Falling through the cracks

September 2015

Up front

Letters to the editor

Volume 44, No.9, September 2015 Pages 617-618

The opinions expressed by correspondents in this column are not endorsed by the editors or The Royal Australian College of General Practitioners

Fish oil in cancer cachexia

I note that the article by Kreijkamp-Kaspers et al on fish oil (AFP July 2015)1 did not mentioned fish oil in the setting of cancer cachexia, which has a large literature base.

Recent work that has incorporated red cell membrane levels, to assess adherence and absorption, has again raised interest in the therapeutic value of fish oil in cancer cachexia combined with other modalities such as exercise, nutritional support and pharmacological agents.2 Given the quality-of-life impact and high prevalence of this condition, its use in this context may warrant a mention.

References

  1. Kreijkamp-Kaspers S, McGuire T, Bedford S, et al. Your questions about complementary medicines answered: fish oil. Aust Fam Physician 2015;44:469–70.
  2. Murphy RA, Yeung E, Mazurak VC, Mourtzakis M. Influence of eicosapentaenoic acid supplementation on lean body mass in cancer cachexia. Br J Cancer 2011;105:1469–73.

Peter Martin
Palliative Medicine Physician
RACP

Reply

We thank Dr Martin for his letter regarding the role of fish oil in the setting of cancer cachexia. In our article we focused on the questions that patients and healthcare professionals asked through a medicines call centre3 about fish oil; the role of fish oil in cancer cachexia was not a major theme.

Despite the large literature base looking at fish oil in cachexia the evidence is still inconclusive and the most recent review has concluded that ‘There is not enough evidence to support a net benefit of n-3-FA in cachexia in advanced cancer’.4

On behalf of the authors,

Sanne Kreijkamp-Kaspers
The University of Queensland, Brisbane, QLD

References

  1. Kreijkamp-Kaspers S, McGuire TM, Bedford S, et al. Your questions about complementary medicines answered. Aust Fam Physician 2015;44:373–74.
  2. Ries A, Trottenberg P, Elsner F, et al. A systematic review on the role of fish oil for the treatment of cachexia in advanced cancer: An EPCRC cachexia guidelines project. Palliat Med 2012;26:294–304.

Consequences of obstructive sleep apnoea in childhood

I read with interest the article ‘Sleep apnoea in the child’ by Nixon et al (AFP June 2015).5 There are two aspects that are worth considering. First, children with obstructive sleep apnoea (OSA) have a reduced exercise capacity (independent of their body mass index) and a higher risk for pedestrian injury when compared with healthy controls.6–7 Second, children with OSA appear to eat more calorie-dense foods, such as fast food, and less high-fibre foods, such as vegetables, fruits and whole grains.8–9 I think that as an additional part of OSA treatment in childhood, healthy eating practices should be implemented.

Dr oec troph Martin Hofmeister
Consumer Centre of the German Federal
State of Bavaria
Department Food and Nutrition Munich,
Germany

References

  1. Nixon GM, Davey MJ. Sleep apnoea in the child. Aust Fam Physician 2015;43:352–55.
  2. Evans CA, Selvadurai H, Baur LA, Waters KA. Effects of obstructive sleep apnea and obesity on exercise function in children. Sleep 2014;37:1103–10.
  3. Avis KT, Gamble KL, Schwebel DC. Obstructive sleep apnea syndrome increases pedestrian injury risk in children. J Pediatr 2015;166:109–14.
  4. Spruyt K, Sans Capdevila O, Serpero LD, Kheirandish-Gozal L, Gozal D. Dietary and physical activity patterns in children with obstructive sleep apnea. J Pediatr 2010;156:724–30:730.e1–e3.
  5. Beebe DW, Miller N, Kirk S, Daniels SR, Amin R. The association between obstructive sleep apnea and dietary choices among obese individuals during middle to late childhood. Sleep Med 2011;12:797–99.

Reply

Dr Hofmeister points out literature pertaining to associations between OSA in childhood, exercise capacity, pedestrian injury and dietary choices. We agree that management of a child with OSA should always include discussion of diet and exercise, and management of obesity if present. Evidence (including the papers referenced) would suggest, however, that consumption of high-calorie foods may be a consequence of sleep disturbance rather than (or as well as) a cause of obesity and thus OSA. Inadequate sleep and OSA can alter the balance between the appetite-related hormones leptin and ghrelin, resulting in an increased drive to eat high-calorie foods. The interactions between OSA, obesity, appetite and exercise are fascinating and complex, and this web of interactions may influence an individual family’s ability to follow dietary advice; however this should not detract from the direct management of OSA initially.

Gillian M Nixon
Paediatric Respiratory and Sleep Physician,
Department of Paediatrics, Monash University
Melbourne Children’s Sleep Centre, Monash
Children’s Hospital
The Ritchie Centre, MIMR-PHI Institute of
Medical Research
Melbourne, VIC

Margot J Davey
Paediatric Sleep Physician
Department of Paediatrics, Monash University
Melbourne Children’s Sleep Centre, Monash
Children’s Hospital
The Ritchie Centre, MIMRPHI Institute of
Medical Research
Melbourne, VIC

Urgent information on peanut allergy: New evidence from the LEAP study

In 2012 AFP published our letter, which discussed the increase in food allergies in Australian children in the past two decades.10 We highlighted recent research at that time, suggesting decreased rates of peanut and egg allergy as a consequence of introducing these allergens from 4 months of age.11,12

In February 2015, the Learning Early about Peanut Allergy trial (LEAP), conducted in the UK, was published in the New England Journal of Medicine. This large, randomised, controlled trial showed that early introduction (between 4 and 11 months) and sustained intake (until age 60 months) of dietary peanut protein can significantly decrease the risk of peanut allergy in children at high risk for this allergy.13 The study children had severe eczema, egg allergy or both.

The LEAP trial showed that regular peanut protein consumption was associated with a reduction in peanut allergy at age 5 years by up to 86% in high-risk, non-sensitised infants, and 70% in high-risk, sensitised infants. Peanut avoidance was associated with a higher frequency of clinical allergy than consumption. Approximately 300,000 babies are born each year in Australia. Almost 3% of Australian children have a peanut allergy.14 Therefore, 9000 children per year are developing a peanut allergy, but this latest research suggests that in 70–86% of infants this need not happen.

As GPs we see antenatal and postnatal families. We are often asked for advice on infant feeding. For too long it has been the norm to state ‘breast is best’ and that the World Health Organization and National Health and Medical Research Council recommend exclusive breastfeeding for 6 months. The current Australasian Society for Clinical Immunology and Allergy (ASCIA) Infant Feeding Advice (2010), states that ‘there is insufficient evidence to support previous advice to specifically delay or avoid potentially allergenic foods (such as egg, peanuts, wheat, cow’s milk and fish) for the prevention of food allergy or eczema’, and recommends the introduction of solid food from 4–6 months.15 ASCIA intends to update their Infant Feeding Advice documents to incorporate findings from a number of recent studies, including the LEAP trial.

It has now become clear that there is strong and compelling evidence that delays in commencing complementary solids, particularly peanuts, conveys significant risk to our patients. Some questions certainly remain, such as the quantity of peanut protein that should be given, and whether ongoing peanut tolerance is dependent on continual inclusion of peanuts in the diet. From a public health perspective, it is imperative that we as GPs are aware of this evidence and consider recommending exposure to peanut protein and probably other potentially allergenic proteins, for the majority of infants, from about 4 months of age.

Dr Brian Symon
Kensington Park Medical Practice,
Kensington Park, SA

Dr Georgina Crichton University of Adelaide,
Adelaide, SA

References

  1. Symon B, Bammann M. Feeding in the first year of life – emerging benefits of introducing complementary solids from 4 months. Aust Fam Physician 2012;41:226–29.
  2. Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122:984–91.
  3. Prescott SL, Smith P, Tang M, et al. The importance of early complementary feeding in the development of oral tolerance: concerns and controversies. Pediatr Allergy Immunol 2008;19:375–80.
  4. Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015;372:803–13.
  5. Allergy and Anaphylaxis Australia. Peanut. Available at www.allergyfacts.org.au/ living-with-the-risk/ allergen-specifics/ peanut [Accessed 2 March 2015].
  6. Australasian Society of Clinical Immunology and Allergy. Infant Feeding Advice. Available at www.allergy.org.au/ images/ stories/ aer/ infobulletins/ 2010pdf/ ASCIA_Infant_Feeding_Advice_2010.pdf  [Accessed 30 April 2015].

 

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Letters to the editor

2015