Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

Nutritional support practices and opinions toward gastrostomy use in pediatric bone marrow transplant centers: A national survey

OBJECTIVE

Previous surveys have shown deviations in nutritional practices from international guidelines during bone marrow transplant (BMT). Guidelines recommend enteral nutrition first-line and nasogastric tubes are the mainstay for its provision. Gastrostomies provide an alternative, yet their use is less common. This national survey investigated nutrition support practices in pediatric allogeneic BMT centers and compared clinicians' opinions on gastrostomy use. The aim of this study was to identify the national picture of nutritional support practices across pediatric allogeneic BMT centers, including use and opinions of dietitians, clinical nurse specialists, and physicians, toward gastrostomy feeding.

METHODS

An online survey was administered to 12 centers. The lead dietitian answered questions regarding nutritional counseling, screening, assessment, and interventions. Questions regarding current use, perceived advantages, and problems of gastrostomies were answered by the dietitian, lead clinical nurse specialist, and physician.

RESULTS

A 100% response rate was achieved from 12 centers (N = 36 clinicians). Nutritional counseling was provided in 92% of centers before and routinely throughout admission, 83% screened on and regularly throughout admission, 83% assessed nutritional status before transplant, and 92% used enteral nutrition first-line. Forty-two percent of the centers used gastrostomies. In those not using gastrostomies, 76% of clinicians felt some children should be offered a gastrostomy. Clinicians perceived less displacements (78%) and cosmetic appearance (69%) as the most common advantages of gastrostomies over nasogastric tubes. Risks associated with surgery (92%) and tube/stoma complications (58%) were the most common perceived problems.

CONCLUSIONS

A similar approach was shown on many aspects of nutritional support. Gastrostomy use divided opinion with differences in use and perceived advantages, but agreement on potential complications. Despite their risks, clinicians wanted to use gastrostomies more. Placement requires careful consideration of the risks, benefits, and family preferences.

Body Mass Index (BMI) and Infectious/Febrile Episodes in Children with Intermediate Risk Acute Lymphoblastic Leukemia (IR ALL)

The incidence of treatment related mortality in children with acute lymphoblastic leukemia (ALL) is reported to be between 2% and 4% with infections being the leading cause.

AIM

To establish a relationship between body mass index at diagnosis (BMI 0), after protocol I therapy completion (BMI I) and the incidence rate ratio (IRR) of infectious/febrile episodes in children with ALL intermediate risk.

METHODS

Thirty one consecutive patients (2-18 years old, with a male to female ratio of 19/12) with newly diagnosed ALL that were treated uniformly according to ALL IC 2009 protocol were included in this analysis.

RESULTS

A BMI decrease of at least 5% during protocol I therapy and BMI 1 under 15th percentile score corresponds significantly with higher IRR (with P-values 0.04 and 0.006 respectively) during the whole intensive therapy.

CONCLUSION

Some relationships between BMI reduction and higher IRR in ALL patients were found, but their significance is limited by the size of the group analyzed.

Burkitt lymphoma – Nutritional support during induction treatment: Effect on anthropometric parameters and morbidity of treatment

Background: Malnutrition is common in children diagnosed with cancer in Africa, and it adds to the morbidity and mortality of treatment. Nutritional support is known to reduce morbidity and mortality of treatment.Aim: The aim of this study was to record changes in anthropometric parameters, morbidity and mortality in patients admitted with Burkitt lymphoma (BL) whose diet was supplemented with protein, vitamins and minerals during induction chemotherapy.Methods: Seventy consecutive newly diagnosed BL patients were enrolled. The diet was supplemented with a daily egg, 200 mL F-75 formula and vitamins. Guardians received 3 cups of dry rice and $1 daily to buy and prepare meals for the patient and themselves whilst in the hospital. Height, weight, triceps skinfold (TSF) and mid-upper arm circumference (MUAC) were recorded on days 1 and 28. Co-morbidities at diagnosis were treated, and neutropenia and febrile episodes managed with a standard protocol. Two patients who died within 24 h after admission were excluded from the anthropometric analyses.Results: The mean age was 8 (range 2–16) years and the male:female ratio was 42:28. The St Jude stage distribution was as follows: Stage I = 6%, II = 4%, III = 69%, IV = 21%. Weight for age was < 10th centile at diagnosis in 18% (but influenced by tumour mass). Weight was unchanged or increased by ≥ 5% in 66% of patients on Day 28. The TSF was < 3rd centile in 47% of patients and increased by ≥ 0.5 cm in 57%. The MUAC was < 3rd centile in 16% of patients at diagnosis and in 10% of patients on Day 28. Febrile episodes in 60% and neutropenia in 18% of patients were successfully treated. Two patients died from presumed renal failure. The overall death rate (including the two deaths within 24 h after admission before chemotherapy was started) was 5.5% (n = 4).Conclusion: The TSF improved in the majority and the MUAC improved in some patients. Febrile neutropenia and febrile episodes could be successfully managed. The death rate during induction was lower than in our previously published results with the same chemotherapy protocol. Dietary supplementation should be a standard component of treatment in paediatric patients with cancer.

The Investigation of the Use of Prealbumin as a Tool for Nutritional Assessment in Adults Coinfected with HIV and Intestinal Helminth Parasites in KwaZulu-Natal, South Africa

Serum prealbumin is considered to be as important as albumin in the nutritional status assessment. However, there is relatively little evidence of its advantage over the commonly used albumin. This study investigated the use of prealbumin compared to albumin as a marker of nutritional status in adults singly and dually infected with human immunodeficiency virus (HIV) and intestinal helminths, with or without inflammatory conditions, in different body mass index (BMI) categories. This cross-sectional study was conducted in a periurban setting in KwaZulu-Natal, South Africa. Multivariate multinomial logistic regression models were fitted to investigate the effect of prealbumin and albumin in nutritional assessment among HIV and helminth individuals with or without inflammation, indicated by elevated and normal C-reactive protein (CRP) levels. In normal CRP, albumin was significantly lower in unadjusted BMI [RRR = 0.8, p = 0.001] and in normal weight [RRR = 0.7, p = 0.003] and overweight [RRR = 0.5, p = 0.001] participants. In elevated CRP, albumin was significantly lower [RRR = 0.8, p = 0.050] and prealbumin was significantly higher in unadjusted BMI [RRR = 1.2, p = 0.034] and overweight [RRR = 1.4, p = 0.052] individuals. The current study found that prealbumin can differentiate between inflammation-induced reduction of albumin and true malnutrition in adults singly or coinfected with HIV and intestinal helminths in the presence or absence of inflammation in various BMI categories.

Assessment of Nutritional Problems in Pediatric Patients with Cancer and the Information Needs of Their Parents: A Parental Perspective

Objective:

The majority of problems and symptoms occur in the gastrointestinal system in children with cancer. Parents have difficulty in coping with the nutritional problems and changing routines of children and need support in this respect. This study aimed to assess the nutritional problems of children with cancer and the information needs of their parents.

Methods:

This descriptive study was performed among children with cancer aged 3–18 years and their parents (n = 69). The data were collected through a data collection form developed by the researchers based on the literature.

Results:

The most prominent nutritional problems experienced by children were loss of appetite (85.5%), nausea (84.1%), vomiting (81.2%), fatigue (79.7%), and mucositis (66.7%). According to the parents, the factors causing these nutritional problems in children were physiological factors (100%) and the foods given to children in the hospital (65.2%). The parents mostly needed information about food–drug interactions (58.0%), food–disease interactions (52.2%), foods that children with neutropenia should avoid or should eat (neutropenic diet) (46.4%), and frequency of nutritional intake (36.2%).

Conclusions:

This study has shown that most children experience at least one nutritional problem, and the parents need comprehensive and regular information about nutrition. Pediatric oncology nurses have a significant responsibility in the evaluation, education, and monitoring of these children.

Effects of malnutrition on treatment-related morbidity and survival of children with cancer in Nicaragua

BACKGROUND

Most children with cancer live in resource-limited countries where malnutrition is often prevalent. We identified the relationship between malnutrition and treatment-related morbidity (TRM), abandonment of therapy, and survival of children with cancer in Nicaragua to better inform targeted nutritional interventions.

PROCEDURE

We conducted a retrospective review of patients aged 6 months to 18 years with newly diagnosed acute lymphoblastic leukemia, acute myeloid leukemia (AML), Wilms tumor, Hodgkin lymphoma, or Burkitt lymphoma (BL) who were treated between January 1, 2004, and December 31, 2007 at Children's Hospital Manuel de Jesus Rivera in Managua, Nicaragua. Statistical analysis examined the relations among nutritional status and cancer type, risk category, TRM, and event-free survival (EFS).

RESULTS

Sixty-seven percent of patients (189/282) were malnourished at diagnosis. Malnutrition was highest among patients with Wilms tumor (85.7%), BL (75%), and AML (74.3%). A total of 92.2% of patients (225/244) experienced morbidity during the first 90 days. Malnutrition was associated with severe infection (P = 0.033). Severely malnourished patients had ≥grade 3 TRM on more days (P = 0.023) and were more likely to experience severe TRM on >50% of days (P = 0.032; OR, 3.27 [95% CI, 1.05-10.16]). Malnourished patients had inferior median EFS (2.25 vs. 5.58 years; P = 0.049), and abandoned therapy more frequently (P = 0.015).

CONCLUSIONS

In Nicaragua, pediatric oncology patients with malnutrition at diagnosis experienced increased TRM, abandoned therapy more frequently, and had inferior EFS. Standardized nutritional evaluation of patients with newly diagnosed cancer and targeted provision of nutritional support are essential to decrease TRM and improve outcomes.

Surgical Feeding Tubes in Pediatric and Adolescent Cancer Patients: A Single-institution Retrospective Review

The purpose of our study was to evaluate surgical enteric access in pediatric cancer patients to determine factors associated with postoperative complications. We performed a single-institution retrospective review of all patients below 21 years old with a primary cancer diagnosis who underwent surgical procedures for enteral access between 2004 and 2014. Multivariate logistic regression was performed to determine independent predictors of postoperative complications. During the study period, 122 patients had surgically placed feeding tubes, of whom 58% developed ≥1 complication(s) and 16% experienced a major complication. No single factor was significantly associated with developing any complication or major complication. Several trends were noted including increased complications associated with jejunostomy tubes, percutaneous endoscopic gastrostomy tubes, and abdominal radiation. Surgically placed enteric access in pediatric and adolescent cancer patients is associated with an extremely high complication rate emphasizing the importance of careful evaluation of these patients before embarking on surgical feeding access. Future work should evaluate mechanisms to decrease complications and/or explore alternative methods to provide supplemental nutrition in children and adolescents with cancer.

Cross-cultural adaptation and content validation into Portuguese of the Subjective Global Nutritional Assessment for pediatric patients hospitalized with cancer

ABSTRACT Objective Cross-cultural adaptation and content validation of the Brazilian Portuguese version of the Subjective Global Nutritional Assessment questionnaire (originally in English) for use in hospitalized children and adolescents being treated in a reference institute of oncology. Methods The cross-cultural adaptation process consisted of the following stages: conceptual, item, semantic, and operational equivalence. The conceptual equivalence and item was carried out through discussion with members of an expert committee. Semantic equivalence was evaluated through initial translation, synthesis of translations, back translation, discussions with experts, and pretest with 32 patients. During operational equivalence, the experts discussed about the format of questions and instructions, setting, target populations, and mode of administration to later propose a final version. Content validation was performed by the expert committee. Results Minor modifications were made in the instrument to facilitate its use in the Brazilian socio-cultural context. Pretest results showed that the instrument is easily understood by health care professionals and the target population. Conclusion The cross-cultural adaptation and validation of the Subjective Global Nutritional Assessment allowed obtaining a Brazilian version equivalent to the original. The adapted instrument will be an important tool for the subjective assessment of the nutritional status of pediatric patients hospitalized with cancer.

Assessment of Body Composition in a Group of Pediatric Patients With Cancer: A Single Romanian Center Experience

Cancer patients are particularly susceptible to nutritional depletion. From March 2014 to December 2015, we assessed 146 patients consecutively hospitalized in a tertiary emergency pediatric hospital. The patients were divided into 2 groups: group I, patients with cancer (43 patients), and group II, the control group consisting of 103 age-matched and sex-matched healthy patients. The anthropometric parameters (weight-W, height-H, body mass index [BMI], middle upper arm circumference [MUAC], tricipital skinfold thickness [TST]) and biochemical parameters (proteins, albumin) were comparatively evaluated. Fat mass (FM, kg and %), fat-free mass (FFM, kg), muscle mass (MM, kg), and total body water (TBW, %) were measured in both groups using Tanita BC 420 S MA Analyzer. Anthropometric and biochemical parameters in group I were significantly different from those in group II for weight, height, BMI, MUAC, TST, protein, and albumin (P<0.05). In the study group, FM was much lower compared with controls 16.9% (3.4% to 33.3%) versus 20.3% (6.6% to 38.4%); (P=0.001), and TBW was much higher 60.8% (48.8% to 70.6%) versus 58.5% (45.2% to 68.6%) (P=0.004). FFM and MM were not statistically different in the 2 groups. The results highlight the complex changes of nutritional status in pediatric patients with cancer.

A Framework for Adapted Nutritional Therapy for Children With Cancer in Low- and Middle-Income Countries: A Report From the SIOP PODC Nutrition Working Group

The utilization of adapted regimens for the treatment of pediatric malignancies has greatly improved clinical outcomes for children receiving treatment in low- and middle-income countries (LMIC). Nutritional depletion has been associated with poorer outcomes, increased abandonment of therapy, and treatment-related toxicities. Surveys have found that nutritional intervention is not incorporated routinely into supportive care regimens. Establishing nutritional programs based upon institutional resources may facilitate the incorporation of nutritional therapy into clinical care in a way that is feasible in all settings. We present a framework for establishing and monitoring of nutritional care based on the infrastructure of institutions in LMIC.

Causes of inadequate intake of nutrients during the treatment of children with chemotherapy

PURPOSE

The purpose of the research was to explore nurses' perceptions of different causes of inadequate food intake in children treated with chemotherapy and to determine how often nurses identify these causes.

METHOD

Qualitative and quantitative approaches were used. Qualitative data were first gathered using semistructured interviews in a sample of six nurses and analysed by conventional content analysis. Based on the results of qualitative data and literature analysis, a 28-item questionnaire was developed and evaluated for its face validity in a sample of fifteen nurses. Questionnaires were then administered to twenty-seven nurses working at one pediatric oncology ward. Quantitative data were analysed using descriptive statistic.

RESULTS

The major themes that emerge from the content analysis, describing nurses' perceptions of causes of inadequate food intake in children undergoing chemotherapy, were as follows: physiological causes of eating problems, psychological causes of eating problems, change in food selection, hospital food and individual counselling. 13 causes of inadequate food intake were identified from the questionnaire data. Pain due to mucositis was the most commonly identified cause of inadequate food intake in children, followed by nausea and vomiting, altered taste, loss of appetite and an altered smell. Psychological causes of eating problems are rarely identified.

CONCLUSION

Nurses identify most of the physiological and psychological causes of inadequate food intake in children treated with chemotherapy. The early identification and management by nurses of inadequate food intakes should be part of the curriculum for nurse education as well as part of treatment planning in clinical environment.

Parent feeding interactions and practices during childhood cancer treatment. A qualitative investigation

In the general population it is evident that parent feeding practices can directly shape a child's life long dietary intake. Young children undergoing childhood cancer treatment may experience feeding difficulties and limited food intake, due to the inherent side effects of their anti-cancer treatment. What is not clear is how these treatment side effects are influencing the parent-child feeding relationship during anti-cancer treatment. This retrospective qualitative study collected telephone based interview data from 38 parents of childhood cancer patients who had recently completed cancer treatment (child's mean age: 6.98 years). Parents described a range of treatment side effects that impacted on their child's ability to eat, often resulting in weight loss. Sixty-one percent of parents (n = 23) reported high levels of stress in regard to their child's eating and weight loss during treatment. Parents reported stress, feelings of helplessness, and conflict and/or tension between parent and the child during feeding/eating interactions. Parents described using both positive and negative feeding practices, such as: pressuring their child to eat, threatening the insertion of a nasogastric feeding tube, encouraging the child to eat and providing home cooked meals in hospital. Results indicated that parent stress may lead to the use of coping strategies such as positive or negative feeding practices to entice their child to eat during cancer treatment. Future research is recommended to determine the implication of parent feeding practice on the long term diet quality and food preferences of childhood cancer survivors.

Longitudinal nutritional assessment in acute lymphoblastic leukemia during treatment

BACKGROUND

A nutritional assessment of pediatric patients with cancer is important to improve their outcome. The number of longitudinal nutritional studies during treatment, however, is limited. The purpose of this study was to investigate the longitudinal changes in anthropometric measures and serum albumin level during chemotherapy in patients with acute lymphoblastic leukemia (ALL).

METHODS

We retrospectively reviewed the charts of 23 patients (19 boys, four girls) with ALL from April 2007 to March 2010. The median age at diagnosis was 4.5 years. Bodyweight, height, and serum albumin levels were measured at the start and the end point of each chemotherapy phase.

RESULTS

At diagnosis, two patients (8.7%) were underweight and five patients (21.7%) were overweight according to body mass index z-score, while five patients were underweight and three (13.0%) were overweight according to Waterlow score. The prevalence of malnourished patients did not change significantly throughout chemotherapy by either assessment. The absolute scores in either assessment were significantly reduced at the sanctuary treatment phase. Low serum albumin (<3.2 g/dL) was found in two patients at diagnosis. Mean albumin decreased significantly at the induction and the re-induction phases.

CONCLUSIONS

Given that nutritional status under a similar chemotherapeutic regimen as assessed by anthropometric measures and albumin level differed among patients, careful observation of the nutritional status and intervention may be necessary at different phases of chemotherapy.

Nutritional status of children and adolescents at diagnosis of hematological and solid malignancies

Objective

To assess the nutritional status of child and adolescent patients with cancer at diagnosis.

Methods

A total of 1154 patients were included and divided into two groups: solid and hematological malignancies. The parameters used for nutritional assessment were weight, height, triceps skinfold thickness, mid-upper arm circumference, arm muscle circumference, body mass index and percentage weight loss.

Results

At diagnosis, below adequate body mass index was observed by anthropometric analysis in 10.85% of the patients – 12.2% in the solid tumor group and 9.52% in the hematologic group. The average weight loss adjusted for a period of 7 days was −2.82% in the hematologic group and −2.9% in the solid tumor group.

Conclusions

The prevalence of malnutrition is higher among patients with malignancies than in the general population, even though no difference was observed between the two groups.

Relationship of serum insulin-like growth factor I (IGF-I) with nutritional status in pediatric patients with malignant diseases--a single Romanian center experience

The aim of this study was to analyze insulin-like growth factor I (IGF-I) serum level in pediatric patients with cancer compared with pediatric patients with nononcological diseases and to assess the relationship between IGF-I and nutritional status of oncological patients. From January 2009 to July 2012, we assessed 151 consecutively hospitalized patients in a tertiary emergency pediatric hospital. The patients were divided into two groups: group I, consisting of patients with malignant diseases (64 patients), and group II, the control group, consisting of 87 age- and gender-matched patients with different pediatric diseases. The anthropometric parameters (weight, height, body mass index, middle upper arm circumference (MUAC), and tricipital skinfold thickness (TST) and biochemical parameters (proteins, albumin, and total IGF-I) were comparatively evaluated at the diagnosis and after intensive chemotherapy in the malignant group. Anthropometric and biochemical parameters in group I were significantly different from those in group II for height, MUAC, TST, total proteins, and albumin (p < 0.05). Twenty-five out of 64 patients with malignant diseases and 5 out of 87 patients in the control group had malnutrition. IGF-I in patients with cancer was much lower than in the control group (median 48.3 ng/ml, range 25.00-662.00 ng/ml vs 129.00 ng/ml, range 25.00-745.00 ng/ml) (p = 0.014). We found a positive correlation between IGF-I, MUAC, and TST at the diagnosis of the malignant disease. Also, we identified positive correlations between IGF-I, protein, and albumin. Serum IGF-I levels in cancer patients were significantly lower at diagnosis than after chemotherapy (48.3 ng/ml, range 25.00-662.00 ng/ml vs 110.0 ng/ml, range 25.00-573.00 ng/ml; p = 0.04).

CONCLUSION

IGF-I seems to be an accurate biochemical parameter used in malnutrition assessment of children with cancer. IGF-I correlated with the anthropometric parameters of the arm, serum protein, and albumin. These parameters most accurately characterize the nutritional status.

Malnutrition in pediatric patients with cancer at diagnosis and throughout therapy: A multicenter cohort study

BACKGROUND

Malnutrition is a common problem in pediatric patients with cancer. Reported prevalence varies widely and has often been assessed only in a subset of childhood types of cancer. This study aimed to describe the prevalence of malnutrition among pediatric patients newly diagnosed with cancer, to describe the occurrence and course of malnutrition during therapy and to identify factors associated with malnutrition during therapy.

PROCEDURE

In a retrospective cohort study of 327 patients diagnosed from 2003 to 2006 in three Swiss tertiary care hospitals, weight and height measures together with patient-, disease-, and treatment-related characteristics were assessed. Malnutrition was defined as body mass index (BMI) below -2 standard deviation scores (SDS) or a weight loss >10% from diagnosis. Malnutrition was assessed at diagnosis and continuously during anticancer therapy.

RESULTS

At diagnosis, 5.8% of the patients (19) were malnourished based on BMI. During anticancer therapy, the cumulative incidence of malnutrition rose to 22% (70 patients) after 30 days, to 36% (116 patients) after 60 days, and finally to 47% (155 patients). In these 155 patients, the median duration of malnutrition was 60 days (interquartile range, 21-122). Age above 10 years at diagnosis, BMI ≤ -1.0 SDS at diagnosis, and a diagnosis of medulloblastoma were positively associated with a higher proportion of malnutrition time during therapy.

CONCLUSIONS

The rapid increase of malnutrition after the start of treatment underlines the need to develop evidence-based and efficient methods to provide nutritional support for children with cancer.

Nutritional Screening and Early Intervention in Children, Adolescents, and Young Adults With Cancer

Children and adolescents with cancer who receive chemotherapy and/or radiation treatments are at risk for malnutrition due to side effects such as nausea, vomiting, anorexia, and mouth sores. Malnutrition during treatment for childhood cancer increases the risk of infection, decreases tolerance to treatment, and even affects overall survival. A retrospective analysis of 79 children, adolescents, and young adults was conducted to evaluate nutritional screening at baseline and for the first 6 months of treatment. Interventions were also documented. Forty-nine participants had a positive screen for risk of malnutrition. In the patients with a positive screen, 78% had intervention within 24 hours of the identified risk for malnutrition. Thirty-five patients had a nutritional referral, which resulted in a full nutritional assessment and plan. Key independent variables were analyzed to determine if they were associated with an increased risk of malnutrition. In addition, individual risk factors were analyzed to determine their association with malnutrition. Future studies should find whether early intervention is effective in reversing the risk of malnutrition during treatment for childhood cancer.

Nutritional status among pediatric cancer patients: a comparison between hematological malignancies and solid tumors

PURPOSE

This study aimed to compare the nutritional status of pediatric patients with hematological malignancies and solid tumors.

DESIGN AND METHODS

A total of 74 pediatric cancer patients were assessed for anthropometric status, biochemical profiles, and dietary intake.

RESULTS

The prevalence of undernutrition was higher among patients with solid tumors as reflected in their lower dietary intakes of energy and nutrients compared with patients with hematological malignancies.

PRACTICE IMPLICATION

Adequate dietary intake is important for pediatric cancer patients, but nurses need to pay more attention to the diets of patients with solid tumors as compared with those with hematological malignancies.

Nutritional status at diagnosis is related to clinical outcomes in children and adolescents with cancer: a perspective from Central America

BACKGROUND

The prevalence of malnutrition in children may exceed 50% in countries with limited resources. The aims of this study were to assess nutritional status at diagnosis in children and adolescents with cancer, and to correlate it with clinical outcomes in the Spanish speaking countries of Central America that formed the AHOPCA (Asociacion de Hemato-Oncologia Pediatrica de Centro America) consortium.

METHODS

Patients aged 1-18 years, diagnosed with cancer between 1st October 2004 and 30th September 2007, were eligible for study. Weight (kg) and height or length (m), mid upper arm circumference--MUAC and triceps skin fold thickness--TSFT were measured and their Z-scores or percentiles were calculated. Three categories of nutritional status were defined according to these parameters.

RESULTS

A total of 2954 new patients were enrolled; 1787 had all anthropometric measurements performed and 1513 also had measurements of serum albumin. By arm anthropometry 322/1787 patients (18%) had moderate nutritional depletion and 813/1787 patients (45%) were severely depleted. Adding serum albumin, the proportion classified as severely depleted rose to 59%. Malnourished children more often abandoned therapy and their event free survival was inferior to that of other children.

CONCLUSIONS

Arm anthropometry in children with cancer is a sensitive measure of nutritional status. Since malnutrition at diagnosis was related to important clinical outcomes, an opportunity exists to devise simple, cost-effective nutritional interventions in such children that may enhance their prospects for survival.

Hormonal, hypothalamic and striatal responses to reduced body weight gain are attenuated in anorectic rats bearing small tumors

Lack of compensatory or even reduced food intake is frequently observed in weight-losing cancer patients and contributes to increased morbidity and mortality. Our previous work has shown increased transcription factor expression in the hypothalamus and ventral striatum of anorectic rats bearing small tumors. mRNA expression of molecules known to be involved in pathways regulating appetite in these structures was therefore assessed in this study. Given that pain, pro-inflammatory cytokines and metabolic hormones can modify food intake, spinal cord cellular activation patterns and plasma concentrations of cytokines and hormones were also studied. Morris hepatoma 7777 cells injected subcutaneously in Buffalo rats provoked a 10% lower body weight and 15% reduction in food intake compared to free-feeding tumor-free animals 4 weeks later when the tumor represented 1-2% of body mass. No differences in spinal cord activation patterns or plasma concentration of pro-inflammatory cytokines were observed between groups. However, the changes in plasma ghrelin and leptin concentrations found in food-restricted weight-matched rats in comparison to ad libitum-fed animals did not occur in anorectic tumor-bearing animals. Real-time PCR showed that tumor-bearing rats did not display the increase in hypothalamic agouti-related peptide mRNA observed in food-restricted weight-matched animals. In addition, microarray analysis and real-time PCR revealed increased ventral striatal prostaglandin D synthase expression in food-restricted animals compared to anorectic tumor-bearing rats. These findings indicate that blunted hypothalamic AgRP mRNA expression, probably as a consequence of relatively high leptin and low ghrelin concentrations, and reduced ventral striatal prostaglandin D synthesis play a role in maintaining cancer-associated anorexia.

Eating experiences of children and adolescents with chemotherapy-related nausea and mucositis

Despite many advances in symptom management, children and adolescents with cancer still have trouble maintaining adequate oral intake during routine chemotherapy treatment. The purpose of this qualitative study was to explore the eating experiences of children and adolescents receiving chemotherapy when they had problems with nausea and mucositis. Eight children and adolescents and their caregivers were interviewed to describe how and what the children and adolescents ate when they were nauseated and/or had a sore mouth. Findings reveal that these children and adolescents all experienced nausea and frequently preferred not to eat during these periods. Eating problems related to mucositis also limited oral intake in this sample. These children and adolescents and their caregivers tried a variety of foods and strategies to maintain intake, including those recommended by health care providers. Prevention and management of nausea remains a challenge for children and adolescents receiving chemotherapy. Health care providers need to offer detailed eating suggestions throughout therapy so that these patients can maintain adequate nutrition and weight for optimal treatment tolerance as well as normal growth and development. Continued research is needed to test the effectiveness of interventions focused on maintaining oral intake during cancer treatment.