Nutrition during childhood cancer treatment: current understanding and a path for future research

Nutritional Support Best Practices in Pediatric Blood and Marrow Transplant Patients: An Integrative Review

Nutrition is vital to the long-term survival of children undergoing blood and marrow transplantation (BMT), but there is no standardization on how to optimize the nutritional status of these patients. A literature search was performed to evaluate nutritional support approaches currently in practice for pediatric patients who are undergoing BMT. CINAHL, Embase, and Cochrane databases were searched for peer-reviewed articles evaluating nutritional interventions for BMT recipients aged 20 or younger. Nine articles published between 2019 and 2023 were found and reviewed. The nutritional support varied between enteral nutrition, parenteral nutrition, a combination of both, and prophylactic feeding tube placement. The post-transplant outcomes identified as associated with alterations in nutritional regimens included length of stay, date of platelet engraftment, incidence of acute graft-versus-host disease, infection rate, and overall survival. The use of any amount of enteral nutrition compared to parenteral alone was beneficial. Complications during BMT can potentially be decreased via prioritizing enteral nutrition over parenteral. The paucity of literature on this topic highlights an unmet need in the field. Future research should focus on ways to optimize the nutritional support of transplant recipients, including increasing the likelihood of enteral feeding tube placement and utilization.

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.

Eating Behavior, Nutritional Status, and Taste Perception Alteration in Children with Cancer

The aim of this study was to investigate eating behavior, nutritional status, and taste alterations in children with cancer. The population of the study consisted of children 8 to 18 years of age and their parents who were followed up and received chemotherapy in the pediatric hematology and oncology clinic and outpatient clinic of a University Faculty of Medicine Oncology Hospital. Data were collected using the Child Identification Form, the Children's Eating Behavior Questionnaire (CEBQ), the Taste Alteration Scale for Children Receiving Chemotherapy (TAC-TAS), and the Subjective Total Taste Acuity Scale (STTA). Body Mass Index (BMI) Z score was between -2 and +2 (normal) in 92.5% of the children and below ≤-2 (malnutrition) in 7.5%. The mean CEBQ subdimensions scores were food craving 12.48±5.36, emotional overeating 5.28±1.45, enjoyment of food 16.83±5.41, passion for drinking 9.72±5.13, satiety enthusiasm 22.93±6.65, slow eating 9.81±4.95, emotional undereating 16.38±4.41, and food selectivity 10.72±2.86, and the mean total TAC-TAS score was 8.66±10.22. A negative, moderate correlation was determined between food craving and enjoyment of food and taste alteration, with food craving and enjoyment decreasing as food alteration increased. A positive moderate correlation was observed between slow eating and taste alteration, with eating slowing down as taste alteration increased.

Nutritional assessment and dietary intervention among survivors of childhood cancer: current landscape and a look to the future

Over 85% of childhood cancer patients become long-term survivors. Still, cancer and its therapies are associated with a myriad of long-term complications such that childhood cancer survivors (CCS) endure excess disease burden, morbidity, and mortality throughout their lifetimes. Existing literature suggests that CCS maintain poor dietary intake and nutritional status. Thus, as childhood cancer cure rates continue to improve, the role of diet and nutrition in mitigating many of the most common adverse long-term health outcomes among CCS has gained significant interest. Herein we present an in-depth review of existing scientific literature evaluating dietary intake and nutrition status among CCS and its impact on treatment-related health complications; as well as contemporary intervention strategies aimed at overcoming distinctive barriers and improving deleterious lifestyle behaviors in this heterogeneous, at-risk population. Patient-specific, clinical, and systemic factors act as barriers to the timely conduct of comprehensive dietary/nutritional assessments and provision of tailored, risk-based recommendations. This Mini Review discusses the current state of the science, persisting research gaps, and opportunities for advancement of assessment and intervention strategies to address the unique needs of CCS. Search Strategy: We searched PubMed for peer-reviewed articles with the search terms "pediatric cancer," "pediatric malignancy," "pediatric oncology," "childhood cancer," "survivorship," "cancer late effects," "long-term follow-up," "body mass index," "nutritional status," "malnutrition," "body weight," "body weight changes," "body composition," "obesity," "overweight ", "Mediterranean diet," "DASH diet," "processed foods," "micronutrients," "antioxidants," "vitamin D," "calcium," "selenium," "zinc," "metabolic syndrome," "heart disease," "cardiovascular disease," "cardiometabolic disease," "hypertension," "hyperlipidemia," "HDL," "LDL," and "small dense LDL" from January 1, 1995, to July 21, 2023. We also selected relevant articles from our personal files and from reference lists of identified papers. We prioritized publications after 2013; however, commonly cited and highly regarded (defined by high citation count and journal impact factor) older publications were also included. Randomized controlled trials, observational studies, retrospective studies, meta-analysis, editorials, and review articles were included, whereas conference abstracts and case reports were excluded. We only searched for articles published in English, or those translated into English.

The influence of pediatric cancer treatment on taste perception and food hedonics: a systematic review

CONTEXT

Children with cancer are at risk of poor nutritional status during treatment and into survivorship. Objectively measured taste perception and self-reported food hedonics are 2 factors that may influence food intake.

OBJECTIVE

This 2-armed systematic review examined whether chemotherapy and radiotherapy affect (1) taste perception and (2) hedonic experiences of children and survivors of childhood cancer.

DATA SOURCE

A 2-armed systematic literature search was conducted in the Medline, CINAHL, Embase, and PsychInfo database until June 2022. The effects of cancer treatment on objective taste perception or food hedonics (ie, food liking or aversion and appetite) were examined.

DATA EXTRACTION

Peer-reviewed articles published in English of studies that included children (aged <18 years) or survivors of childhood cancer (any age) were reviewed. Risk of bias was determined using the Evidence Analysis Library by the Academy of Nutrition and Dietetics.

DATA ANALYSIS

A total of 1417 articles in the taste search arm and 3862 articles in the hedonics search arm were identified. Of these, 9 and 4 articles were eligible for review, respectively. Cancer treatment had highly variable effects on taste perception during treatment and into survivorship. Learned food aversions were experienced by children receiving chemotherapy treatment and liking of meats and salty foods by children with cancer was affected. The impact of treatment on appetite varied.

CONCLUSIONS

Cancer treatment did not uniformly affect taste perception. Food liking may be negatively affected, and learned food aversions may develop during cancer treatment. To establish the clinical relevance of childhood cancer treatment on taste perception and food hedonics, more research is required.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no.CRD42020207127.

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.

The neutropenic diet: Are well-cooked vegetables still good sources of nutrients? A mini-narrative review

A low immune response is fatal for humans because increased infection risk is related to both morbidity and mortality. The neutropenic diet is applied if a person's neutrophil count is <2000 cells/μL. When compared with standard nutrition treatment, the neutropenic diet is found to be related to deficiencies in dietary fiber, vitamins C, A, and D, magnesium, and calcium. This is also related to malnutrition in patients diagnosed with cancer. Although raw vegetables are good sources of these nutrients, they can also be sources of pathogen microorganisms. Thus, the consumption of well-cooked vegetables is an essential principle in the neutropenic diet. Although many cooking methods are available, pressure cooking is the most commonly used in neutropenic diet kitchens to reduce pathogen transmission risk. According to many studies, the cooking process is associated with significant nutrient loss. In particular, boiling is found to be related to losses in vitamins C, A, and K, phenolic compounds, flavonoids, calcium, zinc, manganese, magnesium, copper, and iron in different types of vegetables. Even though some studies have shown that standard nutrition treatment with the adoption of food safety guidelines does not increase infection risk and the neutropenic diet is related to malnutrition, no guidelines have thus far suggested the application of standard nutrition treatment in neutropenic patients. Consequently, additional studies are required to compare the beneficial and harmful effects of the neutropenic diet to a standard nutrition treatment and support the application of standard nutrition treatment with the adoption of food safety guidelines at least in mildly neutropenic patients.

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.

Nutritional risk and clinical outcomes of COVID-19 in hospitalized children and adolescents: a multicenter cohort

OBJECTIVE

To verify the association between nutritional risk on admission and clinical outcomes of COVID-19 in hospitalized children and adolescents.

METHODS

Multicenter cohort study was conducted in two cities in the northeastern region of Brazil, with children under 18 years of age laboratory diagnosed with COVID-19. Sociodemographic data and nutritional risk screening by STRONGKids (low, medium and high risk) were collected remotely and in hospital records, respectively. The outcomes assessed were the need for ICU admission, length of stay (< 10 days or ≥ 10 days), critical cases, and death. Multivariable logistic regression models were used to evaluate the effects of high nutritional risk on COVID-19 clinical outcomes.

RESULTS

103 individuals were evaluated, of these 35 (34.0%) had low risk, 44 (42.7%) medium risk, and 24 (23.3%) had high risk of malnutrition. In multivariate analysis, ICU bed admission (OR: 4.57; 95%CI, 1.39-4.97; p = 0.01), hospitalization longer than or equal to ten days (OR: 3.96; 95%CI, 1.22-2.83; p = 0.02) and critical cases (OR: 4.35; 95%CI, 1.08-7.55; p = 0.04) were associated with high nutritional risk. Death was not associated with high nutritional risk.

CONCLUSIONS

Children and adolescents with high nutritional risk by STRONGkids at hospital admission were more likely to be admitted to the ICU, have hospitalization longer than or equal to ten days, and have critical cases when infected with SARS-CoV-2.

Collaboration for success: the Global Initiative for Childhood Cancer in Latin America

The Global Initiative for Childhood Cancer (GICC) aims to increase the cure rate for children with cancer globally by improving healthcare access and quality. The Pan American Health Organization (PAHO), St. Jude Children's Research Hospital (St. Jude), and collaborators have joined efforts to improve outcomes of children with cancer in Latin America and the Caribbean (LAC) using the CureAll framework. In this article, we describe the process of developing regional resources aimed at accelerating the GICC implementation in LAC. In March 2021, PAHO formed regional working groups to develop core projects aligned with CureAll pillars and enablers. Seven working groups emerged from regional dialogues: early detection, nursing, psychosocial, nutrition, supportive care, treatment abandonment, and palliative care. PAHO arranged regular online meetings under the mentorship and support of St. Jude regional/transversal programs and international mentors. Between April and December 2021, 202 multidisciplinary experts attended 43 online meetings to promote the dialogue between stakeholders to improve childhood cancer outcomes. Fourteen technical outputs were produced: four regional snapshots, four technical documents, two virtual courses, one set of epidemiological country profiles, one educational content series for parents/caregivers, and two communication campaigns. The ongoing dialogue and commitment of PAHO, St. Jude, LAC working committees, and international collaborators are essential foundations to successfully accelerate GICC implementation. This is achievable through the development of materials of regional and global relevance. Further research and evaluation are needed to determine the impact of these strategies and resources on childhood cancer outcomes in LAC and other regions.

Prognostic Value of Inflammation Biomarkers in Penile Squamous Cell Carcinoma Patients Without Distant Metastasis

BACKGROUND

To investigate the value of the presurgical inflammatory biomarkers including C-reactive protein (CRP), albumin (ALB), C-reactive protein to albumin ratio (CAR), Glasgow prognostic score (GPS), the modified GPS (mGPS), and the high-sensitivity modified GPS (Hs-mGPS) in penile squamous cell carcinoma (PSCC) without distant metastasis and develop a tool to predict the overall survival (OS) of PSCC patients.

METHODS

We retrospectively enrolled 271 PSCC patients without distant metastasis from 2006 to 2021. Patients were divided into 2 cohorts by a 7:3 ratio-a training cohort (n = 191) and a validation cohort (n = 80). We performed cox regression analyses on the training cohort and constructed a nomogram to predict OS over 1, 3, and 5 years. Data from the validation cohort was used to validate the nomogram's predictive power.

RESULTS

According to Kaplan-Meier analysis, elevated CRP (P < .001), hypoalbuminemia (P = .008), higher CAR (P < .001), higher GPS score (P < .001), higher mGPS score (P < .001), and higher Hs-mGPS score (P = .015) were associated with a decreased overall survival. GPS score, along with age, pathology N stage, and grade, was found to be an independent risk factor for poor prognosis in the multivariate analysis. We constructed a nomogram based on the prespecified variables predicting 1-, 3- and 5-year OS. The C-indexes of the nomogram in the training and validation cohorts were 0.871 and 0.869, respectively. The decision curve analysis showed that the nomogram had a larger net benefit. The Kaplan-Meier curves showed significant differences between the risk groups categorized according to the nomogram (P < .001).

CONCLUSIONS

Inflammation biomarkers of systemic inflammation and nutritional status play an important role in individual OS predictions for PSCC patients without distant monitoring. The establishment of the nomogram provided a tool to predict the survival of 1-, 3-, and 5-year OS in PSCC patients without distant metastasis.

Identifying central symptom clusters and correlates in children with acute leukemia undergoing chemotherapy: a network analysis

Background

Previous studies have examined symptom clusters in children with acute leukemia, yet a knowledge gap persists regarding central symptom clusters and their influencing factors. By identifying these central clusters and associated factors, healthcare providers can enhance their understanding and effective management of symptoms. Our study seeks to address this gap by identifying symptom clusters, exploring central clusters, and investigating the demographic and health-related factors associated with these clusters in children with acute leukemia undergoing chemotherapy.

Methods

A total of 586 children with acute leukemia from January 2021 to April 2023 were recruited from China. They were investigated using Memorial Symptom Assessment Scale 10-18 during chemotherapy. The principal component analysis was used to identify the symptom clusters. An association network was conducted to describe the relationships among symptoms and clusters. A multiple linear model was used to investigate the associated factors for the severity of overall symptoms and each symptom cluster.

Results

Five clusters were identified, including oral and skin cluster, somatic cluster, self-image disorder cluster, gastrointestinal cluster and psychological cluster. Gastrointestinal cluster was the most central symptom cluster. Age, sex, clinical classification, number of having chemotherapy and education degree and marital status of the primary caregiver are associated with the severity of these five symptom clusters.

Conclusion

Our study highlights the importance of evaluating symptom clusters in children with acute leukemia during chemotherapy. Specifically, addressing gastrointestinal symptoms is crucial for effective symptom management and overall care.

Understanding the patient and family experience of nutrition and dietetic support during childhood cancer treatment

PURPOSE

This study aimed to understand the experience of families caring for a child with cancer in New Zealand (NZ) who received nutrition and dietetic support during cancer treatment and their preferences for the delivery, format, and timing of nutrition information.

METHODS

Childhood cancer patients and their families (N = 21) participated in a mixed-methods study at a specialist paediatric oncology centre in Auckland, NZ. Before the semi-structured interview, participants completed a questionnaire capturing demographic, disease, and treatment characteristics of their child, their nutrition concerns, and their information needs. Quantitative data were described, and qualitative thematic analysis of the semi-structured interviews was performed using NVivo data analysis software.

RESULTS

Eighty-six percent of participants indicated they had concerns about their child's nutrition during treatment. The most common concerns were anorexia, vomiting, and weight loss. While many were happy with the quality of the nutrition support received, one-third of the patients wanted more support. Four key themes emerged from the interviews: (1) patients experience significant and distressing nutrition challenges; (2) patients and families have mixed perceptions of EN; (3) there are gaps in the current nutrition support system for inpatients; and (4) a desire for more accessible nutrition support.

CONCLUSION

Childhood cancer patients and families experience significant and distressing nutrition challenges during treatment. Standardising information given to patients and their families may optimise nutrition support for paediatric oncology patients and reduce the discordance between families and health professionals. Future implementation of a nutrition decision aid in this population is warranted.

Pharmacokinetics of cancer therapeutics and energy balance: the role of diet intake, energy expenditure, and body composition

Energy balance accounts for an individual's energy intake, expenditure, and storage. Each aspect of energy balance has implications for the pharmacokinetics of cancer treatments and may impact an individual's drug exposure and subsequently its tolerance and efficacy. However, the integrated effects of diet, physical activity, and body composition on drug absorption, metabolism, distribution, and excretion are not yet fully understood. This review examines the existing literature on energy balance, specifically the role of dietary intake and nutritional status, physical activity and energy expenditure, and body composition on the pharmacokinetics of cancer therapeutics. As energy balance and pharmacokinetic factors can be influenced by age-related states of metabolism and comorbidities, this review also explores the age-related impact of body composition and physiologic changes on pharmacokinetics among pediatric and older adult populations with cancer.

A cross-sectional study of nutritional status and dietary intake of paediatric oncology patients in Indonesia: Comparison between cancer aetiologies

Background: Adequate energy and protein intakes are required to maintain nutritional status and prevent clinical deterioration in paediatric oncology patients. There are limited investigations of malnutrition and dietary intake adequacy during treatment in developing countries. Aim: This study aimed to assess the nutritional status and macro- and micronutrient intake adequacy in paediatric oncology patients undergoing therapy. Methods: This cross-sectional study was conducted at Dr Sardjito Hospital, Indonesia. Sociodemographic, anthropometry, dietary intake, and anxiety status were collected. Patients were grouped based on cancer aetiology (haematological malignancy (HM) or solid tumour (ST). Variables between groups were compared. P-values of <0.05 were considered statistically significant. Results: 82 patients aged 5-17 years (65.9% HM) were analysed. The prevalence of underweight was 24.4% (ST vs HM: 26.9% vs 23.2%), overweight 9.8% (ST vs HM: 11.5% vs 8.5%), and obesity 6.1% (ST vs HM: 0.0% vs 8.5%) according to BMI-for-age z-score. Mid-upper-arm circumference identified undernutrition in 55.7% and overnutrition in 3.7% of the patients. Stunted growth was found in 20.8% of the patients. Percentages of children with inadequate energy and protein intake were 43.9% and 26.8%, respectively. The percentages of participants meeting the national micronutrient requirements were low, ranging from 3.8% to 56.1%, with the highest adherence rate observed for vitamin A and the lowest for vitamin E. Appetite loss was associated with lower overall intake. Conclusion: This study confirmed that malnutrition is prevalent in paediatric patients treated for cancer. Inadequate intakes of macro- and micro-nutrients were also common, highlighting the need for early nutritional assessment and intervention.

[Validation of the nutritional screening tool for childhood cancer SCAN. Spanish version]

INTRODUCTION

the prevalence of undernutrition in the pediatric cancer population can vary considerably, an element that significantly influences the clinical outcome of patients. However, this is a potentially modifiable prognostic factor, which requires timely identification of nutritional risk to guide the nutritional care process.

OBJECTIVES

to evaluate the operational performance of the Spanish version of the nutritional screening tool for childhood cancer (SCAN) in the context of the validation process of this instrument in a high-complexity hospital in the city of Bogotá, Colombia.

METHODS

the methodological design for the validation of a diagnostic scale was followed. The final sample consisted of 96 patients between 0 and 17 years with cancer and hospitalized at the Children's Cancer Center of the HOMI Foundation in Bogota. The SCAN-SP was applied to each patient and a complete nutritional assessment (CNA) was performed as a gold standard to determine nutritional status.

RESULTS

82.3 % (n = 79) of patients were classified "at risk of malnutrition" by SCAN-SP and 69.8 % (n = 67) of the total sample had undernutrition. The evaluation of the operative performance of SCAN-SP against CNA showed excellent results: sensitivity of 100 %, specificity of 59 %, PPV of 85 %, NPV of 100 %, positive likelihood ratio of 2.4, and negative likelihood ratio of 0.

CONCLUSION

the SCAN-SP scale performs well as a nutritional screening tool in pediatric cancer patients, so its use in clinical practice is recommended.

Risk of Surgical Intervention in Children with Diagnoses of Cancer and Preoperative Malnutrition: A National Analysis

BACKGROUND

Perioperative nutrition is a critical component of appropriate healing and recovery after surgery. We sought to identify perioperative risk in children with cancer and low preoperative hypoalbuminemia undergoing surgical intervention.

METHODS

We queried the 2015-2019 NSQIP-Peds datasets for children with a primary diagnosis of renal or hepatic malignancy undergoing surgical resection. Postoperative outcomes were evaluated for comparative risk between patients with low albumin (albumin<3.0 g/dL) and normal albumin within 30 days of their surgical procedure. Univariate analysis and multivariable logistic regression were conducted to identify perioperative risk in patients with hypoalbuminemia.

RESULTS

We identified 360 children with primary diagnosis of hepatic malignancy and 896 children with renal malignancy undergoing surgical resection. Of these, 77 children had hypoalbuminemia. Patients with renal or hepatic malignancy diagnosis and low albumin levels were more likely to experience postoperative dehiscence, need for TPN at discharge, postoperative bleeding or transfusion, unplanned reoperation, and unplanned readmission, based on univariate analysis (all P > 0.05). Postoperative bleeding, need for nutritional support at discharge, and unplanned readmission were each associated with hypoalbuminemia.

CONCLUSION

We demonstrate that low preoperative albumin is associated with significant perioperative risk. More attention should focus on perioperative nutritional status of children with cancer who are undergoing major resections.

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.

The emerging role of nutritional support in the supportive care of pediatric patients undergoing hematopoietic stem cell transplantation

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) represents a potentially curative strategy for many oncological, hematological, metabolic, and immunological diseases in children. The continuous effort in ameliorating supportive care represents one of the cornerstones in the improvement of outcome in these patients. Nowadays, more than ever nutritional support can be considered a key feature. Oral feeding in the early post-transplant period is severely impaired because of mucositis due to conditioning regimen, characterized by, mainly by vomiting, anorexia, and diarrhea. Gastrointestinal acute graft-versus-host-disease (GvHD), infections and associated treatments, and other medications, such as opioids and calcineurin inhibitors, have also been correlated with decreased oral intake. The consequent reduction in caloric intake combined with the catabolic effect of therapies and transplantation-related complications with consequent extended immobilization, results in a rapid deterioration of nutritional status, which is associated with decreased overall survival and higher complication rates during treatment. Thus, nutritional support during the early post-transplantation period becomes an essential and challenging issue for allo-HSCT recipients. In this context, the role of nutrition in the modulation of the intestinal flora is also emerging as a key player in the pathophysiology of the main complications of HSCT. The pediatric setting is characterized by less evidence, considering the challenge of addressing nutritional needs in this specific population, and many questions are still unanswered. Thus, we perform a narrative review regarding all aspects of nutritional support in pediatric allo-HSCT recipients, addressing the assessment of nutritional status, the relationship between nutritional status and clinical outcomes and the evaluation of the nutritional support, ranging from specific diets to artificial feeding.

Walking a tightrope – as a next-of-kin to an adolescent or young adult with cancer facing eating difficulties

Purpose

Eating difficulties cause reduced food intake and poor quality of life among adolescents and young adults (AYAs) with cancer. Therefore, next-of-kin eating support is crucial. The purpose of this study was to explore the lived experiences of being close to AYAs with cancer in the context of eating when they are at home between high-emetogenic chemotherapy (HEC) sessions.

Method

In-depth interviews were conducted with 12 next-of-kin to AYAs (15–29 years old) with oncological or haematological diseases, treated with HEC. Van Manen’s hermeneutic-phenomenological approach guided the design.

Results

The essential meaning of the next-of-kin experiences is reflected in the overarching theme “Utilizing meals as an action-opportunity” consisting of two subthemes: ’Being on constant alert’ and “Walking a tightrope to maintain usual everyday life.”

Conclusions

Findings revealed that utilizing meals as an action-opportunity towards AYAs’ food intake involved existential feelings including fear of losing their loved ones. Next-of-kin experienced that providing support through and with food was their only avenue of action. However, this sparked feelings of frustration and powerlessness.

The Role of Nutrition in Primary and Secondary Prevention of Cardiovascular Damage in Childhood Cancer Survivors

Innovative therapeutic strategies in childhood cancer led to a significant reduction in cancer-related mortality. Cancer survivors are a growing fragile population, at risk of long-term side effects of cancer treatments, thus requiring customized clinical attention. Antineoplastic drugs have a wide toxicity profile that can limit their clinical usage and spoil patients’ life, even years after the end of treatment. The cardiovascular system is a well-known target of antineoplastic treatments, including anthracyclines, chest radiotherapy and new molecules, such as tyrosine kinase inhibitors. We investigated nutritional changes in children with cancer from the diagnosis to the end of treatment and dietary habits in cancer survivors. At diagnosis, children with cancer may present variable degrees of malnutrition, potentially affecting drug tolerability and prognosis. During cancer treatment, the usage of corticosteroids can lead to rapid weight gain, exposing children to overweight and obesity. Moreover, dietary habits and lifestyle often dramatically change in cancer survivors, who acquire sedentary behavior and weak adherence to dietary guidelines. Furthermore, we speculated on the role of nutrition in the primary prevention of cardiac damage, investigating the potential cardioprotective role of diet-derived compounds with antioxidative properties. Finally, we summarized practical advice to improve the dietary habits of cancer survivors and their families.

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.

Changes in body mass index, weight, and height in children with acute myeloid leukemia and the associations with outcome

Little is known about body composition changes in patients with acute myeloid leukemia (AML) during and after treatment or their associations with outcomes. Z-scores for body mass index (BMI), weight, and height at diagnosis, their longitudinal changes from diagnosis to 5 years off therapy, and their associations with adverse effects and outcomes were evaluated in 227 pediatric patients with AML enrolled in the AML02 and AML08 trials at St. Jude Children's Research Hospital between 2002-2017. The median Z-scores for baseline weight, height, and BMI were 0.193, 0.209, and 0.170, respectively, and those for weight and height decreased significantly during therapy to -0.038 and -0.163, respectively, at off-therapy (P < .001 for both). At 5 years off therapy, the Z-scores for weight and BMI had increased significantly to 0.492 (P = .003) and 0.911 (P < .001), respectively, whereas the height Z-score remained significantly lower at -0.066 (P < .001) compared with baseline. The height Z-score of transplant recipients decreased further from -0.211 at transplant to -0.617 12 months later (P < .001). Baseline BMI category and Z-score were not associated with outcomes, but higher weight Z-scores were associated with lower incidences of refractory or relapsed disease (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-0.99) and higher incidences of death in remission (HR, 1.31; 95% CI, 1.01-1.70). Furthermore, weight Z-score decrease during induction therapy was associated with gastrointestinal, hepatic, and infection toxicities during subsequent therapy and with death in remission (HR, 2.66; 95% CI, 1.11-6.45). Multidisciplinary monitoring for weight changes and short stature is required from diagnosis to the off-therapy period.

Development of an Enhanced Recovery Program in Pediatric, Adolescent, and Young Adult Surgical Oncology Patients

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative treatment plans aimed at improving recovery time in patients following surgery using a multidisciplinary team approach. These protocols have been shown to optimize pain control, improve mobility, and decrease postoperative ileus and other surgical complications, thereby leading to a reduction in length of stay and readmission rates. To date, no ERAS-based protocols have been developed specifically for pediatric patients undergoing oncologic surgery. Our objective is to describe the development of a novel protocol for pediatric, adolescent, and young adult surgical oncology patients. Our protocol includes the following components: preoperative counseling, optimization of nutrition status, minimization of opioids, meticulous titration of fluids, and early mobilization. We describe the planning and implementation challenges and the successes of our protocol. The effectiveness of our program in improving perioperative outcomes in this surgical population could lead to the adaptation of such protocols for similar populations at other centers and would lend support to the use of ERAS in the pediatric population overall.

Love, joy and necessity - A phenomenological study of food and meals in adolescents and young adults with cancer receiving high-emetogenic chemotherapy

PURPOSE

This study explored how the phenomenon of meals appeared in the interrelationship between adolescents and young adults (AYAs) receiving high-emetogenic chemotherapy, their next of kin and health professionals in the clinical setting.

METHOD

Data were collected by 140 h of participant observation conducted to gain insights into the nature of how meals appeared in the interrelationship between 12 AYAs (age 15-29 years), their next-of-kin and health professionals. The AYAs were patients with oncological and haematological diseases recruited from three university hospital departments. Data analysis was guided by van Manen's hermeneutic-phenomenological approach.

RESULTS

The essential meaning of the phenomenon may be characterized by the overarching theme; 'Seeking the joy of meals in the shadow of treatment' and the following three themes: 'Meals as a necessary evil' (AYAs); 'Meals as a matter of love' (next-of-kin); and 'Meals in the shadow of medical treatment' (health professionals).

CONCLUSIONS

Meals is a multi-facetted and complex phenomenon that has different meanings to AYAs, next-of-kin and health professionals. To the AYAs, meals emerged as a necessary evil in connection with which urges to eat occurred as glimpses of desire. Prominent feelings of powerlessness and food as love were highlighted by the next-of-kin, whereas food and meals appeared secondary to treatment for health professionals, reflecting the traditional biomedical paradigm. The findings revealed that adopting a holistic approach to AYAs concerning meals can have the potential to increase their food intake.

Zinc deficiency and its association with treatment-related toxicity in children with cancer

BACKGROUND

Nutritional deficiencies in children with cancer at time of diagnosis and during treatment may negatively affect disease outcome and increase treatment-related toxicity. Yet zinc, an essential nutrient important for supporting immune function and known for reducing diarrheal episodes, is rarely assessed in these children.

PROCEDURES

Fifty children (1 month to 18 years) with recently diagnosed cancer were enrolled in this study. An age and gender matched control group (n = 50) was also recruited. Plasma and urinary zinc, plasma copper, and C-reactive protein (CRP) levels were measured at baseline, 3, and 6 months following diagnosis. A retrospective review of the toxicity profile was performed in the cohort of children with cancer for the first 4 years after initial diagnosis.

RESULTS

CRP and plasma copper (both acute-phase reactants) were elevated in patients with cancer compared to controls at baseline, both p < .03. Plasma zinc levels were not significantly different from controls at baseline, but decreased by 11% in the cancer group over 6 months of treatment, 83.2 ± 15.6 to 74.3 ± 14.8 μg/dl, p = .01. Plasma zinc dropped to deficient levels in 35% of cases over the initial 6 months. Zinc deficiency at 6 months was related to an increased incidence of severe diarrhea during 4 years of follow-up, p < .001.

CONCLUSIONS

Zinc deficiency is an underrecognized problem among patients undergoing treatment for cancer and is associated with severe diarrhea. Further studies are needed to evaluate causes for zinc deficiency, related effects, and a possible role for zinc supplementation.

Struggling to Eat to Survive Cancer-Lived Experiences of Eating Among Adolescents and Young Adults Undergoing High-Emetogenic Chemotherapy

Purpose: The purpose of this study was to provide in-depth understanding of adolescents' and young adults' (AYAs') lived experiences of eating when they are at home between high-emetogenic chemotherapy sessions. Methods: The study was guided by van Manen's hermeneutic-phenomenological methodology. Eligible AYAs were 15-29 years old, diagnosed with either oncological or hematological cancer, treated with high-emetogenic chemotherapy, and Danish speaking. AYAs were recruited from three university hospital departments. Data were collected using semi-structured in-depth interviews. Results: Thirteen AYAs, aged 17-29 years, participated in the interviews via telephone or face-to-face in their homes. The essential meaning of the phenomenon of eating can be characterized by the overarching theme "Struggling to eat to survive" and unfolded through the following three themes: "Cooperating with a deceiving body", "Capturing moments of eating opportunities", and "Being loved and cared for at home". Conclusions: Struggling to eat was essential for survival and a fundamental existential challenge that required reflection and consciousness. AYAs experienced their deceiving bodies as a major concern, which challenged their ability to eat and forced them to develop strategies to capture moments of eating opportunities. AYAs kept hold of doing "something" themselves to maintain the slightest control of their own lives and thereby assist clinical outcomes and cure. However, AYAs had to struggle with food and start viewing food as a friend, not an enemy.

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.

Nutritional Screening and Assessment, and Quality of Life in Children with Cancer: A Cross-Sectional Study in Mainland China

PURPOSE

To apply Screening Tool for Risk on Nutritional status and Growth (STRONGkids) and the subjective global nutritional assessment (SGNA) for evaluating nutritional status, to identify the disease-related and demographic-related factors of malnutrition, and to examine the relationship between nutritional status and quality of life (QOL) in children with cancer during chemotherapy in mainland China.

DESIGN AND METHODS

Children, ages 2-18, with a leukemia, lymphoma, or solid tumor diagnosis were recruited from a top cancer center in Guangzhou, China. Socio-demographic information, clinical information were collected, while nutritional status using SGNA, malnutrition risk using STRONGkids, and QOL of these children were measured. Descriptive analyses, Chi²-tests, ANOVA and logistic regression analysis were used to analyze data.

RESULTS

Among included participants, 55.8% of them were malnourished, and 74.2% of them had moderate to high risk of malnutrition. The overall QOL and subscales were associated with nutritional status. In the logistic-regression model, high malnutrition risk, patients' mother having primary school education or less, worse physical functioning quality of life, and lower BMI level were strongly associated with malnutrition.

CONCLUSIONS

The prevalence of malnutrition in children with cancer is high, which related to worse QOL. Patients' BMI, physical functioning QOL and mothers' educational level could help to predict their nutritional status.

PRACTICE IMPLICATIONS

STRONGkids and SGNA could be widely used in mainland China. Health professionals should pay attention to patients with lower BMI and physical functioning scores, and patients' mother having primary school education or less.

Prevalence of Undernutrition and Effect of Body Weight Loss on Survival among Pediatric Cancer Patients in Northeastern Hungary

Undernutrition is a prevalent condition in pediatric malignancy patients leading to unfavorable outcomes. The aim of this retrospective study was to determine the nutritional status and rate of undernutrition in 174 Hungarian pediatric patients with malignancies and the impact on 5-year survival based on anthropometric measurements. At the time of diagnosis, 5.0%, 4.6%, and 4.0% of patients were undernourished as determined by body weight (BW), weight-for-height (WFH), and body mass index (BMI) Z-score, respectively. The rate of undernutrition was 30.5% using ideal body weight percent (IBW%). Undernutrition at the time of diagnosis worsened the five-year overall survival only in solid tumor patients as defined by BMI Z-score and IBW%. Furthermore, 26.5% of patients became undernourished based on IBW% during the treatment period. Deterioration of nutritional status during treatment unfavorably influenced overall survival in both hematological and solid tumor subsets. Abnormal BW, WFH, and BMI Z-score were associated with poor prognosis in the hematologic group. The mortality risk was higher among hematologic patients with weight loss exceeding 20%. In conclusion, IBW% seems to be the most sensitive parameter to estimate undernutrition. Furthermore, BMI Z-score in both groups and severe weight loss in the hematological group may influence clinical outcome and play a role in prognosis assessment.

Assessment of nutritional status in children with cancer: Significance of arm anthropometry and serum visceral proteins

BACKGROUND

Arm anthropometry is a better indicator of nutritional status in children with cancer. The value of serum albumin and prealbumin in nutritional assesment is debatable. We investigated the nutritional status of children with cancer and their serum albumin and prealbumin levels.

PATIENTS AND METHODS

At diagnosis and following induction therapies, weight, height, body mass index (BMI), mid-upper arm circumference (MUAC), and triceps skin-fold thickness (TSFT) were measured; serum albumin and prealbumin levels were determined. Prevalences of malnutrition defined by anthropometric indices were calculated. Correlations of anthropometric indices with each other, with serum albumin/prealbumin levels, and clinicopathological parameters were analyzed.

RESULTS

In 81 patients, median age was 7.5 years (males/females = 50/31), tumors were located mostly in the abdomen, and abdominal tumors were more common under 5 years. Prevalence of malnutrition according to weight for age, BMI, MUAC, TSFT z scores were 14.8%, 23.5%, 27.2%, 21%, respectively. Defined by combined BMI/MUAC/TSFT measurements, 33/81 cases (40.7%) had malnutrition (z scores < -1, 23 mild; z scores < -2, 10 moderate). Malnutrition was more prevalent under 5 years (P = .03), also in abdominal tumors (P = .03) and advanced disease (P < .001). Younger age and advanced disease were risk factors for malnutrition. At diagnosis, prevalences of low serum albumin and prealbumin levels were 7.4% and 54%, respectively. Cases with malnutrition had significantly lower survival rates.

CONCLUSIONS

Nutritional status is assessed best by MUAC and TSFT measurements. Serum prealbumin levels can be used to identify patients at risk of undernutrition. Presence of malnutrition is a significant poor prognostic factor. All children with cancer should undergo nutritional evaluation and active nutritional support.

Feasibility and Acceptability Findings of an Energy Balance Data Repository of Children, Adolescents, and Young Adults with Cancer

Cancer patients suffer changes in energy balance (EB), the combination of energy intake (nutrition) and energy expenditure (physical activity (PA)), which may influence cancer-related morbidity, mortality, and quality of life. Significant gaps remain in our understanding of the frequency and magnitude of these EB changes. Herein, we report on the feasibility and acceptability of a longitudinal repository of EB outcomes in children, adolescents and young adults (AYA) with cancer along the cancer continuum to fill these gaps. This EB repository includes PA, nutrition, and physical function (PF) parameters. PA data were gathered through activity trackers. Nutritional data were gathered through food diaries and micronutrient labs. PF was assessed with validated objective and patient-reported measures. Feasibility was achieved with >50% enrollment of eligible patients (n = 80, Mage = 18.1 ± 7.5); 26 were children with cancer and 54 were AYAs with cancer. An 88.75% retention rate indicated acceptability. Despite COVID-19 disruptions, >50% of participants provided completed data for PA and micronutrient labs as of April 2020. Food diaries and PF data collection experienced disruptions. Methodological adaptations are in progress to minimize future disruptions. Overall, our findings demonstrate that prospective EB assessments are feasible and acceptable among children and AYAs with cancer.