Pediatric Nutrition Guidelines for Discharge Home

When you return home after your transplant, your immune system is still functioning below normal. You may also have increased nutrient needs due to medications or loss of muscle mass. Calories, protein, fluid, vitamins, and minerals are necessary for you to regain your immunity, maintain or achieve your weight goal, strengthen your muscles, and feel better!

Food Safety

• Allogeneic patients should continue the "Immunosuppressed Patient Diet" until off all immunosuppressive therapy (such as prednisone, FK506, cyclosporine). Autologous patients should continue the diet during the first three months after transplant.
• When you discontinue the Immunosuppressed Patient Diet continue to use care when purchasing foods, preparing meals and dining out. Situations where you cannot control the cleanliness of the food put you at greater risk for acquiring a food-borne illness. Examples include salad bars, smorgasbords, delicatessens, bulk food bins, free food samples offered in stores. Review the Food Safety Guidelines in the Patient/Caregiver Manual.
• Continue to avoid herbal and other preparations, since they may contain harmful ingredients or infectious organisms. Herbs are not regulated for purity or for effect on health.
• If you rely on well water at home, have the water checked for purity at your local or county health department before using this water for drinking or food preparation. If you are unable to do this prior to moving home, you can boil the water at a full rolling boil for one minute prior to consumption or use in recipes. Boiled water may be stored up to three days in the refrigerator.

Calories and Body Weight

• Your goal is to maintain or achieve an appropriate weight for your body size.
• It is important to consume a nutritious diet including a variety of foods to promote recovery of your immune system.
• If you are underweight, weight gain may be slow after transplant. Set small goals (2-4 pounds or 1-2 kg per month). Don't skip meals or snacks. Drink beverages with calories and protein. Use supplements, such as Instant Breakfast®, Sustacal®, Ensure®, or Polycose®. Exercise to promote muscle gain.
• If you are overweight and medically stable (as determined by your physician and dietitian), you may choose to lose weight gradually - 1 pound/week. You must continue to eat a nutritious diet, following any special nutrition needs your dietitian has advised. Exercise is important prevent muscle loss.
• Calorie needs increase with fever, infection, and physical activity. Some people with Graft-versus-Host Disease (GVHD) may require more calories to maintain or gain weight.

Monitoring Height and Weight

Height and weight should be measured at your doctor's office: every month for pre-pubertal children or every three months following puberty. Record these values on the growth chart provided by your dietitian. When your child returns to Seattle for long-term evaluation, bring the growth chart with you.

Magnesium

• Cyclosporine and FK-506 increase magnesium loss from your body. Some people also lose magnesium due to other medications or after surgery, illness or autologous transplant. Supplementation (pill or intravenous infusion) is usually necessary. Your physician may need to adjust your magnesium dose based on your serum magnesium level.
• Magnesium-rich foods include nuts, bran cereals, brown rice and whole grain breads.

Fluid

• A high fluid intake helps flush your kidneys when you take medications that can impair kidney function, including Cyclosporine, FK-506, and some antibiotics.
• Serum (blood) Creatinine is a measure of kidney function. An above normal serum creatinine means that your kidneys are working below normal.

Blood Lipid Levels

Serum cholesterol and triglyceride levels can change after transplant due to medications including Cyclosporine and prednisone. If your cholesterol and triglyceride levels are elevated after transplant, have them remeasured two to three months after immunosuppressive drugs (Cyclosporine, prednisone, FK-506) are discontinued.

Normal Cholesterol and Triglyceride Ranges

Age:	Cholesterol (mg/dl)	Triglyceride (mg/dl)
Below 1 year	50-120	29-154
1-2 years	70-190	29-154
2-16 years	<200	29-154
Adults	<200	30-150

Vitamin and Mineral Supplements

Take a multiple vitamin/mineral supplement for one year following your transplant to ensure you get the vitamins and minerals you need while your body and immune system are recovering. A generic brand is fine. If you are considering taking any supplement (including antioxidants and herbal preparations) in addition to the vitamin/mineral supplement that has been recommended, discuss its' safety with your SCCA dietitian.

When selecting a supplement, it should:

• Contain NO iron.
• Not be greater than 200% of the Recommended Dietary Allowance (RDA)
• Contain NO herbs or other plant materials.

Recommended Supplements:

Children under 10 years: Fruity Chews, Sesame Street Vitamin Chewable Tablets (Follow the dose listed on the label for the age of your child.)
Children 10 years or older: Mature Balance, One-a-Day 55 Plus

Protein

Your protein needs were higher than normal early after transplant to allow repair of cell damage caused by chemotherapy and radiation. Protein continues to be an important part of your diet to promote recovery of your immune system. Your protein requirement returns to normal two to three months after transplant, unless you have lost a large amount of muscle or are taking prednisone. Protein-rich foods are listed below. Your dietitian will tell you your daily requirement.

Protein Content of Selected Foods

Food Item	Serving Size	Grams Protein
Beans: baked Refried	1/2 cup 1/2 cup	7 8
Cheese	1 oz. or 1" cube	7
Chicken: breast thigh or drumstick wing	1/2 1 1	27 14 8
Chicken Noodle Soup, Campbell's Healthy Request Chunky	1/2 cup 10 3/4 oz.	3 12
Cocoa, instant - mixed with milk	1 cup	11
Cooked beef, fish, lamb, pork: size of a deck of cards	3 oz.	21
Cottage cheese	1/4 cup	7
Egg	1	6
Hot dog	1 (10/lb.)	5-6
Ice cream or ice milk	1 cup	5
Luncheon meat: ham, turkey	1 oz.	5
Macaroni and cheese: Healthy Choice Stouffers Kraft Original	9 oz. 6 oz. 1 cup	15 11 11
Milk (nonfat, 2%, whole, buttermilk)	1 cup	8
McDonald's hamburger, single patty cheeseburger chicken nuggets shake	1 1 6 nuggets 1 regular	14 17 19 9
Peanut butter	1 Tbs.	4
Pizza: meat, vegetable, cheese	1/8 of 12"	13
Franco American Spaghettios with meatballs	1 cup	11
Pudding	1/2 cup	2 to 4
Taco Bellâ: taco	1	10
Tofu	1/2 cup	10
Tuna	1 oz. 1/6 can	7
Yogurt: Yoplait fruit	6 oz.	5
Pediasure	1 cup	8
Instant Breakfast (made with milk)	1 serving	15
ScandiShake made with 8 oz. milk	1 serving	14
Sustacal, Boost, Sustacal Plus	1 cup	14-15

Calcium and Vitamin D

Calcium is essential for bone health, especially in:

• Adult females with hormonal changes
• Children and teens
• People taking prednisone

Vitamin D is needed for calcium absorption and transport to the bones. Food sources include fortified milk (100 IU/8 ounces); canned tuna and salmon (200-300 IU/3 ounces), fortified cereals (40-80 IU/serving), Carnation breakfast bars (100 IU/bar).

Calcium and Vitamin D Requirements after Transplant

Age:	Calcium		Vitamin D
	Adequate Intake	During Prednisone	Adequate Intake	During Prednisone
0-6 months	210 mg	400 mg	200 IU	300 IU
6-12 months	270 mg	600 mg	200 IU	400 IU
1-3 years	500 mg	800 mg	200 IU	400 IU
4-5 years	800 mg	800 mg	200 IU	400 IU
6-8 years	800 mg	1200 mg	200 IU	400 IU
9-18 years	1300 mg	1600 mg	200 IU	400-800 IU

Choosing a calcium supplement

If you are not able to get the amount of calcium you require from foods, you should take a calcium supplement. Choose a supplement with vitamin D if your intake of vitamin D from food and your multiple vitamin supplement does not meet your requirement.

There are two main types of calcium supplements: calcium citrate and calcium carbonate. The following table shows the differences between these supplements and the best time to take them. Note: if you are taking a prescription to decrease stomach acid or use antacids on a daily basis, calcium citrate is recommended (instead of calcium carbonate).

Calcium Citrate (Citracal)	Calcium Carbonate (Tums, Oscal, Caltrate)
Can be taken any time during the day.	Must to taken with meals or snacks for best absorption.
Does not require stomach acid for absorption.	Requires stomach acid for absorption. Do not take with antacids.
Gentle on stomach.	May cause gas, constipation, bloating
	Look for "USP" on label or box (confirms pill will dissolve in normal stomach acidity.)

Calcium Content of Selected Foods

Food	Serving Size	mg Calcium
Cheddar cheese	1 oz. or 1" cube	200
Swiss cheese	1 oz.	270
Cottage cheese	1/4 cup	35
Cream cheese	1 Tbs.	12
Kraft string cheese stick	1 oz.	150
Kraft processed American cheese slice	3/4 oz. slice	100
Kraft parmesan cheese	1 Tbs.	69
Beans: baked or refried	1/2 cup	65
Calcium-fortified orange juice	1/2 cup	150
Cocoa, instant - made with water made with milk	1 cup 1 cup	95 315
Cream soup (made with milk)	1 cup	180
Ice cream or ice milk	1/2 cup	85
Macaroni and cheese: Frozen: Healthy Choice Stouffers Made from box mix: Kraft Original	9 oz. 6 oz. 1 cup	300 240 100
Milk (nonfat, 2%, whole, buttermilk)	1 cup	300
Milk, calcium fortified	1 cup	400
McDonald's shake	1 shake (10 oz.)	325
Pizza: meat, vegetable, cheese	1/8 of 12" pie	100
Pudding: Del Monte or Snack Pack pudding cup Jello pudding snack Instant, made from mix	3.5 oz. 4 oz. 1/2 cup	50-60 94 150
Tofu	1/2 cup	130
Yogurt: Yoplait fruit flavor Dannon fruit flavor	6 oz. 8 oz.	200 350
Pediasure	1 cup	230
Instant Breakfast (made with 8 oz. milk)	1 serving	500
ScandiShake (made with 8 oz. milk)	1 serving	400
Sustacal, Boost, and Sustacal Plus	1 cup	200
Citracal	1	200
Citracal + D (200 IU vitamin D per pill)	1	315
Tums: Regular Strength E-X Ultra	1 1 1	200 300 400

Nutrition Guidelines During Prednisone Treatment

• Protein: A protein-rich diet and exercise can help prevent muscle loss. Include a protein-rich food in every meal and consume 2 to 3 protein-rich beverages or snacks daily. Exercise can include walking, bicycling, low-impact aerobics.
• Calcium: Consume a calcium-rich diet and exercise daily to minimize bone loss. If your calcium intake is low, take a supplement of calcium carbonate (such as Tums) or calcium citrate (such as Citracal).
• Sugar (carbohydrate, glucose): If your blood glucose level is above normal, discuss with your dietitian or doctor whether dietary changes or insulin therapy are needed. You may be able to improve your blood glucose levels by avoiding sugar-containing beverages and fruit juices, and being careful to avoid eating more energy (calories) than your body needs.
• Potassium: You may need more potassium in your diet while taking prednisone. The following are good sources of potassium: bananas, oranges and orange juice, canteloupe, Instant Breakfast, beans (chili, kidney, refried, etc.), potatoes, Sustacal, Boost, tomatoes, tomato juice, V-8, winter squash, ScandiShake (Your dietitian can give you a more complete list.)
• Salt: A high salt intake can worsen fluid retention caused by prednisone. Avoid salt and salty foods such as canned, instant, and frozen soups and entrees, soy sauce, cured meats, and packaged sauces and seasonings. In general, processed foods contain too much salt.

Discuss With Your Doctor If:

• Your weight drops more than 2 pounds (1 kg) in 7 days
• You develop nausea, vomiting, diarrhea, stomach or intestinal cramps
• Your mouth becomes drier, sensitive, or develops sores
• You have swallowing difficulties

Resources

If you have nutrition questions after returning home, contact a SCCA dietitian:

Seattle Cancer Care Alliance
Nutrition Services Department
825 Eastlake Ave. E. - 6-206
PO Box 19023
Seattle, WA 98109-1023
Phone: 206/288-1148 Fax: 206/288-6615

	Adult Nutrition Guidelines
	Diet Guidelines
	Gastrointestinal Diet 1
	Gastrointestinal Diet 2
	Pediatric Nutrition Guidelines
	Water Safety Guidelines