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

Validity of a nutrition screening tool for childhood cancer

BACKGROUND

Malnutrition in pediatric oncology patients is a serious clinical condition. There is a need for standardized nutrition screening in pediatric oncology patients, as nutrition screening can offer a simple method to identify children with cancer at risk of malnutrition. This study aimed to determine the validity of a Turkish version of nutrition screening tool for childhood cancer (SCAN) in identifying the risk of malnutrition among children with cancer.

MATERIALS AND METHODS

A cross-sectional study was conducted with 78 children with cancer admitted to the pediatric hematology-oncology unit of a university hospital. In the first stage of this study, SCAN was translated into Turkish, and in the second stage, the validity of SCAN against pediatric Subjective Global Nutritional Assessment (SGNA) and Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) malnutrition criteria were evaluated.

RESULTS

Patients had a median age of 8.0 years (range, 2-18 years; IQR, 5-14 years), 61.5% were male, and 60.3% were diagnosed with leukemia. According to SCAN, 53.8% had high risk of malnutrition. Validation of SCAN against pediatric SGNA showed that SCAN has a sensitivity of 97.5%, specificity of 94.5%, and accuracy of 96.1%.

CONCLUSION

The risk of malnutrition is common in children with cancer. The Turkish version of the SCAN is a simple, quick, and valid tool to determine the risk of malnutrition in children with cancer. Further research is needed to understand the impact of nutrition interventions on clinical outcomes in children at risk for malnutrition based on SCAN.

Challenges and Opportunities of a Multi-Institutional Treatment Guideline for Wilms Tumor in Low-Middle-Income Countries-A Report From the Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA)

Since 2000, centers across Central America have shared treatment guidelines for Wilms tumor, using histology (anaplasia present or absent) and tumor stage to stratify patients into low-, intermediate-, and high-risk groups. Weekly virtual tumor board meetings involving local and international experts were held to ensure consistent treatment assignments. We analyzed data from 367 children with unilateral tumors treated per these guidelines. Five-year abandonment-sensitive event-free and overall survival estimates were: low risk 82% ± 3.8% and 86% ± 3.6%, intermediate risk 50% ± 3.4% and 60% ± 3.4%, and high risk 36% ± 7.6% and 45% ± 7.9%. Survival outcomes were suboptimal, primarily due to advanced disease in fragile children at presentation and abandonment of treatment.

Nutritional Challenges in Paediatric Oncology: Screening and Managing Malnutrition and Sarcopenia

Sarcopenia and malnutrition can coexist in pediatric patients with neoplasia, worsening the patient's prognosis. The classification of primary and secondary sarcopenia may be helpful in clinical practice, as it can help with timely initiation of appropriate and tailored dietary treatments to address it. This review summarizes the current state of the art of assessing skeletal muscle function in children and adolescents with cancer and discusses the role of nutritional interventions in the management of children with cancer. It highlights the urgent need for comprehensive nutritional support and interventions to mitigate the impact of malnutritions on both treatment outcomes and patients' well-being.

Short-term chemotherapy-related complications and undernutrition in children diagnosed with cancer at Korle Bu Teaching Hospital, Accra, Ghana: A prospective cohort study

Undernutrition in children with cancer is associated with complications during cancer therapy. The study objective was to determine the association between specific anthropometric parameters and short-term chemotherapy-related complications and mortality. This was a hospital-based, prospective cohort study of children, age ≤12 years, with a new cancer diagnosis at the Paediatric Oncology Unit, Korle Bu Teaching Hospital, Ghana. Socio-demographic information, cancer characteristics and anthropometric measurements were obtained at enrolment. Participants were followed up for twelve weeks from commencement of chemotherapy and selected treatment-related complications such as anaemia and thrombocytopenia requiring transfusions, prolonged neutropenia resulting in treatment delays, febrile neutropenia, mucositis and death were recorded. A total of 133 participants were recruited with a median age of 4.5 years. Eighty-one (60.9%) were diagnosed with solid tumours, 31 (23.3%) had leukaemias and 21 (15.8%) had lymphomas. Of the anthropometric parameters assessed, only arm anthropometry using upper arm muscle area (UAMA) and mid-upper arm circumference (MUAC) were associated with complications. Participants with wasting were more likely to develop anaemia and mucositis. However, the incidence of prolonged neutropenia was significantly higher among participants with average UAMA (p = 0.043) and low average UAMA (p = 0.049) compared to those with low UAMA. Risk of neutropenia was also significantly less among those with wasting by MUAC compared to those well-nourished (p = 0.045). Twenty-three participants (17.3%) died with a greater proportion (11/44; 25%) occurring in those who were wasted using MUAC. These findings underscore the need for nutritional surveillance at diagnosis and during chemotherapy, particularly where co-morbid disease is prevalent.

Clinician perspectives on nutritional impairment in children undergoing cancer chemotherapy in Thailand: A qualitative descriptive study

Objective

This study aimed to explore the perspectives of pediatric oncology clinicians in Thailand on children's gastrointestinal ​symptoms, eating habits, and nutrition during cancer chemotherapy. Additionally, it sought to identify factors influencing children's nutritional status, including the characteristics of the children, clinician-related factors, and hospital-level factors.

Methods

The study involved pediatric oncology clinicians working at a tertiary hospital in Bangkok. Data were collected through interviews, focusing on three key areas: (1) children's gastrointestinal symptoms, eating behaviors, and nutrition, (2) clinicians' cognitions and behaviors that impact children's nutrition, and (3) environmental factors. Each participating clinician also identified a colleague who could offer additional perspectives. Interviews were conducted in the Thai language and analyzed using directed content analysis.

Results

A total of 22 participants were enrolled in the study, comprising sixteen nurses, four physicians, one child life specialist, and one Hospital Nutrition Service staff member. The majority of participants were female (95.4%), with an average age of 37.77 years and an average of 15.55 years of experience in caring for children with cancer. Factors influencing children's nutritional status included the children's cancer diagnosis, treatment exposures, and symptoms. Clinicians attributed changes in children's weight and eating patterns to these symptoms. Influential clinician-related factors included current practices that impacted children's symptoms and food intake. Hospital-level factors included both direct influences on children and those arising from clinical practices.

Conclusions

To optimize the nutritional status of Thai children undergoing chemotherapy, multi-level interventions are needed. These interventions should target children's symptoms, clinician knowledge, role norms, and address issues related to the hospital environment, specifically those elements that contribute to unpleasant experiences.

Effect of Moderate Malnutrition on the Pharmacokinetics of Etoposide and Vincristine in Freshly Weaned Rats

BACKGROUND

Moderate malnutrition is a common problem in young children. It is observed that severe malnutrition affects the pharmacokinetics of chemotherapy drugs in pediatric cancer patients, but moderate malnutrition is not well studied in this context.

OBJECTIVES

In this study, we aimed to understand how moderate malnutrition affects the pharmacokinetics of two chemotherapy drugs, etoposide and vincristine, using a murine model of early age moderate malnutrition.

METHODS

We developed a murine model of moderate childhood malnutrition by subjecting freshly weaned Sprague-Dawley rats to 8% protein diet for 8 weeks. In two separate experiments, we administered etoposide and vincristine (N = 8 for etoposide and N = 12 for vincristine each in protein deficient and control groups) through tail vein injection for pharmacokinetics study.

RESULTS

We found ~ 60% increase in area under the concentration-time curve (AUC) of etoposide in malnourished animals as compared to well-nourished animals. Furthermore, clearance, volume of distribution, and half-life were decreased by ~ 37, 53, and 24%, respectively, in malnourished animals. Pharmacokinetic parameters of vincristine showed only marginal differences between well-nourished and malnourished groups.

CONCLUSIONS

Our results suggest that while moderate malnutrition significantly affects the pharmacokinetics of etoposide, pharmacokinetics of vincristine remain unchanged. Since chemotherapy drugs have a narrow therapeutic index, the difference in AUC observed in our study might explain the increased toxicity of etoposide in malnourished pediatric cancer patients. This brings forth a need for robust clinical studies to validate our findings and optimize dose for malnourished patients.

Mid-upper arm circumference in hospitalized pediatric patients with cancer: Is there an association with malnutrition?

BACKGROUND

Malnutrition is common in children/adolescents with cancer. Mid-upper arm circumference (MUAC) is recommended by the International Society of Pediatric Oncology for measuring nutrition status. The aim was to evaluate the nutrition status of pediatric patients with cancer and verify whether MUAC is associated with malnutrition and length of stay (LOS).

METHODS

This was an observational study of patients aged 0-19 years with solid and hematological neoplasms. Data included anthropometric measurements of nutrition status by body mass index/age (BMI/A), weight/age, weight/height, height/age, MUAC, mid-arm muscle circumference, triceps skinfold thickness (TSF), and biochemical measurements of characterizing inflammation (serum prealbumin level, serum albumin level, and C-reactive protein [CRP]). Statistical tests such as the Student t test, Mann-Whitney test, and Spearman correlation were employed to analyze the data. Logistic regression was used for multivariate analysis.

RESULTS

Of 111 patients, 51.7% (n = 57) were male, and solid tumors were prevalent (76.6%, n = 85). The median age was 8.5 years. The anthropometric measurements of the arm revealed a higher prevalence of malnutrition when compared with anthropometric indices. According to the Spearman correlation, a high and positive correlation was observed between MUAC and BMI/A (ρ = 0.800 and P < 0.001). There was an association between MUAC, TSF, and high CRP with LOS (P = 0.025, P = 0.003, and P < 0.001, respectively). Patients with a MUAC (less than the fifth percentile) had almost 2.73 times the chance of having a prolonged LOS.

CONCLUSION

MUAC was a good parameter for the classification of nutrition status and the assessment of LOS in pediatric patients with cancer.

Pediatric Acute Lymphoblastic Leukemia: Clinical Characteristics, Treatment Outcomes, and Prognostic Factors: 10 Years' Experience From a Low- and Middle-Income Country

PURPOSE

Acute lymphoblastic leukemia (ALL) represents around 70% of pediatric leukemia. In high-income countries, the 5-year survival is above 90%, but survival in low- and middle-income countries is inferior. This study documents the treatment outcome and prognostic factors of pediatric ALL in Pakistan.

MATERIALS AND METHODS

In this prospective cohort study, all newly diagnosed patients with ALL/lymphoblastic lymphoma from age 1 to 16 years enrolled between January 1, 2012, and December 31, 2021, were included. The treatment was based on the standard arm of the UKALL2011 protocol.

RESULTS

Data from 945 patients with ALL, including 597 males (63.2%), were analyzed. The mean age at diagnosis was 5.73 ± 3.51 years. Pallor was the commonest presentation in 95.2% followed by fever in 84.2% of patients. The mean WBC count was 56.6 ± 103.4 × 109/L. Neutropenic fever followed by myopathy was the most common complication during induction. In univariate analysis, the high WBC count (P ≤ 0.001), intensive chemotherapy (P ≤ 0.001), malnutrition (P = .007), poor response to induction chemotherapy (P = .001), delayed presentation (P = .004), and use of steroids before chemotherapy (P = .023) significantly adversely affected overall survival (OS). The delayed presentation was the most significant prognostic factor in the multivariate analysis (P ≤ .002). After a median follow-up of 54.64 ± 33.80 months, the 5-year OS and disease-free survival (DFS) were 69.9% and 67.8%, respectively.

CONCLUSION

In this largest cohort of childhood ALL from Pakistan, a high WBC count, malnutrition, delayed presentation, previous steroids use, intensive chemotherapy, and poor response to the induction chemotherapy were associated with decreased OS and DFS rates.

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

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

Current status of African pediatric oncology education efforts aligned with the Global Initiative for Childhood Cancer

Education of the pediatric oncology workforce is an important pillar of the World Health Organization CureAll technical package. This is not only limited to healthcare workers, but all stakeholders in the childhood cancer management process. It includes governmental structures, academic institutions, parents and communities. This review evaluated the current educational and advocacy training resources available to the childhood cancer community, the contribution of SIOP Africa in the continental educational needs and evaluated future needs to improve the management of pediatric malignancies in reaching the Global Initiative for Childhood Cancer goals. Childhood cancer, unlike adult cancers, has not been prioritized in African cancer control plans nor the teaching and advocacy surrounding pediatric oncology. The availability of formal training programs for pediatric oncologists, pediatric surgeons and radiotherapy specialists are limited to particular countries. In pharmacy and nutritional services, the exposure to pediatric oncology is limited while training in advocacy doesn't exist. Many nonacademic stakeholders are creating the opportunities in Africa to gain experience and train in these various fields, but formal training programs should still be advocated for. LEARNING POINTSThe African continent has various resources to increase the capacity of childhood cancer care stakeholders to increase their knowledge.African pediatric oncology teams rely on a multitude of international sources for training while developing their own.There is a greater need for formal, standardized cancer training especially for pediatric surgeons, radio-oncologists and nurses.Greater inclusion of pathologists, pediatric oncology pharmacists and dieticians into multidisciplinary care and childhood cancer training should be facilitated and resourced.Successful advocacy programs and tool kits exist in parts of Africa, but the training in advocacy is still underdeveloped.

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.

Novel nutritional indicator as predictors among subtypes of lung cancer in diagnosis

Introduction

Lung cancer is a serious global health concern, and its subtypes are closely linked to lifestyle and dietary habits. Recent research has suggested that malnutrition, over-nutrition, electrolytes, and granulocytes have an effect on the development of cancer. This study investigated the impact of combining patient nutritional indicators, electrolytes, and granulocytes as comprehensive predictors for lung cancer treatment outcomes, and applied a machine learning algorithm to predict lung cancer.

Methods

6,336 blood samples were collected from lung cancer patients classified as lung squamous cell carcinoma (LUSC), lung adenocarcinoma (LUAD), and small cell lung cancer (SCLC). 2,191 healthy individuals were used as controls to compare the differences in nutritional indicators, electrolytes and granulocytes among different subtypes of lung cancer, respectively.

Results

Our results demonstrated significant differences between men and women in healthy people and NSCLC, but no significant difference between men and women in SCLC patients. The relationship between indicators is basically that the range of indicators for cancer patients is wider, including healthy population indicators. In the process of predicting lung cancer through nutritional indicators by machine learning, the AUC of the random forest model was as high as 93.5%, with a sensitivity of 75.9% and specificity of 96.5%.

Discussion

This study supports the feasibility and accuracy of nutritional indicators in predicting lung cancer through the random forest model. The successful implementation of this novel prediction method could guide clinicians in providing both effective diagnostics and treatment of lung cancers.

The Burden of Malnutrition in Childhood Cancer in Malawi - Risk Regardless of Age

Malnutrion among children with childhood cancer in low and middle income countries (LMICs) is prevelant. While national nutrition programs focus on children under 5 years, childhood cancer can occur regardless of their age. Through a single-center retrospective cohort in Lilongwe, Malawi, we aim to characterize the burden of age-related malnutrition among children diagnosed with cancer in Lilongwe, Malawi, and evaluate them for any associations with mortality. Four hundred and sixty-three children (63.5% ≥5 years and 58.3% males) were identified.The majority of children (63.3%) were malnourished; 23.1% had moderate acute malnutrition (MAM) and 40.2% had severe acute malnutrition (SAM). Malnutrition was more common in children ≥5 years (70.0%) compared to children <5 years (51.8%); p < 0.0001. Age <5 years (HR 1.6; 95%CI 1.1-2.3, p = 0.016) and presence of sever acute malnutrition (HR 1.6, 95%CI 1.1-2.3, p = 0.012) were both associated with increased mortality risk. Acute malnutrition was highly prevalent among children with cancer above 5 years of age. This age group is not prioritized among malnutrition programs in LMICs, hence there is a direct need to include children with cancer regardless of age in national nutrition guidelines in LMICs to give them acces to adequate nutritional support.

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

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

Wilms’ tumor in low- and middle-income countries: survey of current practices, challenges, and priorities

Purpose

To identify the current practices and priorities in Wilms’ tumor management for surgeons in low- and middle-income countries (LMICs).

Methods

One hundred thirty-seven pediatric surgeons from 44 countries completed surveys on Wilms’ tumor surgical strategy in LMIC. This survey was distributed through the Global Initiative for Children’s Surgery, Pan-African Pediatric Surgical Association, and Latin American Pediatric Surgical Oncology Group.

Results

Ninety-two respondents (67.2%) participated from 19 lower middle-income countries (43.2%). Twenty-one respondents (15.3%) participated from nine lower income countries (20.5%). Nineteen respondents (13.9%) participated from 13 upper middle-income countries (29.5%). Most providers do not obtain biopsy for suspected Wilms’ tumor (79%). Delayed resection after preoperative chemotherapy is the preferred approach (70%), which providers chose due to protocol (45%), to decrease tumor rupture (22%), and to decrease complications (8%). The providers’ goal was to prevent tumor spillage and upstaging (46%) or to prevent bleeding, complication, or other organ resections (21%). Most surgeons believed that upfront resection increased the risk of tumor spillage (72%).

Conclusion

Providers in LMICs prefer delayed resection after preoperative chemotherapy to reduce the incidence of tumor spillage and upstaging of Wilms’ tumor. An evidence-based guideline tailored to the LMIC context can be developed from these findings.

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

Introduction

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

Materials and Methods

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

Results

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

Conclusion

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

Nutritional status in the pediatric oncology patients

Nutritional status plays a vital role in the growth of children. In pediatric patients, disease-related malnutrition is a dynamic and multifactorial process supported by several factors such as inflammation, increased energy expenditure, decreased intake or reduced utilization of nutrients. In pediatric patients with malignancies, sarcopenia may coexist with malnutrition, amplifying its negative impact on prognosis. Careful monitoring of nutritional status both at diagnosis and during chemotherapy treatment allows early detection of the risk and/or presence of malnutrition. A rapid and personalized nutritional intervention can improve adherence to treatment, reduce complications and improve the patients' quality of life.

Childhood aggressive B-cell non-Hodgkin lymphoma in low-middle-income countries

In high-income countries (HICs) paediatric aggressive B-cell lymphomas are curable in about 90% of cases. Much worse results, with cure rates ranging from less than 30% to about 70%, are achieved in low- and middle-income countries (LMICs), where 90% of paediatric non-Hodgkin lymphomas occur. Low socio-economic and cultural conditions, the lack of optimal diagnostic procedures, laboratory facilities and adequate supportive care exert a strong negative impact on compliance, treatment delivery, toxicity and, consequently, on the clinical outcome. Published data are scarce, generally originating from single institutions, and are difficult to compare. National and international cooperation projects have been undertaken to reduce the unacceptable gap between HICs and LMICs in the management of children with cancer, by promoting the sharing of knowledge and by implementing adequate local healthcare facilities, with initial promising results. In the present review, we will summarize the results so far obtained in the management of paediatric aggressive B-cell NHL in LMICs.

Malnutrition at diagnosis and throughout therapy in pediatric patients with solid tumors: A single-institution study in a developing country

BACKGROUND

Changesin nutritional status can constitute a risk factor for reduced tolerance and effectiveness of antineoplastic treatment. Knowledge of the nutritional status of pediatric patients is important for implementing interventions to improve outcomes. We aimed to evaluate nutritional status at diagnosis and throughout therapy in pediatric patients with solid tumors.

OBJECTIVES

To study the prevalence of malnutrition at diagnosis, compare different assessment tools, and examine longitudinal changes in nutritional status during the treatment of pediatric patients with solid tumors in a Brazilian institution.

METHODS

This prospective single-center study enrolled patients with solid tumors (age <19 years) from June 2017 to May 2018. Nutritional evaluations were performed at diagnosis and after 3 and 6 months of treatment. z-Scores for height for age (H/A) and body mass index for age (BMI/A) were calculated using the Anthro/AnthroPlus software and mid-upper arm circumference (MUAC) percentile was used for nutritional classification.

RESULTS

The prevalence of nutritional status at diagnosis was 29.3% malnourished, 49.5% adequate, and 21.2% overweight/obese. Nutritional status improved during the first 3 months of treatment, with a reduction in the proportion of malnourished patients and an increased number of patients with adequate nutritional status.

CONCLUSIONS

The two combined indices, BMI/A and MUAC, facilitated the diagnosis of a greater number of patients with solid tumors who had nutritional alterations. A high prevalence of malnutrition was present at diagnosis. Nutritional status improved in the first 3 months of treatment and could be related to the multidisciplinary institutional approach following the diagnosis.

Features Associated With Weight Loss and Growth Stunting for Young Children During Cancer Therapy

Features associated with malnutrition are poorly elucidated in pediatric cancer care. We aimed to better understand characteristics associated with weight-for-height (WHZ) and height-for-age (HAZ) changes for infants and young children during cancer treatment. This retrospective study included 434 patients diagnosed <3 years old from 2007 to 2015 at a large pediatric cancer center. Patients starting treatment outside our center, those with relapsed or secondary malignancies, or with inaccurate information were excluded. Abstracted weights and heights for a 24-month period after treatment initiation were converted to sex-specific and age-specific z scores. Although not statistically different at baseline, patients with hematologic malignancies gained weight over time, while other tumor types did not. Higher treatment intensity and younger age at diagnosis increased odds of clinically significant weight loss. Older children had higher HAZ at diagnosis and HAZ also significantly decreased over time for all examined risk factors, which is distinctly different from patterns in WHZ over time. In conclusion, WHZ and HAZ are affected differently by cancer treatment in infants and young children. We identify key risk factors for weight loss and growth stunting which will be necessary to develop prospective trials to examine anthropometric, biochemical, and patient recorded outcomes around nutrition.

Wilms tumour

Wilms tumour (WT) is a childhood embryonal tumour that is paradigmatic of the intersection between disrupted organogenesis and tumorigenesis. Many WT genes play a critical (non-redundant) role in early nephrogenesis. Improving patient outcomes requires advances in understanding and targeting of the multiple genes and cellular control pathways now identified as active in WT development. Decades of clinical and basic research have helped to gradually optimize clinical care. Curative therapy is achievable in 90% of affected children, even those with disseminated disease, yet survival disparities within and between countries exist and deserve commitment to change. Updated epidemiological studies have also provided novel insights into global incidence variations. Introduction of biology-driven approaches to risk stratification and new drug development has been slower in WT than in other childhood tumours. Current prognostic classification for children with WT is grounded in clinical and pathological findings and in dedicated protocols on molecular alterations. Treatment includes conventional cytotoxic chemotherapy and surgery, and radiation therapy in some cases. Advanced imaging to capture tumour composition, optimizing irradiation techniques to reduce target volumes, and evaluation of newer surgical procedures are key areas for future research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Influence of Nutritional Status at Diagnosis of Childhood B-Cell Acute Lymphoblastic Leukemia on Survival Rates: Data from a Hispanic Cohort

The impact of nutritional status at diagnosis of childhood acute lymphoblastic leukemia (ALL) on survival rates was assessed in a Hispanic cohort. Children <16 years with newly diagnosed ALL-B from 2011 to 2019 were studied. Overweight and obesity were classified by body mass index (BMI) and Z-score according to WHO and CDC criteria. BMI, weight percentiles for age and Z-Score were assessed using the WHO Anthro (0-5 years) and AnthroPlus (5-19 years) programs. Cox model was used to estimate risk factors for relapse and death; differences between groups were assessed with Student's T test for parametric and Mann-Whitney U test for non-parametric variables. Disease-free survival (DFS) and overall survival (OS) were determined by the Kaplan-Meier method, calculating time, status, cumulative survival and standard error with a 95% confidence interval. Equal data distribution was estimated with the log-rank test. One-hundred and seventy-two B-ALL children were studied. The overweight-obese group had a non-significant lower DFS (CDC: 54% vs. 60%, p = 0.80; WHO: 57% vs. 64%, p = 0.89) and OS rate (CDC:76% vs. 82%, p = 0.38; WHO:65% vs. 81%, p = 0.13). An association between nutritional status determined by CDC and WHO criteria at diagnosis of B-cell ALL and survival rates was not documented.

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.

Diet as a Potential Moderator for Genome Stability and Immune Response in Pediatric Leukemia

Simple Summary

Pediatric acute lymphoblastic leukemia (ALL) is the most prevalent cancer affecting children in developed societies. Here, we review the role of diet in control of the incidence and progression of childhood ALL. Prenatally, ALL risk is associated with higher birthweights of newborns, suggesting that ALL begins to evolve in-utero. Indeed, maternal diet influences the fetal genome and immune development. Postnatally, breastfeeding associates with decreased risk of ALL development. Finally, for the ALL-affected child, certain dietary regimens that impact the hormonal environment may impede disease progression. Improved understanding of the dietary regulation of hormones and immunity may inform better approaches to predict, protect, and ultimately save children afflicted with pediatric leukemia.

Abstract

Pediatric leukemias are the most prevalent cancers affecting children in developed societies, with childhood acute lymphoblastic leukemia (ALL) being the most common subtype. As diet is a likely modulator of many diseases, this review focuses on the potential for diet to influence the incidence and progression of childhood ALL. In particular, the potential effect of diets on genome stability and immunity during the prenatal and postnatal stages of early childhood development are discussed. Maternal diet plays an integral role in shaping the bodily composition of the newborn, and thus may influence fetal genome stability and immune system development. Indeed, higher birth weights of newborns are associated with increased risk of ALL, which suggests in-utero biology may shape the evolution of preleukemic clones. Postnatally, the ingestion of maternal breastmilk both nourishes the infant, and provides essential components that strengthen and educate the developing immune system. Consistently, breast-feeding associates with decreased risk of ALL development. For children already suffering from ALL, certain dietary regimens have been proposed. These regimens, which have been validated in both animals and humans, alter the internal hormonal environment. Thus, hormonal regulation by diet may shape childhood metabolism and immunity in a manner that is detrimental to the evolution or expansion of preleukemic and leukemic ALL clones.

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.

Undernutrition as an Aggravating Risk for Hospital Death in Critically Ill Children with Cancer

OBJECTIVES

Undernourished children with cancer are at major risk for adverse outcomes. We intended to model nutritional status as risk factor for hospital death.

METHODS

Retrospective analysis of two cohorts of children admitted in an oncology/hematology intensive care unit. Logistic regression was used for model building.

RESULTS

The derivation cohort had 155 patients, with a median age of 104.9 mo., and 36 deaths (23.2%). Twenty-eight children (18.1%) had the z score of the body mass index < -2. A multivariate model with the variables "relapse of oncological disease" (Odds Ratio 3.14, P = 0.025), "surgical case" (OR 0.22, P = 0.002), "intubation/mechanical ventilation" (OR 8.38, P = 0.000) and "body mass index z score < -2" (OR 3.21, P = 0.024) generated a logit with good predictive capacity for "hospital death". In the validation cohort, with 450 patients (median age of 92.7 mo.), the model was able to predict 55.5 of the 58 observed deaths (Standardized Mortality Rate = 1.04, 95% CI 0.80-1.34, P = 0.72), with P = 0.68 in the Hosmer test. The AUC was 0.90 (95% CI 0.86-0.93).

CONCLUSION

Undernutrition increases the risk of death, and is a variable that should be included in predictive mortality algorithms.

Nutritional Status of Pediatric Cancer Patients at Diagnosis and Correlations with Treatment, Clinical Outcome and the Long-Term Growth and Health of Survivors

Malnutrition is caused either by cancer itself or by its treatment, and affects the clinical outcome, the quality of life (QOL), and the overall survival (OS) of the patient. However, malnutrition in children with cancer should not be accepted or tolerated as an inevitable procedure at any stage of the disease. A review of the international literature from 2014 to 2019 was performed. Despite the difficulty of accurately assessing the prevalence of malnutrition, poor nutritional status has adverse effects from diagnosis to subsequent survival. Nutritional status (NS) at diagnosis relates to undernutrition, while correlations with clinical outcome are still unclear. Malnutrition adversely affects health-related quality of life (HRQOL) in children with cancer and collective evidence constantly shows poor nutritional quality in childhood cancer survivors (CCSs). Nutritional assessment and early intervention in pediatric cancer patients could minimize the side effects of treatment, improve their survival, and reduce the risk of nutritional morbidity with a positive impact on QOL, in view of the potentially manageable nature of this risk factor.

Investigating Wilms' Tumours Worldwide: A Report of the OxPLORE Collaboration-A Cross-Sectional Observational Study

BACKGROUND

Childhood cancer is neglected within global health. Oxford Pediatrics Linking Oncology Research with Electives describes early outcomes following collaboration between low- and high-income paediatric surgery and oncology centres. The aim of this paper is twofold: to describe the development of a medical student-led research collaboration; and to report on the experience of Wilms' tumour (WT).

METHODS

This cross-sectional observational study is reported as per STROBE guidelines. Collaborating centres included three tertiary hospitals in Tanzania, Rwanda and the UK. Data were submitted by medical students following retrospective patient note review of 2 years using a standardised data collection tool. Primary outcome was survival (point of discharge/death).

RESULTS

There were 104 patients with WT reported across all centres over the study period (Tanzania n = 71, Rwanda n = 26, UK n = 7). Survival was higher in the high-income institution [87% in Tanzania, 92% in Rwanda, 100% in the UK (X² 36.19, p < 0.0001)]. Given the short-term follow-up and retrospective study design, this likely underestimates the true discrepancy. Age at presentation was comparable at the two African sites but lower in the UK (one-way ANOVA, F = 0.2997, p = 0.74). Disease was more advanced in Tanzania at presentation (84% stage III-IV cf. 60% and 57% in Rwanda and UK, respectively, X² 7.57, p = 0.02). All patients had pre-operative chemotherapy, and a majority had nephrectomy. Post-operative morbidity was higher in lower resourced settings (X² 33.72, p < 0.0001). Methodology involving medical students and junior doctors proved time- and cost-effective. This collaboration was a valuable learning experience for students about global research networks.

CONCLUSIONS

This study demonstrates novel research methodology involving medical students collaborating across the global south and global north. The comparison of outcomes advocates, on an institutional level, for development in access to services and multidisciplinary treatment of WT.

High Burden of Serious Bacterial Infections in African Children Treated for Cancer

BACKGROUND

Infections in children treated for cancer contribute to morbidity and mortality. There is a paucity of studies on the incidence, etiology, risk factors and outcome of bacterial infections in African children treated for cancer. The aim of the study was to delineate the epidemiology of infectious morbidity and mortality in children with cancer.

METHODS

The study enrolled children 1-19 years old with cancer and infections. Children were investigated for infection as part of standard of care.

RESULTS

One hundred sixty-nine children were enrolled, 82 with hematologic malignancies and 87 with solid tumors and 10.7% were HIV infected. The incidence (per 100 child-years) of septic episodes (101) microbiologically confirmed (70.9) septic episodes, Gram-positive (48.5) and Gram-negative (37.6) sepsis was higher in children with hematologic malignancies than in those with solid tumors. The most common Gram-positive bacteria were Coagulase-negative Staphylococci, Streptococcus viridans and Enterococcus faecium, while the most common Gram-negative bacteria were Escherichia coli, Acinetobacter baumannii and Pseudomonas species. The C-reactive protein and procalcitonin was higher in microbiologically confirmed sepsis. The case fatality risk was 40.4%; 80% attributed to sepsis. The odds of dying from sepsis were higher in children with profound [adjusted odds ratio (aOR) = 3.96; P = 0.004] or prolonged neutropenia (aOR = 3.71; P = 0.011) and profound lymphopenia (aOR = 4.09; P = 0.003) and independently associated with pneumonia (53.85% vs. 29.23%; aOR = 2.38; P = 0.025) and tuberculosis (70.83% vs. 34.91%; aOR = 4.3; P = 0.005).

CONCLUSION

The study emphasizes the high burden of sepsis in African children treated for cancer and highlights the association of tuberculosis and pneumonia as independent predictors of death in children with cancer.

Nutritional Status and Growth Deficit in Children and Adolescents with Cancer at Different Moments of Treatment

BACKGROUND

Nutrition deficits are common in children and adolescents undergoing cancer treatment and can contribute to a worse prognosis. There are scarce studies regarding this context considering different moments of treatment. The aim of this study was to evaluate the association between moment of treatment and nutritional status in children and adolescents with cancer.

METHODS

A retrospective study was performed from January 2013 to December 2015, including data from all clinical records of patients under 18 years old with cancer. Clinical, nutritional support and anthropometric data were collected at four moments of treatment from cancer diagnosis: diagnosis (t₀), 3 mo, (t₁), 6 mo, (t₂) and 1 year (t₃). In addition, nutritional indicators were evaluated. Generalized Estimating Equation models were performed to analyze changes on anthropometric indices throughout four moments of treatment.

RESULTS

The sample comprised 73 patients and frequency of nutritional deficits ranged from 13.0% to 18.6%. All nutritional indicators decreased at t₁, showed a modest recovery at t₂ and a stronger recovery at t₃ (p < 0.001). Growth was also impacted during treatment, mainly on patients under 2 years in the first three months of treatment.

CONCLUSIONS

Moment of treatment was associated with growth deficit and decreased percentiles in development indicators.

NUTRITIONAL STATUS IN CHILDREN WITH CANCER: COMPARISON OF DEUTERIUM OXIDE DILUTION WITH BIOELECTRIC IMPEDANCE ANALYSIS AND ANTHROPOMETRY

Objective:

To explore changes in the nutritional status of pediatric cancer patients before and after chemotherapy and evaluate the correlation between deuterium oxide dilution, bioelectric impedance analysis, and anthropometry for assessment of body composition.

Methods:

This study included 14 children (aged 5.6 to 13.6 years) and classified them as having hematologic or solid tumors. They had their body composition analyzed according to deuterium oxide, bioelectric impedance, and anthropometric measurements before the first chemotherapy cycle and after three and six months of therapy.

Results:

The patients in the hematologic tumor group had an increase in weight, height, body mass index, waist, hip, and arm circumference, subscapular skinfold thickness, and fat mass with the isotope dilution technique during chemotherapy. In the solid tumor group, the children showed a reduction in fat-free mass when assessed by bioimpedance analysis. We found a positive correlation between the triceps skinfold thickness and fat mass determined by bioimpedance analysis and deuterium oxide. The arm muscle circumference correlated with the fat-free mass estimated by bioimpedance analysis and deuterium oxide.

Conclusions:

Patients with hematologic tumors had an increase in body weight, height, and fat mass, which was not identified in the solid tumor group. The positive correlation between anthropometry (triceps skinfold thickness and arm muscle circumference), deuterium oxide dilution, and bioelectric impedance analysis shows the applicability of anthropometry in clinical practice.

Pediatric Cancer Outcomes in an Intensive Care Unit in Pakistan

PURPOSE

Although cancer is uncommon, it is a significant cause of pediatric morbidity and mortality in the developing world. The need for intensive care in pediatric oncology has increased with more intense chemotherapeutic interventions. It is important to identify patients who will benefit from management in the intensive care unit (ICU), given the resource limitation in developing countries. In this review, we examine our institutional experience with pediatric patients with cancer needing ICU care.

METHODS

A retrospective chart review from December 2015 to June 2017 was performed with institutional review board approval for all pediatric oncology patients admitted to the ICU. Data collection included age, diagnosis, disease stage, Pediatric Risk of Mortality (PRISM III) score, and therapeutic interventions.

RESULTS

We reviewed 59 pediatric oncology ICU medical records. There were 36 boys (61%) and 23 girls (39%). The median age was 4 years. Average stay in the ICU was 4.6 days. Three significant reasons for ICU referral were respiratory distress, sepsis, and circulatory collapse. There were 34 ICU survivors (57.6%). Among those who survived the ICU, 20 patients (58.8%) later died of therapy-related complications. Factors related to increased ICU mortality included the need for mechanical ventilation, the need for inotropic support, the number of failing organs, and a high PRISM III score.

CONCLUSION

The mortality rate for pediatric oncology patients admitted to the ICU in developing countries is higher than in developed countries. Mortality was significantly related to the need for mechanical ventilation. PRISM III scoring can help identify patients who can benefit from ICU treatment, which is expensive in resource-limited low- and middle-income countries such as Pakistan.

Prognostic Factors in Childhood Acute Myeloid Leukemia; Experience from A Developing Country

BACKGROUND

In the developed world, 5-years survival of childhood acute myeloid leukaemia (AML) has improved to 70%. However, the survival rates in the developing world are below 40%. The main contributing factors to these reduced survival rates are a late presentation, malnutrition and high treatment-related mortality.

AIM

To document the factors affecting treatment outcome of childhood AML at a tertiary care facility of Pakistan.

METHODS AND RESULTS

All newly registered cases of AML under 18 years of age from January 1, 2012 onwards who completed their treatment before November 30, 2019 were included. Data of 219 cases of AML containing 140 (63.9%) males and 79 (36.1%) females was analyzed. The mean age was 6.30 ± 3.66 years. Pallor was the commonest presenting features in 180 (82.2%) and M2 was the commonest French American-British (FAB) subtype in 103 (47.0%) cases. In univariate analysis, high white blood cells (WBC) count at presentation (P = .006), poor nutritional status (P = .005), unfavourable cytogenetics (P = .019), certain types of FAB AML subtype (P = .005), and use of etoposide in induction chemotherapy (P = .042) significantly adversely affected overall survival (OS). Neutropenic sepsis and bleeding were the major causes of treatment-related mortality. Response to induction chemotherapy was the most significant prognostic factor in the multivariate analysis (P = <.001). After a median follow-up of 40.96 ± 26.23 months, 5-year OS and DFS of the cohort were 40.6% and 38.3% respectively.

CONCLUSIONS

In this largest cohort of childhood AML from Pakistan, high WBC count at presentation, malnutrition, unfavourable cytogenetics and use of etoposide during induction chemotherapy were associated with decreased OS and DFS rates. Response to the induction chemotherapy was the most significant prognostic factor.

Nutritional status at diagnosis among children with cancer referred to a nutritional service in Brazil

Introduction

Children and adolescents with cancer are particularly vulnerable to malnutrition and require special attention on nutritional assessment. An adequate nutritional status during treatment is essential in reducing morbidity and mortality, being a modifiable risk factor for clinical outcomes. This study aims to determine the nutritional status of pediatric patients with cancer assessed by the nutrition team at diagnosis and evaluate its association with the overall survival.

Method

This is a retrospective cross-sectional study of patients at the time of cancer diagnosis who had nutritional assessments when hospitalized or referred to the nutrition outpatient clinic. Nutritional status was classified by the mid-upper arm circumference (MUAC) and body mass index for age z-score (zBMI/A). The Cox regression analysis was used to determine the association between the nutritional status and overall survival, adjusting for gender, tumor group and age.

Results

The study included 366 patients. The prevalence of undernutrition varied from 8 to 23% and overweight, from 5 to 20%. The MUAC identified more children as undernourished than the zBMI/A in patients with solid and hematological tumors. There was no significant difference in the overall survival by malnutrition classified by the zBMI/A (p =  0.1507) or MUAC (p =  0.8135). When adjusted for gender, tumor group and age, the nutritional status classification by the zBMI/A (hazard ratio [HR], 1.27; 95% confidence interval [CI], 0.88–1.83; p =  0.209) and MUAC (HR, 0.94; 95% CI, 0.61–1.44; p =  0.773) did not impact overall survival.

Conclusion

The nutritional status at diagnosis did not significantly impact the overall survival, which suggests there may have been a protective effect by successful nutritional intervention during the subsequent care.

Assessment of nutritional status in children with cancer: A narrative review

A child's appropriate development stems in large part from proper nutrition. Malnutrition is an adverse prognostic factor in children with cancer, and its prevalence is highly variable. Currently, there is no standardized definition and assessment method of nutritional status in pediatric oncology. A complete nutritional assessment includes anthropometry, biochemical, clinical, and dietary assessments. In this article, we explore these methods and suggest practical approaches for pediatric cancer units depending on the levels of care that these can provide. We also advise on the monitoring and follow-up of children with cancer during and after treatment, and discuss potential areas for future research.

Pediatric screening tools for malnutrition: an update

PURPOSE OF REVIEW

There is ongoing interest in nutritional screening tools in pediatrics to facilitate the identification of children at risk for malnutrition who need further assessment and possible nutritional intervention. The choice for a specific tool depends on various factors. This review aims to provide an overview of recent progress in pediatric nutritional screening methods.

RECENT FINDINGS

We present recent studies about newly developed or adjusted tools, the applicability of nutritional screening tools in specific populations, and how to implement screening in the overall process of improving nutritional care in the pediatric hospital setting.

SUMMARY

Three new screening tools have been developed for use on admission to hospital: two for the mixed pediatric hospitalized population and one for infants. A simple weekly rescreening tool to identify hospital-acquired nutritional deterioration was developed for use in children with prolonged hospital stay. Different from most previous studies that only assessed the relationship between the nutritional risk score and anthropometric parameters of malnutrition, new studies in children with cancer, burns, and biliary atresia show significant associations between high nutritional risk and short-term outcome measures such as increased complication rate and weight loss. For implementation of a nutritional care process incorporating nutritional screening in daily practice, simplicity seems to be of great importance.

Prevalencia de desnutrición en niños y adolescentes en instituciones hospitalarias de América Latina: una revisión

Esta revisión buscó identificar la prevalencia de desnutrición en menores de 18 años hospitalizados en instituciones de América Latina, los criterios empleados para su clasificación, así como, la estancia hospitalaria y riesgo nutricional. Para esto, se realizó una búsqueda bibliográfica sistemática siguiendo la metodología PRISMA de artículos sobre prevalencia de desnutrición en niños y adolescentes relacionada con enfermedades en países latinoamericanos, publicados entre 1995 y enero del 2019. Fueron elegibles para su inclusión los estudios que informaron datos sobre la prevalencia de desnutrición en pacientes hospitalizados < de 18 años con un tamaño de muestra mayor a 50 sujetos. La revisión se llevó a cabo por tres revisores independientes que evaluaron la calidad metodológica. Como principal resultado se identifica que la prevalencia informada de desnutrición en pacientes pediátricos hospitalizados varía considerablemente. Esta cifra osciló entre 3,3 y 67%. La diferencia se debe principalmente a la diversidad de las poblaciones evaluadas y a los métodos utilizados para detectar y evaluar el estado nutricional. Se tiene como principal conclusión que la elevada variabilidad reportada en cuanto a evaluación del estado nutricional plantea la necesidad de la unificación de estándares de clasificación que permitan favorecer la toma de decisiones a nivel hospitalario.

Perspective: Creating the Evidence Base for Nutritional Support in Childhood Cancer in Low- and Middle-Income Countries: Priorities for Body Composition Research

There is a striking disparity in survival rates for children in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Many of the contributing factors are preventable, including the comorbidity of malnutrition. There are emerging data that malnutrition, as reflected in body composition changes, impacts survival of cancer. However, not enough priority is given to nutrition management of children with cancer, particularly in LMICs. The primary purpose of this article is to review the current knowledge on childhood cancer and body composition in LMICs and identify priorities for future research into the interlinking associations between cancer, body composition, and clinical outcomes for childhood cancer patients. Evidence will ensure feasible and effective nutrition management is prioritized in childhood cancer centers in LMICs and contribute to improving outcomes for children with cancer.

Nutrition of Children With Cancer in Brazil: A Systematic Review

PURPOSE

The objective of this systematic review was to describe nutrition-related publications on children and adolescents diagnosed with cancer in Brazil.

METHODS

The methodology followed that of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Medline, LILACS (the Latin American & Caribbean Health Sciences Literature), and Embase were searched in April 2019, and data extraction and rating of methodologic study quality (according to the National Institutes of Health quality score assessment) were performed independently by reviewers.

RESULTS

Twenty-seven studies met the inclusion criteria, reporting on 3,509 patients from 1994 to 2018. Most of the studies (74%) were of poor quality in methodology and reporting. Different cancer diagnoses were included in 52% of studies, whereas acute leukemia was the exclusive focus in 41%. The majority of the articles (70%) were from institutions in the Southeast Region of Brazil, mainly the state of São Paulo (74%); no publications were from the North Region of the country. Twelve studies addressed nutritional status and body composition, reporting an abundance of malnourished patients in the Brazilian population of children and adolescents with cancer. Six studies on micronutrients pointed to possible deficiencies in this population, with a yet unclear but promising role for supplementation during treatment.

CONCLUSION

Evidence indicates that there is great interest in the impact of nutrition on childhood cancer treatment and clinical outcomes in Brazil. However, there is a need to focus on high-quality research, particularly with multicentric/national studies. This will help establish research priorities and better planned clinical interventions, adapted to each region of the country.

The role of nutrition in pediatric oncology

Introduction: Obesity compromises survival in children with cancer in high-income countries (HICs) and is accompanied often by sarcopenia. In low and middle-income countries (LMICs), where the great majority of children live, the prevalence of under-nutrition is as high as 95% in those with cancer. Nutritional support improves clinical outcomes, including survival.Areas covered: This narrative review describes the evolution of attention to nutrition in children with cancer and the increasing understanding of this relationship. An initial focus on obesity in children with acute leukemias in HICs has been matched more recently by a recognition of the negative effect of under-nutrition on survival in children with cancer in LMICs. These observations have stimulated explorations of underlying mechanisms, including dysbiosis of the gut microbiome, and structured nutritional interventions to redress adverse outcomes.Expert opinion: Studies of the gut microbiome and metabolome have yielded important information on the pathogenesis of malnutrition in children, providing new avenues for interventions. Combinations of plant products that are inexpensive and readily available in LMICs have been shown to 'mature' the microbiome and the corresponding plasma proteome in children with acute malnutrition, offering the prospect of cost-effective remedies that are tested in children with cancer.

Validation of an algorithmic nutritional approach in children undergoing chemotherapy for cancer

BACKGROUND

Undernutrition impacts clinical outcome adversely in children with cancer. This study aimed to validate a nutritional algorithm with specific application to the low- and middle-income country (LMIC) setting.

PROCEDURE

Fifty children with a new diagnosis of cancer were enrolled in this randomized interventional study. Weight, height/length, and mid-upper-arm circumference (MUAC) were measured at baseline. The study arm was administered nutritional care as per the algorithm and the control arm received the institutional standard of care. Weight was monitored regularly and MUAC was repeated after 3 months. Children were classified based on weight for height if <2 years of age or body mass index if ≥2 years, as normal, wasted, and severely wasted. The algorithmic approach comprised administration of oral supplements, nasogastric feeds, and/or parenteral nutrition based on objective assessment of the nutritional status.

RESULTS

Fifty patients were analyzed (study: 25, control: 25). Four in the study arm (16%) and six in the control arm (24%) had wasting at baseline. MUAC was <5th percentile in 15 (60%) and 13 (52%) patients in the study and control arms, respectively. At the end of 3 months, the median increment in weight was 0.8 kg (interquartile range [IQR]: -0.02; 2.00) and 0.0 kg (IQR: -0.70; 1.25) in the study and control arms, respectively (P = .153). The median increment in MUAC was 1.20 cm (IQR: 0.10; 2.30) and 0.00 cm (IQR: -0.50; 1.10) in the study and control arms, respectively (P = .020).

CONCLUSIONS

The application of an algorithm designed for use in LMICs resulted in significant improvement in nutritional status, as measured by MUAC.

A Global Strategy for Building Clinical Capacity and Advancing Research in the Context of Malnutrition and Cancer in Children within Low- and Middle-Income Countries

Cancer is one of the prominent noncommunicable diseases and is responsible for more than 8 million deaths each year worldwide. It is expected to impact up to 22 million people annually by 2030, and more than 60% of new patient cases will be in Asia, Africa, and Central and South America. Despite improvements in the delivery of care to children in low- and middle-income countries, survival of those with cancer is as low as 10%; a figure that is in stark contrast to overall childhood cancer survival rates in North America and Western Europe. Although many factors are contributing to this disparity, access to well-educated health-care workers, knowledgeable in both antineoplastic and supportive care, particularly nutritional assessment and therapy, is necessary for effective treatment and reduced morbidities of children with cancer. To this end, we identify approaches for advancing nutritional care such as building nutritional capacity and education as well as advancing rigorous nutritional science through the establishment of multicountry research groups among pediatric oncology units located in low- and middle-income countries.

Unmet Needs in Nutritional Care in African Paediatric Oncology Units

BACKGROUND

Up to 50% of children diagnosed with cancer in low- and middle-income countries are malnourished, which likely affects survival.

SUBJECTS AND METHODS

An online survey to paediatric oncology units (POUs) in Africa was done regarding nutritional assessment and care.

RESULTS

Sixty-six surveys were received from POUs in 31 countries. Only 44.4% had a dedicated dietician for nutritional assessment and support; 29.6% undertook routine nutritional assessment during treatment. None reported defined criteria for nutritional intervention. Total parenteral nutrition was not available for 42.6% of POUs, while 51.8% did not have access to commercial enteral nutrition for inpatients, and 25.9% of the hospitals could not supply any home-based nutritional supplements.

CONCLUSION

Nutritional assessment in POUs in Africa is neither routinely undertaken nor are there defined criteria to initiate nutritional interventions. Standardized guidelines for nutritional assessment and interventions are needed for African POUs to enable improved outcome.