Reduced energy requirements during pediatric allogeneic hematopoietic stem cell transplantation measured by indirect calorimetry.
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BACKGROUND & AIMS: Although nutritional therapy is crucial for children undergoing allogeneic hematopoietic stem cell transplantation (HSCT) standard equations used for calculating energy requirements in healthy children may be misleading in these heavily treated patients. High-dose chemotherapy, total body irradiation, and acute graft-versus-host disease may increase energy needs, while immobilization may reduce it. This study aimed to assess energy requirements during HSCT in children and compare resting energy expenditure (REE) measured by indirect calorimetry (IC) with REE calculated using standard equations for healthy children. METHODS: We included 12 children (9 males) undergoing myeloablative HSCT for benign diseases (n = 6) or malignant disorders (n = 6). REE was measured by IC before conditioning, at day of transplant, and between days +7-14, +21-28 and beyond day +90 post transplantation, under generally standardized conditions. A planned fasting interval could not always be achieved due to clinical needs, and in 16/53 cases, measurements were performed approximately 2 h after the last meal. REE was further calculated using The Oxford Equation for REE in healthy children, based on the patients' weight at referral to transplant. Energy intake, enteral and parenteral nutrition (PN) including intravenous fluids, were recorded. RESULTS: Measured REE decreased during the early phase of transplantation, reaching a nadir at day +7-14 post-transplant (1408 vs 1154 kcal, p = 0.007), corresponding to 89.9 % of the calculated REE (75.8-93.4 %, P = 0.007), indicating a risk of overestimation of energy expenditure by the standard equation during the most toxic phase of the treatment. Dietary intake was generally reduced during the study period, with the most significant reduction observed at day 0, prior to initiation of parenteral nutrition (PN). At this time point, median intake covered 35 % of measured REE (26-52 %) and was given primarily through glucose-containing IV fluids. On day +7-14, where 92 % (11/12) of the patients received PN, measured REE requirements were covered by the diet in 50 % of patients. On day 21-28, where 50 % of patients remained on PN, 19 % of REE was met, while on day 90, when none of the patients received PN, sufficient coverage by enteral intake was observed in 7/9 patients (77 %). CONCLUSION: Our findings suggest that the standard equation for calculating REE may overestimate energy needs during the early toxic phase of pediatric HSCT. However, even with these conservative estimates based on IC measurements, energy needs are not sufficiently met in a significant proportion of the patients. Overall, this study emphasizes the importance of increased focus on individualized dietary support based on measured energy demands.