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.     

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.     

Dénutrition périnatale : prise en charge nutritionnelle spécifique du nouveau-né

Malnutrition is quite rare in neonates. However perinatal malnutrition occurs in two situations. Fetal malnutrition leading to intra-uterine growth retardation with a birth weight below the lower limit for gestational age. On the other hand a postnatal relative malnutrition ("extra-uterine" growth retardation) which occurs mainly in preterm neonates. Both these situations need specific nutritional care after birth but also during the first years of life as there is probably a relationship between post-natal nutrition and health in adults (Barker hypothesis).     

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.     

Mécanismes de la dénutrition chez l'enfant et l'adolescent

Malnutrition in child and adolescent is observed in various situations where there is an imbalance between the food intakes and caloric and proteic needs. Child is particularly vulnerable because its reserves are weak and its high caloric and proteic needs because of its growth. Various mechanisms leading to malnutrition were brought back and correspond to distinct clinical entities. The situations of malnutrition by exclusive mechanism of intake deficiency meet primarily in third world where they can take the form of starvation, extreme adaptive situation with prolonged fast. During situations known as of aggression like severe sepsis, polytraumatism, extended burn, surgery, malnutrition can settle quickly. Mechanism brought back in situation of acute aggression is defined classically like related to hypermetabolism with hypercatabolism. Kwashiorkor, another type of caloric and proteic malnutrition concerning child in third world, cannot be regarded as a simple caloric and proteic deficiency. It currently seems that a deficiency at the same time in macronutriments and micronutriments plays a part in genesis of this pathology. The glutathion seems in particular, to play a fundamental part in the kwashiorkor's pathophysiology. The most documented hypothesis relates imbalance between production of free radicals and mechanisms of defence. Mechanisms of repair would be insufficient, and persistence of membrane deteriorations would cause anomalies observed in kwashiorkor like oedema, hepatic overload, neurological disorders and diarrhoea.     

Prise en charge nutritionnelle périopératoire du patient obèse

Recommendations for perioperative nutrition in obese subjects require considering the following evidences. Obesity has long been falsely considered a risk factor for poor outcomes from a variety of surgical procedures, yet recent studies of critically and chronically ill patients suggest that overweight and obese patients may paradoxically have better outcomes than normal weight patients. Preoperative weight loss should be considered as a risk factor of postoperative complications in obese subjects as in normal weight patients. Obese patients could be malnourished because of vitamin deficiencies and of sarcopenia. The prevalence of vitamin deficiencies in the morbidly obese population prior to surgery is high, especially for vitamins B1, B12, B9, A, C, D and E. Standard of care should include perioperative thiamine replacement, especially in case of prolonged vomiting. Vitamin B12 deficiency could appear fast after gastric or ileal surgery, and iron deficiency is more frequent. Low caloric diet is not recommended in obese subjects before surgery, especially for the elderly, because of the frequent sarcopenia in this population. Energy and protein recommendations are not easy to be determined in obese subjects. Recommended allowance for protein should be defined according of the fat free mass, which is not easy to evaluate in clinical practice. So it is recommended to use a normalized weigh for a theoretic BMI between 25 and 30 kg/m². The loss of muscle mass can be very fast in the postoperative period in these subjects. The nutritional objective of care is to preserve skeletal muscle mass and to enhance the protein balance.     

Prise en charge nutritionnelle préopératoire

Undernutrition is an independent factor of postoperative morbidity and mortality. The aim of a preoperative nutritional support is to enhance immune, muscular and cognitive functions, and to support wound healing. This nutritional support (e.g. dietary management, enteral or parenteral nutrition) should be limited to high-risk situations with a beneficial effect of nutrition for the patient: undernutrition, major surgery and elderly. Preoperative nutritional support should be scheduled for at least 7 to 10 days before the surgery. During the preoperative period, the type and route of an eventual postoperative nutritional assistance should be anticipated. In the case of emergency surgery, nutritional assessment of the patient should be done as soon as possible before surgery or in the 48-h postoperative period. Finally, in elective surgery, preoperative fasting should be limited to 2–3 hours for clear liquids and 6 hours for solids.     

Prévention et prise en charge de la dénutrition dans les EHPAD

In order to identify best practices for undernutrition prevention and management in the 597 institutions for the dependent elderly in Pays de la Loire, two questionnaires were sent in early 2009. Three-quarters had a nutritional axis in their care project, 25% worked with a Diet and Nutrition Liaison Committee (CLAN), and 67% with dieticians; 70% had less than 25% of their staff recently trained to food-nutrition for the elderly. Two thirds were conducting detection of malnutrition at admission and during follow-up. There was enough time for meals in 60% cases, and 48% had all their residents who underwent a long overnight fast. Among beneficial environmental factors identified, the nutritional axis in the care project seemed to be a major determinant of food-nutrition practices. In conclusion, these results show the real structures involvement in this field in the region, but some practices must be further improved. Nutritional policies seem to be a major way to achieve.     

Évaluation et prise en charge des troubles de la déglutition

Swallowing is a complex phenomenon, allowing per os feeding but with a protection of respiratory tract. Swallowing disorders are frequent, involve liquids, solids or theses two textures, and are mainly caused by neurological or otorhinolaryngological diseases. They may have severe consequences, like an alteration of quality of life for patients or their relatives, an increased risk of aspiration, of malnutrition or dehydration, and finally a possible decrease of survival. Assessment includes careful questioning and physical examination. The reference complementary investigation is videofluoroscopic evaluation. Nutritional assessment is mandatory. Taking care of swallowing disorders in a multidisciplinary manner is recommended, with interventions of physician, speech therapist, dietician, sometimes dentist or surgeon, and needs a strong contribution of the paramedical staff and the patient relatives. Enteral nutrition is recommended when repeated or severe respiratory complications occur, when the nutritional status is altered in spite of feeding enrichment, modulations of textures or use of oral nutritional supplements, or when the meals are too long.     

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.     

Conséquences de la dénutrition chez l'enfant et l'adolescent. Mortalité, morbidité, conséquences médicoéconomiques

In the developed countries, the sick children are at risk of protein-energy malnutrition (PEM). Marasmus is the most common form of severe PEM in such children. Its major characteristics are low muscle and fat masses with the presence of marked facial, axillary and inguinal skinfolds. Furthermore the marastic children are irritable and depressed. When the PEM is moderate, which is more frequent, the affected children present a failure to thrive. Severe and moderate PEM have multiple functional consequences on different systems and organs with an impact on mortality, morbidity and costs. In this paper, the functional consequences on the immune system, digestive tract, liver, lung, heart, kidney, skin, bone and brain are passed in review. To end, some comments are done about the particularities of PEM in mental anorexia and obesity.     

Nutrition artificielle : utilité ou futilité chez l'enfant en situation palliative

Palliative care are intended to children with life limiting conditions. In France, for the majority of pediatric team, the idea of continuity of cares is essential for the announcement of the diagnosis to the final state. The author describes here different situations according to the initial disease of these children. In all cases, the choices of artificial feeding depend of pluridisciplinary medical teams and their experience, and of family opinion. Ethical consideration must be present in this decision.     

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.     

Connaissances et attentes d’une communauté d’internautes hypercholestérolémiques sur leur prise en charge nutritionnelle

Hygienodietetic recommendations are poorly followed by hypercholesterolemic subjects despite general practitioners’ advices. We aimed at determining the reasons for this failure. We studied an Internet community made of hypercholesterolemic subjects in order to assess their level of knowledge, their wish to learn and to take care of themselves. The nutritional solution of hypercholesterolemia is perceived as a daily effort. In that context, doctor's advices are crucial. However, mainly due to lack of time and tools, these advices are not adequately delivered to the subjects. Patients are therefore ready to look for information on Internet. The dietary changes are therefore limited rather because of a lack of knowledge than a lack of will. Internet became a daily and essential reference for searching information, which should be considered as complementary to the doctor. Our study showed that patients are ready to use the Internet in order to learn how to better manage their cholesterol and to be better informed.     

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.     

Prise en charge nutritionnelle des troubles du comportement alimentaire chez l'adolescent

This review underlines the importance of a structured nutritional treatment in eating disorders particularly in anorexia nervosa, its physiopathological bases and influence on short and long term prognosis of the disease. Somatic and neuropsychological effects of undernutrition, their consequences in terms of morbidity, mortality and sequelae are underlined. The modalities of refeeding at home and during hospitalisation, the necessity of renutrition to a right target weight, and, after that, the importance to work for maintaining a good nutritional state are indicated. The frequency of relapses (around 50%) is underlined, as well as the importance of "therapeutic alliance" between physicians and families (and, as soon as possible, with anorectic adolescent) and the advantage of a good collaboration between psychiatric and pediatric teams. They discuss more briefly about nutritional aspects of bulimia management. Finally the authors state on their own results about 161 patients followed for more than 4 years of which 144 participate in an evaluation (68% of good, 23.3% of intermediary and 8.7% of bad results) attesting of progress versus an anterior evaluation and best results than 2 other studies, published in 1991 and 2001, with the same tests for evaluation.     

Place de la pharmaconutrition en périopératoire

Since 20 years, data from high quality studies have demonstrated that perioperative immunonutrition is able, even in well-nourished patients, to reduce septic complications, length of stay and costs, in elective digestive cancer surgery. Then update of recommendations for clinical practice has been proposed. As this treatment is effective, French system reimburses the cost of treatment since 2006. Educational programme is now necessary to diffuse state of art.