Assessment and management of nutritional challenges in children’s cancer care: A survey of current practice in the United Kingdom

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Supportive Care in Pediatric Oncology: Opportunities and Future Directions

The optimization of outcomes for pediatric cancer patients relies on the successful advancement of supportive care to ease the treatment burden and mitigate the long-term impacts of cancer therapy. Advancing pediatric supportive care requires research prioritization as well as the development and implementation of innovations. Like the prevailing theme throughout pediatric oncology, there is a clear need for personalized or precision approaches that are consistent, evidence-based, and guided by clinical practice guidelines. By incorporating technology and datasets, we can address questions which may not be feasible to explore in clinical trials. Now is the time to listen to patients' voices by using patient-reported outcomes (PROs) to ensure that their contributions and experiences inform clinical care plans. Furthermore, while the extrapolation of knowledge and approaches from adult populations may suffice in the absence of pediatric-specific evidence, there is a critical need to specifically understand and implement elements of general and developmental pediatrics like growth, nutrition, development, and physical activity into care. Increased research funding for pediatric supportive care is critical to address resource availability, equity, and disparities across the globe. Our patients deserve to enjoy healthy, productive lives with optimized and enriched supportive care that spans the spectrum from diagnosis to survivorship.

The role of nutrition in children with cancer

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Nutritional Needs in Pediatric Oncology: A Consensus Statement

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

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.

Systematic review of gastrostomy complications and outcomes in pediatric cancer and bone marrow transplant

BACKGROUND

Nutrition support is essential in children with cancer, including those undergoing bone marrow transplant (BMT), to reduce the risk of malnutrition and associated deleterious outcomes. Enteral nutrition is more commonly provided via nasogastric than gastrostomy tubes because of safety concerns with the latter in immunocompromised children. This systematic review investigated the incidence and type of complications and outcomes in pediatric cancer patients fed by gastrostomy.

METHODS

Databases were searched for randomized and observational studies investigating the use of any gastrostomy device in children aged <18 years with any cancer diagnosis, including those undergoing BMT. Five cohort and 11 case series studies were included. Owing to clinical heterogeneity, meta-analyses were not performed.

RESULTS

Quality of evidence varied, with five studies judged at serious risk of bias and poor quality; however, the remaining 11 were considered to range from moderate to good quality. Across studies, 54.6% of children developed one or more complications, of which 76.6% were classified as minor, 23.4% major. The most frequent complications included inflammation (52% of episodes), infection (42.1%), leakage (22.3%), and granuloma (21%). Evidence regarding infection rates in cancer/BMT patients compared with other disease states was inconclusive. Gastrostomy feeding was associated with improvement or stabilization of nutrition status in 77%-92.7% of children.

CONCLUSION

Gastrostomy feeding in this population is relatively safe and effective in stabilizing or improving nutrition status throughout treatment. Complications are frequent but mostly minor. Placement requires careful consideration of the complications, benefits, nutrition risk and status at diagnosis, and quality of life.

Omega-3 Fatty Acids and Their Role in Pediatric Cancer

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of malnutrition and malnutrition screening tools in pediatric oncology patients: A cross-sectional study

OBJECTIVES

The aim of this study was to determine the prevalence of malnutrition, to compare nutritional evaluation tools, and to highlight the importance of nutritional status in pediatric oncology patients.

METHODS

This study evaluated the nutritional status, based on height, weight, and midupper arm circumference, of 170 patients ages 5 months to 18 years who were hospitalized at the Ege University Hospital Pediatric Oncology Clinic. The prevalence of malnutrition was determined using the malnutrition screening tools, STRONGkids (SK) and Pediatric Yorkhill Malnutrition Score (PYMS). Correlations, sensitivity, specificity, and the positive and negative predictive values between the screening tools were calculated.

RESULTS

In all, 68.2% of the patients were diagnosed with a solid tumor. According to SK, 59.4% had a moderate risk of malnutrition, and 40.6% had a high risk. According to PYMS, 30.6% of patients had a low to moderate risk of malnutrition, and 69.4% had a high risk of malnutrition. Minimal agreement was noted between SK and PYMS (Kappa value: 0.40 and 0.18, respectively). The sensitivity of PYMS was higher than that of SK (92.68 and 78.05, respectively). In total, 22.9% of the patients had a body mass index of <5%, and 21.2% had a midupper arm circumference of <5.

CONCLUSIONS

The present findings show that, in general, pediatric oncology patients have a high risk of malnutrition. Although SK and PYMS do not differ significantly, PYMS has higher sensitivity for detecting malnutrition. The nutritional status of pediatric oncology patients should be monitored using appropriate screening techniques throughout their treatment.

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

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

Development and Validation of a Logic Model for Utilization of Nutrition Support among Patients with Cancer

Cancer is the leading cause of morbidity and mortality, and about one in six people die from cancer globally. Approximately 20% to 70% of cancer patients are accompanied with malnutrition, and nutrition support plays an important role among cancer patients. However, the utilization of nutrition support is generally irrational in clinical practices and it is affected by multiple factors. Logic models not only present a framework to improve intervention of health care setting but also identify all the elements, pathways, outcomes, and their relationships between systems. This study developed a logic model of nutrition support for cancer patients based on current literature and conducted interview with medical staff in Macao to validate the logic model. In addition, suggestions were given as references to improve the utilization of nutrition support among cancer patients.

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.

The importance of enteral nutrition to prevent or treat undernutrition in children undergoing treatment for cancer

Nutrition therapy is a therapeutic approach to treating medical conditions and symptoms via diet, which can be done by oral, enteral or parenteral routes. It is desirable to include nutritional interventions as a standard of care in pediatric cancer units (PCUs) at all levels of care. The interventions are dependent on available resources and personnel across all clinical settings. Enteral nutrition is easy, inexpensive, uses the gastrointestinal tract, maintains gut mucosal integrity, and allows for individualized nutritional strategies. This narrative review describes enteral nutritional interventions for children undergoing cancer treatment and is aimed at PCUs of all levels of care located in a low- and middle-income country.

Nutritional Status and Clinical Outcomes in Children with Cancer on Admission to Intensive Care Units

Malnutrition is prevalent among pediatric oncology patients admitted to the pediatric intensive care unit (PICU), which leads to unfavorable clinical outcomes. This was a secondary data analysis of the nutrition data of 160 pediatric oncology patients admitted to the PICU. Cox's regression (adjusted for sex, age, and pediatric critical illness score) and Chi-square were used to examine the association between nutritional status and outcomes. Most of the patients were diagnosed with leukemia and admitted to PICU for medical reasons. The prevalence of malnutrition was 11.3% according to weight-for-age z-score, 16.3% according to height-for-age z-score, 21.3% according to body mass index-for-age z-score, 14.4% according to weight-for-height z-score, 34.4% according to mid-upper arm circumference-for-age z-score. Anthropometrical parameters that predicted the duration of mechanical ventilation were weight-for-age (hazard ratio [HR], 2.727; 95% confidence interval [CI], 1.729-4.302); height-for-age (HR, 1.969; 95% CI, 1.440-2.693); weight-for-height (HR, 2.645; 95% CI, 1.575-4.441); and upper arm muscle area-for-age (HR, 2.098; 95% CI, 1.430-3.077). Length of PICU stay was predicted by weight-for-age (HR, 1.207; 95% CI, 1.014-1.436). Malnutrition is prevalent among pediatric oncology patients admitted to the PICU, which lead to unfavorable clinical outcomes. Comprehensive nutritional status assessment should be performed for these children.

Dietary intake and micronutrient deficiency in children with cancer

Data regarding micronutrient deficiencies in children with cancer are lacking. We measured micronutrients in a subset of children with cancer (n = 23) participating in a randomized trial of the neutropenic diet. Ninety-six percent of children had ≥1 micronutrient deficiency and 39% had ≥3 micronutrient deficiencies. Eighty-six percent of children had vitamin C deficiency, 87% had 25-hydroxyvitamin D deficiency, 50% had zinc deficiency, and 13% had vitamin A deficiency. Dietary intake did not correlate with micronutrient deficiency status. More data are needed regarding the prevalence and etiology of micronutrient deficiencies in children with cancer to further understand their implications and treatment.

Dietary and Exercise Interventions for Pediatric Oncology Patients: The Way Forward

This review focuses on diet and exercise interventions that have been conducted in pediatric cancer and pediatric stem cell transplant patients. It examines the different reasons for conducting lifestyle interventions with attention to the different outcome measurements and feasibility of these measures with an argument toward a need for standardization to move the field forward.

Revised antiemetics guidelines and the impact on nutritional status during induction chemotherapy in children with high-risk neuroblastoma

BACKGROUND

High-risk neuroblastoma (HR NBL) treatment requires intensive induction chemotherapy. The profoundly emetogenic agents used can compromise nutritional status. Our institution introduced a new antiemetic guideline in 2010 incorporating regular dexamethasone, in addition to ondansetron, for all highly emetogenic protocols.

PROCEDURE

A retrospective comparative review of pediatric patients diagnosed with HR NBL who received rapid COJEC induction chemotherapy as per HR-SIOPEN NBL trial. Prophylactic antiemetics were prescribed regardless of chemotherapy emetogenicity in group A (2004-2010) but for defined time periods considering chemotherapy emetogenicity in group B (2010-2017).

RESULTS

Sixty-three children were eligible for inclusion (median age, 31 months; range, 1-88 months). Group A had more episodes of emesis than group B (189 vs. 116, P < 0.0001). There was a significant difference in weight-for-age Z score change between the groups by induction end (P = 0.0027). Four children (13%) in group A lost >10% body weight versus none in group B. Nutrition support (NS) was utilized by 29 children (94%) in group A and 22 children (69%) in group B. Group A had a median of 3 (range, 1-7) admissions for febrile neutropenia (FN) versus a median of 1.5 (range, 0-4) for group B (P = 0.003) during induction.

CONCLUSION

The review of our guidelines led to reduced emesis frequency for group B. They also required less NS, followed expected growth trajectories more closely and had fewer FN admissions. We propose that this may have occurred due to better emesis control resulting in improved nutritional status and associated enhanced immune function.

Diet and exercise interventions for pediatric cancer patients during therapy: tipping the scales for better outcomes

Obesity at diagnosis is a negative prognostic indicator for several pediatric cancers including acute leukemia and bone tumors. Incidence of obesity in children has increased three-fold over the past 2 decades, and causes for this include poor diet, excessive caloric intake, and lack of physical activity, which are collectively referred to as energy balance-related behaviors. Few energy balance interventions have been implemented in pediatric cancer patients during treatment, and here we will probe the rationale for pursuing such studies. The need to modify composition of calories consumed and to identify specific beneficial exercise regimens will be discussed, relative to weight reduction or management.

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.

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.

Equivalência semântica do Questionário Pediatric Subjective Global Nutritional Assessment para triagem nutricional em pacientes pediátricos com câncer

Objetivo: Realizar a equivalência semântica da Avaliação Nutricional Subjetiva Global Pediátrica e sua adaptação para a língua portuguesa para aplicação em pacientes pediátricos hospitalizados com câncer. Métodos: O processo de equivalência semântica envolveu as seguintes etapas: tradução, síntese das traduções, retrotradução, discussão com comitê de especialistas e pré-teste, etapas que aconteceram na Universidade Federal do Rio de Janeiro e no Instituto Nacional de Câncer José Alencar Gomes da Silva. O questionário foi pré-testado em 32 pacientes pediátricos com câncer, de 2 a 18 anos, para verificar sua adequação nessa população. Resultados: Todas as etapas fundamentaram a equivalência semântica do instrumento. Foram necessárias discretas alterações no instrumento Avaliação Nutricional Subjetiva Global Pediátrica para o contexto brasileiro. Na avaliação das 56 assertivas traduzidas para o português, 81% das respostas dos especialistas classificaram como "inalterado" o significado geral. Evidenciou-se uma boa equivalência semântica entre a tradução e a retrotradução e a versão original. Conclusão: A versão brasileira da Avaliação Nutricional Subjetiva Global Pediátrica foi bem compreendida pela população do estudo e mostrou-se adequada para seguir com as demais etapas de adaptação transcultural e validação da ferramenta para posterior aplicação na população pediátrica hospitalizada com câncer.

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 and dietary intake of children with acute leukaemia during induction or consolidation chemotherapy

BACKGROUND

The assessment of nutritional status among paediatric patients is important for the planning and execution of nutritional strategies that strive to optimise the quality of life and growth among sick children. The present study aimed to evaluate the nutritional status and dietary intake among children with acute leukaemia.

METHODS

This cross-sectional study included 53 paediatric patients aged 3-12 years old, who were diagnosed with either acute lymphoblastic leukaemia or acute myelogenous leukaemia and were undergoing chemotherapy treatments (induction or consolidation phase). Patients were matched for sex, age (±6 months) and ethnicity with healthy children as controls. Weight, height, body mass index, waist circumference, mid-upper arm circumference, triceps skinfold thickness, mid-upper arm muscle area and fat area were determined. Dietary intake was assessed using 3-day food records.

RESULTS

Anthropometric variables were generally higher among patients compared to controls, although the differences were not statistically significant (P > 0.05). The prevalence of overnutrition among patients according to body mass index-for-age, waist circumference-for-age, mid-upper arm circumference-for-age and triceps skinfold-for-age were 24.5%, 29.1%, 17.0% and 30.2%, respectively. Mean energy [5732 ± 1958 kJ (1370 ± 468 kcal) versus 6945 ± 1970 kJ (1660 ± 471 kcal), P < 0.01], protein (50.0 ± 19.7 g versus 62.3 ± 22.3 g, P < 0.01) and fat (43.6 ± 18.9 g versus 58.3 ± 16.7, P < 0.001) intakes of patients were significantly lower than controls.

CONCLUSIONS

The prevalence of being overweight and obesity in children with acute leukaemia was higher despite lower energy intake compared to controls. Studies assessing physical activity, the complex interaction and the effects of treatment drugs are warranted to better manage malnutrition among paediatric patients.

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.