The negative impact of being underweight and weight loss on survival of children with acute lymphoblastic leukemia

Nutritional status at diagnosis and its relationship with survival and relapse in Mexican children with acute lymphoblastic leukemia: a retrospective study

BACKGROUND & AIMS

Childhood acute lymphoblastic leukemia (ALL) is a malignancy with varying survival rates across countries with low, middle, and high income. The assessment of nutritional status (NS) using anthropometric indicators has been explored for its potential relationship on treatment outcomes. This study analyzed a 3-year retrospective cohort of Mexican pediatric patients with ALL, exploring the association between NS at diagnosis and relapse/mortality.

METHODS

Retrospective observational study. Medical records from 252 pediatric patients with ALL were included; anthropometric indicators (Z-scores) of body weight, height, mid-upper arm circumference (MUAC), and triceps and subscapular skinfolds (TSF and SSF, respectively) measurements were used to assess NS. The relapse/mortality data were collected from medical records. Kaplan-Meier (KM) functions and Cox regression models were performed to evaluate the effect of indicators on survival, relapse, and event (death or disease relapse).

RESULTS

Patients with malnutrition showed a significantly lower survival rate according to their BMI (76% vs 63%, p = 0.049), while relapses were higher in the group with TSF < -2 SD (41% vs 12%, p = 0.007). Patients with stunting and TSF < -2 SD showed a higher risk of mortality (HR:6.214, 95%CI: 1.372 to 28.154; HR:2.91, 95%CI: 1.27 to 6.68, respectively), while in patients with higher MUAC Z-score showed a decrease in the mortality risk (HR:0.85, 95%CI:0.73 to 1.00).

CONCLUSIONS

The nutritional status assessed by anthropometric measurements was a strong predictor of survival and relapse outcomes 3y post/diagnosis in this cohort of pediatric patients with ALL.

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.

Comparison of nutritional screening tools in pediatric oncology patients receiving chemotherapy treatment

BACKGROUND

Malnutrition in pediatric oncology patients is a complex and multifactorial process, and the most appropriate screening tool to determine the risk of malnutrition is not clear. The study aimed to compare the Screening Tool for Risk on Nutritional Status and Growth (StrongKids), Pediatric Yorkhill Malnutrition Score (PYMS), Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP), which are commonly used in the general pediatric population, with the Nutrition Screening Tool for Childhood Cancer (SCAN), which was specifically validated for pediatric cancer, in determining the risk of malnutrition.

METHODS

This cross-sectional study included 92 children aged 2-18 years who were admitted to the hematology-oncology unit and were receiving chemotherapy. The prevalence of nutritional risk was determined using the SCAN, StrongKids, PYMS, STAMP, and anthropometric assessments were performed. Sensitivity and specificity values, and the degree of agreement between screening tools were calculated.

RESULT

The SCAN identified nutritional risk in 69.6 % of the children. According to StrongKids, PYMS and STAMP, the high nutritional risk in children was 43.5 %, 56.5 % and 64.1 %, respectively. The sensitivity of STAMP (81.2 %) was higher than that of StrongKids (60.9 %) and PYMS (79.7 %). The specificity of StrongKids, PYMS and STAMP was 96.4 %, 96.4 %, and 75.0 %, respectively. There was substantial agreement between SCAN and PYMS.

CONCLUSION

PYMS has the best specificity and sensitivity in identifying patients at risk of malnutrition as determined by SCAN.

IMPLICATIONS FOR PRACTICE

In addition to anthropometric measurements, population-specific or highly sensitive nutritional screening tools should be used to determine the risk of malnutrition.

Impact of Acute Lymphoblastic Leukaemia Treatment on the Nutritional Status of Paediatric Patients: A Systematic Review

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) is the most prevalent cancer in childhood and is one of the leading causes of death annually. Antineoplastic treatments are associated with a high risk of malnutrition, which is important for continuous growth and development.

OBJECTIVE

This systematic review aimed to evaluate the effect of these treatments on the nutritional status of paediatric patients with ALL. Data were collected from the PubMed, Scopus, and Web of Science databases following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) method. All the studies in which nutritional status was assessed in human beings diagnosed with ALL up to 18 years and published in English or Spanish between January 1900 and December 2023 were included.

RESULTS

A total of 18 articles and 1692 participants were analysed in this review. Article quality was evaluated using the ROBINS-I tool. This systematic review has been registered on PROSPERO (CRD42024505111). ALL treatment has a negative impact on the nutritional status of these patients and played an important role in their growth and global development. ALL treatments can modify hunger perception and the palatability of food.

CONCLUSIONS

Nutritional status is important for patient prognosis and survival. Nutritional evaluation, a specific nutritional assessment, and follow-up should be recommended for these patients to decrease the nutritional impact on global health. More homogeneous studies must be conducted to reach robust conclusions regarding the best type of nutritional intervention for these patients.

Nutritional interventions in children with acute lymphoblastic leukemia undergoing antineoplastic treatment: a systematic review

BACKGROUND

A compromised nutritional status jeopardizes a positive prognosis in acute lymphoblastic leukemia (ALL) patients. In low- and middle-income countries, ~ 50% of children with ALL are malnourished at diagnosis time, and undergoing antineoplastic treatment increases the risk of depleting their nutrient stores. Nutrition interventions are implemented in patients with cancer related malnutrition. We aimed to evaluate the effect of nutrition interventions in children diagnosed with ALL under treatment.

METHODS

Using a predefined protocol, we searched for published or unpublished randomized controlled trials in: Cochrane CENTRAL, MEDLINE, EMBASE, LILACS, and SciELO, and conducted complementary searches. Studies where at least 50% of participants had an ALL diagnosis in children ≤ 18 years, active antineoplastic treatment, and a nutrition intervention were included. Study selection and data extraction were conducted independently by three reviewers, and assessment of the risk of bias by two reviewers. Results were synthesized in both tabular format and narratively.

RESULTS

Twenty-five studies (out of 4097 records) satisfied the inclusion requirements. There was a high risk of bias in eighteen studies. Interventions analyzed were classified by compound/food (n = 14), micronutrient (n = 8), and nutritional support (n = 3). Within each group the interventions and components (dose and time) tested were heterogeneous. In relation to our primary outcomes, none of the studies reported fat-free mass as an outcome. Inflammatory and metabolic markers related to nutritional status and anthropometric measurements were reported in many studies but varied greatly across the studies. For our secondary outcomes, fat mass or total body water were not reported as an outcome in any of the studies. However, some different adverse events were reported in some studies.

CONCLUSIONS

This review highlights the need to conduct high-quality randomized controlled trials for nutrition interventions in children with ALL, based on their limited number and heterogeneous outcomes.

REGISTRATION OF THE REVIEW PROTOCOL

Guzmán-León AE, Lopez-Teros V, Avila-Prado J, Bracamontes-Picos L, Haby MM, Stein K. Protocol for a Systematic Review: Nutritional interventions in children with acute lymphoblastic leukemia undergoing an tineoplastic treatment. International prospective register of systematic reviews. 2021; PROSPERO CRD:42,021,266,761 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266761 ).

Caregiver perceptions of child heath behaviors and weight during treatment for acute lymphoblastic leukemia

BACKGROUND

Changes in health behaviors and weight are common during the early phases of pediatric acute lymphoblastic leukemia treatment, and may negatively impact treatment tolerability. Given that ALL is most prevalent in children, caregivers play an essential role in shaping health behaviors during treatment. This study presents a qualitative analysis of semi-structured interviews with caregivers of youth in the early phases of ALL treatment.

PROCEDURE

Caregivers (N = 17, 95% female) of a child (M age = 6.76 years) diagnosed with ALL and on treatment for less than 1 year (M = 8.7 months since diagnosis) completed a semi-structured interview about perceptions of their child's nutrition, physical activity, sedentary time, and weight during ALL treatment. Thematic analysis followed Braun and Clark's six-step framework (2006). Two coders established reliability (alpha = .88) and used a multi-pass coding system to extract themes.

RESULTS

Caregivers' concerns around their child's weight during ALL treatment primarily centered around avoiding malnutrition. Weight gain during treatment was less of a concern and often viewed as protective. Caregivers reported encouraging their child to eat palatable, calorie-dense foods to mitigate risk for weight loss. Caregivers also expressed concern that children were less active and more sedentary due to treatment-related pain. Caregivers discussed health behaviors during treatment as being child-directed, rather than parent- or provider-directed.

CONCLUSION

Future interventions may consider strategies to engage in joint parent-child decisions and caregiver education around risks of excessive weight gain during treatment. Interventions should include anticipatory guidance and aim to support parents in developing skills to support their child's health behaviors during treatment.

Nutritional status, body composition and diet quality in children with cancer

During cancer treatment, nutritional status disorders such as malnutrition or obesity affect the tolerance of cancer treatment, quality of life, but also the pharmacokinetics of drugs. It is hypothesized that changes in fat and lean body mass can modify chemotherapy volume distribution, metabolism and clearance. In children with cancer, lean body mass decreases or remains low during treatment and fat mass increases. Body composition is influenced by the cancer itself, aggressive multimodal-therapies, changes in metabolism, unbalanced diet and reduced physical activity. Due to the side effects of treatment, including changes in the sense of taste and smell, nausea, vomiting, diarrhea, and stress, eating according to recommendation for macronutrients and micronutrients is difficult. Research indicates that throughout cancer treatment, the consumption of fruits, vegetables, and dairy products tends to be insufficient, whereas there is an elevated intake of sugar and unhealthy snacks. Children exhibit a preference for high-carbohydrate, salty, and strongly flavored products. This review revealed the importance of body composition and its changes during cancer treatment in children, as well as eating habits and diet quality.

Physical frailty deteriorates after a 5-day dexamethasone course in children with acute lymphoblastic leukemia, results of a national prospective study

BACKGROUND

Dexamethasone is important in the treatment for pediatric acute lymphoblastic leukemia (ALL) but induces muscle atrophy with negative consequences for muscle mass, muscle strength, and functional abilities. The aim of this study was to establish the effect of a dexamethasone course on sarcopenia and physical frailty in children with ALL, and to explore prognostic factors.

METHODS

Patients with ALL aged 3-18 years were included during maintenance therapy. Patients had a sarcopenia/frailty assessment on the first day of (T1) and on the day after (T2) a 5-day dexamethasone course. Sarcopenia was defined as low muscle strength in combination with low muscle mass. Prefrailty and frailty were defined as having two or ≥three of the following components, respectively: low muscle mass, low muscle strength, fatigue, slow walking speed, and low physical activity. Chi-squared and paired t-tests were used to assess differences between T1 and T2. Logistic regression models were estimated to explore patient- and therapy-related prognostic factors for frailty on T2.

RESULTS

We included 105 patients, 61% were boys. Median age was 5.3 years (range: 3-18.8). At T1, sarcopenia, prefrailty, and frailty were observed in respectively 2.8%, 23.5%, and 4.2% of patients. At T2, the amount of patients with frailty had increased to 17.7% (p = 0.002), whereas the number of patients with sarcopenia and prefrailty remained similar. Higher ASMM (odds ratio [OR]: 0.49, 95% CI: 0.28-0.83), stronger handgrip strength (OR: 0.41, 95% CI: 0.22-0.77) and more physical activity minutes per day (OR: 0.98, 95% CI: 0.96-0.99) decreased the risk of frailty at T2. Slower walking performance (OR: 2, 95% CI: 1.2-3.39) increased the risk. Fatigue levels at T1 were not associated with frailty at T2.

CONCLUSION

Physical frailty increased strikingly after a 5-days dexamethasone course in children with ALL. Children with poor physical state at start of the dexamethasone course were more likely to be frail after the course.

Age-associated augmented renal clearance and low BMI trigger suboptimal vancomycin trough concentrations in children with haematologic diseases: data of 1453 paediatric patients from 2017 to 2022

BACKGROUND

It is usually difficult for the trough concentration of vancomycin to reach the recommended lower limit of 10 mg/L per the label dose in the paediatric population. Moreover, children with haematologic diseases who suffer from neutropenia are more likely to have lower exposure of vancomycin, and the risk factors have been poorly explored.

METHOD

We reviewed and analysed the initial trough concentration of vancomycin and synchronous cytometry and biochemical parameters in the blood of 1453 paediatric patients with haematologic diseases over a 6 year period, from 2017 to 2022.

RESULTS

Forty-five percent of the enrolled children had vancomycin trough concentrations below 5 mg/L after receiving a dose of 40 mg/kg/day, and the multiple regression showed that age (OR = 0.881, 95% CI 0.855 to 0.909, P < 0.001), BMI (OR = 0.941, 95% CI 0.904 to 0.980, P = 0.003) and the glomerular filtration rate (OR = 1.006, 95% CI 1.004 to 1.008, P < 0.001) were independent risk factors. A total of 79.7% of the children experienced augmented renal clearance, which was closely correlated to age-associated levels of serum creatinine. The vancomycin trough concentration was higher in children with aplastic anaemia than in those with other haematologic diseases due to a higher BMI and a lower glomerular filtration rate.

CONCLUSION

Age-associated augmented renal clearance and low BMI values contributed to suboptimal trough concentrations of vancomycin in children with haematologic diseases, and the effects of long-term use of cyclosporine and glucocorticoids need to be taken into account.

The utility of a portable muscle ultrasound in the assessment of muscle alterations in children with acute lymphoblastic leukaemia

BACKGROUND

During treatment for acute lymphoblastic leukaemia (ALL), children are prone to musculoskeletal deterioration. However, non-invasive tools to measure muscle mass and intramuscular alterations are limited. In this study we explored the feasibility of muscle ultrasound in children with ALL. Additionally, we analysed whether automated ultrasound outcomes of muscle size and intramuscular fat infiltration (IMAT) were associated with appendicular skeletal muscle mass (ASMM), muscle strength and physical performance.

METHODS

Children with ALL, aged 3-18 years were included during maintenance therapy. Bilateral images of the rectus femoris muscle were captured using a portable linear array transducer connected to a tablet. Subsequently, an automated image annotation software (MuscleSound) was used to estimate cross-sectional area, muscle thickness and IMAT. Feasibility was assessed using acceptance (percentage of children approached who were enrolled), practicality (percentage of children that completed the ultrasound measurement after enrolment) and implementation (percentage of children that had sufficient imaging to be processed and analysed by the software). Assessments of ASMM by bioimpedance analysis, muscle strength using handheld dynamometry and timed physical performance tests were administered at the same visit. Multivariable linear models were estimated to study the associations between muscle ultrasound outcomes and ASMM, strength and physical performance, adjusted for sex, age, body mass index and ALL treatment week.

RESULTS

Muscle ultrasound was performed in 60 out of 73 invited patients (76.9%), of which 37 were boys (61.7%), and median age was 6.1 years (range: 3-18.8 years). The acceptance was 98.7%, practicality 77.9% and implementation was 100%. Patients who refused the examination (n = 13) were younger (median: 3.6, range: 3-11.2 years) compared with the 60 examined children (P = 0.0009). In multivariable models, cross-sectional area was associated with ASMM (β = 0.49 Z-score, 95% confidence interval [CI]:0.3,2.4), knee-extension strength (β = 16.9 Newton [N], 95% CI: 4.8, 28.9), walking performance (β = -0.46 s, 95% CI: -0.75, -0.18) and rising from the floor (β = -1.07 s, 95% CI: -1.71, -0.42). Muscle thickness was associated with ASMM (β = 0.14 Z-score, 95% CI: 0.04, 0.24), knee-extension strength (β = 4.73 N, 95% CI: 0.99, 8.47), walking performance (β = -0.13 s, 95% CI: -0.22, -0.04) and rising from the floor (β = -0.28 s, 95% CI: -0.48, -0.08). IMAT was associated with knee-extension strength (β = -6.84 N, 95% CI: -12.26, -1.41), walking performance (β = 0.2 s, 95% CI: 0.08, 0.32) and rising from the floor (β = 0.54 s, 95% CI: 0.27, 0.8). None of the muscle ultrasound outcomes was associated with handgrip strength.

CONCLUSIONS

Portable muscle ultrasound appears a feasible and useful tool to measure muscle size and intramuscular alterations in children with ALL. Validation studies using magnetic resonance imaging (gold standard) are necessary to confirm accuracy in paediatric populations.

Association between body mass index at diagnosis and outcomes in Chinese children with newly diagnosed acute lymphoblastic leukemia

PURPOSE

Studies of the association between body mass index (BMI) at diagnosis and treatment outcome in children with acute lymphoblastic leukemia (ALL) have yielded inconsistent results. Hence, we conducted a retrospective study in a large cohort of Chinese children with ALL treated with contemporary protocols.

PATIENTS AND METHODS

A total of 1437 children (62.1% male; median age at diagnosis 5.7 years, range: 2.3-16.3 years) were enrolled in two consecutive clinical trials at the Shanghai Children's Medical Center. The rates of overall survival, event-free survival, relapse, treatment-related mortality, and adverse events were compared among patients who were underweight (BMI < 5th percentile), at a healthy weight (5th to 85th percentile), overweight (>85th to <95th percentile), and obese (≥95th percentile).

RESULTS

At diagnosis, 91 (6.3%) patients were underweight, 1070 (74.5%) were at a healthy weight, 91 (6.3%) were overweight, and 185 (12.9%) were obese. No significant association was found between weight status and 5-year overall survival, event-free survival, or relapse in the overall cohort. When analyzed as a continuous variable, a higher BMI Z-score was associated with treatment-related mortality (hazard ratio 1.33 (95% confidence interval [CI], 1.05-1.68%), p = 0.02). The treatment-related mortality rate was higher in the overweight (5.5%, 95% CI 0.8-10.2%) and obese (3.2%, 95% CI 0.6-5.8%) groups compared with the underweight (0.0%) and healthy-weight groups (1.9%, 95% CI 1.1-2.7%; p = 0.04). Multivariable analysis showed that children who were overweight had a higher risk of treatment-related mortality (hazard ratio 3.8, 95% CI 1.3-11.4).

CONCLUSION

While body weight status was not associated with event-free survival or overall survival, overweight patients were at higher risk of treatment-related mortality.

Novel Adaption of the SARC-F Score to Classify Pediatric Hemato-Oncology Patients with Functional Sarcopenia

Sarcopenia in pediatric hemato-oncology patients is undesirable because of the consequences it may have for treatment continuation and outcome, physical abilities and participation in daily life. An easy-to-use screening tool for sarcopenia will facilitate the identification of children at risk who need interventions to prevent serious physical deterioration. In the elderly, the use of the SARC-F score as a case-finding tool for sarcopenia is recommended. The aim of this cross-sectional study was to investigate the accuracy of the pediatric SARC-F (PED-SARC-F) for identifying sarcopenia in pediatric hemato-oncology patients, including the determination of a cut-off point for clinical use. Patients 3−20 years of age, under active treatment or within 12 months after treatment cessation were eligible. Patients had a physiotherapy assessment including a PED-SARC-F (0−10) and measurements of muscle strength (handheld dynamometry), physical performance (various tests) and/or muscle mass (bio-impedance analysis), as part of the standard of care. Spearman’s correlation coefficient (rs) between the PED-SARC-F and physiotherapy outcomes were calculated. Structural sarcopenia was defined as low appendicular skeletal muscle mass (ASMM) in combination with low muscle strength and/or low physical performance. Functional sarcopenia indicated low muscle strength combined with low physical performance. Multiple logistic regression models were estimated to study the associations between the PED-SARC-F and structural/functional sarcopenia. To evaluate which cut-off point provides the most accurate classification, the area under the receiver operating characteristic curve (AUCs), sensitivity and specificity per point were calculated. In total, 215 assessments were included, 62% were performed in boys and the median age was 12.9 years (interquartile range: 8.5−15.8). The PED-SARC-F scores correlated moderately with the measurements of muscle strength (rs = −0.37 to −0.47, p < 0.001) and physical performance (rs = −0.45 to −0.66, p < 0.001), and weakly with ASMM (rs = −0.27, p < 0.001). The PED-SARC-F had an AUC of 0.90 (95% confidence interval (CI) = 0.84−0.95) for functional sarcopenia and 0.79 (95% CI = 0.68−0.90) for structural sarcopenia. A cut-off point of ≥5 had the highest specificity of 96% and a sensitivity of 74%. In conclusion, we adapted the SARC-F to a pediatric version, confirmed its excellent diagnostic accuracy for identifying functional sarcopenia and defined a clinically useful cut-off point in pediatric hemato-oncology patients.

Changes in body mass index during treatment of childhood acute lymphoblastic leukemia with the Nordic ALL2008 protocol

OBJECTIVES

Children with acute lymphoblastic leukemia (ALL) have a tendency to gain weight during treatment. As overweight and obesity associate with health problems, prophylactic interventions are warranted. Therefore, it is important to identify the children most prone to gain weight.

METHODS

Patients aged 2.0-17.9 years at ALL diagnosis were identified from the NOPHO ALL2008 registry. Registry data was complemented with height and weight at the end of therapy from questionnaires. Body mass index (BMI) was classified according to international age- and sex-adjusted International Obesity Task Force BMI cut-offs. BMI values were transformed into standard deviation scores (SDS) to calculate the difference in BMISDS during treatment.

RESULTS

Data on BMI change were available for 765 children. Overweight and obesity doubled during treatment: 9.7% were overweight and 2.1% obese at diagnosis and 21.8% and 5.4% at the end of therapy, respectively. The mean BMISDS change was +0.64. Younger (2.0-5.9 years) and healthy weight children were most prone to become overweight (mean change in BMI SDS +0.85 and + 0.65, respectively).

CONCLUSIONS

Younger children (2.0-5.9 years) with healthy weight at diagnosis were most prone to becoming overweight and therefore are an important group to target while considering interventions.

Nutritional Status at Diagnosis as Predictor of Survival from Childhood Cancer: A Review of the Literature

Few studies so far have examined the impact of nutritional status on the survival of children with cancer, with the majority of them focusing on hematological malignancies. We summarized published evidence reporting the association of nutritional status at diagnosis with overall survival (OS), event-free survival (EFS), relapse, and treatment-related toxicity (TRT) in children with cancer. Published studies on children with leukemia, lymphoma, and other solid tumors have shown that both under-nourished and over-nourished children at cancer diagnosis had worse OS and EFS. Particularly, the risk of death and relapse increased by 30-50% among children with leukemia with increased body mass index at diagnosis. Likewise, the risk of TRT was higher among malnourished children with osteosarcoma and Ewing sarcoma. Nutritional status seems to play a crucial role in clinical outcomes of children with cancer, thus providing a significant modifiable prognostic tool in childhood cancer management. Future studies with adequate power and longitudinal design are needed to further evaluate the association of nutritional status with childhood cancer outcomes using a more standardized definition to measure nutritional status in this population. The use of new technologies is expected to shed further light on this understudied area and give room to person-targeted intervention strategies.

Quantification of chemotherapy-induced changes in body composition in pediatric, adolescent, and young adult lymphoma using standard of care CT imaging

OBJECTIVES

The objective of this study was to use computed tomography (CT) imaging to quantify chemotherapy-induced changes in body composition (BC) in pediatric, adolescent, and young adult (AYA) patients with lymphoma and to compare image-derived changes in BC measures to changes in traditional body mass index (BMI) measures.

METHODS

Skeletal muscle (SkM), subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT) volumes were manually segmented using low-dose CT images acquired from a 10-year retrospective, single-site cohort of 110 patients with lymphoma. CT images and BMI percentiles (BMI%) were acquired from baseline and first therapeutic follow-up. CT image segmentation was performed at vertebral level L3 using 5 consecutive axial CT images.

RESULTS

CT imaging detected significant treatment-induced changes in BC measures from baseline to first follow-up time points, with SAT and VAT significantly increasing and SkM significantly decreasing. BMI% measures did not change from baseline to first follow-up and were not significantly correlated with changes in image-derived BC measures. Patients who were male, younger than 12 years old, diagnosed with non-Hodgkin's lymphoma, and presented with stage 3 or 4 disease gained more adipose tissue and lost more SkM in response to the first cycle of treatment compared to their clinical counterparts.

CONCLUSIONS

Standard of care CT imaging can quantify treatment-induced changes in BC that are not reflected by traditional BMI assessment. Image-based monitoring of BC parameters may offer personalized approaches to lymphoma treatment for pediatric and AYA patients by guiding cancer treatment recommendations and subsequently enhance clinical outcomes.

KEY POINTS

• Standard of care low-dose CT imaging quantifies chemotherapy-induced changes in body composition in pediatric, adolescent, and young adults with lymphoma. • Body mass index could not detect changes in body composition during treatment that were quantified by CT imaging. • Pediatric and AYA patients who were male, younger than 12 years old, and diagnosed with non-Hodgkin's lymphoma, and presented with stage 3 or 4 disease gained more adipose tissue and lost more skeletal muscle tissue in response to the first cycle of treatment compared to their clinical counterparts.

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.

Evolução do Estado Nutricional de Crianças e Adolescentes com Leucemia Linfoide Aguda submetidos a Terapia Oncológica

Introdução: Quando se fala em câncer infantojuvenil, a leucemia linfoide aguda (LLA) ganha destaque por causa da sua elevada prevalência nessa população. De todos os tipos de câncer que atingem esse público, crianças e adolescentes parecem ser mais suscetíveis aos efeitos adversos como a má nutrição e/ou excesso de peso ao longo do tratamento. Objetivo: Avaliar a evolução do estado nutricional de crianças e adolescentes com LLA submetidos a terapia oncológica. Método: Estudo retrospectivo, longitudinal, com pacientes portadores de LLA submetidos a terapia antineoplásica, realizado com 69 crianças e adolescentes (até 19 anos), de ambos os sexos. As medidas de peso e altura foram coletadas em oito ocasiões distintas ao longo de todo o tratamento, tendo o primeiro registro acontecido no início e o ultimo ao termino de todas as sessões do tratamento antineoplásico. Resultados: Ao diagnostico, houve uma prevalência de pacientes classificados como estróficos. Quando correlacionados a faixa etária e o indicador Altura/Idade para idade, foi observado que crianças menores de 10 anos apresentaram valores mais baixos se comparados com os maiores de 10 anos no decorrer do tratamento, além de uma tendência de incremento no escore Peso/Idade de forma lenta ate o seu final. Conclusão: Os pacientes submetidos ao tratamento antineoplásico de LLA apresentaram uma redução na velocidade de crescimento, além de leve ganho de peso ao final da terapia, o que sugere uma interferência negativa da terapêutica empregada sobre o estado nutricional nessa população.

Normal anthropometry does not equal normal body composition in pediatric intestinal failure

BACKGROUND

Published reports on abnormal body composition in pediatric patients with intestinal failure have been in patients with poor growth. The goal of the current study is to report the body composition of normally growing patients with intestinal failure.

METHODS

Children 8-18 years old with a dual-energy x-ray absorptiometry (DXA) between January 1, 2013, and July 15, 2018, were included in the study. Data were retrospectively collected from the medical charts and included demographics, residual bowel anatomy, nutrition support, height, and weight. DXA data, including total body less head bone mineral density (BMD), fat mass (FM), and fat-free mass (FFM), were collected and compared with published literature controls matched for age and sex.

RESULTS

Thirty-four children met inclusion criteria. Mean age at the time of DXA was 9.6 ± 1.8 years. Weight- and height-for-age z-scores were -0.4 ± 0.9 and -0.5 ± 1.0, respectively. Mean BMD z-score was -1.0 ± 1.3. Twenty-six percent of patients (n = 9) had reduced BMD. Patients with intestinal failure had higher FM (P = .02) and lower FFM (P = .02) compared with controls.

CONCLUSIONS

These data show that, despite reference range z-scores for height and weight, children with intestinal failure are at risk for abnormal body composition. Body composition should be routinely measured in children with intestinal failure to direct nutrition interventions.

Dexamethasone-induced sarcopenia and physical frailty in children with acute lymphoblastic leukemia: Protocol for a prospective cohort study (Preprint)

Background

During treatment for pediatric acute lymphoblastic leukemia (ALL), children receive high doses of dexamethasone for its apoptotic effect on leukemia cells; however, muscle atrophy is a well-known serious side effect. Muscle atrophy (loss of muscle mass) accompanied by a decreased muscle strength may lead to a generalized impaired skeletal muscle state called sarcopenia. Loss of muscle mass is also an indicator of physical frailty, which is defined as a state of increased vulnerability that is characterized by co-occurrence of low muscle mass, muscle weakness, fatigue, slow walking speed, and low physical activity. Both sarcopenia and physical frailty are related to an increased risk of infections, hospitalizations, and decreased survival in children with chronic diseases.

Objective

This study aims to (1) estimate the occurrence of sarcopenia and physical frailty in children during ALL maintenance therapy, (2) evaluate the effect of administering dexamethasone, and (3) explore determinants associated with these outcomes.

Methods

This prospective study is being pursued within the framework of the DexaDays-2 study: a randomized controlled trial on neurobehavioral side effects in pediatric patients with ALL. A total of 105 children (3-18 years) undergoing ALL maintenance treatment at the Princess Máxima Center for Pediatric Oncology are included in this study. Sarcopenia/frailty assessments are performed before and just after a 5-day dexamethasone course. A subset of 50 children participating in the DexaDays-2 trial because of severe dexamethasone-induced neurobehavioral problems were assessed at 3 additional timepoints. The sarcopenia/frailty assessment consists of bioimpedance analysis (skeletal muscle mass [SMM]), handheld dynamometry (handgrip strength), Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (fatigue), Timed Up and Go Test (TUG; walking speed), and physical activity questionnaires. To evaluate potential change in sarcopenia/frailty components after a 5-day dexamethasone administration, a paired Student t test or Mann-Whitney U test will be used. Because of the presence of repeated measurements, generalized linear mixed models will be used to estimate the effect of dexamethasone on sarcopenia and frailty outcomes. Multivariable regression models will be estimated to investigate associations between the assessment scores and patient and treatment-related factors.

Results

Patient accrual started in 2018 and was finalized in spring 2021. From autumn 2021 onward final data analyses will be performed.

Conclusions

This first study combining parameters of sarcopenia and physical frailty is of importance because these conditions can seriously complicate continuation of ALL therapy, independence in physical functioning, reaching motor milestones, and participating in daily life activities. The results will provide knowledge about these complications, the association between dexamethasone treatment and muscle loss and other components of frailty, and therefore insights into the severity of this side effect. By exploring potential determinants that may be associated with sarcopenia and physical frailty, we may be able to identify children at risk at an earlier stage and provide timely interventions.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33517

Skeletal muscle and adipose tissue changes in the first phase of treatment of pediatric solid tumors

Body composition is increasingly recognized as an important factor in cancer outcomes. Use of computed tomography (CT) in cancer care provides the opportunity to accurately quantify whole‐body lean and adipose tissues from images at the third lumbar spine. We sought to substantiate the use of routinely captured, single‐slice chest CT images at the thoracic level for evaluation of skeletal muscle, residual lean tissue, and adiposity among pediatric solid tumor patients. We performed a retrospective analysis among children who underwent treatment for a solid tumor at Columbia University Irving Medical Center. Skeletal muscle (SM), residual lean tissue (RLT), and adipose tissue cross‐sectional areas (cm²) were analyzed at diagnosis and at first follow‐up for disease evaluation (6–14 weeks). Imaging analysis was performed utilizing slice‐O‐matic image analysis software. Of the 57 patients identified, 39 had chest CT imaging that included intervertebral level T12‐L1, and 22 also had concurrent imaging at L3. Correlation coefficients between body composition variables at T12‐L1 and L3 were strong (r = 0.93–0.98). Paired t‐test showed a significant decrease in SM (−4.2 ± 8.12, p = 0.003) and RLT (−10.7 ± 28.5, p = 0.025) as well as a trend toward a significant increase in visceral adipose tissue (3.10 ± 9.65, p = 0.052). Univariable analysis demonstrated a significant association between increasing age and increased SM loss (β = −0.496 with SE = 0.194, p = 0.011), and a lack of association between body mass index and body composition changes. We provide the first line of evidence that single‐slice images from routinely obtained chest CT scans provide a simple, readily available mechanism for assessing body composition in pediatric solid tumor patients. Adverse body composition changes were observed, particularly among adolescents and young adults.

Precis: Changes in body composition can be detected via routine CT images in pediatric patients undergoing treatment for solid tumors.

Impact of body mass index on relapse in children with acute lymphoblastic leukemia treated according to Nordic treatment protocols

Objectives

High body mass index (BMI) is associated with poorer survival in childhood acute lymphoblastic leukemia (ALL), but the actual impact on the risk of relapse still needs to be clarified. We evaluated the impact of BMI at diagnosis on the risk of relapse in children with ALL treated according to Nordic Society of Paediatric Haematology and Oncology (NOPHO) protocols.

Method

In a multicenter study, we collected data on BMI at diagnosis and outcome of 2558 children aged 2.0‐17.9 years diagnosed between 1992 and 2016. Patients were divided into four groups according to International Obesity Task Force (IOTF) childhood BMI cut‐offs: underweight, <17; healthy weight, 17‐25; overweight, 25‐30; and obese, ≥30 kg/m².

Results

In Cox multivariate regression analyses, an increased risk of relapse was observed in children aged 10‐17.9 years with unhealthy BMI at diagnosis (underweight hazard ratio HR: 2.90 [95% confidence interval: 1.24‐6.78], P = .01; overweight, HR: 1.95 [1.11‐3.43], P = .02, and obese HR: 4.32 [95% 2.08‐8.97], P < .001), compared to children with healthy weight. BMI had no impact on relapse in children under 10 years of age.

Conclusion

High BMI, and especially obesity at diagnosis, is an independent adverse prognostic factor for relapse in older children with ALL.

Prevalence and predictors of weight loss during induction therapy for childhood acute lymphoblastic leukemia

OBJECTIVE

Children with acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma often experience significant weight gain during induction therapy. However, a subgroup of patients may experience weight loss, which can impact outcomes; thus, identifying and understanding this underrecognized concern is important. Our aim was to identify the prevalence and predictors for weight loss during ALL induction therapy.

METHODS

This was a single-institution retrospective study of 187 patients, ages 2 to 20 y, diagnosed with ALL or lymphoblastic lymphoma. We analyzed weight trends during induction therapy and predictors of weight loss.

RESULTS

Significant weight loss (≥5%) occurred in 17% of patients. Having high-risk disease, trisomy 21, overweight/obese status at the time of diagnosis, and/or hyperglycemia were positively associated with weight loss and negatively associated with weight gain during induction therapy.

CONCLUSION

Future studies should aim to better understand the etiology and importance of weight loss during induction therapy.

A Review on the Impact of Body Mass Index on Outcomes in Pediatric Leukemia

In the last decades, adults and pediatric obesity have become a major issue in developed countries. Considerable research has been conducted in patients with acute lymphoblastic (ALL) and myeloid leukemia (AML) with the aim of correlating body mass index (BMI) and outcomes in patients undergoing chemotherapy for hematological diseases. In adults, a high BMI has been associated with increased leukemia-related mortality. Whether a similar effect exists in the pediatric setting remains controversial. Some of the studies detailed in this review have reported no differences in outcomes according to BMI, whilst other reports have described higher treatment-related mortality, increased risk of relapse and death. Although the link between BMI and acute leukemia outcomes is controversial, a large number of studies describe poorer survival rates in children with AML or ALL with higher BMI. On the other hand, being underweight has been associated with higher treatment-related toxicity. Understanding more about the impact of BMI in pediatric leukemia is of utmost importance to provide prompt intervention and improve outcomes.

Changes in hunger among pediatric patients with cancer and hematopoietic stem cell transplantation recipients

PURPOSE

Change in hunger is a common and bothersome symptom among pediatric patients receiving cancer treatments. Objectives were to describe how children and adolescents receiving cancer treatments experience changes in hunger, factors associated with both increases and decreases in hunger, and coping strategies used by these patients.

METHODS

We enrolled children and adolescents 4-18 years of age with cancer or hematopoietic stem cell transplantation (HSCT) recipients who were actively receiving treatment or who had completed therapy. Using a single, qualitative, semi-structured interview, we asked participants about the experience of increases or decreases in hunger, including characteristics of the change and identified coping strategies.

RESULTS

There were 50 children enrolled; 25 (50%) were 4-10 years of age and 33 (66%) were boys. Most often, patients associated an increase in hunger with corticosteroid administration, while other treatments, accompanying symptoms, inactivity, and the hospital environment were associated with a decrease in hunger. Many reported that no coping strategies were successful. For those who did report successful strategies to manage an increase in hunger, these included sleep and having food available. Strategies used to manage a decrease in hunger included anti-emetic medications, increased caloric intake, varied food choices, encouragement to eat, scheduling or tracking of meals, and physical activity.

CONCLUSIONS

Both increases and decreases in hunger were commonly described. Some coping strategies were reported to be successful. Further research should identify and test interventions to manage changes in hunger in pediatric cancer patients.

The leukaemia stem cell: similarities, differences and clinical prospects in CML and AML

For two decades, leukaemia stem cells (LSCs) in chronic myeloid leukaemia (CML) and acute myeloid leukaemia (AML) have been advanced paradigms for the cancer stem cell field. In CML, the acquisition of the fusion tyrosine kinase BCR-ABL1 in a haematopoietic stem cell drives its transformation to become a LSC. In AML, LSCs can arise from multiple cell types through the activity of a number of oncogenic drivers and pre-leukaemic events, adding further layers of context and genetic and cellular heterogeneity to AML LSCs not observed in most cases of CML. Furthermore, LSCs from both AML and CML can be refractory to standard-of-care therapies and persist in patients, diversify clonally and serve as reservoirs to drive relapse, recurrence or progression to more aggressive forms. Despite these complexities, LSCs in both diseases share biological features, making them distinct from other CML or AML progenitor cells and from normal haematopoietic stem cells. These features may represent Achilles' heels against which novel therapies can be developed. Here, we review many of the similarities and differences that exist between LSCs in CML and AML and examine the therapeutic strategies that could be used to eradicate them.

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

Proper nutritional status during cancer therapy has been recognised as being integral to a variety of health outcome measures, including overall survival, treatment tolerance, and quality of life. The prevalence of malnutrition, defined by WHO as either undernutrition or overnutrition, among children and adolescents with cancer is reported to be as high as 75%. Yet, over the past two decades there have been limited advances in elucidating the underlying pathophysiological drivers of malnutrition in this population. This effect has resulted in a paucity of research aimed at improving nutritional assessment and intervention among this group. This Review presents an in-depth discussion of the role of nutritional status in paediatric cancer care, as well as evolving avenues of investigation that might propel personalised nutrition into a viable reality. Thus, nutritional science might facilitate individualised intervention strategies, and thereby help to optimise clinical outcomes for patients and survivors of childhood cancer.

Associations between pretherapeutic body mass index, outcome, and cytogenetic abnormalities in pediatric acute myeloid leukemia

Background

Associations between body mass index (BMI), outcome, and leukemia‐related factors in children with acute myeloid leukemia (AML) remain unclear. We investigated associations between pretherapeutic BMI, cytogenetic abnormalities, and outcome in a large multinational cohort of children with AML.

Methods

We included patients, age 2‐17 years, diagnosed with de novo AML from the five Nordic countries (2004‐2016), Hong Kong (2007‐2016), the Netherlands and Belgium (2010‐2016), and Canada and USA (1995‐2012). BMI standard deviations score for age and sex was calculated and categorized according to the World Health Organization. Cumulative incidence functions, Kaplan‐Meier estimator, Cox regression, and logistic regression were used to investigate associations.

Results

In total, 867 patients were included. The median age was 10 years (range 2‐17 years). At diagnosis, 32 (4%) were underweight, 632 (73%) were healthy weight, 127 (15%) were overweight, and 76 (9%) were obese. There was no difference in relapse risk, treatment‐related mortality or overall mortality across BMI groups. The frequency of t(8;21) and inv(16) increased with increasing BMI. For obese patients, the sex, age, and country adjusted odds ratio of having t(8;21) or inv(16) were 1.9 (95% confidence interval (CI) 1.1‐3.4) and 2.8 (95% CI 1.3‐5.8), respectively, compared to healthy weight patients.

Conclusions

This study did not confirm previous reports of associations between overweight and increased treatment‐related or overall mortality in children. Obesity was associated with a higher frequency of t(8;21) and inv(16). AML cytogenetics appear to differ by BMI status.

The Effect of Soy Nut Compared to Cowpea Nut on Body Weight, Blood Cells, Inflammatory Markers and Chemotherapy Complications in Children with Acute Lymphoblastic Leukemia: A Randomized Controlled Clinical Trial

No previous studies were found to examine the effect of soy as a whole food on patients with leukemia. The present randomized controlled clinical trial studied the effect of soy nut on children with B-cell acute lymphoblastic leukemia (ALL) who were in the maintenance phase of chemotherapy. The eligible patients were randomized to receive 30 g/day soy or cowpea nut powder for 12 weeks. Dietary intake, physical activity, anthropometric measurements, complete blood count, serum albumin, serum highly sensitive C-reactive protein (hs-CRP), and Tumor necrosis factor alpha (TNF-α) as well as chemotherapy side effects were assessed at the start and the end of the study. In total 29 and 27 children completed the study (aged 6.34 ± 2.44 and 5.85 ± 2.35 years) in soy and cowpea nut groups, respectively. The total energy and protein intake, and physical activity as well as body weight, body mass index, number of red blood cells, hemoglobin and hematocrit levels, and fatigue were significantly improved in the soy nut group compared to patients who consumed cowpea nut (P < 0.05). Soy nut intake might improve the nutritional status, anemia, and fatigue in children with ALL. Studies targeting blood cell fractions and disease recurrence are highly recommended.

Body composition analysis and references in children: clinical usefulness and limitations

The prevalence of obesity is increasing over the world. Especially in Asians compared to Caucasians, there has been a significant increase in the population with major chronic diseases. This has developed over a shorter time period which is associated with socioeconomic changes in recent decades and a greater predisposition to cardiometabolic disorders. Many Asians could be classified has having normal weight but with obesity as evidenced by body composition (BC) and fat distribution. Overweight in Asian adults is classified as a BMI > 23 kg/m² and obesity as a BMI > 25 kg/m². An effective strategy to manage the obesity epidemic by focusing on childhood obesity is needed because of the huge impact that obesity exerts on population health. However, monitoring tools are limited to anthropometry such as BMI and BMI z-scores which define overweight and obese as a BMI exceeding the 85th and 95th percentiles, respectively, on reference growth charts. To overcome the limitations of BMI, reference values for BC components have been produced using various techniques. The use of BC charts for children in personalized therapeutic approach has increased, although there is a lack of a consensus on a single reference technique. Zones on BC charts and the personalized values of BC components could be practical, especially for the detection of metabolically unhealthy normal weight (MUN) children. BC charts should be included in the growth chart package and BC monitoring through the entire life course will help us understand the association between growth, aging, health and disease.

The Associations of Height-for-Age, Weight-for-Age, and Weight-for-Height With Pediatric Acute Lymphoblastic Leukemia

Height at diagnosis has been analyzed in connection with acute lymphoblastic leukemia (ALL). Most prior studies have compared cases to national reference data derived from previous birth cohorts. Our objective was to determine the association of height-for-age Z score (HAZ) at time of diagnosis with the odds ratio (OR) of ALL in a case-control study (N=498) with a contemporaneous population of age-matched, sex-matched, and ethnicity-matched controls. We hypothesized that cases would have greater mean HAZ at time of diagnosis/interview, after adjustment for weight-for-age (WAZ) and weight-for-height (WHZ). HAZ was not associated with ALL. For each 1 SD increase in WAZ the OR of ALL was 0.83 (95% confidence interval [CI], 0.68-0.99). The OR of ALL was increased among children who had either a WAZ ≤-2 (OR, 5.10; 95% CI, 1.85-16.75) or WHZ of ≤-2 (OR, 5.27; 95% CI, 1.65-23.61). Previous findings of taller height among ALL cases may arise from the choice of control populations. Children with low WAZ or WHZ were at increased odds of ALL.

Relationship of lean mass and obesity in Indian urban children and adolescents

BACKGROUND

The association of obesity and lean mass (LM) has not been examined well in children and adolescents, and it remains controversial.

OBJECTIVE

The objective of this study was to evaluate the relationship of body mass index (BMI) categories and regional obesity with total and regional LM in children and adolescents.

METHODS

A total of 1408 children and adolescents (boys 58.9%; girls 41.1%) divided according to BMI (normal weight 79.5%, overweight 16.0%, and obese 4.5%) were included in this cross-sectional study. Total and regional LM and fat mass were measured by DXA. Leg and arm fat-to-total fat ratio (LATR) indicative of subcutaneous fat and trunk fat-to-total fat ratio (TTR), an indicator of visceral fat, were calculated.

RESULTS

Mean age of the study population was 13.2 ± 2.7 years (boys - 13.0 ± 2.7; girls - 13.4 ± 2.8 years). Total LM (TLM) and its regional distribution were higher in overweight and obese groups when compared with those with normal BMI in both genders. TLM was comparable between overweight and obese in both genders. TLM per unit of fat progressively decreased from normal to obese categories. The difference in LM per unit fat between BMI categories persisted after adjustment for age, height, and sexual maturity score. TLM increased across the quartiles of TTR, but decreased with an increment in subcutaneous fat (quartiles of LATR).

CONCLUSIONS

Obese children and adolescents apparently have higher LM than normal BMI children, but have lower LM per unit of fat. Subcutaneous fat had a negative impact and visceral fat had a positive impact on TLM.

Effect of age and body weight on toxicity and survival in pediatric acute myeloid leukemia: results from NOPHO-AML 2004

Treatment for pediatric acute myeloid leukemia is very toxic and the association between outcome and age and Body Mass Index is unclear. We investigated effect of age and Body Mass Index on toxicity and survival in pediatric acute myeloid leukemia. We studied all patients who completed first induction course of NOPHO-AML 2004 (n=318). Toxicity following induction and consolidation courses (n=6) was analyzed. The probabilities of toxicity and death were determined using time-to-event analyses with Cox multivariate proportional hazard regression for comparative analyses. Age 10-17 years was associated with sepsis with hypotension [hazard ratio 2.3 (95% confidence interval 1.1-4.6)]. Being overweight (>1 standard deviation) was associated with requiring supplemental oxygen [1.9 (1.0-3.5)]. The 5-year event-free and overall survival were 47% and 71%. Children aged 10-17 years showed a trend for inferior 5-year overall survival compared to children aged 2-9 (64% vs. 76%; P=0.07). Infants showed a trend for superior 5-year event-free survival (66% vs. 43%; P=0.06). Overweight children aged 10-17 years showed a trend for superior survival [5-year event-free survival 59% vs. 40% (P=0.09) and 5-year overall survival 78% vs. 56% (P=0.06)] compared to healthy weight children aged 10-17 years. In conclusion, children aged 10-17 years and overweight children had a higher risk of grade 3-4 toxicity. Children aged 10-17 years showed inferior survival, but, unexpectedly, in this age group overweight children tended to have increased survival. This suggests different pharmacokinetics of chemotherapeutic drugs in adolescents and warrants further studies.