Theoretical Construction and Expert Validation of a Nutritional Protocol for Hematopoietic Stem Cell Transplantation: Early Enteral Nutrition Therapy

Silva, Luíza Maria da; Lima, Andressa Alves de; Pereira, Annemberg Salvino; Daltro, Ana Filomena Camacho Santos; Barroso, Karine Sampaio Nunes; Duarte, Fernando Barroso; Mendonça, Priscila da Silva

doi:10.32635/2176-9745.RBC.2025v71n4.5354

person Luíza Maria da Silva

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUniversidade Federal do Ceará (UFC). Fortaleza (CE), Brasil. E-mails: luuizams3@gmail.com

0009-0007-2856-6929

person Andressa Alves de Lima

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUniversidade Federal do Ceará (UFC). Fortaleza (CE), Brasil. E-mails: limadiessa@gmail.com

0000-0003-3419-3069

person Annemberg Salvino Pereira

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUniversidade Federal do Ceará (UFC). Fortaleza (CE), Brasil. E-mails: annembergsalvino15@gmail.com.

0000-0003-2541-9927

person Ana Filomena Camacho Santos Daltro

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUFC, Complexo Hospitalar. Fortaleza (CE), Brasil. E-mails: anadaltro@unifor.br

0000-0003-2196-9198

person Karine Sampaio Nunes Barroso

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUFC, Complexo Hospitalar. Fortaleza (CE), Brasil. E-mails: karinesampaionb@gmail.com

0000-0002-5346-9414

person Fernando Barroso Duarte

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUFC, Complexo Hospitalar. Fortaleza (CE), Brasil. E-mails: nutriquimio@uol.com.br

0000-0001-5170-695X

person Priscila da Silva Mendonça

substantially contributed to the study design · data acquisition, analysis, interpretation · wording, and critical review · approved the final version for publication

schoolUFC, Complexo Hospitalar. Fortaleza (CE), Brasil. E-mails: n.priscilas@gmail.com.

0000-0001-6474-9019

personCorresponding author: Luíza Maria da Silva. Rua Professor Costa Mendes, 1608 – Rodolfo Teófilo. Fortaleza (CE), Brasil. CEP
60430-140. E-mail:
luuizams3@gmail.com

DECLARATION OF CONFLICT OF INTERESTS

There is no conflict of interest to declare.

Associate editor:

Livia Costa de Oliveira. Orcid iD: https://orcid.org/0000-0002-5052-1846

Scientific-editor:

Anke Bergmann. Orcid iD: https://orcid.org/0000-0002-1972-8777

Access route	Indication
Oral nutritional therapy	Diet acceptance or tolerance <70% of EER over the last 3 days
Enteral nutritional therapy	Oral tolerance <60% of EER over the last 3 days Severe dysphagia or odynophagia that impairs the oral route diet Lower consciousness level Patients who meet the inclusion criteria (see previously listed topic) Insert the tube preferably until D+1 (in case it does not happen, D+3 is the limit)
Parenteral nutritional therapy	Unable to use the GIT Persistent discomfort when using the GIT (distension, worsening diarrhea, fullness, intestinal bleeding, and severe mucositis), with no prospect of improvement PNT may be associated with ENT and the oral route

Variables	n	%
Sex
Female	10	91
Male	1	9
Age group (Years)
<40	8	72.7
40-60	2	18.2
>60	1	9.1
Time since graduation in nutrition (years)
<10	2	18.2
10-20	7	63.6
>20	2	18.2
Professional occupation
Hospital clinic	5	45.4
Hospital clinic/Teaching	1	9.1
Outpatient clinic	2	18.2
Clinical nutrition management/coordination	2	18.2
Teaching	1	9.1
Time working at hospital/outpatient clinical nutrition (years)
<10	5	45.5
10-20	5	45.5
>20	1	9
Professional qualification (highest title)
Doctorate	6	54.5
Master's degree	4	36.4
Specialization	1	9.1
Journal publication (onco-hematology, oncology, and/or enteral nutritional therapy)
Yes	10	90.9
No	1	9.1

Score	n	%
12	4	36.3
10	2	18.2
8.5	1	9.1
8	1	9.1
6.5	2	18.2
6.0	1	9.1

Evaluated items	Identified issues	Changes
Nutritional screening	According to NRS (2002), the patient is already considered at nutritional risk, which raises the question of its applicability in this context	Add NRS (2002) score ≥4 to the inclusion criteria
Hand grip strength	Threshold for elders: ≤16 kg (women); ≤27 kg (men)	<16.2 kg (women); <29.7 kg (men)²⁸
Calf circumference	Using calf circumference without adjusting for BMI	BMI<18.5 (+4 cm); BMI 25–29 (-3 cm); BMI 30–39 (-7 cm); BMI≥40 (-12 cm)²⁹
Calf circumference	Threshold for elders: ≤33 cm (women); ≤34 cm (men)	Adjusting the threshold value to the BMI attenuates the effect of age on calf circumference²⁹
Nurse attributions	Not attributing to nurses the task of notifying nutrition on the expiration of the enteral diet	Ensure enteral diet in the intermittent system is administered in the first 30 minutes after receiving it; otherwise, the nutrition team should be contacted
Energetic needs	The recommendation of 30-50 kcal/kg/day is too broad	Malnutrition: 40-50 kcal/kg/day Eutrophy: 35-45 kcal/kg/day Overweight: 35-40 kcal/kg/day Obesity: 30-35 kcal/kg/day
Enteral nutrition	Lack of detailing of enteral nutrition administration: time range and period (day/night)	The standardization of the number of enteral nutrition steps does not apply to the protocol; the steps should be adjusted individually according to the last 24 hours’ food recall, as a complement to oral nutrition. The administration period should be during the day, preferably

[TFN3] Captions: EER = estimated energetic requirement; GIT = gastrointestinal tract; ENT = enteral nutritional therapy; PNT = parenteral nutritional therapy.

[2] Source: Adapted from SBNO⁷ and Barban et al.⁹

Theoretical Construction and Expert Validation of a Nutritional Protocol for Hematopoietic Stem Cell Transplantation: Early Enteral Nutrition Therapy

ABSTRACT