The influence of nutrition on clinical outcomes in children with cancer

The Nutritional Burden of Cancer: Nutritional Status and Body Composition Differences Between Children with Acute Lymphoblastic Leukemia and their Siblings in Guatemala

During treatment, children with acute lymphoblastic leukemia (ALL) gain fat mass and lose skeletal muscle mass. The great majority live in low- and middle-income countries with few studies of their body composition and none addressing the hypothesis that the disease itself contributes to nutritional morbidity. At diagnosis, children with ALL were compared to their siblings on socioeconomic status (SES). Nutritional status was assessed by mid-upper arm circumference (MUAC)-for-age Z scores and body composition by dual energy x-ray absorptiometry (DXA). Median SES scores for the patients (47.5) and their siblings (47.0) were very similar (P = 0.5). MUAC Z scores for patients aged >5 years were lower than for siblings (P < 0.001). On DXA siblings had a higher mean appendicular lean mass index Z score, a surrogate of skeletal muscle mass, than patients (P = 0.019). A logistic model to estimate the odds ratio (OR) of being severely/moderately under-nourished (classified by MUAC Z score) by SES revealed that, compared with siblings (n = 49), children with ALL (n = 60) had a higher probability of being under-nourished (OR 5.25, 95% CI 1.44-25.95, P = 0.02). The results support the hypothesis that children at diagnosis of ALL in Guatemala are more nutritionally depleted than their apparently healthy siblings.

Nutritional interventions in children with acute lymphoblastic leukemia undergoing antineoplastic treatment: a systematic review

BACKGROUND

A compromised nutritional status jeopardizes a positive prognosis in acute lymphoblastic leukemia (ALL) patients. In low- and middle-income countries, ~ 50% of children with ALL are malnourished at diagnosis time, and undergoing antineoplastic treatment increases the risk of depleting their nutrient stores. Nutrition interventions are implemented in patients with cancer related malnutrition. We aimed to evaluate the effect of nutrition interventions in children diagnosed with ALL under treatment.

METHODS

Using a predefined protocol, we searched for published or unpublished randomized controlled trials in: Cochrane CENTRAL, MEDLINE, EMBASE, LILACS, and SciELO, and conducted complementary searches. Studies where at least 50% of participants had an ALL diagnosis in children ≤ 18 years, active antineoplastic treatment, and a nutrition intervention were included. Study selection and data extraction were conducted independently by three reviewers, and assessment of the risk of bias by two reviewers. Results were synthesized in both tabular format and narratively.

RESULTS

Twenty-five studies (out of 4097 records) satisfied the inclusion requirements. There was a high risk of bias in eighteen studies. Interventions analyzed were classified by compound/food (n = 14), micronutrient (n = 8), and nutritional support (n = 3). Within each group the interventions and components (dose and time) tested were heterogeneous. In relation to our primary outcomes, none of the studies reported fat-free mass as an outcome. Inflammatory and metabolic markers related to nutritional status and anthropometric measurements were reported in many studies but varied greatly across the studies. For our secondary outcomes, fat mass or total body water were not reported as an outcome in any of the studies. However, some different adverse events were reported in some studies.

CONCLUSIONS

This review highlights the need to conduct high-quality randomized controlled trials for nutrition interventions in children with ALL, based on their limited number and heterogeneous outcomes.

REGISTRATION OF THE REVIEW PROTOCOL

Guzmán-León AE, Lopez-Teros V, Avila-Prado J, Bracamontes-Picos L, Haby MM, Stein K. Protocol for a Systematic Review: Nutritional interventions in children with acute lymphoblastic leukemia undergoing an tineoplastic treatment. International prospective register of systematic reviews. 2021; PROSPERO CRD:42,021,266,761 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266761 ).

Feasibility study of micronutrient status and body mass index of newly diagnosed pediatric oncology patients: Research commentary

We conducted a feasibility study to evaluate micronutrients and body mass index (BMI). Fat soluble vitamins A, D, E and trace elements copper (Cu), selenium (Se), and zinc (Zn) levels were evaluated. Weight, height, BMI, and Z-scores were recorded. Side effects or specific adverse events were documented. No patient had a Z-score for height, weight, or BMI of less than 2 SD or greater than 2 SD. Ninety percent of patients had one or more micronutrient levels below normal. These results suggest that micronutrient abnormalities are common despite no obvious evidence of malnutrition. Side effects of chemotherapy may be exacerbated by micronutrient depletion.

Nutritional status, body composition and diet quality in children with cancer

During cancer treatment, nutritional status disorders such as malnutrition or obesity affect the tolerance of cancer treatment, quality of life, but also the pharmacokinetics of drugs. It is hypothesized that changes in fat and lean body mass can modify chemotherapy volume distribution, metabolism and clearance. In children with cancer, lean body mass decreases or remains low during treatment and fat mass increases. Body composition is influenced by the cancer itself, aggressive multimodal-therapies, changes in metabolism, unbalanced diet and reduced physical activity. Due to the side effects of treatment, including changes in the sense of taste and smell, nausea, vomiting, diarrhea, and stress, eating according to recommendation for macronutrients and micronutrients is difficult. Research indicates that throughout cancer treatment, the consumption of fruits, vegetables, and dairy products tends to be insufficient, whereas there is an elevated intake of sugar and unhealthy snacks. Children exhibit a preference for high-carbohydrate, salty, and strongly flavored products. This review revealed the importance of body composition and its changes during cancer treatment in children, as well as eating habits and diet quality.

Current practices for nutritional evaluation and care during the treatment of pediatric oncology patients: a survey among AIEOP centers

Nutritional status plays a crucial role in the mortality rates of the pediatric oncology patients. However, there is a lack of systematic approaches for nutritional assessment in this population. This study aims to assess the current practice for nutritional assessment and care of pediatric cancer patients in Italy. A 25-items web-based, nation-wide questionnaire was circulated as of January 9, 2023 among physicians within the AIEOP network, composed of 49 national centers, out of which 21 routinely perform HCT. This survey examined the practices of 21 Italian pediatric oncology centers, revealing significant heterogeneity in nutritional practices. Only half of the centers routinely assessed all patients, utilizing different clinical and biochemical parameters. The use of neutropenic diets remained prevalent after chemotherapy or stem cell transplantation.

CONCLUSION

This study underscores the pressing need for unified recommendations to improve nutritional care and potentially enhance outcomes for pediatric cancer patients.

WHAT IS KNOWN

• The assessment and support of nutrition are gaining interest in the overall care of children with cancer. • The assessment and management of nutritional needs in pediatric cancer patients, including those undergoing hematopoietic cell transplantation, currently lack a systematic approach.

WHAT IS NEW

• There is considerable variability in the nutritional assessment and support among Italian centers treating pediatric patients with cancer. • To enhance nutritional assessment and support for pediatric cancer patients, it is essential to establish shared national and international guidelines.

Impact of Childhood Cancer on Growth

Along with improvements in cancer treatment over time, the number of childhood cancer survivors has been growing. Survivors are at risk for serious medical complications, and growth impairment is among the most common. There are multiple factors that may cause impaired growth among survivors. In this article, we review the impact of cancer on growth in children and adolescents. We first provide an overview of growth disturbance among childhood cancer patients and survivors due to nonhormonal causes, including a recent understanding of the effect of targeted cancer therapies (eg, tyrosine kinase inhibitors and immune checkpoint inhibitors) on growth. Then we describe the hormonal causes of growth impairment among survivors, focusing on growth hormone deficiency, including the prevalence, risk factors, and treatment. Lastly, we briefly summarize overgrowth and tall stature in childhood cancer. It is critical to assess the linear growth of children and adolescents, especially in cancer survivors who are at risk for growth disturbance, since growth is an important measure of their health.

Association of European Paediatric and Congenital Cardiology practical recommendations for surveillance and prevention of cardiac disease in childhood cancer survivors: the importance of physical activity and lifestyle changes From the Association of European Paediatric and Congenital Cardiology Working Group Sports Cardiology, Physical Activity and Prevention, Working Group Adult Congenital Heart Disease, Working Group Imaging and Working Group Heart Failure

BACKGROUND

Childhood cancer survivors are at increased risk of developing cardiovascular diseases, presenting as the main causes of morbidity and mortality within this group. Besides the usual primary and secondary prevention in combination with screening during follow-up, the modifiable lifestyle factors of physical activity, nutrition, and body weight have not yet gained enough attention regarding potential cardiovascular risk reduction.

OBJECTIVE

These practical recommendations aim to provide summarised information and practical implications to paediatricians and health professionals treating childhood cancer survivors to reduce the risk of cardiovascular late effects.

METHODS

The content derives from either published guidelines or expert opinions from Association of European Paediatric and Congenital Cardiology working groups and is in accordance with current state-of-the-art.

RESULTS

All usual methods of prevention and screening regarding the risk, monitoring, and treatment of occurring cardiovascular diseases are summarised. Additionally, modifiable lifestyle factors are explained, and clear practical implications are named.

CONCLUSION

Modifiable lifestyle factors should definitely be considered as a cost-effective and complementary approach to already implemented follow-up care programs in cardio-oncology, which can be actively addressed by the survivors themselves. However, treating physicians are strongly encouraged to support survivors to develop and maintain a healthy lifestyle, including physical activity as one of the major influencing factors. This article summarises relevant background information and provides specific practical recommendations on how to advise survivors to increase their level of physical activity.

The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy in the world. Advances in treatment protocols have resulted in survival rates of >80% in most high-income countries (HIC); however, children and young people (CYP) with ALL continue to face significant nutrition-related challenges during treatment.

METHODS

This narrative review outlines the changing landscape of treatment and survivorship for CYP with ALL and the advances in nutrition knowledge that call for changes to clinical nutrition practice.

RESULTS

The incidence of ALL has remained stable in HIC; however, there have been significant advances in survival over the past 30 years. Overweight and obesity are increasingly prevalent in CYP with ALL at diagnosis, during treatment and in survivorship. Coupled with poor diet quality, high-energy and saturated fat intakes, altered eating behaviours and inactivity, this necessitates the need for a shift in nutrition intervention. Undernutrition remains a concern for CYP with high-risk treatment protocols where oral or enteral nutrition support remains a cornerstone of maintaining nutrition status.

CONCLUSIONS

With improved treatment protocols and high survival rates, a shift to focusing on diet quality, prevention of excessive weight gain and obesity during treatment and survivorship is necessary.

Innovative strategies to predict and prevent the risk for malnutrition in child, adolescent, and young adult cancer survivors

Children, adolescents, and young adult cancer survivors (CAYAs) constitute a growing population requiring a customized approach to mitigate the incidence of severe complications throughout their lifetimes. During cancer treatment, CAYAs cancer survivors undergo significant disruptions in their nutritional status, elevating the risks of mortality, morbidity, and cardiovascular events. The assessment of nutritional status during cancer treatment involves anthropometric and dietary evaluations, emphasizing the necessity for regular assessments and the timely identification of risk factors. Proactive nutritional interventions, addressing both undernutrition and overnutrition, should be tailored to specific age groups and incorporate a family-centered approach. Despite encouraging interventions, a notable evidence gap persists. The goal of this review is to comprehensively examine the existing evidence on potential nutritional interventions for CAYAs cancer survivors. We explore the evidence so far collected on the nutritional intervention strategies elaborated for CAYAs cancer survivors that should target both undernutrition and overnutrition, being age-specific and involving a family-based approach. Furthermore, we suggest harnessing artificial intelligence (AI) to anticipate and prevent malnutrition in CAYAs cancer survivors, contributing to the identification of novel risk factors and promoting proactive, personalized healthcare.

Nutrition screening, assessment, and intervention practices for children with cancer in Aotearoa, New Zealand

OBJECTIVE

The purpose of this study was to investigate dietetic resources and current nutrition screening, assessment, and intervention practices in pediatric oncology centers in Aotearoa, New Zealand.

METHODS

A national survey of the two specialist treatment centers and 14 shared care centers that provide care to childhood cancer patients in Aotearoa, New Zealand, was conducted.

RESULTS

The two specialist treatment centers in Aotearoa, New Zealand, were the only centers with a dedicated dietetic oncology full-time equivalent resource; this full-time equivalent resource was devoted to inpatient care. Only 5 shared care centers (44%) had access to general pediatric dietetic support. Dietetic cover for outpatients or day-stay patients and use of standardized nutrition screening and assessment tools were limited. Weight and height were commonly measured, but there was inconsistency in the frequency and recording of measurements. Nutrition interventions, including nutrition education, oral nutrition support, enteral nutrition, and intravenous nutrition, were available within all centers but criteria for initiating support varied. Common barriers to providing nutrition interventions included staff resourcing and ad hoc referral pathways. Awareness of the relevance and clinical benefit of nutrition in pediatric oncology was low. Suggestions to improve nutrition screening, assessment, and intervention within Aotearoa, New Zealand, included the creation of standardized screening and referral criteria.

CONCLUSIONS

Resource limitations and lack of nutritional screening and assessment prevent adequate nutritional intervention for children with cancer in Aotearoa, New Zealand. Akin to other high-income countries, there is a need to harmonize the management of nutritional challenges in children with cancer. This study provides a first step in establishing an evidence base to help support efforts to address this need in Aotearoa, New Zealand.

Diagnostic accuracy of clinical indicators of Imbalanced nutrition in pediatric patients submitted to chemotherapy

To analyze the accuracy of clinical indicators of nursing diagnosis, Imbalanced nutrition: less than the body requirements in pediatric patients undergoing chemotherapy. A cross-sectional study was carried out in a pediatric oncohematology unit. A total of 123 children aged 5-18 years were evaluated. The Standards for Reporting Diagnostic Accuracy Studies (STARD) protocol was used. Latent class analysis was performed to obtain sensitivity and specificity of clinical indicators. The diagnosis was identified in six children (5.23%). The most frequent clinical indicator in the study was report of food intake less than recommended daily allowance (n = 61; 49.6%), followed by excessive hair loss (n = 49; 39.8%), misperception (n = 42; 34.1%), satiety immediately upon ingesting food (n = 32; 26%), lack of information (n = 30; 24.4%), and pale mucous membranes (n = 22; 17.9%). The 10 indicators that sensitivity and specificity were statistically superior to 50% were food intake less than recommended daily allowance, misperception, insufficient interest in food, lack of food, hyperactive bowel sounds, body weight 20% or more below ideal weight range, insufficient muscle tone, food aversion, abdominal cramping, and misinformation. The clinical indicators Food intake less than recommended daily allowance and Misperception can be considered the most important indicators for the initial inference of the diagnosis due to their high values of specificity and sensitivity. It is essential that nurses provide targeted and qualified assistance based on the signs and symptoms presented by patients, as they will be able to design appropriate interventions to obtain the desired results.

Education by a social robot on nutrition and catheter care in pediatric oncology patients

PURPOSE

To improve knowledge on nutrition and catheter care in children with cancer by an educational intervention with a social robot.

METHODS

We conducted a cohort study on pediatric cancer patients in a high complexity Hospital in Bogotá, Colombia. We included 14 patients (8-17 years old) who underwent an educational intervention with the help of a humanoid robot (Nao V6). The robot was programmed to transmit educational messages about self-care in feeding and using the central venous catheter. A survey with yes-no questions was administered before and after the intervention.

RESULTS

We found an improvement in understanding of the subject matter related to nutrition and catheter care, when comparing the knowledge on topics before and after the educational intervention (p < .001).

CONCLUSION

Education by a social robot on nutrition and catheter care showed a positive effect on children's knowledge on these topics. Therefore, it potentially decreases the risk of poor feeding habits and inadequate central venous catheter management, and improves adherence to recommendations and quality of life.

Children's Oncology Group's 2023 blueprint for research: Cancer control and supportive care

The objective of the Cancer Control and Supportive Care (CCL) Committee in the Children's Oncology Group (COG) is to reduce the overall morbidity and mortality of therapy-related toxicities in children, adolescents, and young adults with cancer. We have targeted five major domains that cause clinically important toxicity: (i) infections and inflammation; (ii) malnutrition and metabolic dysfunction; (iii) chemotherapy-induced nausea and vomiting; (iv) neuro- and oto-toxicty; and (v) patient-reported outcomes and health-related quality of life. Subcommittees for each domain prioritize randomized controlled trials and biology aims to determine which strategies best mitigate the toxicities. The findings of these trials are impactful, informing clinical practice guidelines (CPGs) and directly leading to changes in the standard of care for oncology practice. With the development of new therapies, there will be new toxicities, and the COG CCL Committee is dedicated to developing interventions to minimize acute and delayed toxicities, lessen morbidity and mortality, and improve quality of life in pediatric and young adult patients with cancer.

Changes in Nutritional Status during Induction Phase and Their Association with Fever and Minimal Residual Disease in Paediatric Acute Lymphoblastic Leukaemia

Background and objectives: Acute lymphoblastic leukaemia (ALL) is associated with a cytokine imbalance and oxidative stress, which can be aggravated by malnutrition. Malnutrition, defined by the World Health Organisation (WHO) as obesity or undernutrition, can affect treatment complications and outcomes. Therefore, we aimed to analyse the change in the body mass index (BMI) z-score during induction, as well as evaluate the impact of childhood malnutrition on fevers at an ALL presentation and early response to therapy. Methods: An observational cohort study of 50 consecutive children with ALL, diagnosed in 2019-2022, was performed. Patients were divided into age groups of 0-5, 6-11, and 12-17 years. BMI-for-age z-scores were used to define undernutrition and overnutrition according to WHO growth standards. Results: The number of patients with an abnormal BMI increased from 3 (6%) at diagnosis to 10 (20%) at the end of induction (from 2 (4%) to 6 (12%) in overweight/obese, and from 1 (2%) to 4 (8%) in underweight patients). At the end of induction, all overweight/obese patients were 0-5 years old. On the other hand, a statistically significant decrease in the mean BMI z-score among patients aged 12-17 was observed (p = 0.005). The mean BMI z-score differed statistically significantly among children aged 0-5 presenting with and without fever (p = 0.001). The minimal residual disease (MRD) level at the end of induction was not related to BMI at diagnosis. Conclusions: Despite the use of steroids, adolescents are prone to losing weight during an ALL induction, in contrast to preschool children, who tend to gain weight under the same treatment. BMI at diagnosis was related to a fever of ≥38 °C (at ALL presentation) in the 0-5 age group. The results emphasise the importance of careful nutritional status monitoring, with younger and older children as important target groups for weight gain and weight loss interventions, respectively.

Changes in anthropometrical status and body composition in children with cancer during initial chemotherapy

Children with cancer require adequate nutritional support to prevent malnutrition. This study investigated the impact of chemotherapy on anthropometrical status and body composition during the first six months of treatment. Anthropometrical status and body composition were measured at diagnosis, utilizing standardized protocols and validated S10 InBody bio-electrical impedance (BIA) measurements and compared to subsequent consecutive monthly follow-up measurements to plot changes over time during the first six months. Statistical significance was defined as p < 0.05. Forty-three newly diagnosed children (median age 4 years, IQR: 2.0-7.6; male-female ratio 1:0.9; 53% haematological malignancies and 47% solid tumors) were included. Prevalence of malnutrition varied, with under-nutrition 14% (mid-upper arm circumference (MUAC)/body mass index (BMI)), over-nutrition 9.3% (BMI) and stunting 7% at diagnosis. MUAC (14%) identified fewer participants with underlying muscle store depletion than BIA (41.8%). Chemotherapy exposure acutely exacerbated existing nutritional depletion during the first two months after diagnosis for all variables except fat mass (FM), with contrary effects on cancer type. Haematological malignancies had rapid increases in weight, BMI and FM. All patients had an acute loss of skeletal muscle mass. Nutritional improvement experienced by all cancer types during month two to three of treatment resulted in catch-up growth, with a significant increase in weight (chi2=40.43, p < 0.001), height (chi2=53.79, p < 0.001), BMI (chi2=16.32, p < 0.005), fat free mass (chi2=23.69, p < 0.003) and skeletal muscle mass (chi2=24.19, p < 0.001) after six months. Monthly nutritional assessments, including advanced body composition measurements, are essential to provide timely nutritional interventions to overcome the acute decline in nutritional reserves observed during the first two months of chemotherapy exposure.

Prevalence of vitamin and iron deficiencies at cancer diagnosis at two pediatric oncology units in South Africa

This study investigates the prevalence of vitamin and iron deficiencies at cancer diagnosis. Newly diagnosed children between October 2018 and December 2020 at two South African pediatric oncology units (POUs) were assessed for nutritional and micronutrient status (Vit A, Vit B12, Vit D, folate, and iron). A structured interview with caregivers provided information regarding hunger and poverty risks. There were 261 patients enrolled with a median age of 5.5 years and a male-to-female ratio of 1:0.8. Nearly half had iron deficiency (47.6%), while a third had either Vit A (30.6%), Vit D (32.6%), or folate (29.7%) deficiencies. Significant associations existed between moderate acute malnutrition (MAM) and low levels of Vit A (48.4%; p = .005), Vit B12 (29.6%; p < .001), and folate (47.3%; p = .003), while Vit D deficiency was associated with wasting (63.6%) (p < .001). Males had significantly lower Vit D levels (respectively, 40.9%; p = .004). Folate deficiency was significantly associated with patients born at full term (33.5%; p = .017), age older than five years (39.8%; p = .002), residing in provinces Mpumalanga (40.9%) and Gauteng (31.5%) (P = .032); as well as having food insecurity (46.3%; p < .001), or hematological malignancies (41.3%; p = .004). This study documents the high prevalence of Vit A, Vit D, Vit B12, folate, and iron deficiency in South African pediatric cancer patients, demonstrating the need to include micronutrient assessment at diagnosis to ensure optimal nutritional support for macro-and micronutrients.

The role of nutrition in children with cancer

In recent years, the influence of nutrition on the health and growth of children has become increasingly important. The relevance of nutrition is even greater for children who are facing cancer. Malnutrition, within the context of undernutrition and overnutrition, may impact not only the effectiveness of treatments and outcomes, but also the quality of life for patients and their families. In this article, we review nutritional assessment methods for children with cancer, focusing on the specific characteristics of this population and analyze the efficacy of nutritional interventions, which include enteral, parenteral, and nutritional education. From our analysis, two important conclusions emerged: i) there is a need to focus our attention on the nutritional status and the body composition of oncologic children, since these factors have a relevant impact on clinical outcomes during treatment as well as after their conclusion; ii) the support of skilled clinical nutrition personnel would be extremely helpful for the global management of these patients.

Role of Nutrition in Pediatric Patients with Cancer

Children with cancer are at high risk for developing short-term and long-term nutritional problems related to their underlying disease and side effects of multimodal treatments. Nutritional status (NS) can influence several clinical outcomes, such as overall survival (OS) and event-free survival (EFS), treatment tolerance, risk of developing infections and quality of life (QoL). However, the importance of nutrition in children with cancer is still underestimated. This review focuses on alterations of NS that occurs in children during cancer treatment. In particular, we reviewed the pathogenesis of undernutrition in oncological children, as well as how NS affects treatment tolerance and response, the immune system and the risk of infections of children with cancer. Thanks to recent advances in all types of supportive therapy and to the progress of knowledge on this topic, it has been realized that NS is a modifiable prognostic factor that can be intervened upon to improve the outcome of these patients. Currently, there is a lack of a systematic approach and standard recommendations for nutritional care in the pediatric cancer population. Literature analysis showed that it is essential to define the NS and treat any alterations in a timely manner ensuring proper growth and development. Nutritional follow-up should become an integral part of the care pathway. Regular nutritional monitoring should be performed at diagnosis, during treatment and during follow-up. A close collaboration and sharing of expertise between pediatric oncologists and nutrition specialists, combined with careful and participatory sharing of the feeding experience with the family and the child (after age 6 years), is strongly required.

Nutritional Status at Diagnosis as Predictor of Survival from Childhood Cancer: A Review of the Literature

Few studies so far have examined the impact of nutritional status on the survival of children with cancer, with the majority of them focusing on hematological malignancies. We summarized published evidence reporting the association of nutritional status at diagnosis with overall survival (OS), event-free survival (EFS), relapse, and treatment-related toxicity (TRT) in children with cancer. Published studies on children with leukemia, lymphoma, and other solid tumors have shown that both under-nourished and over-nourished children at cancer diagnosis had worse OS and EFS. Particularly, the risk of death and relapse increased by 30-50% among children with leukemia with increased body mass index at diagnosis. Likewise, the risk of TRT was higher among malnourished children with osteosarcoma and Ewing sarcoma. Nutritional status seems to play a crucial role in clinical outcomes of children with cancer, thus providing a significant modifiable prognostic tool in childhood cancer management. Future studies with adequate power and longitudinal design are needed to further evaluate the association of nutritional status with childhood cancer outcomes using a more standardized definition to measure nutritional status in this population. The use of new technologies is expected to shed further light on this understudied area and give room to person-targeted intervention strategies.

Nutritional assessment and dietetic resource for children and young people with cancer in the United Kingdom

BACKGROUND

Both under- and overnutrition may have adverse impact on outcome of cancer in children and teenagers/young adults (CTYA). Previous studies confirm that screening for nutritional risk and detection of nutritional abnormality is inconsistently undertaken in practice.

METHODS

We undertook a survey of dietetic resource and nutritional assessment in CTYA principal treatment centres (PTC) in the United Kingdom. Responses were received from 95% children's and 69% TYA PTC.

RESULTS

Only 13/18 (72%) children's PTC, and one of 11 (9%) TYA PTC, met national standards for dietetic resource; one of 18 (6%) paediatric and six of 11(54%) TYA PTC had no such resource. While resources were greater in larger paediatric PTC, who were also most likely to undertake stem cell transplantation, resources in TYA PTC were too low to assess relationship to centre size. Most centres focused resources on inpatient care and <50% considered staffing adequate; 82% used nutritional screening tools but without consistency in the tool used. Weight and height were the principal method for assessment, but with inconsistency in the frequency of measurement and use in different clinical settings. Measures derived from weight and height, including body mass index (BMI), were inconsistently utilised. The use of arm anthropometry was rare despite evidence that use increases recognition of undernutrition. Detailed nutritional assessment was infrequently attempted.

CONCLUSION

Barriers to adequate nutritional assessment and treatment for all patients include resource limitations (particularly TYA), training for staff, and uncertainty about detailed assessment of nutritional status. There is a need to harmonise screening and assessment of nutritional status in CTYA with cancer.

Management of Nutritional Needs in Pediatric Oncology: A Consensus Statement

Simple Summary

Nutritional management is an underestimated issue in treating pediatric cancer, since a systematic approach is currently lacking. In this consensus statement, a cohort of 12 experts selected from four different tertiary pediatric oncology centers formulated 21 clinical questions regarding the identification and treatment of nutritional issues in children with cancer. These questions were discussed, and practical recommendations were provided. With this paper, we aimed to give consensus-based guidance for addressing the nutritional needs of children with cancer, filling a gap in the field.

Abstract

Malnutrition, intended as both overnutrition and undernutrition, is a common problem in children with cancer, impacting quality of life as well as survival. In addition, nutritional imbalances during childhood can significantly affect proper growth. Nevertheless, there is currently a lack of a systematic approach to this issue in the pediatric oncology population. To fill this gap, we aimed to provide practice recommendations for the uniform management of nutritional needs in children with cancer. Twenty-one clinical questions addressing evaluation and treatment of nutritional problems in children with cancer were formulated by selected members from four Italian Association of Pediatric Hematology and Oncology (AIEOP) centers and from the Survivorship Care and Nutritional Support Working Group of Alliance Against Cancer. A literature search in PubMed was performed; during two consensus meetings, all recommendations were discussed and finalized using the nominal group technique. Members representing every institution voted on each recommendation. Finally, recommendations were approved by all authors.

Impact of a pediatric oncology nutrition program: Lessons learnt over a decade

BACKGROUND

The management of malnutrition in children with cancer remains a challenge in low-middle-income countries (LMICs). We describe our pediatric oncology nutrition program and its impact over the past decade.

METHODS

We evaluated the impact of our nutrition program in accordance with the International Society of Paediatric Oncology-Paediatric Oncology in Developing Countries (SIOP PODC) Nutritional Program Evaluation in the areas of service delivery (number served, increments in delivery, number of trained care providers), patients at-risk (proportion identified with malnutrition at diagnosis/follow-up), and efficiency of nutritional interventions (proportion assessed, proportion achieved healthy weight, clinicians trained). We analyzed available data for trends between 2009 and 2020, and comparisons were made using the Fisher t test. This study was approved by our institutional ethics committee.

RESULTS

From 2010 to 2020, 17 749 children treated at our center were beneficiaries of the nutritional program, including assessment and intervention. During this period, trained pediatric nutritionists increased from 2 to 8; SIOP PODC level from 2 to 3-4, and nutrition budget increased 15-fold. At diagnosis (n = 5618) and six-month follow-up (n = 2674), 59.6% and 51.2% children were undernourished, 34.8% and 43% well nourished, and 4.7% and 5.7% overnourished. From 2016 onward, fewer children were undernourished at follow-up-69.5% (2016), 60% (2018), 54% (2019), and 55% (2020, P < 0.001). The program helped train over 500 clinicians in nutrition.

CONCLUSIONS

Improved financial support and capacity building have helped build and sustain an effective nutrition program. Priority areas include implementation of best practices, early nutritional intervention, continued education, and locally relevant research.

Performance of subjective global nutritional assessment in predicting clinical outcomes: Data from the Brazilian survey of pediatric oncology nutrition

BACKGROUND

Methods for assessing nutritional status in children and adolescents with cancer is a difficult in clinical practice. The study aimed to evaluate the performance of Subjective Global Nutritional Assessment (SGNA) in predicting clinical outcomes in children and adolescents with cancer in Brazil.

METHODS

This was a prospective cohort multicenter study. It was included 723 children and adolescents with cancer aged 2-18 years between March 2018 and August 2019. Nutritional assessment was performed according to World Health Organization recommendations and using SGNA within 48h of hospitalization. Unplanned readmission, length of hospital stay, and post-discharge death were analyzed. Cohen's kappa coefficient was used to ascertain the agreement between body mass index for age (BMI/A) and SGNA. The sensitivity, specificity, positive and negative predictive values, and accuracy of SGNA were estimated. Odds ratios (ORs) with 95% confidence intervals (CIs) were evaluated using multiple logistic regression.

RESULTS

The mean patient age was 9.4 ± 4.9 years. SGNA showed that 29.7% (n = 215) and 6.5% (n = 47) patients had moderate and severe malnutrition, respectively. Considering the concurrent validity criterion, SGNA had an OR (95% CI) of 6.8 (3.1-14.9) for predicting low and very low weight for age at admission, with a sensitivity and specificity of 72.4% (59%-82.1%) and 72% (64.2%-78.9%), respectively. SGNA could predict death in children with severe/moderate malnutrition, with an accuracy of 63.8% (63%-65.1%). Logistic multivariate analysis showed that the adjusted effect of death; hematological tumor; living in the northeast, southeast, and midwest regions of Brazil; and older age was associated with malnutrition according to SGNA.

CONCLUSION

Based on concurrent validity between SGNA and anthropometry, SGNA performed well and had a good ability to predict death in Brazilian children with cancer.

The Role of Nutritional Status, Gastrointestinal Peptides, and Endocannabinoids in the Prognosis and Treatment of Children with Cancer

Neoplastic diseases in children are the second most frequent cause of death among the young. It is estimated that 400,000 children worldwide will be diagnosed with cancer each year. The nutritional status at diagnosis is a prognostic indicator and influences the treatment tolerance. Both malnutrition and obesity increase the risk of mortality and complications during treatment. It is necessary to constantly search for new factors that impair the nutritional status. The endocannabinoid system (ECS) is a signaling system whose best-known function is regulating energy balance and food intake, but it also plays a role in pain control, embryogenesis, neurogenesis, learning, and the regulation of lipid and glucose metabolism. Its action is multidirectional, and its role is being discovered in an increasing number of diseases. In adults, cannabinoids have been shown to have anti-cancer properties against breast and pancreatic cancer, melanoma, lymphoma, and brain tumors. Data on the importance of both the endocannabinoid system and synthetic cannabinoids are lacking in children with cancer. This review highlights the role of nutritional status in the oncological treatment process, and describes the role of ECS and gastrointestinal peptides in regulating appetite. We also point to the need for research to evaluate the role of the endocannabinoid system in children with cancer, together with a prospective assessment of nutritional status during oncological treatment.

Psychometric validation of the simplified Chinese version of the therapy-related symptom checklist in children with cancer

PURPOSE

To validate a simplified Chinese version of the therapy-related symptom checklist for children (TRSC-C) in children with cancer.

METHODS

Reliability was assessed by internal consistency and test-retest coefficients. Dimensionality and construct validity were clarified using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Pearson's correlation coefficient was calculated between the TRSC-C and the PedsQL 3.0 cancer model (PedsQL 3.0) and the Lansky Play Performance Scale (LPPS) to test concurrent validity. A Student's t-test was used to compare the scores of the simplified Chinese version of the TRSC-C subscales by gender, age groups, and functional status to test sensitivity of the TRSC-C.

RESULTS

A sample of 170 children with cancer was recruited (11.27 ± 2.31 years). Cronbach's alpha (0.89) and interclass correlation coefficient (0.98) were acceptable. Seven factors with eigenvalues >1 explained 56.86% of the total variances. CFA demonstrated an acceptable model (CFI = 0.93, RMSE = 0.04). Concurrent validity was supported by moderate to high correlations between the TRSC-C and both the PedsQL 3.0 (r = -0.71) and LPPS (r = -0.43). The TRSC-C scores significantly differed by age groups and functional status (effect size 0.40-0.93), indicating adequate sensitivity.

CONCLUSION

The simplified Chinese version of the TRSC-C demonstrated acceptable reliability, validity, and sensitivity to support its use in clinical practice and future studies.

Malnutrition in paediatric patients with leukaemia and lymphoma: a retrospective cohort study

Introduction

Paediatric cancer is a potentially curable disease and its prognosis has been linked to several factors, such as nutritional status. The impact of malnutrition on these patients, either by overnutrition or undernutrition, varies and its relationship with outcomes is inconsistent. This study was conducted in order to determine the frequency of malnutrition in children with haematolymphoid malignancies at the time of diagnosis, as well as during treatment and to also investigate its relationship with the development of infections and death.

Materials and Methods

A retrospective cohort study of 191 children with a recent diagnosis of a haematolymphoid malignancy. The risks and nutritional classification were determined using anthropometry, follow-ups were conducted for up to 24 months and the presentation and frequency of infections and/or death were also recorded. Bivariate and multivariate analyses were conducted using binomial logistic regressions, for death and infection outcomes during follow-up. Survival analysis was conducted for various factors and types of cancer.

Results

83.7% of children had a sufficient nutritional classification at diagnosis, 6.8% had malnutrition by undernutrition and 9.4% by overnutrition. 83.8% had at least one infectious complication during follow-up and 47.1% had ≥ 3. This percentage increased to 69.2% when configuring it in the malnutrition by undernutrition group. 18.3% of patients died. When configuring the mortality, the percentage was greater in patients with Acute Myeloid Leukaemia (AML) (57.1%) and malnutrition by undernutrition (30.7%). The multivariate analysis for the outcome of death, only showed a statistically significant variable (AML odds ratio = 26.52; confidence interval = 1.09–643.24; p = 0.04).

Conclusion

No statistically significant relationship was found between the nutritional status of children with haematolymphoid neoplasms, and outcomes such as infections or death. The differences in the results obtained in these investigations may be related to the varied nutritional status definitions and the ways of measuring them, thus limiting comparisons between them.

Supportive methods for childhood acute lymphoblastic leukemia then and now: A compilation for clinical practice

Survival of childhood acute lymphoblastic leukemia has significantly improved over the past decades. In the early years of chemotherapeutic development, improvement in survival rates could be attained only by increasing the cytostatic dose, also by modulation of the frequency and combination of chemotherapeutic agents associated with severe short- and long-time side-effects and toxicity in a developing child's organism. Years later, new treatment options have yielded promising results through targeted immune and molecular drugs, especially in relapsed and refractory leukemia, and are continuously added to conventional therapy or even replace first-line treatment. Compared to conventional strategies, these new therapies have different side-effects, requiring special supportive measures. Supportive treatment includes the prevention of serious acute and sometimes life-threatening events as well as managing therapy-related long-term side-effects and preemptive treatment of complications and is thus mandatory for successful oncological therapy. Inadequate supportive therapy is still one of the main causes of treatment failure, mortality, poor quality of life, and unsatisfactory long-term outcome in children with acute lymphoblastic leukemia. But nowadays it is a challenge to find a way through the flood of supportive recommendations and guidelines that are available in the literature. Furthermore, the development of new therapies for childhood leukemia has changed the range of supportive methods and must be observed in addition to conventional recommendations. This review aims to provide a clear and recent compilation of the most important supportive methods in the field of childhood leukemia, based on conventional regimes as well as the most promising new therapeutic approaches to date.

Applied nutritional investigation The clinical application value of the extracellular-water-to-total-body-water ratio obtained by bioelectrical impedance analysis in people with advanced cancer

OBJECTIVES

Body-composition analysis using bioelectrical impedance analysis is gradually becoming more widely used in clinical practice. The ratio of extracellular water (ECW) to total body water (TBW) is thought to be related to the prognosis of a variety of diseases. However, its performance in people with advanced cancer deserves further discussion.

METHODS

A retrospective analysis was performed on 784 people with advanced cancer. Anthropometric indicators, serologic indicators, nutritional status, health-related quality of life, and body composition were analyzed. Participants were grouped into two groups according to ECW/TBW ratio. We used t tests and χ² tests to analyze differences between the groups. Univariate and multivariate Cox regressions were conducted to analyze the factors influencing overall survival. Logistic regression was used to analyze the related factors of malnutrition, and linear regression for factors of health-related quality of life.

RESULTS

Age, body mass index, Patient-Generated Subjective Global Assessment score, Karnofsky Performance Status questionnaire score, skeletal muscle mass index, and fat-free mass index were statistically different between the non-overhydrated and overhydrated groups. Univariate and multivariate Cox regression models showed that an ECW/TBW ≥ 0.40 is a risk factor for poor prognosis in people with advanced cancer (hazard ratio = 1.511; 95% confidence interval, 1.103-2.070; P = 0.010). Subgroup analyses were next conducted according to tumor type, with ECW/TBW ≥ 0.40 emerging as a risk factor for poor prognosis for people with advanced breast cancer and advanced gastric cancer. Logistic regression showed that ECW/TBW ≥ 0.40 is a risk factor for malnutrition in people with advanced cancer (odds ratio = 1.988; 95% confidence interval, 1.049-3.767; P = 0.035). The univariate and multivariate linear regression models showed that the ECW/TBW ratio is an influencing factor for health-related quality of life in the domains of physical functioning, role functioning, and constipation.

CONCLUSION

We found that in people with cancer, an ECW/TBW ≥ 0.40 was a risk factor for malnutrition and lower health-related quality of life, and in people with advanced cancer, it was a risk factor for poor prognosis.

Unique Features of a Web-Based Nutrition Website for Childhood Cancer Populations: Descriptive Study

Background

Children with cancer experience a myriad of nutritional challenges that impact their nutrition status during treatment and into survivorship. Growing evidence suggests that weight at diagnosis impacts cancer outcomes, but provider guidance on nutrition and diet during treatment varies. Nutrition literacy and culinary resources may help mitigate some common nutritional problems; however, many patients may face barriers to accessing in-person classes. Along with dietitian-led clinical interventions, web-based resources such as the newly updated electronic cookbook (e-cookbook) created by The University of Texas MD Anderson Cancer Center, @TheTable, may facilitate access to nutrition and culinary education during treatment and into survivorship.

Objective

We sought to define and describe the features and content of the @TheTable e-cookbook and compare it with analogous resources for a lay audience of patients with childhood cancer and childhood cancer survivors as well as their families.

Methods

We evaluated freely available web-based resources via a popular online search engine (ie, Google). These searches yielded three web-based resources analogous to @TheTable: the American Institute for Cancer Research’s Healthy Recipes, The Children’s Hospital of San Antonio’s Culinary Health Education for Families Recipe for Life, and Ann Ogden Gaffney and Fred Hutchinson Cancer Research Center’s Cook for Your Life. These sites were analyzed for the following: number of recipes, search functionality, child or family focus, cancer focus, specific dietary guidance, videos or other media, and miscellaneous unique features.

Results

Cook for Your Life and Culinary Health Education for Families Recipe for Life were the most comparable to @TheTable with respect to cancer focus and family focus, respectively. Healthy Recipes is the least user-friendly, with few search options and no didactic videos.

Conclusions

The @TheTable e-cookbook is unique in its offering of child- and family-focused content centered on the cancer and survivorship experience.

Efficacy of ready-to-use therapeutic food in malnourished children with cancer: Results of a randomized, open-label phase 3 trial

BACKGROUND

The adverse influence of undernutrition in children with cancer may be remediated by early nutritional intervention. This study assessed the efficacy of ready-to-use therapeutic food (RUTF) in improving nutritional status and reducing treatment-related toxicities (TRTs) in such children.

METHODS

In a randomized controlled phase-3 open-label trial, severely and moderately undernourished children with cancer were randomized 1:1 to receive standard nutritional therapy (SNT) or SNT+RUTF for 6 weeks. The primary outcome (weight gain >10%) and secondary outcomes (improved/maintained nutritional status, improved body composition) were assessed after 6 weeks. TRTs were assessed over 6 months.

RESULTS

Between July 2015 and March 2018, 260 subjects were enrolled, 126 were analyzable in both arms at 6 weeks. More children on RUTF had weight gain (98 [77.8%] vs. 81 [64.2%], p = .025) with a greater increase in fat mass as a percentage of body mass (median 2% [IQR -0.12 to 4.9] vs. 0.5% [IQR -1.45 to 2.27, p = .005]) but a greater loss of lean mass (median -1.86% [IQR -4.4 to 0.50] vs. -0.4% [IQR -2.4 to 1.4, p = .007]) compared to the SNT arm. Fewer subjects on the RUTF arm had episodes of severe infection (10.6% vs. 31%, p < .0001), treatment delays (17.7% vs. 39%, p < .0001), and severe mucositis (11% vs. 23.8%, p = .006) compared to the SNT arm. The odds of developing TRTs on the RUTF arm were lower even after adjusting for improvement in nutritional status.

CONCLUSIONS

RUTF is efficacious in improving weight gain and nutritional status in undernourished children with cancer and decreases TRTs. Incorporating RUTF into a healthy, balanced diet should be considered in undernourished children with cancer.

Examining the expectations of healing care environment of hospitalized children with cancer based on Watson's theory of human caring

AIM

To describe the expectations of children with cancer about the healing care environment during hospitalization based on Watson's Theory of Human Caring.

DESIGN

A descriptive qualitative research design was used in this study.

METHODS

Data were collected between December 2019 and February 2020 from purposively selected children with cancer in a paediatric haematology and oncology clinic at a university hospital in Turkey. Twelve participants (7 females and 5 males) aged 10-17 were recruited to carry out individual semi-structured interviews. All interviews were recorded via a digital audio recorder and transcribed verbatim. The content analysis method was used to analyse the data.

FINDINGS

As a result of the analysis, three main themes with related sub-themes were identified that revealed the expectations of children with cancer: 'healing care behaviors', 'creating the physical environment of the hospital' and 'support from the social environment'.

CONCLUSION

Watson's Theory of Human Caring may be a useful and applicable guide for drawing a conceptual framework of the expectations of children with cancer regarding a healing care environment. The study revealed these children's need for humanistic, compassionate, honest and problem-focused care. In addition, participants wished for improvements in the physical environment. They also stated that they feel lonely and need social support from their family, peers and society.

IMPACT

This study presents a comprehensive picture of the expectations regarding a healing care environment (caring behaviours and physical and social aspects) of hospitalized children with cancer undergoing treatment. The qualitative findings generated by our study have the potential to facilitate these children's healthy adjustment to the hospital environment and procedures during hospitalization. Knowledge acquired through this study may be used to shape nursing care, enhance the healing care environment, and ensure that hospital design and setting are acceptable to and appropriate for paediatric patients.

Omega-3 Fatty Acids and Their Role in Pediatric Cancer

BACKGROUND

Malnutrition is common in children with cancer and is associated with adverse clinical outcomes. The need for supportive care is becoming ever more evident and the role of nutrition in oncology is still not sufficiently understood. In particular, the consequences of macro- and micronutrient deficiencies require further research. As epidemiological data suggest anti-tumoral properties of omega-3 (n-3) polyunsaturated fatty acids (PUFAs), we reviewed the role of nutrition and n-3 supplementation in pediatric oncology.

METHODS

A comprehensive literature search was conducted on PubMed through 5 February 2021 to select meta-analyses, systematic reviews, observational studies, and individual randomized controlled trials (RCTs) on macro- and micronutrient supplementation in pediatric oncology. The search strategy included the following medical subject headings (MeSH) and keywords: "childhood cancer", "pediatric oncology", "nutritional status", "malnutrition", and "omega-3-fatty-acids". The reference lists of all relevant articles were screened to include potentially pertinent studies.

RESULTS

We summarize evidence about the importance of adequate nutrition in childhood cancer and the role of n-3 PUFAs and critically interpret findings. Possible effects of supplementation on the nutritional status and benefits during chemotherapy are discussed as well as strategies for primary and secondary prevention.

CONCLUSION

We here describe the obvious benefits of omega-3 supplementation in childhood cancer. Further large scale clinical trials are required to verify potential anti-cancer effects of n-3 fatty acids.

Adiposity in Survivors of Cancer in Childhood: How is it Measured and Why Does it Matter?

Survival of cancer in childhood is increasingly common with modern therapeutic protocols but leads frequently to adverse long-term impacts on health, including metabolic and cardiovascular disease. Changes in body composition, especially an increase in fat mass and a decrease in muscle mass, are found early in patients with pediatric cancer, persist long after treatment has been completed and seem to contribute to the development of chronic disease. This review details the effects of such changes in body composition and reviews the underlying pathophysiology of the development of sarcopenic obesity and its adverse metabolic impact. The authors discuss the particular challenges in identifying obesity accurately in survivors of pediatric cancer using available measurement techniques, given that common measures, such as body mass index, do not distinguish between muscle and adipose tissue or assess their distribution. The authors highlight the importance of a harmonized approach to the assessment of body composition in pediatric cancer survivors and early identification of risk using "gold-standard" measurements. This will improve our understanding of the significance of adiposity and sarcopenia in this population, help identify thresholds predictive of metabolic risk, and ultimately prevent or ameliorate the long-term metabolic and cardiovascular impacts on health experienced by survivors of cancer in childhood.

The relevance of nutrition to pediatric oncology: A cancer control perspective

It is indisputable that adequate and appropriate nutrition is fundamental to the health, growth, and development of infants, children, and adolescents, including those with cancer. Nutrition has a role in most of the accepted components of the cancer control spectrum, from prevention through to palliation. The science of nutrigenomics, nutrigenetics, and bioactive foods (phytochemicals), and how nutrition affects cancer biology and cancer treatment, is growing. Nutritional epigenetics is giving us an understanding that there are possible primary prevention strategies for pediatric cancers, especially during conception and pregnancy, which need to be studied. Primary prevention of cancer in adults, such as colorectal cancer, should commence early in childhood, given the long gestation of nutritionally related cancers. Obesity avoidance is definitely a target for both pediatric and adult cancer prevention, commencing in childhood. There is now compelling evidence that the nutritional status of children with cancer, both overweight and underweight, does affect cancer outcomes. This is a potentially modifiable prognostic factor. Consistent longitudinal nutritional assessment of patients from diagnosis through treatment and long-term follow-up is required so that interventions can be implemented and evaluated. While improving, there remains a dearth of basic and clinical nutritional research in pediatric oncology. The perspective of evaluating nutrition as a cancer control factor is discussed in this article.