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Algorithm for nutritional support: experience of the Metabolic and Infusion Support Service of St. Jude Children's
L C Bowman1, R Williams, M Sanders
1Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA. laura.bowman@stjude.org
Insights
The Metabolic and Infusion Support Service (MISS) developed an algorithm to optimize nutritional support for pediatric cancer patients. This led to increased use of enteral nutrition, improving patient care quality.
Area of Science:
- Pediatric Oncology
- Clinical Nutrition
Background:
- The Metabolic and Infusion Support Service (MISS) was established in 1988 at St. Jude Children's Research Hospital.
- It is a multidisciplinary team focused on enhancing nutritional support for children undergoing cancer therapy.
Purpose of the Study:
- To implement and evaluate an algorithm for nutritional support in pediatric cancer patients.
- To improve the quality and appropriateness of enteral versus parenteral nutrition.
Main Methods:
- Development of a nutritional support algorithm in 1991, prioritizing enteral nutrition for patients with functional gastrointestinal tracts.
- Annual monitoring of algorithm compliance from 1992 to 1994.
- Revision of the algorithm in 1994 to include oral supplementation criteria and patient stratification.
Main Results:
- Algorithm compliance reached 93% in 1992, 95% in 1993, and 100% in 1994.
- The algorithm's adoption resulted in a threefold increase in enteral nutritional support, particularly via gastrostomies.
- Patients were classified based on their ability to tolerate gastrointestinal feeding.
Conclusions:
- The implemented algorithm significantly improved the utilization of enteral nutrition.
- The MISS continues to refine nutritional intervention timing for optimal patient outcomes in pediatric cancer therapy.
Abstract:
The Metabolic and Infusion Support Service (MISS) at St. Jude Children's Research Hospital was established in 1988 to improve the quality of nutritional support given to children undergoing therapy for cancer. This multidisciplinary group, representing each of the clinical services within the hospital, provides a range of services to all patients requiring full enteral or parenteral nutritional support. In 1991, the MISS developed an algorithm for nutritional support which emphasized a demand for a compelling rationale for choosing parenteral over enteral support in patients with functional gastrointestinal tracts. Compliance with the algorithm was monitored annually for 3 years, with full compliance defined as meeting all criteria for initiating support and selection of an appropriate type of support. Compliance rates were 93% in 1992, 95% in 1993 and 100% in 1994. The algorithm was revised in 1994 to include criteria for offering oral supplementation to patients whose body weight was at least 90% of their ideal weight and whose protein stores were considered adequate. Full support was begun if no weight gain occurred. Patients likely to tolerate and absorb food from the gastrointestinal tract were classified into groups defined by the absence of intractable vomiting, severe diarrhea, graft-vs.-host disease affecting the gut, radiation enteritis, strictures, ileus, mucositis and treatment with allogeneic bone marrow transplant. Overall, the adoption of the algorithm has increased the frequency of enteral nutritional support, particularly via gastrostomies, by at least 3-fold. Our current emphasis is to define the time points in therapy at which nutritional intervention is most warranted.