Nutrition au cours des radiothérapies et chimiothérapiesNutritional support during cancer chemotherapy and radiotherapy

Nutritional support for cancer patients treated with radiotherapy and chemotherapy are strongly requested with regard to the frequent malnutrition at time of diagnosis. Furthermore, the malnutrition often progresses with adverse effects of therapy and disease progression. Nutritional screening and assessment are essential. Dietetic care is mandatory for patients with malnutrition or at risk of malnutrition when they are still able to eat. But this oral nutritional support is frequently unable to maintain sufficient nutritional intakes with regard to tumour effect or treatment toxicity. Enteral or parenteral nutrition must be provided to patients unable to absorb adequate quantity of nutrients for a prolonged period. The primary goal is to avoid, especially for malnourished patients, further nutritional degradation which can lead to treatment interruptions, complications or increased risk of death. Routine administration of artificial nutrition has been tested during radiotherapy and chemotherapy but results are conflicting and data are missing for severely malnourished patients. No benefits in terms of treatment toxicity, tumour response, risk of complications and finally mortality have been demonstrated for routine use of artificial nutrition. Most decisions for indication of nutritional support, route of administration and quality of artificial nutrition in this field can't rely today on evidence-based medicine. However, artificial nutrition can provide nutrients and hydration necessary to maintain comfort and to improve survival for patients unable to eat sufficient nutrition for a prolonged period.     

La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

Stratégies de dépistage de la dénutrition chez l''enfant hospitalisé

Metabolic stress modifies homeostasis, therefore nutrient's metabolism and nutritional needs. Stress is a risk factor of malnutrition, which increases morbidity and short-term mortality, and, in the child, can threaten long-term growth. Nutritional assessment is difficult in critically ill children. Nutritional support must be undertaken early as possible, especially in malnourished children and with severe agression. Enteral nutrition must be privileged. Parenteral nutrition is indicated when enteral nutrition is impossible, badly supported or insufficient to satisfy needs. Monitoring must be rigorous because aggression increases the risk of metabolic complications.     

Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Nutrition périopératoire : protocoles de soins

Based on texts written by experts, the objective of this paper is to propose a practical approach to nutrition for clinicians, according to the nutritional status of patients and the evaluation of surgical risk. Any patient with a nutritional grade greater than or equal to 2 should benefit from nutritional support. Indeed, current data confirm that preoperative and early nutritional support in surgery at risk can reduce significantly postoperative morbidity for patients with non-malnourished (immunonutrition in cancer surgery GI), and the morbidity and mortality in malnourished patients (enteral nutrition when possible). A preoperative oral intake is recommended 2 to 3 hours before elective surgery for clear fluids and 6 hours for a light meal. Moreover, a preoperative oral intake of carbohydrates (maltodextrin 12.5%) is recommended (except in diabetic patients). Postoperatively, early oral feeding (within 24 hours) is recommended in the absence of cons to surgery. Glutamine is recommended in case of postoperative complications.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant en cancérologie

In children with cancer, malnutrition may antedate the diagnosis or be a result of aggressive chemotherapeutic regimens. The prevalence of malnutrition at diagnosis is related to the type of tumour and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukaemia to 50% in children with advanced neuroblastoma. The pathogenis of the energy imbalance that underlies the development of malnutrition is complex, including increased breakdown of fat and protein as well as energy-consumptive changes in carbohydrate metabolism (Cori cycle). Despite several confounding factors (different definitions of nutritional status and the wide variety of measures used for its assessment), studies have shown decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, altered quality of life and possibly poor clinical outcome in malnourished patients. In this article, we review guidelines for the nutritional management of a child with cancer and we purpose an algorithm for nutritional support.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Troubles nutritionnels lors de la sclérose latérale amyotrophique (SLA)

Amyotrophic lateral sclerosis (ALS) is a rare neuromuscular disease, with a severe prognostic. Its consequences are not only neurological, but also nutritional, linked with a decrease of feeding, caused by swallowing and salivation disorders, a frequent anorexia or constipation, troubles due to a possible respiratory insufficiency, and sometimes important difficulties for going shopping, cooking and more simply putting the food into the mouth. Although fat-free mass is usually decreased during ALS, a paradoxical hypermetabolism is present in 50 to 70% cases, favouring nutritional alterations. The tools used for assessment, sometimes specific to the disability, are anthropometric criteria, body impedance analysis (BIA), dietetic surveys, dual X-ray absorptiometry and indirect calorimetry. Alimentary intakes, weight, fat-free mass and body mass index are progressively reduced, leading to malnutrition. BIA phase angle is largely decreased, reflecting severe cellular alterations. Disorders of lipid status are possible but inconsistent across studies and perhaps linked with cultural feeding habits. The loss of weight at diagnosis and malnutrition during evolution are independent prognostic factors for survival, justifying early nutritional assessment and care. During evolution of ALS, a higher level of fat mass seems to be a positive factor for survival. French, European and American recommendations give precisions on follow-up, modalities of fight against the causes of malnutrition, nutritional care, mainly including the use of oral energy and protein-enriched nutritional supplements and enteral nutrition.     

Nutrition and lung function in cystic fibrosis patients: review

Complex interactions between nutrition, skeletal and respiratory muscle function and energy expenditure in cystic fibrosis patients exist. Malnutrition significantly contributes to muscle weakness in patients with chronic obstructive pulmonary disease of the adult or in cystic fibrosis in childhood. Together with a measurable increase in resting energy expenditure the malnutrition, as a consequence of pancreatic insufficiency, leads to pulmonary deterioration. Whether pulmonary disease, pancreatic insufficiency, increased energy expenditure or insufficient intake of nutrition are the starters for the destructive circle or whether the basic defect is responsible for some of the components interacting with each other remains to be determined.     

Nutritional status and requirements in cystic fibrosis

Cystic fibrosis, the most common lethal inherited condition in most developed countries represents amajor challenge to clinicians from many aspects. The anorexia of chronic disease coupled with pancreatic insufficiency and inefficient functioning of exogenous pancreatic enzymes often leads to difficulty in achieving daily energy requirements. Increased energy expenditure associated with chronic lung infection not infrequently exacerbated by the co-existence of diabetes increases the challenge in maintaining adequate nutritional status for patients with cystic fibrosis. Manipulation of adverse issues such as duodenal pH to ensure increased efficiency of exogenous pancreatic enzyme function and aggressive nutritional supplementation both by the oral and enteral routes has seen improved nutrition, quality of life and survival for patients with cystic fibrosis. Improvements in respiratory care have aided this improvement by decreasing energy expenditure. This review will examine some of the challenges of achieving optimal nutrition in cystic fibrosis and describe interventions that have been developed to achieve this.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Duodéno-pancréatectomie céphalique : quelle prise en charge en postopératoire ?

Pancreaticoduodenectomy (PD) according to Whipple is a major surgical procedure which may result in exocrine pancreatic insufficiency (PI), both functional due to duodenectomy and organic due to pancreatic resection itself. These disorders may favor macronutrients maldigestion (carbohydrates, lipids, proteins) and malabsorption of micronutrients including vitamins A, D, E, K. These changes explain the persistent weight loss observed in 70–80% of patients after PD. Malnutrition and/or comorbidities may lead to early postoperative enteral nutrition via a jejunostomy or a nasoenteral tube allowing to recover a faster oral feeding and to reduce both the postoperative complications and the length of hospital stay. Pancreatic enzyme and vitamin D supplements should be routinely initiated. Long-term management should include a normal diet which may be fractioned in case of disabling functional signs. In case of chronic malnutrition, an oral nutritional supplementation should be considered, associated to/replaced by an overnight home enteral nutrition if necessary. Parenteral nutrition should not a priori be recommended. A clinical and biological nutritional long-term follow-up is further required in these patients.     

Nutrition et fonction immunitaireNutrition and immune function

A deficiency of total energy or of one or more essential nutrients, including vitamins A, B₆, B₁₂, C, and E, folic acid, zinc, iron, copper, selenium, essential amino acids and essential fatty acids, will impair immune function and increase susceptibility of the host to infectious pathogens. This is most likely because these nutrients are involved in the molecular and cellular responses to challenge of the immune system. Providing these nutrients to deficient individuals restores immune function and improves resistance to infection. Thus, appropriate nutrition is required in order for the host to maintain adequate immune defences towards bacteria, viruses, fungi, parasites and tumour celîs. Although the intakes of several nutrients which result in greatest enhancement of immune function appear to be greater than recommended intakes, excess intake of certain nutrients also impairs immune responses. Some nutrients (e.g. glutamine, arginine) may become limiting in critical illness and there is mounting evidence that provision of these will aid patient recovery.     

Malnutrition and Clinical Outcomes: The Case for Medical Nutrition Therapy

Malnutrition is not a new or a rare problem. In studies involving more than 1,327 hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Surgical patients with likelihood of malnutrition are two to three times more likely to have minor and major complications as well as increased mortality; and their length of stay can be extended by 90% compared with the stay of well-nourished patients. Hospital charges are reported to be from 35% to 75% higher for malnourished patients than for well-nourished patients. Obtaining data to assess the nutritional status of patients is essential to optimal patient care, especially for patients at high risk for malnutrition. Nutrition assessment can be done with readily available and relatively inexpensive methods. But it is not enough to assess and identify malnutrition. Outcomes are improved and costs are saved only when appropriate intervention follows. This article identifies many well-conducted, published studies that support the findings that health outcomes of malnourished patients can be improved and that overall use of resources can be reduced by nutrition counseling, oral diet and oral supplements, enteral formula delivered via tube, and parenteral nutrition support via central or peripheral line. Early nutrition assessment and appropriate nutrition intervention must be accepted as essential for the delivery of quality health care. Appropriately selected nutrition support can address the problem of malnutrition, improve clinical outcomes, and help reduce the costs of health care. J Am Diet Assoc. 1996; 96:361-366,369.     

Nutrition en cancérologie : aspects pédiatriquesNutrition and cancer in children

Cancer is associated with a high risk of malnutrition in children. This risk is different from one tumor to another, at the time of diagnosis and at any time of the disease course. Numerous tumor-related and treatment-related factors are involved. High dose-chemotherapy, with its specific side effects is particularly deleterious. Growth curves are of major interest for the long-term follow up of the nutritional status in children. The systematic use of nutritional risk scores is recommended, in order to improve prevention and early treatment of malnutrition. Nutritional supplies should meet the high protein and energy needs associated with cancer and its treatments. Oral and tube-feeding should be used preferably, according to digestive function. Peripheral parenteral nutrition may serve only as a complementary, short-term nutritional support. Central lines are required for all total and/or long term parenteral nutrition periods. Whatever the nutritional support, it can help to fulfil chemotherapy programmes, with benefit on remission duration and survival.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

Le cirrhotique face à la chirurgie : rôle de la dénutrition dans les complications infectieuses

Postoperative complications, particularly infectious complications, are more frequent in cirrhotic than in non-cirrhotic patients after abdominal surgery. This is probably the result of a decrease in antiinfectious mechanisms in cirrhotic patients, including humoral and cellular immunodeficiency and an increase in bacterial translocation. The immunodeficient status of cirrhotic patients is partly related to malnutrition. Several clinical studies have recently suggested that enteral and parenteral nutrition improve nitrogen balance and nutritional parameters in patients with chronic liver disease. Chronic or acute encephalopathy has also been improved as well as survival. However the beneficial effect of artificial nutrition on postoperative septic complications in cirrhotic patients has so far never been confirmed in a well conducted randomized study. Giving protein and energy support to patients with cirrhosis undergoing abdominal surgery, together with specific measures such as prevention of intraoperative bleeding, treatment of sodium and water retention, and antibiotic prophylaxis against intestinal gram-negative bacteria needs to be further investigated.