Diet, Social Restrictions Fail to Decrease Infections in Pediatric AML

Dietary, pet, and social contact restrictions did not have any effect on infectious complications in children undergoing intensive treatment of acute myeloid leukemia (AML), according to the results of a study published recently in Journal of Clinical Oncology.

“Our data suggest that a strict neutropenic diet and strict policies regarding restrictions of social contacts (eg, school attendance) and restrictions of pets at home during intensive chemotherapy for pediatric AML do not decrease the rate of infections,” wrote researchers led by Lars Tramsen, of Johann Wolfgang Goethe-University, Germany. “Therefore, changing this strict policy could improve the patients’ quality of life without increasing the risk of infectious complications.”

Infectious complications are a significant cause of morbidity and mortality among children undergoing treatment for AML. Many non-pharmacologic measures, such as dietary restrictions and restrictions on social or pet contact, are taken with these patients in an attempt to try to minimize infections.

In this study, Tramsen and colleagues used data from the AML-BFM 2004 trial to assess the effect of these non-pharmacologic restrictions on the incidence of infectious complications such as fever of unknown origin, bacteremia, pneumonia, and gastroenteritis. They surveyed 43 German institutions on the use of non-pharmacologic anti-infection measures.

“Our approach is novel, combining the daily practices of pediatric cancer centers with the results of a prospective multi-institutional trial,” the researchers wrote. “This approach has recently been applied for the first time, and it results in an intention-to-treat measure of supportive care.”

Some of the social restrictions evaluated included use of indoor public places, friends visiting at home, or daycare centers. Pet restrictions related to dogs, cats, turtles, hamsters, or guinea pigs at home, and food restrictions looking at raw seafood or meat, unpasteurized milk or cheese, and uncooked or unpeeled vegetables were evaluated.

“For decades, the concept of neutropenic diet has implied a strict limitation of foods allowed for patients with cancer, which may considerably decrease the quality of life,” the researchers wrote. “The theoretical rationale of the neutropenic diet is to limit the introduction of potentially harmful pathogens into the GI tract by restricting certain foods that might harbor those organisms.”

By analyzing the infectious complications seen in 339 children in this study, the researchers developed a scoring system with a restriction score for each item: social contacts (six items), pets (five items), and food (eight items). In the social restrictions category, with a highest possible score of 12, the median observed score was 9. For pet restrictions the median score was 8, and for food restrictions, the median score was 14.

When the researchers conducted a multivariable analysis adjusting for sex, age, weight groups, risk stratification, and antibiotic prophylaxis, they found that none of the restrictions scores for social contacts, pets at home, and food were significantly associated with the risk for fever of unknown origin, bacteremia, pneumonia, and gastroenteritis.

Instead, their analysis showed that patients who were underweight had an increased risk for fever of unknown origin compared with normal weight children or overweight children. Risk for bacteremia was significantly associated with risk stratification and prophylactic use of non-absorbable antibiotics. In addition, gastroenteritis risk was significantly associated with age, with a lower risk seen in older children.

“Future studies in children with all kinds of malignancies are needed to evaluate the impact of non-pharmacologic measures on the incidence of infections, the immune system, the quality of life, and overall clinical outcome,” the researchers wrote.