weight and poor body image. The RDN can assist by giving tips for how the family can support the patient during periods of intense hunger due to steroids, to minimize overeating. Such tips may include, keeping less healthy foods out of the household, keeping foods out of sight, encouraging all foods be consumed at the kitchen table, providing extra portions of vegetables, limiting sugar sweetened beverages, and staying hydrated with water, sparkling water, or other non-caloric options. Weight maintenance

and/or healthy eating are the goals in the overweight pediatric oncology patient.

For those at risk for malnutrition and those at risk for adiposity, food often becomes a focus for discussion and/or argument between the pediatric cancer patient and their caregivers. It is believed an unhealthy relationship with food can have long lasting, negative effects, though there are currently no definitive studies to date that support this. The RDN’s role should be one of support and assistance to the family, and to be mindful of the need for good nutrition and a positive, proactive mindset regarding eating throughout cancer treatment.

Survivorship/Late EffectsAs of January 1, 2010, there were approximately 380,000 survivors of childhood and adolescent cancer (diagnosed at ages 0 to 19 years) alive in the United States (24). Approximately 60-90% developed chronic health conditions, and 20-80% experienced life-threatening conditions (24). These late effects can be long lasting, and include, but are not limited to, obesity, metabolic syndrome, osteopenia, infertility, type 2 diabetes, cognitive deficits, cardiovascular disease, and GI problems (15,24). Many survivors report dietary intakes that do not meet United States dietary guidelines for a healthful diet (26). Additionally, pediatric cancer survivors reported lower intake of fruits, vegetables, and fiber than healthy children (25). Guidelines for managing late effects associated with childhood cancer survivorship are available through reputable, online resources (https://www.childrensoncologygroup.org/ and https://www.nccn.org/patients/resources/life_after_cancer/nutrition.aspx). Unfortunately, many of the guidelines are expert consensus vs. evidenced-based (due to lack of research), and are similar to adult guidelines at this time.

Survivorship is an area of pediatric cancer care in which the RDN can have a significant impact, as the management of many of the late effects can be improved with


http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=CDR0000450125&version=Patient&language=English

https://www.nccn.org/patients/resources/life_after_cancer/nutrition.aspx




nutritional intervention. Utilizing an eating questionnaire may be an effective way of screening for survivors who may be at risk for less healthy eating behaviors, though there is not research to support this yet. When providing MNT, it is important to consider all of the areas in which the patient’s nutritional choices may be influenced. These areas include school, before or after care, the home of their peers, grandparents, access to the corner store, and any other place or context where food choices are made. The RDN may be able to connect the family to community resources that support the child or adolescent in a healthy lifestyle. As with pediatric patients undergoing cancer therapy, pediatric cancer survivors are dependent on others for their food choices. Encouraging the family to provide a supportive and healthy eating environment for the survivor is imperative for success in implementing healthy eating choices. Having ongoing conversations before, during, and after treatment may help the transition into survivorship care and healthy eating.

ConclusionRDNs play an essential role in the ongoing care and treatment of the pediatric cancer patient from diagnosis through survivorship. Currently, centers vary widely in terms of nutrition screening, interventions, and assessment (27). A structured institutional approach to care of the pediatric cancer population may assist in providing optimal patient care, in addition to the provision of research findings to help develop best practices. As cancer treatment evolves, the number of survivors who carry late effects into adulthood will increase. Pediatric patients and survivors of childhood cancer have different medical risks than their peers. Nutrition plays an important role in the treatment of their disease, prevention, management of delayed side effects, and long term well-being. Research and evidence based guidelines are evolving and should be a focus for oncology RDN’s. RDNs are uniquely qualified to ensure that the best possible nutritional care is provided to this highly vulnerable population.

References 1. Cancer in Children and Adolescence.

Available at : http://www.cancer.gov/types/childhood-cancers/child-adolescent-cancers-fact-sheet. Accessed December 2015.

2. Secker DJ, Jeejeebhoy KN. How to perform Subjective Global assessment in children. J Acad Nutr Diet. 2012; 112(3):424–431.

3. Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual. Oncology; General Guidance. http://www.peds.nutrition caremanual.org. Accessed December 2015.

4. Linabery AM, Li W, Roesler MA, Spector LG, Gamis AS, Olshan AF. Heerema NA, Ross JA. Immune-related conditions and acute leukemia in children with Down syndrome: a Children’s Oncology Group report. Cancer Epidemiol Biomarkers Prev. 2015;24(2): 454–458.

5. Grummer-Strawn LM, Reinold C, Krebs NF. Centers for Disease Control and Prevention . Use of the World Health Organization and CDC growth charts for children aged 0-59 months in the United States. Recommendations and Reports. MMWR Recomm Rep. 2010;59 (RR-9);1–15.

6. Zemel BS, Pipan M, Stallings VA, et al. Growth charts for children with down sydrome in the United States. Pediatrics. Published online October 2015.

7. Becker P, Carney LN, Corkins MR, et al. Consensus statement of the Academy of Nutrition and Dietetics/ American Society for Parenteral and Enteral Nutrition: Indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). Nutr Clin Pract. 2015;30(1): 147–161.

8. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: A paradigm shift toward etiology-related definitions. JPEN. 2013;37(4):460–481.

9. Danner E, Joeckel R, Michalak S, Phillips S, Goday PS. Weight velocity in infants and children. Nutr Clin Pract. 2009;24(1):76–79.

10. Rasmussen, J., Andersen, A., Fisker, A.B. et al, Mid-upper-arm-circumference and mid-upper-arm circumference z-score: The best predictor of mortality? Eur J Clin Nutr. 2012;66:998–1003.

11. White M, Davies P, Murphy A. Validation of percent body fat indicators in pediatric oncology nutrition assessment. J Pediatr Hematol Oncol. 2008;30(2):124–129.

12. Green Corkins, K. nutrition Focused physical exam in pediatric patients. Nutr Clin Pract. 2015;30(2):203–9.

13. Sala A, Pencharz P, Barr, R. Children, cancer and nutrition—A dynamic triangle in Review. Cancer. 2004;100(4):677–687.

14. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007;120suppl 4: S164–192.

15. Co-Reyes E. Li R, Huh W, Chandra J. Malnutrition and obesity in pediatric oncology patients: Causes, consequences, and interventions. Pediatr Blood Cancer. 2012; 59(7):1160–1167

16. Sacks N, Henry D, Bunger K, et al. Oncology, Hematopoietic Transplant, Gastrointestinal Supportive Care and Survivorship, 2nd Ed. In: Corkins MR, ed. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD; 2015:459–486.

17. Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122(2):398–417.

18. Rayar MS, Nayiager T, Webber CE, Barr RD, Athale UH. Predictors of bony morbidity in children with acute lymphoblastic leukemia. Pediatr Blood Cancer. 2012;59(1):77–82.

19. Emel T, Dogan DA, Erdem G, Faruk O. Therapy strategies in vitamin D deficiency with or without rickets: efficiency of low dose stoss therapy. J Pediatr Endocrinol Metab. 2012;25 (1-2):107–110.

20. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Accessed March 1, 2015: https://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/ Vitamin D and Calcium 2010 Report Brief.pdf.

21. Han-Markey T. Nutritional considerations in pediatric oncology. Semin Oncol Nurs. 2000; 16(2):145–151.

22. Human Energy Requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. FEO Food and Nutrition Technical Report Series 1. Rome, Italy: Food and Agriculture Organization of the United Nations; 2001.

23. Treatment decisions regarding infants, children and adolescents; Canadian Pediatric Society, Ontario. Pediatri Child Health. 2004; 9(2)99–103.

24. Late effect of treatment for childhood cancer-for health professionals. Available at http://www.cancer.gov/types/childhood-cancers/late-effects-hp-pdq#link/_990_toc. Accessed December 2015.

25. Ladas, EJ. Nutritional counseling in survivors of childhood cancer: an essential component of survivorship care. Children. 2014;1(2): 107–118.

26. Zhang FF, Saltzman E, Kelly MJ, Liu S, Must A, Parsons SK, Roberts SB. Comparison of childhood cancer survivors’ nutritional intake with US dietary guidelines. Pediatr Blood Cancer. 2015;62(8):1461–7.

27. Ladas EJ, Sacks N, Brophy P, Rogers PC. Standards of nutritional care in pediatric oncology: results from a nationwide survey on the standards of practice in pediatric oncology. A Children’s Oncology Group study. Pediatr Blood Cancer. 2006;46(3): 339–344.

http://www.cancer.gov/types/childhood-cancers/child-adolescent-cancers-fact-sheet



http://www.peds.nutritioncaremanual.org

http://www.peds.nutritioncaremanual.org


The American Institute for Cancer Research (AICR) states that consuming certain nutrients found in butternut squash may prevent several types of cancers. Butternut squash is an excellent source of vitamin C, which AICR ranks as “probable” for lowering the risk for esophageal cancer. Dietary fiber intake is linked with decreasing overall cancer risk by assisting with weight control, and is specifically known for lowering the risk of developing colorectal cancer. Carotenoids, precursors to the formation of vitamin A within the body, (e.g. beta-carotene, alpha-carotene, and beta-cryptoxanthin) have antioxidant and other biological activity that may lower the risk of developing cancers of the mouth, pharynx, larynx, esophagus, and lung (4). The pro-vitamin A activity of some carotenoids can be critical to health, because vitamin A is a vital nutrient. It plays an important role in vision and eye health, skeletal development, reproduction, and immunity (5). A vitamin A deficiency can lead to reversible night blindness, if corrected early, and to permanent blindness due to corneal damage known as xerophthalmia. Hyperkeratosis, otherwise known as dry, scaly skin, may arise when vitamin A intake is insufficient (6). Toxicity from naturally occurring vitamin A intake is rare and typically occurs only when Vitamin A is ingested in supplemental form, such as dietary supplements and cod liver oil (6). However, cases of sub-acute vitamin A toxicity may occur due to chronic dietary vitamin A intake of only several times the RDA (7). A high intake of carotenoids, on the

other hand, appears to be safe and does not contribute to vitamin A toxicity (6). Carotenoid conversion to vitamin A will decrease as intake increases. Excessive carotenoid intake can turn the skin a yellow-orange tint, which appears to be a harmless side-effect. Normal skin coloration returns with decreased intake. Although there are defined upper limits of preformed vitamin A, upper limits for beta-carotene and other vitamin A precursors have not been established (6,7). As a general rule, the deeper the orange color, the more beta-carotene a food contains (2).

When selecting a butternut squash, it is imperative to look for a tough rind and a lack of bruising. Surprisingly, this fruit can be stored for 2-3 months at room temperature, though with longer storage, the fruit may become drier and tougher. Butternut squash can be prepared in a variety of ways. It can be baked, roasted alone or with other vegetables, or even cubed for use in casseroles, stews and stir-fries (8). Steaming is always a great option, because this preparation method helps retain the nutrient content of foods, and cooking can help enhance the bioavailability of beta-carotene (9,10). Proper storage ensures that flavor, safety, quality, and nutrients are not jeopardized (9). Cut pieces keep about two days in the refrigerator if tightly wrapped, or freeze butternut squash in small uncooked portions or in pureed, cooked form (8).

Eat Right to Fight Cancer: Butternut SquashBy Kim Boone, Dietetic Intern

When walking in the supermarket, it may be easy to skip over oddly shaped or unfamiliar foods, like butternut squash. Butternut squash is a member of the Cucurbitaceae family, and is native to North America (1,2). This fruit (although commonly used as, and referred to as, a vegetable), is typically planted in the summer and harvested during the fall months when a deep color has appeared and the rind has hardened (2). This nutrient-packed food may provide health benefits such as cancer risk reduction and you can recognize butternut squash by its beige hue, elongated shape, bulb end, and orange pulp (3).

Try replacing the monotonous potato with this healthy side dish. This Weelicious: Cinnamon-Roasted Butternut Squash recipe provides 191 kcal, 1.4 g protein and 2.8 g fiber per serving and provides plenty of vitamin A (as pro-vitamin A carotenoids) and vitamin C (11,12).

While it may seem more convenient to just grab frozen potatoes, there are many reasons why butternut squash should be added to the regular grocery list!

References 1. Foods That Fight Cancer: Squash. (2015).

American Institute for Cancer Research. Accessed July 18, 2016: http://www.aicr.org/foods-that-fight-cancer/squash.html#intro.

2. Watch Your Garden Grow: Winter Squash. (2015). University of Illinois Extension. Accessed July 18, 2016: http://extension.illinois.edu/veggies/wsquash.cfm.

3. Food of the Week: Butternut Squash. (2015). Iowa State University Extension. Accessed July 18, 2016: http://www.extension.iastate.edu/sites/www.extension.iastate.edu/files/allamakee/ButternutSquash1.pdf.

4. AICR’s Foods That Fight Cancer: Squash. (2015). American Institute for Cancer Research. Accessed July 18, 2016: http://www.aicr.org/foods-that-fight-cancer/squash.html#research.

5. Science on Your Plate: The Science of Squash. (2015). American Institute for Cancer Research. Accessed July 18, 2016: http://preventcancer.aicr.org/site/News2?page=NewsArticle&id=19609.

Ingredients

• 2 cups peeled and chopped butternut squash (about 1 small squash)

• 2 teaspoons canola or vegetable oil

• 1/4 teaspoon ground cinnamon

• 1 tablespoon maple syrup

Preparation

1. Preheat the oven to 425°F.

2. Place the butternut squash on a baking sheet, drizzle or spray with oil and toss to coat well.

3. Bake for 40 minutes or until fork-tender. Remove from oven, sprinkle with cinnamon and drizzle with the maple syrup. Toss to coat, return to oven and bake an additional 5 minutes.


http://extension.illinois.edu/veggies/wsquash.cfm

http://extension.illinois.edu/veggies/wsquash.cfm

http://www.extension.iastate.edu/sites/www.extension.iastate.edu/files/allamakee/ButternutSquash1.pdf



http://preventcancer.aicr.org/site/News2?page=NewsArticle&id=19609



6. Vitamin A: Fact Sheet for Health Professionals. (2013). National Institutes of Health. Accessed June 28 2016: https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/

7. Wax, E. (2015). Vitamin A. Medline Plus. Accessed June 28, 2016: https://www.nlm.nih.gov/medlineplus/ency/article/002400.htm.

8. AICR’s Foods That Fight Cancer: Squash. (2015). American Institute for Cancer Research. Accessed July 18, 2016: http://www.aicr.org/foods-that-fight-cancer/squash.html#tips.

9. Marcason, W. (2015). How to Get the Most Flavor and Nutrients. Academy of Nutrition and Dietetics. Accessed July 10, 2016: http://www.eatright.org/resource/homefoodsafety/safety-tips/food-poisoning/getting-the-most-flavor-and-nutrients.

10. Livny O, Reifen R, Levy I, Madar Z, Faulks R, Southon S, Schwartz B. Beta-carotene bioavailability from differently processed carrot meals in human ileostomy volunteers. Eur J Nutr. 2003;42(6):338–45.

11. Cinnamon Roast Butternut Squash. (2015). Weelicious. Accessed July 18, 2016: http://weelicious.com/2012/11/14/cinnamon-roast-butternut-squash/.

12. United States Department of Agriculture National Nutrient Database for Standard Reference Release 28. Accessed July 18, 2016: http://ndb.nal.usda.gov/ndb/foods/show/6329.


https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/



https://www.nlm.nih.gov/medlineplus/ency/article/002400.htm

https://www.nlm.nih.gov/medlineplus/ency/article/002400.htm

http://www.eatright.org/resource/homefoodsafety/safety-tips/food-poisoning/getting-the-most-flavor-and-nutrients




http://weelicious.com/2012/11/14/cinnamon-roast-butternut-squash/



http://ndb.nal.usda.gov/ndb/foods/show/6329

http://ndb.nal.usda.gov/ndb/foods/show/6329


(* Voting member)

Chair*Kelay Trentham, MS, RDN, CSO, [email protected]

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Jeannine Mills, MS RD CSO LD [email protected]

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Janet Mildrew, [email protected]

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2016-2017 Oncology Nutrition DPG Officers and Committee Chairs

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