|Year : 2015 | Volume
| Issue : 2 | Page : 173-175
Nutritional status in children with cancer: Before, during and after therapy
Department of Pediatrics; Pathology; Medicine, McMaster University, Hamilton, Ontario, Canada
|Date of Web Publication||5-Feb-2016|
R D Barr
Department of Pediatrics; Pathology; Medicine, McMaster University, Hamilton, Ontario
Source of Support: None, Conflict of Interest: None
Context: Malnutrition is prevalent in children with cancer at diagnosis, especially in low- and middle-income countries (LMIC) where the great majority of children live. It is associated with an added burden of morbidity and mortality. Aims: Answers were sought to the best measure of nutritional status in LMIC, the impact of anti-neoplastic therapy, effective interventions to achieve normal nutritional status and the impact of these on clinical outcomes. Results: Arm anthropometry offers reasonable estimates of fat mass and lean body mass that are both impacted adversely by treatment. Nutritional supplementation, including the use of simple local resources, is beneficial and can improve survival. Long-term survivors may continue to exhibit perturbed nutritional status. Conclusions: The prevalence and severity of malnutrition in children with cancer in LMIC demand attention. Opportunities exist to conduct studies in India to examine the effects of nutritional interventions, including on the overall well-being of survivors.
Keywords: Cancer, children, interventions, nutrition, outcomes
|How to cite this article:|
Barr R D. Nutritional status in children with cancer: Before, during and after therapy. Indian J Cancer 2015;52:173-5
| » Introduction|| |
Normal nutritional status in children with acute lymphoblastic leukemia (ALL), the most common form of cancer in this age group, is associated with lower burdens of morbidity and mortality than both over- and under-nutrition. In high-income countries (HIC), the dominant challenge in children with cancer is with overweight and obesity, though the prevalence and severity of under-nutrition (commonly referred to as malnutrition, defined as “a state of nutrition in which a deficiency of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form and function and clinical outcomes”) may be underestimated. By contrast, malnutrition is much more common in low- and middle-income countries (LMIC) where the prevalence in children with cancer has been reported to be almost as high at 90% at diagnosis (of ALL in Chandigarh in India) and where the great majority of these children live. This circumstance demands answers to several important questions. What is the best method for assessing nutritional status? What is the impact of anti-neoplastic therapy on the nutritional status? What interventions have been effective in maintaining or restoring normal nutritional status? What is the influence of such interventions on cancer outcomes? This brief review will touch on each of these issues.
| » Assessment of Nutritional Status|| |
Although sophisticated measures of body composition, such as total body potassium, air displacement plethysmography and isotope dilution methods, are well-established in research settings, these are inapplicable in clinical practice. The “gold standard” in the hospital environment is dual energy X-ray absorptiometry (DEXA). This technique provides accurate measures of fat mass, fat-free mass (essentially equivalent to lean body mass) and bone mineral mass that sum almost exactly to body weight. Moreover, DEXA is more accurate than bioelectrical impedance analysis (BIA) in healthy children and patients, especially in the setting of obesity. However, DEXA is not readily available in many LMIC and even in HIC is inappropriate for frequently repeated measurements, mainly because of cost.
In most circumstances, reliance is placed on anthropometry, and the WHO recommends the use of weight-for-height index to assess the nutritional status of children and adolescents. However, measures based on height and weight, such as weight-for-height, body mass index (BMI), and ideal body weight (IBW), may not provide accurate determinations of nutritional status in children with cancer, mainly because of the factor of the tumor mass. Consequently, attention has been paid to the use of triceps skinfold thickness (TSFT, a measure of fat mass) and mid-upper arm circumference (MUAC, a measure of lean body mass) in this population. Attempts have been made to validate TSFT and MUAC with DEXA. MUAC is a good predictor of lean body mass, but TSFT is less accurate as a predictor of fat mass and underestimates this compartment of body composition in children with ALL in HIC, as does BMI. Nevertheless, arm anthropometry may be a more sensitive indicator of malnutrition in children with cancer than BMI and IBW, and the sensitivity may be enhanced by the addition of serum albumin.
| » Impact of Antineoplastic Therapy on Nutritional Status|| |
Perturbations of nutritional status are all too common in children who are undergoing treatment for malignant disease. A striking example is provided by Zimmermann et al. in Switzerland with a cohort of children (n = 327) who were receiving treatment for cancer. At diagnosis, fewer than 6% had a BMI Z score of <−2.0. By 30 days this was 22%, by 60 days 36% and eventually 47% were malnourished by this criterion, including 15 of 16 patients with medulloblastoma. Contributing factors include nausea, vomiting, loss of appetite, alteration of taste and mucositis, leading to a combination of macro- and micro-nutrient deficiencies. A tool for nutritional screening has been developed at St. Jude Children's Research Hospital [Table 1]. Linear growth frequently slows  and weight gain (especially from steroid therapy) or weight loss (from a multiplicity of mechanisms) occur in a high proportion of patients. These adverse effects may be accompanied by metabolic aberrations. Again, changes in body composition may be under-recognized. As measured by BIA fat mass increases steadily after completion of intensive therapy while lean body mass remains low. The use of DEXA has revealed prominent loss of bone mineral  and the early reduction in skeletal muscle mass, both of which are multifactorial in origin. Whether these recover to normal values is the proper subject of study in long-term survivors.
|Table 1: Nutritional screening of inpatients at admission and outpatients at diagnosis and every 6 months|
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| » Interventions to Maintain or Restore Normal Nutritional Status|| |
Whether supplementation is delivered by the oral, enteral or parenteral route is dictated by the individual clinical situation, though the “7–10 days rule” is a useful guide to avoid over-utilization of parenteral nutrition, and the “re-feeding syndrome” can be prevented by introducing nutritional supplementation slowly. Control of nausea, vomiting, and diarrhea are essential, as is the adequate management of pain. Use of glutamine to limit mucosal injury  and appetite stimulation, as with cyproheptadine, may be beneficial. Attention to specific metabolic needs requires the expertise of dietitians/nutritionists, and child life specialists are often helpful in managing behavioral problems in young children. Physical activity makes an important contribution to nutritional health, as addressed in guidelines from the American Cancer Society.
| » Influence of Nutritional Interventions on Cancer Outcomes|| |
Although there is not yet a clear consensus on the impact of nutritional status at diagnosis on ultimate cancer outcomes, there is a considerable interest in examining the influence of nutritional interventions on these important variables in children. A recent study in Guatemala demonstrated that correction of malnutrition within 6 months of diagnosis, in children with ALL, resulted in improvement in their survival to approximate that of children who had not exhibited nutritional depletion. Malnutrition is associated with socioeconomic deprivation that can be ameliorated, including an element of nutritional supplementation. Such intervention should take advantage of local opportunities, as in the use of peanut butter, in the form of “chiponde,” in children with Wilms tumor in Malawi  and “incaparina” (based on a mixture of maize and soy flours) in Guatemala. What is sorely needed are well-designed clinical trials, for to date such efforts have been of poor quality, as assessed by the Cochrane collaboration.
| » Nutritional Status After Completion of Therapy|| |
Long-term follow-up studies of survivors of cancer in childhood and adolescence, virtually absent in LMIC, have relied largely on BMI. Almost 40 years ago Costa and Donaldson observed that obesity and being overweight was common in those who had had ALL while being underweight (BMI ≤18.5) was more common in survivors of soft tissue sarcoma, neuroblastoma, Wilms tumor, Hodgkin and non-Hodgkin lymphoma, and brain tumors. Very similar findings, based on self-report by more than 7000 subjects, were recorded by the Childhood Cancer Survivor Study in 2005. However, in a population-based sample of more than 1000 subjects, derived from the Utah Cancer Registry using BMI calculated from drivers' license data, survivors were not at higher risk of being under- or over-weight than comparable subjects in the general population. Using DEXA, it is apparent that BMI underestimates fat mass in survivors and DEXA reveals that lean body mass is reduced, though only in males who received cranial  or total body  irradiation.
| » Contributions from India|| |
Given the prevalence of malnutrition in the Indian population, it is not surprising that studies of nutritional status have been undertaken in children with cancer in several parts of the country. In addition to those reported at the SIOP symposium in Mumbai in September 2014, Kumar et al. from Chandigarh observed that 88% of children with ALL were malnourished at diagnosis when arm anthropometry was added to weight-for-age as defining measures. Moreover, loss of mid-upper arm muscle area occurred in 56% of this small sample (n = 25) during remission induction.
Three studies have addressed the impact of nutritional status on survival. Barman et al. from Kolkata studied 700 children at diagnosis and found that a serum albumen of <3 g/100 ml and an MUAC <3rd centile were associated with shorter disease-free survival duration. Vora et al. in Mumbai, studying patients with nonmetastatic Ewing sarcoma (n = 343), observed that a serum albumin of <4 g/100 ml was associated with an event-free survival (EFS), at a median follow-up of 24 months, of 43% compared to those with higher levels (EFS 68%, P = 0.002). Radhnakrishnan et al. in New Delhi reported that a BMI for age <10th centile was associated with poorer overall 3 years survival (60% vs. 79%, P = 0.031) in 190 children with ALL.
As there are large populations of incident cases of cancer in childhood presenting to numerous institutions in India, there is an obvious opportunity to undertake well-designed studies, including trials of nutritional intervention, especially if performed collaboratively. Indeed, India could lead the way in these endeavors and even rise to the challenge of measuring health-related quality of life in this context; an area of study that is essentially unexplored.
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Conflicts of interest
There are no conflicts of interest.
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