Indications and Patterns of Use for Parenteral Nutrition in Pediatric Oncology

Abstract

Background: Children with cancer are at risk of treatment related gastrointestinal toxicity and malnutrition. Intestinal dysfunction may preclude or limit use of enteral nutrition, and parenteral nutrition (PN) may be required. Published indications for PN use in children with cancer are generally nonspecific. We sought to describe patterns of use, indications, and frequency of PN prescription in children with cancer and propose indicators to guide appropriate PN use. Methods: Retrospective chart review of children with cancer receiving inpatient PN in a tertiary referral pediatric hospital over 12 months was performed using electronic medical record search and paper records. Data were summarized using descriptive statistics. Results: PN was prescribed to 88 patients in 111 episodes. Total use (2377 days) represented 24% of annual inpatient days in all children with cancer. Primary clinical indications were mucositis (40%), feed intolerance (29%), postoperative (16%), or "other" (15%), (including nasogastric tube refusal (n = 6)). Patients with hematological cancer had longer median episodes (19 vs 12.5 days) and earlier commencement of PN after diagnosis (50 vs 80 days) than children with nonhematological cancer. Most PN episodes longer than 28 days were in children with hematopoietic stem cell transplant (HSCT). Conclusion: Inpatient PN use is common in childhood cancer. Indications include mucositis, feed intolerance, and surgical management. Patterns of use are influenced by cancer diagnosis and treatment, with greater use in children with hematological cancer and HSCT. Improved understanding and specific indications may guide appropriate PN prescription and minimize unnecessary risk, cost, and inconsistency in care.

Systematic review of gastrostomy complications and outcomes in pediatric cancer and bone marrow transplant

“…49,50 Less parenteral nutrition with gastrostomy use has economic and safety implications, given the cost of parenteral nutrition 51 and avoidance of parenteral nutrition-related complications. 19,52 Most studies assessed nutrition status using weight 17,22,27,38,[40][41][42]45 and BMI, 36 which have limitations in this population, as they can be distorted by tumor mass and hydration status. 53 More sensitive methods, such as mid-upper arm circumference, which is independent of such confounding factors, 7,53 should be used in future studies.…”

“…Enteral nutrition initiated systematically on day 1 post‐BMT, compared with parenteral nutrition initiated at the same time, has also reduced hospital stay and improved survival in BMT 49,50 . Less parenteral nutrition with gastrostomy use has economic and safety implications, given the cost of parenteral nutrition 51 and avoidance of parenteral nutrition–related complications 19,52 …”

Supportive care in pediatric acute myeloid leukemia:Expert-based recommendations of the NOPHO-DB-SHIP consortium

“…Both Enteral Nutrition (EN) and Parenteral Nutrition (PN) can play a role in supporting children's nutritional needs during AML treatment [69][70][71].…”

Polymorphism but not methylation status in the vitamin D receptor gene contributes to oral mucositis in children

“…Oral mucositis is an inflammatory disease associated with pain, which can vary between mild, moderate and severe forms, resulting in difficulties in eating, drinking and speaking. Severe oral mucositis (SOM) cases may require nutritional support (nasogastric tube) (McGrath et al, 2020; Villa & Sonis, 2015). It can worsen the patient's cachexia, decrease quality of life and lead to the temporary interruption of chemotherapy treatment to recover the oral mucosa (Qutob et al, 2013, Villa & Sonis, 2015).…”