Deborah L O’Connor PhD

The Art and Science of Keeping

Infants With Cancer Well-Nourished

Disclosures

I serve as Co-Chair on the Advisory Board of the

Rogers Hixon Ontario Human Donor Milk Bank

Lead a Canadian Institutes of Health Research

program with the aim to optimize use of human

milk for preterm infants

Objectives

Participants will be:

1. Able to describe current recommendations for

feeding healthy infants during the first year of

life including the introduction of solids and the

need for vitamin and mineral drops

2. Knowledgeable about reliable resources to

support families in adhering to feeding

guidelines

Important Definition for this

Presentation

While benefits of feeding at the breast are

acknowledged:

Breastfeeding = feeding human milk (fresh or

frozen) at the breast, by bottle, feeding tube

or supplemental nursing system

***Promote skin-to-skin contact for infants not fed at

the breast

Exclusive Breastfeeding to 6

Months

“….exclusive breastfeeding

for 6 months is the optimal

way of feeding infants.

Thereafter infants should

receive complementary foods

with continued breastfeeding up

to 2 years of age or beyond.”

World Health Organization. 2001. Global Strategies for Infant and Young Child Feeding. Resolution

Passed at: Fifty-fourth World Health Assembly; May 9, 2001

https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding.html

Benefits of Breast Milk: Short

Term Outcomes

• Uniquely meets the Nutritional Requirement

of Infants

• Is Well Tolerated

• Association between breastfeeding and

outcomes assessed from 28 systematic

reviews and meta-analyses, of which 22 were

commissioned for this paper

Benefits of Breast Milk: Short

Term Outcomes

• Uniquely meets the nutritional requirement of

infants

• Is well tolerated

• Decreases incidence of malocclusion

• Mortality

• Decreases incidence of infectious diseaseo Diarrhea**

o Respiratory tract infection

o Otitis media

Victora C et al Lancet 2016 475-90

Relative Risk (95%CI) of Diarrhea

Morbidity in Children < 6months

http://apps.who.int/iris/bitstream/10665/95585/1/9789241506120_eng.pdf?ua=1

Relative Risk of diarrhea with breastfeeding

0.37 (0.27-0.50) compared to formula feeding

Relative Risk (95%CI) of Hospitalization Due to

Respiratory Infection, Lower Respiratory Tract

Infection or Pneumonia in Children < 5 Years

http://apps.who.int/iris/bitstream/10665/95585/1/9789241506120_eng.pdf?ua=1

Relative Risk of with breastfeeding

0.43 (0.33-0.55) compared to formula feeding

Evidence of Breastfeeding

Improving Long-term Health

Outcomes ?

Benefits of Breast Milk: Long

Term Outcomes

Most studies were conducted in high income

countries

Probable reduction in:

• Overweight and obesity

• Diabetes

Victora C et al Lancet 2016 475-90

Horta BL et al Acta Paediatrica 2015 104, pp. 14-19

• 17 studies with 18 estimates of the relationship between

breastfeeding and performance on intelligence tests

• 17 cohort and one observational study

• Studies excluded if no adjustment for stimulation or

interaction at home

• Breastfed infants achieved a higher IQ [mean difference:

3.44 points (95% CI 2.30, 4.58)]

• Studies that controlled for maternal IQ showed a smaller

benefit: 2.62 points (95% CI 1.25, 3.98) but still

statistically significant

Benefits of Breastfeeding:

To the Mother• Birth spacing - predominant breastfeeding

associated with longer periods of

amenorrhea

• Reduced risk of breast cancer (exposure

lifetime breastfeeding duration)

• Reduced risk of ovarian cancer with longer

duration of breastfeeding (probable)

• Reduced risk of type 2 diabetes (probable)

Victora C et al Lancet 2016 475-90

Introduction of Iron Rich or Iron-Fortified

Complementary Foods at 6 Months

Nutrition for Healthy

Term InfantsJoint Statement of Health Canada,

CPS, Dietitians of Canada and

Breastfeeding Committee for Canada

• Birth to six months

• 6 months to 24

months

Iron stores laid down in

pregnancy depleted by six

months

Iron naturally low in breast

milk

Deficiency can lead to

anemia and is associated

with irreversible decrease

in cognitive function

https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding.html

Strategies to Prevent Iron

Deficiency

Iron rich foods• meat, poultry, or fish

• fortified cereals

Tip: homemade pureed foods work great (don’t add salt or sugar)

Tip: can transition from infant cereals to ready-to-eat breakfast cereals

Delay introduction of cow’s milk to 12 months as

also low in iron; use iron-fortified cow’s milk-based

formula if weaning

Once cow’s milk introduced limit volume to 3 cups

per day; will limit displacement of iron-rich foods

Iron drops

https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding.html

Other Consideration in

Introducing Solids: Allergy

• When introducing a food that is among the list of

common food allergens, suggest avoid offering >

one of these per day and wait two days before

introducing another of the common food allergens

• Once a potential food allergen has been introduced

successfully, continue to offer the food regularly in

order to maintain the child's tolerance

• Begin introduction of solids while

still breastfeeding

• The order that solid foods are

introduced does not affect the risk

of developing food allergy

Common Food Allergens

• Eggs

• Milk

• Mustard

• Peanuts

• Crustaceans and molluscs

• Fish

• Sesame Seeds

• Soy

• Sulphites

• Tree Nuts

• Wheat and Triticale

Other Consideration in

Introducing Solids

• Encourage parents to be responsive to

their infant’s hunger cues

• Gradually increase number of times/day

complementary foods are offered while

continuing to breastfeed

• Ensure lumpy textures are offered no later

than nine months. Encourage progress

toward a variety of textures, modified from

family foods (limited salt and sugar) by

one year of age

Do Infants Need Vitamin Drops?

Vitamin D Drops

• Vitamin D is low in breast milk

• Vitamin D is an essential nutrient for development of

strong bones and teeth

• Humans can synthesize vitamin D in their skin but

infants should not be exposed to direct sunlight due

to risk of skin cancer

• All breastfed infants should receive a supplement of

400 IU/day

• Vitamin D is added to all cow’s milk and infant

formulas in Canada (it is the law)

• Vitamin D can be added to plant-based beverages

but it is voluntary (need to read labels)

My Child Doesn’t Like

Vegetables

Prevalence of Inadequacy of Vitamins A,

C and Folate from Diet Alone among

Canadian Children - Supplement Users

Age Vitamin A Vitamin C Folate

1-3 years 0 0 0

4-8 years <5 0 0

Males: 9-13 years 16 <5 <5

Females: 9-13 years 14 <5 <5

Shakur Y et al Journal of Nutrition 142(3):534-40, 2012.

Intakes of Vitamins A, C and Folic Acid

Among Canadian Children Above the

Tolerable Upper Level - Supplement Users

Shakur Y et al Journal of Nutrition 142(3):534-40, 2012.

Age Vitamin A Vitamin C Folic acid

1-3 years 88 10 7

4-8 years 67 <5 5

9-13 years 18 <5 <5

Prevalence of Low Blood Levels of

Vitamin A and C in American Children

6 to 11 Years Old

Blood value Sample size Prevalence

Serum vitamin C, <11.4 umol/L 1,703 <1%

Serum vitamin A*, <20 ug/dl 860 1%

CDC. 2nd National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population, 2012

Resources to Support Parents

https:/www.ontario.ca/page/breastfeeding

Bilingual On-Line Ontario Breastfeeding Services on-line lactation consultant

locations of clinics, peer support locally

Introduction of Solids to your baby

Sample Meals for babies 6-12 months

Homemade baby foods

https://www.eatrightontario.ca/en/default.aspx

www.canada.ca/en/health-canada/services/food-nutrition/

healthy-eating/infant-feeding.html

Resources for Professionals/Parents

for the More Nutritionally Complex

Breastfeeding Program Videos:

The Hospital for Sick Children Toronto

http://www.sickkids.ca/breastfeeding-

program/videos/index.html

The Society of Obstetricians and

Gynecologists: Clinical Practice

GuidelineNo. 333, June 2016

Canadian Consensus on Female Nutrition:

Adolescence, Reproduction, Menopause, and

Beyond

J Obstet Gynaecol Can 2016;38(6):508-554

Concluding Thoughts

• Breastfeed exclusively for the first 6 months,

with introduction of solids at this time and

continued breastfeeding

• First solids should include iron-rich foods

• Breastfed infants require a vitamin D

supplement

• If weaning from the breast before 12 months

use an iron-fortified cow’s milk formula

Nourishing an infant with Cancer

Laura Collins, RD

Overview

• the significance of malnutrition

• the role of the Registered Dietitian

• components of a nutrition assessment

• the nutrition complications

• strategies to optimize nutrition

• future opportunities

• case study

Why is good nutrition important?

• promote growth and development

• improve QOL

• improve treatment tolerance

• decrease infection rate

• decreased LOS

• improve survival

Why is malnutrition in infants with cancerso significant?

• rapid wt gain/growth/development

• limited body reserves

• ability to play and interact

• brain development

What are the causes of malnutrition?

• increased needs: Cancer is a catabolic state

• increased losses: vomiting, diarrhea, malabsorption

• decreased intake: anorexia, nausea, taste changes, mucositis

• Host/Disease/Treatment factors

What are the challenges

in preventing malnutrition?

• poor intake and weight loss

• continuation of breastfeeding and supply

• healthy food choices

• feeding skills/aversions/food battles

• acceptance/tolerance to feeds

• frequent NG re-insertions

• weaning tube feed and transition to oral

The Registered Dietitian

Who is seen by the RD?

All infants with cancer

• weight loss• large tumour burden• HR cancers• intensive treatment protocols• receiving nutrition support

The RD role in pediatric oncology

1. nutrition assessment 2. develop nutrition care plan (NCP)3. provide nutrition education

4. discharge planning for NS

5. ongoing follow-up

6. Interdisciplinary team involvement

Common Goals with Team members

OT/PT: rehab/participation

OT: feeding/swallowing

PharmD: improved tolerance to EN

MD/RN: allies to promote NCP

Case Study: NBLDiagnosis:

• 11mth old female with intermediate risk NBL with a

significant suprarenal mass.

HPI:

• 2 mth history of poor growth and decreased intake of

solids and increased demand for breastfeeding

Clinical:

• appears very pale and thin

Social:

• lives with both parents, no siblings, ++anxious parents

Nutrition Assessment

ABCDE’s of Nutrition Assessment

• Anthropometrics

• Biochemical indices

• Clinical

• Diet/feeding history

• Estimate nutritional requirements

The WHO Growth Charts

Categories of Nutritional Status

Measure Underweight

Weight for length <10th%ile

-1.32 z score

BMI

(> 2yrs)

<5th%ile

-1.70 z score

Arm

Anthropometry

MUAC (FFM)

< 5th%ile

IBW Severe <70%

Moderate 70-80%

Mild 80-90%

Weight loss > 5-10% in a month

GROWTH FAILURE: crosses over 2 growth channels

Case study - anthropometricsDate/Age Age Weight Height Weight for Length

Wt change & MUAC

Jun 11/16 Birth 2.77kg = 15 %ile

Prior to Dx 2 - 9m

9.5 - 11m

15-50%ile (8.2kg)

50-15%ile (7.8kg)

50%ile

(0 - 6m)

Wt loss:

380g (4.6%)

May 19 (Dx)

May 31

(NGT insert)

11m 7.82kg

16%ile (-0.96 z)

7.6kg

12%ile (-1.14z)

220 g(3% wt loss)

71.2cm

26%ile (-0.62 z)

22%ile (0.76 z)

MUAC:

13.0 (15t%ile)

Nov 3 1yr 5m 9.98kg

48%ile (-0.03 z)

up 2.16kg since dx

(12.9 g/day)

76cm

9%ile (-1.29 z)

76% (0.74 z)

MUAC: 14.2 (50%)

Case study - anthropometrics

Case study - anthropometrics

Case study - anthropometrics

Growth Velocity

AGE WEIGHT

(g/day)

LENGTH

(cm/mth)

<3 mo 25-35 2.6-3.5

3-6 mo 15-21 1.6-2.5

6-12 mo 10-15 1.2-1.7

1-3 yr 4-10 0.7-1.1

Diet History

• fluid intake (Br.Milk, formula, milk, juice)

• introduction to solids

• changes in intake

• nutritional adequacy of diet

• food/feeding aversions

• allergies and intolerances

• 3 day food record or 24hr recall

• current intake

Case study – diet assessment

Prior to Dx:

• increase in BF demand (ad lib q 3-5 hrs)

• taking some EBM via sippy cup,

• no homo milk or formula being used.

• exclusively breastfed until 5-6mths

• intro to solids was limited (texture sensitive)

• purees often with limited variety of solid

• feed self with finger foods

5

2

Estimating Nutritional Requirements

Calculating nutrition requirements

Fluids: 4:2:1 rule

Calories: 95-100 kcal/kg

Protein: 2g/kg

Carbs: ~ 25-35% of kcals

Fat: ~ 60% of kcals

vit/mins: use DRIs

https://www.nal.usda.gov/fnic/interactiveDRI/

Nutrition Interventions

Nutrition Support Options

• nutrition counseling/education

• dietary modifications and oral suppl’s

• enteral nutrition

• parenteral nutrition

Enteral Nutrition (EN)

• provision of nutrients via tube feeding

• functional GI tract• NG, NJ, GT, GJ

• partial supplementation vs sole source

• proactive EN is encouraged (team/family)

• EBM or formula (concentrated or diluted)

TABLE 1: concentrating EBM with liquid concentrate formula

DiLauro et al, 2016

Breastmilk/Infant Formula

• EBM

• Enfamil A+

• Similac Advance

• Goodstart

• specialized formulas

• standard dilution (0.67kcal/ml)

• Use liquid concentrate (powder used as per

family request) to concentrate formula

Pediatric Formula Choices for >1yr

Type Name/Brand

Standard Polymeric Pediasure

Pediasure Plus

Semi-elemental Peptamen Jr

Peptamen Jr 1.5

Pediasure peptide

Hydrolyzed Vivonex pediatric

Blenderized Tube Feed

(BTF)

Compleat Pediatric

Homemade

Case study – NCP for EN

• concentrated EBM (bottle/cup) & encouraged solids

• NG tube inserted (may 26)

• continuous to intermittent feeds (4 hrs on and 2 hrs off QID)

• concentrated EBM or concentrated Goodstart (up to

30kcal/oz)

• 1:1 ratio of concentrated EBM and Goodstart (due to supply)

• transition to pediatric formula (semi-elemental then

hypercaloric)

• oral intake remains very low with limited variety and textures

• unable to wean off NG feeds due to feeding aversions

• now 3 BOLUS FEEDS: 80% of est needs

6

1

Nutrition Monitoring

Monitoring and adjusting NCP

ORAL: breastfeeding, food intolerances/aversions

EN: tolerance of feed and schedule, adjustments with

chemo oral intake and optimized meds

TPN: not required throughout her treatment

GROWTH: changes (% and z scores) or no growth

nutrition assessment is only as good as the monitoring

ADJUST THE CARE PLAN TO IMPROVE NUTRITION STATUS

Ongoing and Future Projects

• SCAN – implementing screening tool

• Arm anthropometry measurements – serial measures and

consistent use

• Education Tool to help wean/transition from EN to oral

“Helping your child eat while on a tube feed”

• Healthy Eating interventions

Validated Nutrition screening tool for

childhood cancer

SCAN (reference article)

• identifies children with cancer at risk of malnutrition

• 6 simple questions

• Total Score ≥ 3 (“at risk of malnutrition”)

Murphy AJ, et al.

SCANa validated Nutrition Screening tool

1. Does the patient have a high risk cancer?

2. Is the patient currently undergoing intensive treatment?

3. Does the patient have any symptoms relating to the GI

tract?

4. Has the patient had poor oral intake over the past

week?

5. Has the patient had any weight loss over the past

month?

6. Does the patient show signs of undernutrition?

References1. DiLauro S, Unger S, Stone D, O’Connor D. Human milk for ill and

medically compromised infants: Strategies and ongoing innovation.

JPEN. 2016;40(6) 768-782.

2. Ladas, E.D., Sacks, N., Brophy, P., Rogers, P.C. Standards of nutritional

care in pediatric oncology.Pediatr Blood Cancer. 2006;46:339–344.

3. Murphy AJ, et al., Evaluation of the nutrition screening tool for

childhood cancer (SCAN). Clinical Nutrition. 2016;35(1):219-224.

4. Barron M, Pencharz P. Nutritional issues in infants with cancer.

Pediatr Blood Cancer. 2007;49:1093-1096

5. Gaynor EPT, Sullivan PB. Nutritional status and nutritional

management in children with cancer. Arch Dis Child.2015;100:1169-

1172

6. Rogers P. Importance of nutrition in pediatric oncology. Indian J

Cancer. 2015;52:176

7. World Health Organization. The WHO child growth standards.

www.whogrowthcharts.ca

THANK YOUcollinla@hhsc.ca