Oral nutritional supplements tolerance and compliance in pediatric oncology

Introduction. Patients treated with chemotherapy and hematopoietic stem cell transplantation (HSCT) often suffer from complications that have a negative impact on appetite and the functional ability of the digestive system, which can lead to the malnutrition – a factor of poor overall survival prognosis in hematology. Oral nutritional supplementation is one of the nutrition support (NS) types, which is currently developing by improving the taste properties and optimizing formula chemical composition, but is an underestimated NS option in clinical practice.

The aim of the study – to evaluate oral nutritional supplements (ONS) tolerability and compliance in pediatric oncology patients during anticancer treatment.

Materials and methods. From 2015 to 2022, in the Raisa Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantation, First Pavlov State Medical University of St. Petersburg, Ministry of Health of Russia 988 cases of oral nutritional supplementation in patients from birth to 18 years old, with acute leukemia – 49.5 % (n = 489), hereditary diseases – 17.4 % (n = 172) and solid tumors – 16.9 % (n = 167) were included to a retrospective analysis. The median age was 7 (3–13) years. Male patients were in 61 % of cases (n = 603), female patients – 39 % (n = 385). In 74.2 % of cases (n = 733) allogeneic HSCT was used as a treatment option, in 22.4 % (n = 221) chemotherapy and autologous HSCT, in 3.4 % (n = 34) surgery, 11 of them as a primary tumor removal, 23 as a part of the main treatment’s complications cure. At the time of sipping initiation in 50.7 % of cases (n = 501), there was hyporexia, in 26.8 % of cases (n = 265) maldigestion, in 27.2 % (n = 269) malabsorption. In 54.6 % of cases (n = 203), a chronic graft-versus-host disease (GVHD) was observed, including the mucous membranes and gastrointestinal tract involvement. In 1.8 % of cases (n = 18), ONS was used in combination with breastfeeding, in 2.8 % (n = 28) with enteral nutrition and in 15.1 % (n = 149) with parenteral nutrition. The formula composition included standard (n = 766), semi-elemental (n = 97), balanced infant formula (n = 89) and specialized (n = 36) samples. The sipping usage in the relation of HSCT onset was preventive (n = 130), in the early period – up to D+30 (n = 212), D+31–100 (n = 182), D > +101 (n = 400).

Results. Good ONS tolerability in the general cohort of patients was in 96.1 % (n = 948). Cases of poor tolerance were noted in 3.9 % of patients (n = 38). The factors that matched children with reduced sipping tolerance compared with acceptable one were: age – median 13.5 (4.0; 15.8, Q₁ –Q₃ ) and 7 (3.0; 12.0, Q₁ –Q₃ ) years, p = 0.002; presence of chronic GVHD – 91.3 % (n = 21) and 52 % (n = 181), p = 0.001; unpleasant formula taste – 42.1 % (n = 16) and 12.1 % (n = 115), p < 0.001, respectively. The effectiveness of sipping was evaluated before and after therapy based on the dynamics of body mass index (BMI) in three age groups: 14.5 (13.1; 16, Q₁ –Q₃ ) and 14.5 (13.4; 16.0, Q₁ –Q₃ ) in patients 2–8 years old, p = 0.12; 15.2 (13.7; 17.3, Q₁ –Q₃ ) and 14.7 (13.6 and 16.4, Q₁ –Q₃ ) in patients 9–12 years old, p = 0.009; 17.1 (14.6 and 19.9, Q₁ –Q₃ ) and 16.3 (14.3 and 18.4, Q₁ –Q₃ ) in patients aged 13–18 years, p = 0.0000. These results indicate that oral nutritional supplementation alone or as part of NS allow maintaining BMI within the average age standards, but only in younger patients in comparison with adolescents. In the group of patients with allogeneic HSCT (n = 731) in comparison with the general cohort of patients included in the follow-up, reduced ONS tolerance was determined somewhat more often – in 4.5 % of cases (n = 33). Chronic GVHD (91.3 %, n = 21, p = 0.001) was identified among the factors influencing the risk of developing reduced formula tolerance, while hyporexia (36.4 %, n = 12, p = 0.28), maldigestion (30.3 %, n = 10, p = 0.73) and malabsorption (42.4 %, n = 14, p = 0.1) did not have a negative effect. In 86.7 % of cases, patients characterized the sipping taste like: “I enjoy it”; and in infants, the criterion of adequate compliance was the absence of baby bottle rejection. Among the subjects who used sipping for more than one week with a pleasant taste for them (n = 810), 8.8 % (n = 79) developed formula rejection. In the group of patients with reduced compliance (n = 131) – who initially did not like the ONS taste and texture – an increase in the frequency of poor tolerability was noted from 2.6 to 12.2 % (n = 16), p < 0.001. Combined NS was also more often required: enteral nutrition 1.6 % (n = 14) and 10.7 % (n = 14), parenteral nutrition – 13.2 % (n = 113) and 27.5 % (n = 36), respectively, p < 0.001. Conclusions. Oral nutritional supplementation is an essential part of NS in pediatric oncology and hereditary diseases treatment, including the HSCT, which, on the example of patients with malfunctioned digestive system, has an appropriate tolerance and compliance.

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