Construction of a nutritional assessment tool for the pediatric cancer population (ANPEDCancer): content validation using the Delphi method

Saraiva, Danúbia da Cunha Antunes; Martucci, Renata Brum; Monteiro, Gina Torres Rego

doi:10.1590/1984-0462/2023/41/2021126

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Revista Paulista de Pediatria

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Original Article • Rev. paul. pediatr. 41 • 2023 • https://doi.org/10.1590/1984-0462/2023/41/2021126 copy

Construction of a nutritional assessment tool for the pediatric cancer population (ANPEDCancer): content validation using the Delphi method

Construção de um instrumento de avaliação nutricional para a população pediátrica com câncer (ANPEDCancer): validação de conteúdo pelo método Delphi

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To develop and establish content validation of a nutritional assessment tool for pediatric cancer patients using the Delphi method.

Methods:

A literature review was performed and the nutritional assessment in pediatrics and cancer construct was discussed with experts. Forty-six nutrition experts from Brazil with experience in oncology participated in the panel. Rounds were held to discuss and judge the items that should be included in this tool. With the aid of an algorithm, it was possible to simultaneously consider the adequacy, relevance and measurement of the items. The consensus was reached with an agreement equal to or greater than 80% among the experts.

Results:

From the 7 domains suggested by the literature, the first round generated 81 items, which were assessed for adequacy, relevance and the possibility of being measured in the routine of nutritional assessment, by specialists in the following two rounds. The percentage of specialists who responded to each round was high (above 90%) and the dropout rate between the stages was relatively low. After applying the algorithm, the ANPEDCancer tool had 36 items considered appropriate by specialists from the five different geographical regions of Brazil.

Conclusions:

The Delphi method allowed the construction and content validation of the nutritional assessment tool for children and adolescents with cancer, providing the first stage for use in the Brazilian hospital setting.

Keywords:
Nutrition assessment; Pediatrics; Delphi technique; Consensus; Validation study

			n (%)
Gender
	Female		45	(97.8)
	Male		1	(2.2)
Academic degree
	PhD		4	(8.7)
	Master		11	(23.9)
	Specialization		30	(65.2)
	Graduation		1	(2.2)
Years of experience in pediatric oncology, median (min.-max.)			6	(2–20)
State of professional activity		1^st Round	2^nd Round	3^rd Round
Midwest region		5 (10.9)	5 (11.9)	5 (12.8)
	Federal District	2	2	2
	Goiás	1	1	1
	Mato Grosso	1	1	1
	Mato Grosso do Sul	1	1	1
Northeast region		9 (19.6)	8 (19)	7 (18)
	Bahia	3	3	3
	Maranhão	1	1	1
	Pernambuco	2	2	2
	Rio Grande do Norte	2	1	1
	Sergipe	1	1	0
North region		6 (13)	6 (14.3)	5 (12.8)
	Acre	1	1	1
	Amazonas	1	1	1
	Pará	3	3	3
	Roraima	1	1	0
Southeast region		20 (43.5)	17 (40.5)	17 (43.6)
	Espírito Santo	1	1	1
	Minas Gerais	2	2	2
	Rio de Janeiro	7	6	6
	São Paulo	10	8	8
South region		6 (13)	6 (14.3)	5 (12.8)
	Paraná	2	2	2
	Rio Grande do Sul	1	1	1
	Santa Catarina	3	3	2
Total		46	42	39

Domains	Items	Consensus (%)
Anthropometric assessment	Include all anthropometric indicators	80.9
Anthropometric assessment	Use anthropometric indices and MUAC	82.0
Adequacy of food intake	Include: food preferences, allergies, restrictions	88.1
	Change in the text: “did not present a reduction in food intake or maintained a good dietary pattern”	80.9
	Change in the text: “in the last days”	80.9
	Use a scale to quantify food intake	80.9
Body weight adequacy	Use weight loss percentage calculation	92.9
	Add: presence of edema	95.2
	Assessment of weight evolution in patients regardless of age	83.3
Gastrointestinal symptoms	Inappetence/hyporexia	95.2
	Anorexia	88.1
	Diarrhea	97.6
	Constipation	90.5
	Nausea/urge to vomit	97.6
	Vomiting/emesis	97.6
	Mucositis in GIT	100
	Dysgeusia/altered taste	92.9
	Odynophagia	92.9
	Dysphagia	100
	Xerostomia	90.5
	Abdominal pain/discomfort	90.5
	Oral cavity injury	95.2
	Gastroesophageal reflux	80.95
	Enterocolitis	80.95
	Abdominal distension	88.1
Clinical/oncological condition	Include in high nutritional risk: patient in a pediatric intensive care unit	88.1
Physical exam	Assess oral cavity (mucositis, moniliasis)	83.3
	Assess abdomen (flaccid, globular, tense, distended)	92.9
	Assess the presence of a bulky mass (abdominal, lower and upper limbs, neck)	80.9
Nutritional diagnosis/plan of action	Plan of action – eutrophic	95.2
	Plan of action– nutritional risk	97.6
	Plan of action – malnourished	95.2
	Plan of action – risk of/or overweight/obesity	92.9
	Reassessment: nutritional risk (mean 6.2 days)	89.7
	Reassessment: malnourished (mean 6.8 days)	84.6
	Routine assessment should be based on current nutritional diagnosis	89.7

Clinical/Oncological Condition
High nutritional impairment	Medium nutritional impairment	Low nutritional impairment
□ Medulloblastoma □ Neuroblastoma □ Wilms tumor □ Osteosarcoma □ Ewing sarcoma □ Rhabdomyosarcoma □ Acute myeloid leukemia □ Hodgkin lymphoma □ Head and neck tumors □ Diencephalic and Other CNS tumors □ Irradiation of the gastrointestinal tract □ Bone marrow transplantation □ Leukemia in relapse situations and high-risk group (protocol) □ Extensive abdominal surgery □ Presence of fistulas □ Frequent cycles of chemotherapy (interval ≤ 3 weeks) □ Highly emetogenic chemotherapeutics (e.g.: cisplatin, Cyclophosphamide (CTX), Methotrexate (MTX)) □ Gastrointestinal postoperative period (< 4 weeks) □ Organ failure (kidney, liver, lung, heart) □ Clinical conditions (HIV, colitis, pancreatitis) □ Metabolic abnormalities (acidosis, alkalosis, hypoglycemia, hyperglycemia) □ Infants (< 2 years) □ Patients in severe conditions (ICU)	□ Good prognosis of acute lymphocytic leukemia (Low Risk according to protocol) □ Oncological diseases in remission or during maintenance treatment; □ Chemotherapy with corticosteroids (such as prednisone; methylprednisone, dexamethasone); □ Non-metastatic solid tumors (which are not listed in the High-risk group) □ Fever (> 37.5°C, for 2 consecutive days)	□ Absence of fever in the last 48h* □ Absence of use of corticosteroids* *provided it does not meet any of the above conditions

Nutritional diagnosis	Plan of action
Malnutrition	Reassess within 7 days. Optimize oral nutritional supplementation and/or indication of an alternative route for nutritional therapy. Regain nutritional status through adequacy of nutritional needs and symptom management. Nutritional education. Carry out individualized nutritional planning, considering the reported changes and daily monitoring. Immediate nutritional supplementation, offer tube feeding (nasoenteral or gastrostomy) if intake is <60% of what was planned, for 3 consecutive days.
Nutritional risk	Reassess within 7 days. Nutritional therapy best suited to the case (oral or enteral). Nutritional guidance and education. Adequacy of diet according to habits with the inclusion of more caloric foods (with good nutritional value). Regain nutritional status by adjusting nutritional needs and managing symptoms. Nutritional supplementation if intake < 75% of what was planned, propose tube feeding if intake is < 60% of what was planned.
Risk of overweight/obesity	Reassess within 15 days (or as directed by the hospital service). Assess and adjust food intake, as well as change the habits necessary for healthy eating. Evaluate the use of corticosteroids and use strategies to improve muscle mass. Make healthier adaptations within the patient’s eating habits. Do food reeducation. Maintain nutritional monitoring, verifying food acceptance, organizing a healthy eating plan in order to avoid further weight gain.
Well nourished	Reassess within 15 days (or as directed by the hospital service). Nutritional guidance on healthy eating and food safety (good hygiene practices, food handling). Qualitative and quantitative assessment of food intake, monitoring of the current therapeutic regimen. Monitor in order to maintain nutritional status. Monitoring of symptoms and nutritional follow-up.

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[1] *Corresponding author. E-mail: danubia.saraiva@inca.gov.br (D. C. A. Saraiva).