The pathophysiology of undernutrition in the child with cancer

Arm anthropometry in evaluation of malnutrition in children with cancer

Malnutrition in children with cancer is reported to be relatively uncommon at the time of diagnosis. However, in most studies nutritional status measurement has relied almost exclusively on weight-related indices. This can be misleading, because in children with malignancy, tumor masses can reach more than 10% of total body weight. A controlled study was performed in 62 patients using arm anthropometry to provide a more accurate evaluation of the nutritional status of children with cancer at presentation. Height, weight, midupper arm circumference (MUAC), and triceps skinfold thickness (TSFT) were measured in all patients (40 boys, 22 girls) and controls (18 boys, 13 girls). Weight for height (WFH) of each patient was compared with the national standards. MUAC and TSFT were also interpreted according to the standards developed by A. Roberto Frisancho. The mean ages were 6.5 +/- 3.7 years (range 0.08-13) and 5.7 +/- 4.7 years (range 0.25-15) in patients and control group, respectively. Results showed that although the WFH values for patients were normal, MUAC and TSFT values were significantly less than control values (P < 0.001). Moreover, 27% of patients showed malnutrition (they had MUAC and TSFT below 5th percentile). Patients with intraabdominal solid tumors had significantly lower MUAC and TSFT values than those with extraabdominal solid tumors (P < 0.05). The data strongly indicate that malnutrition is common at the time of diagnosis in children with cancer, and arm anthropometry should replace the use of weight-related indices to identify malnutrition in children.

Total parenteral nutrition and home parenteral nutrition: an effective combination to sustain malnourished children with cancer

A patient with Wilms' tumor and severe failure to thrive required total parenteral nutrition (TPN) for "catch-up" growth. This case underscores how TPN might be useful in the management of a child with cancer. Cancer cachexia, chemotherapy, radiation, and infections caused by immune suppression can lead to potentially serious macro- and micronutrient deficiencies.

Enteral nutrition after bone marrow transplantation

Nutritional insult after bone marrow transplantation (BMT) is complex and its nutritional management challenging. Enteral nutrition is cheaper and easier to provide than parenteral nutrition, but its tolerance and effectiveness in reversing nutritional depletion after BMT is poorly defined. Nutritional status, wellbeing, and nutritional biochemistry were prospectively assessed in 21 children (mean age 7.5 years; 14 boys) who received nasogastric feeding after BMT (mean duration 17 days) and in eight children (mean age 8 years, four boys) who refused enteral nutrition and who received dietetic advice only. Enteral nutrition was stopped prematurely in eight patients. Greater changes in weight and mid upper arm circumference were observed in the enteral nutrition group, while positive correlations were found between the duration of feeds and increase in weight and in mid upper arm circumference. Vomiting and diarrhoea had a similar incidence in the two groups, while fever and positive blood cultures occurred more frequently in the dietetic advice group. Diarrhoea occurring during enteral nutrition was not associated with fat malabsorption, while carbohydrate malabsorption was associated with rotavirus infection only. Enteral feeding did not, however, affect bone marrow recovery, hospital stay, general wellbeing, or serum albumin concentrations. Hypomagnesaemia, hypophosphataemia, zinc and selenium deficiency were common in both groups. In conclusion, enteral nutrition, when tolerated, is effective in limiting nutritional insult after BMT. With existing regimens nutritional biochemistry should be closely monitored in order to provide supplements when required.

Nutritional and treatment-related characteristics of pediatric oncology patients referred or not referred for nutritional support

Nutritional problems often result from malignancies and aggressive multimodal treatment. Early identification of reliable risk factors associated with malnutrition and need for nutritional support is necessary for development of preventative approaches. Nutritional and treatment-related characteristics were examined for 173 pediatric oncology patients referred for nutritional support and a comparison sample of 43 patients matched on treatment protocol and/or diagnosis who had never been referred for nutritional support. Abnormally low serum albumin levels, poor oral intake, mucositis, prior radiation therapy, and increased gastrointestinal toxicity were significantly more frequent among referred than non-referred patients. A discriminant function analysis indicated that poor oral intake was the single best predictor of need for nutritional support. Patients with solid tumors were more nutritionally depleted at the time of referral; all bone marrow transplant patients received nutritional support. Patients with central nervous system (CNS) tumors required nutritional support for longer time periods. We conclude that routine documentation of poor oral intake (i.e., observation of change in a child's eating patterns) is the most reliable indicator of children who eventually require nutritional support and who may benefit from interventions that could delay or prevent nutritional problems. Prophylactic interventions should be tailored to meet the specific needs of individual diagnostic groups.

Nutritional support of the child with cancer

The purpose of this article is to outline how the disease, treatment, and psychological state of a child with cancer impact on the child's nutritional status. The methods of assessing nutritional status, including anthropometric measurements, laboratory indices, clinical observation, dietary assessment, and psychosocial evaluation, are summarized. After nutrition assessment, the pediatric oncology nurse and the dietitian, along with the oncologist, the family, and the child, develop a plan of care. The specific roles of the pediatric oncology nurse and dietitian in the nutrition intervention are described.

Energy intake and basal metabolic rate during maintenance chemotherapy

Energy intakes and basal metabolic rates were determined in 26 children receiving chemotherapy in remission from acute lymphoblastic leukaemia or solid tumours and 26 healthy controls matched for age and sex. Body weight and height on the two groups were comparable, although one patient was stunted (height for age) and three others wasted (weight for height). Energy intake in the patients at 7705 kJ/day (1842 kcal) and controls at 7773 kJ/day (1866 kcal)) and basal metabolic rate (BMR) in the patients at 4873 kJ/day (1172 kcal) and controls 4987 kJ/day (1196 kcal) for the two groups were not significantly different. Although the energy intake:BMR ratio for both groups was 1.59, the range of values for the patient group was large (0.96-2.73) and appeared to be greater than that observed in the control group (1.23-2.46). These results demonstrated that during this period of chemotherapy there was no evidence of raised energy expenditure at rest or reduced energy intake in the patient group. No indication of undernutrition in the patients as a group was evident, although some individuals might require further clinical nutritional assessment.

Malnutrition at diagnosis of malignancy in childhood: common but mostly missed

A prospective, controlled study of nutritional status in 100 newly diagnosed paediatric oncology patients is reported. Results showed that although patients' height-for-age and weight-for-height were normal, mid-upper arm circumference (MUAC) and triceps skinfold thickness (TSFT) were significantly less than reference and control values. Moreover, 20% of patients had MUAC below the 5th percentile (P less than 0.001) and 23% had TSFT more than 2 SD below the mean (P less than 0.001). The discrepancy between these assessments is attributed to the effect of large tumour masses masking diminished true body weight. Children with intra-abdominal solid tumours had significantly lower MUAC and TSFT than those with either extra-abdominal solid tumours or leukaemia, and were more likely to be malnourished based on arm anthropometric criteria. Of all subjects, 44% were consuming less than 80% of their recommended daily allowance of energy at diagnosis, compared with 0% of controls (P = 0.001).

Abnormal vitamin B6 status in childhood leukemia

Vitamin B6 is involved in many biological processes of potential relevance to carcinogenesis and tumor growth, including DNA synthesis and maintenance of immunocompetence, yet very little information exists on B6 nutritional status in childhood leukemia. Using a radioenzymatic assay, the authors measured plasma pyridoxal 5'-phosphate (PLP), the biologically active form of B6, in 11 newly diagnosed untreated children with leukemia and 11 age-matched controls. The children with leukemia had significantly lower PLP levels than the controls. In 26 additional leukemia patients and 26 additional controls, a high-performance liquid chromatography assay also demonstrated lower plasma PLP levels in childhood leukemia compared with controls. These differences were significant for both acute lymphoblastic leukemia (ALL) and for acute nonlymphoblastic leukemia (ANLL). The PLP values did not correlate with indices of leukemia cell burden, but did correlate with reported B6 intake, suggesting that illness-related diet changes are at least partially responsible for the low PLP levels. Before any chemotherapy, overall nutritional status was suboptimal in 53% of ALL cases and 57% of ANLL cases. Newly diagnosed children with leukemia have suboptimal overall nutrition as well as suboptimal vitamin B6 status.

Special nutritional needs of children with malignancies: a review

Nutrition support for the patient with cancer is an important part of the overall treatment regimen. Nutrition support for the child with cancer poses a special challenge. For the purpose of reviewing the special nutritional needs of children with cancer, a Task Force was formed by the American Academy of Pediatrics to review the current state of knowledge. The work of the Task Force was supported by the Food and Drug Administration through its Liaison Representative, Joginder Chopra, M.D., Staff support from the Academy was provided by Jean D. Lockhart, M.D., This review is prepared from the Task Force Report to the FDA. It is designed to review factors enhancing nutritional risks for the child with cancer and to discuss nutritional intervention strategies and their efficacies.

Iron nutrition in childhood malignancy

Status of iron nutrition along with demographic, anthropometric, dietary, and biochemical parameters were recorded in 98 pediatric cancer patients at the time of referral. Dietary intake in each patient was analyzed for calories, protein, and iron. Blood specimens were analyzed for hemoglobin (Hgb), hematocrit (Hct), iron, total iron-binding capacity (TIBC), transferrin, and ferritin. Dietary intake measures were assessed according to each subject's Recommended Dietary Allowance (RDA). The results were compared among three diagnostic groups, namely, benign, solid tumor, and hematopoietic. The nutrient lowest in intake was iron. The overall measures revealed significant differences between the benign and hematopoietic groups in all parameters except TIBC and transferrin. A correlation coefficient of 0.55 (p less than 10(-5) between transferrin and TIBC was generated in our patients. Significant differences were noted for ferritin in the acute lymphocytic leukemia (p = 0.0001) and lymphoma (p = 0.0007) groups when compared with the benign group. A correlation coefficient of 0.55 (p less than 10(-5) was generated in our patients. A 3-month follow-up assessment was conducted in order to document the effects of therapy. Tumor response and progression was compared to changes in ferritin levels from baseline to follow-up. Our results support the literature, that ferritin is a sensitive tumor marker in various malignancies.

Home parenteral nutrition for the child with cancer

Compliance with treatment is greatly increased when the caregiver(s) understand the treatment, the need for the treatment, and the need for strict adherence to sterile technique. When the caregiver is not ready to handle home care of the child, compliance is less than optimal and may be a threat to the child. Parenteral nutrition support can be both safe and effective in children with cancer when the family and health-care team work together. Nutrition support facilitates treatment of the whole child and can help improve his or her quality of life.

Indicators of malnutrition in leukaemic children

In 24 children with acute leukaemia a low serum albumin concentration (31 g/l or less) and a median weight:height ratio of less than 0.95 on admission were indicators of severe weight loss.