The emerging role of nutritional support in the supportive care of pediatric patients undergoing hematopoietic stem cell transplantation

Abstract

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) represents a potentially curative strategy for many oncological, hematological, metabolic, and immunological diseases in children. The continuous effort in ameliorating supportive care represents one of the cornerstones in the improvement of outcome in these patients. Nowadays, more than ever nutritional support can be considered a key feature. Oral feeding in the early post-transplant period is severely impaired because of mucositis due to conditioning regimen, characterized by, mainly by vomiting, anorexia, and diarrhea. Gastrointestinal acute graft-versus-host-disease (GvHD), infections and associated treatments, and other medications, such as opioids and calcineurin inhibitors, have also been correlated with decreased oral intake. The consequent reduction in caloric intake combined with the catabolic effect of therapies and transplantation-related complications with consequent extended immobilization, results in a rapid deterioration of nutritional status, which is associated with decreased overall survival and higher complication rates during treatment. Thus, nutritional support during the early post-transplantation period becomes an essential and challenging issue for allo-HSCT recipients. In this context, the role of nutrition in the modulation of the intestinal flora is also emerging as a key player in the pathophysiology of the main complications of HSCT. The pediatric setting is characterized by less evidence, considering the challenge of addressing nutritional needs in this specific population, and many questions are still unanswered. Thus, we perform a narrative review regarding all aspects of nutritional support in pediatric allo-HSCT recipients, addressing the assessment of nutritional status, the relationship between nutritional status and clinical outcomes and the evaluation of the nutritional support, ranging from specific diets to artificial feeding.

Nutritional interventions in patients with graft-versus-host disease

“…In the months leading up to the allo-HCT procedure, induction and consolidation chemotherapies performed to control the underlying disease induces side effects (diarrhea, nausea, mucositis, and infections) that potentiate the disease's catabolic and anorectic effects, harming one's nutritional status. Malnutrition before and during allo-HCT is a recognized risk factor that influences short-term clinical outcome, survival, and GvHD regardless of age [3,4 ▪ ,5,6]. A study evaluated a composite anthropometric score in a pediatric population using a ROC curve.…”

“…Furthermore, ESPEN recommends patients maintain physical activity and ensure adequate nutritional intake. Doctors may advice the additional use of oral nutritional supplements when the diet is insufficient to meet nutritional goals, but they have no reported effect on GvHD [4 ▪ ]. Although oral glutamine supplementation was shown to reduce the incidence of GvHD, no studies have confirmed this effect in the last 15 years.…”

“…Conversely, parenteral nutrition is unable to fight against epithelial atrophy following intestinal fasting. Parenteral nutrition is also responsible for more catheter-related infections, metabolic disorders (hyperglycemia, hypertriglyceridemia, hepatic disorders), thrombopenia, and complications linked to allo-HCT procedures such as sinusoidal obstruction syndrome [4 ▪ ,37,38,39 ▪▪ ,40,44].…”

The Efficacy of Three Different Oral Hygiene Regimens in Preventing Chemotherapy-Induced Oral Mucositis in Pediatric Patients Receiving Hematopoietic Stem Cell Transplantation

“…In addition, OM increases the risk of infection by causing the need for total parenteral nutrition due to oral nutrition intolerance of the patient. Nutritional deficiency caused by mucositis directly contributes to increased mortality in children who have had a transplant [5]. Since patients are immunosuppressed due to chemotherapy, oral lesions can lead to severe, life-threatening sepsis [6].…”

Caregiver self-efficacy providing nutritional support for pediatric patients undergoing hematopoietic stem cell transplant is associated with psychosocial factors

“…Children undergoing hematopoietic stem cell transplant (HSCT) are required to follow strict medical regimens, including taking medication, deploying behavioral strategies to minimize infections, and following dietary guidelines. Adhering to these dietary guidelines can be particularly challenging as pre-HSCT conditioning regimens can adversely affect their food intake ( 1 ), much like infections, various medications, and the well-described post-HSCT complication, graft-vs.-host disease ( 2 , 3 ).…”