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 »  Abstract
 » Introduction
 »  Assessment of Nu...
 »  Impact of Antine...
 »  Interventions to...
 »  Influence of Nut...
 »  Nutritional Stat...
 »  Contributions fr...
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  Table of Contents  
Year : 2015  |  Volume : 52  |  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 Publication5-Feb-2016

Correspondence Address:
R D Barr
Department of Pediatrics; Pathology; Medicine, McMaster University, Hamilton, Ontario
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.175827

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 » Abstract 

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

How to cite this URL:
Barr R D. Nutritional status in children with cancer: Before, during and after therapy. Indian J Cancer [serial online] 2015 [cited 2022 Dec 6];52:173-5. Available from:

 » Introduction Top

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.[1] 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”)[2] may be underestimated.[3] 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)[4] and where the great majority of these children live.[5] 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 Top

Although sophisticated measures of body composition, such as total body potassium, air displacement plethysmography and isotope dilution methods,[6] are well-established in research settings, these are inapplicable in clinical practice.[6] 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.[7] Moreover, DEXA is more accurate than bioelectrical impedance analysis (BIA) in healthy children and patients,[8] especially in the setting of obesity.[9] 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.[10] 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.[11] 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.[9] Attempts have been made to validate TSFT and MUAC with DEXA.[12] 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,[13] as does BMI.[14] 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.[15]

 » Impact of Antineoplastic Therapy on Nutritional Status Top

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.[16] 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.[6] A tool for nutritional screening has been developed at St. Jude Children's Research Hospital [Table 1].[6] Linear growth frequently slows [17] and weight gain (especially from steroid therapy) or weight loss (from a multiplicity of mechanisms) occur in a high proportion of patients.[6] 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.[18] The use of DEXA has revealed prominent loss of bone mineral [19] and the early reduction in skeletal muscle mass,[20] both of which are multifactorial in origin. Whether these recover to normal values is the proper subject of study in long-term survivors.[21]
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 Top

Whether supplementation is delivered by the oral, enteral or parenteral route is dictated by the individual clinical situation, though the “7–10 days rule”[6] is a useful guide to avoid over-utilization of parenteral nutrition, and the “re-feeding syndrome” can be prevented by introducing nutritional supplementation slowly.[6] Control of nausea, vomiting, and diarrhea are essential, as is the adequate management of pain. Use of glutamine to limit mucosal injury [22] and appetite stimulation, as with cyproheptadine,[6] 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.[23]

 » Influence of Nutritional Interventions on Cancer Outcomes Top

Although there is not yet a clear consensus on the impact of nutritional status at diagnosis on ultimate cancer outcomes,[24] 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.[24] Malnutrition is associated with socioeconomic deprivation that can be ameliorated, including an element of nutritional supplementation.[25] 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 [26] and “incaparina” (based on a mixture of maize and soy flours) in Guatemala.[25] 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.[27]

 » Nutritional Status After Completion of Therapy Top

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.[28] Very similar findings, based on self-report by more than 7000 subjects, were recorded by the Childhood Cancer Survivor Study in 2005.[29] 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.[30] 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 [14] or total body [31] irradiation.

 » Contributions from India Top

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.[4] 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.[32] 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).[33] 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.[34]

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.[35]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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Smith DE, Stevens MC, Booth IW. Malnutrition at diagnosis of malignancy in childhood: Common but mostly missed. Eur J Pediatr 1991;150:318-22.  Back to cited text no. 2
Stratton RJ, Green CJ, Elia M. Disease Related Malnutrition, an Evidence Based Approach to Treatment. Wallingford, Oxon: CAB International; 2003.  Back to cited text no. 3
Kumar R, Marwaha RK, Bhalla AK, Gulati M. Protein energey malnutrition and skeletal muscle wasting in childhood acute lymphoblastic lukemia. Indian Pediatr 2000;37:720-6.  Back to cited text no. 4
Barr R, Antillon F, Agarwal B, Mehta P, Ribeiro R. Pediatric oncology in countries with limited resources. In: Pizzo PA, Poplack DG, editors. Principles and Practice of Pediatric Oncology. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2011. p. 1463-73.  Back to cited text no. 5
Mosby TT, Barr RD. Nutrition in children and adolescents with cancer. In: Cvercko G, Predovnik L, editors. Child Nutrition and Health. Hauppauge, NY: Nova Science Publishers; 2013. p. 1-42.  Back to cited text no. 6
Sala A, Webber CE, Morrison J, Beaumont LF, Barr RD. Whole-body bone mineral content, lean body mass, and fat mass measured by dual-energy X-ray absorptiometry in a population of normal Canadian children and adolescents. Can Assoc Radiol J 2007;58:46-52.  Back to cited text no. 7
Atherton RR, Williams JE, Wells JC, Fewtrell MS. Use of fat mass and fat free mass standard deviation scores obtained using simple measurement methods in healthy children and patients: Comparison with the reference 4-component model. PLoS One 2013;8:e62139.  Back to cited text no. 8
Wan CS, Ward LC, Halim J, Gow ML, Ho M, Briody JN, et al. Bioelectrical impedance analysis to estimate body composition, and change in adiposity, in overweight and obese adolescents: Comparison with dual-energy x-ray absorptiometry. BMC Pediatr 2014;14:249.  Back to cited text no. 9
Butte NE, Garza C, de Onis M. Evaluation of the feasibility of international growth standards for school-aged children and adolescents. Food Nutr Bull 2006;27 4 Suppl: S169-74.  Back to cited text no. 10
Sala A, Pencharz P, Barr RD. Children, cancer, and nutrition – A dynamic triangle in review. Cancer 2004;100:677-87.  Back to cited text no. 11
Barr R, Collins L, Nayiager T, Doring N, Kennedy C, Halton J, et al. Nutritional status at diagnosis in children with cancer 2. An assessment by arm anthropometry. J Pediatr Hematol Oncol 2011;33:e101-4.  Back to cited text no. 12
Webber C, Halton J, Walker S, Young A, Barr RD. The prediction of lean body mass and fat mass from arm anthropometry at diagnosis in children with cancer. J Pediatr Hematol Oncol 2013;35:530-3.  Back to cited text no. 13
Jarfelt M, Lannering B, Bosaeus I, Johannsson G, Bjarnason R. Body composition in young adult survivors of childhood acute lymphoblastic leukaemia. Eur J Endocrinol 2005;153:81-9.  Back to cited text no. 14
Sala A, Rossi E, Antillon F, Molina AL, de Maselli T, Bonilla M, et al. Nutritional status at diagnosis is related to clinical outcomes in children and adolescents with cancer: A perspective from Central America. Eur J Cancer 2012;48:243-52.  Back to cited text no. 15
Zimmermann K, Ammann RA, Kuehni CE, De Geest S, Cignacco E. Malnutrition in pediatric patients with cancer at diagnosis and throughout therapy: A multicenter cohort study. Pediatr Blood Cancer 2013;60:642-9.  Back to cited text no. 16
Collins L, Zarzabal LA, Nayiager T, Pollock BH, Barr RD. Growth in children with acute lymphoblastic leukemia during treatment. J Pediatr Hematol Oncol 2010;32:e304-7.  Back to cited text no. 17
Brinksma A, Roodbol PF, Sulkers E, Kamps WA, de Bont ES, Boot AM, et al. Changes in nutritional status in childhood cancer patients: A prospective cohort study. Clin Nutr 2015;34:66-73.  Back to cited text no. 18
Sala A, Barr RD. Osteopenia and cancer in children and adolescents: The fragility of success. Cancer 2007;109:1420-31.  Back to cited text no. 19
Rayar M, Webber CE, Nayiager T, Sala A, Barr RD. Sarcopenia in children with acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2013;35:98-102.  Back to cited text no. 20
Barr R, Nayiager T, Gordon C, Marriott C, Athale U. Body composition and bone health in long-term survivors of acute lymphoblastic leukaemia in childhood and adolescence: The protocol for a cross-sectional cohort study. BMJ Open 2015;5:e006191.  Back to cited text no. 21
Aquino VM, Harvey AR, Garvin JH, Godder KT, Nieder ML, Adams RH, et al. A double-blind randomized placebo-controlled study of oral glutamine in the prevention of mucositis in children undergoing hematopoietic stem cell transplantation: A pediatric blood and marrow transplant consortium study. Bone Marrow Transplant 2005;36:611-6.  Back to cited text no. 22
Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin 2012;62:243-74.  Back to cited text no. 23
Antillon F, Rossi E, Molina AL, Sala A, Pencharz P, Valsecchi MG, et al. Nutritional status of children during treatment for acute lymphoblastic leukemia in Guatemala. Pediatr Blood Cancer 2013;60:911-5.  Back to cited text no. 24
De Pernillo M, Rivas S, Fuentes L, Antillon F, Barr RD. Measurement of socio-economic status in families of children with cancer in Guatemala. Pediatr Blood Cancer 2014;61:2071-3.  Back to cited text no. 25
Israëls T, Borgstein E, Jamali M, de Kraker J, Caron HN, Molyneux EM. Acute malnutrition is common in Malawian patients with a Wilms tumour: A role for peanut butter. Pediatr Blood Cancer 2009;53:1221-6.  Back to cited text no. 26
Jones L, Watling RM, Wilkins S, Pizer B. Nutritional support in children and young people with cancer undergoing chemotherapy (Review). The Cochrane Collaboration, John Wiley and Sons; 2011.  Back to cited text no. 27
Costa G, Donaldson SS. Current concepts in cancer: Effects of cancer and cancer treatment on the nutrition of the host. N Engl J Med 1979;300:1471-4.  Back to cited text no. 28
Meacham LR, Gurney JG, Mertens AC, Ness KK, Sklar CA, Robison LL, et al. Body mass index in long-term adult survivors of childhood cancer: A report of the Childhood Cancer Survivor Study. Cancer 2005;103:1730-9.  Back to cited text no. 29
Warner EL, Fluchel M, Wright J, Sweeney C, Boucher KM, Fraser A, et al. A population-based study of childhood cancer survivors' body mass index. J Cancer Epidemiol 2014;2014:531958.  Back to cited text no. 30
Blijdorp K, van den Heuvel-Eibrink MM, Pieters R, Boot AM, Delhanty PJ, van der Lely AJ, et al. Obesity is underestimated using body mass index and waist-hip ratio in long-term adult survivors of childhood cancer. PLoS One 2012;7:e43269.  Back to cited text no. 31
Barman B, Ghosh R, Saha K, et al. Assessment of nutrition for children in childhood cancer – A study from a developing country. Int Soc Pediatr Oncol 2008. [Abstract PN 008].  Back to cited text no. 32
Vora T, Kurkure P, Arora B, et al. Baseline serum albumen – An independent prognostic factor in non-metastatic Ewing sarcoma family of tumors. A prospective study in 343 patients from India. Pediatr Blood Cancer 2011;57:711. [Abstract O 016].  Back to cited text no. 33
Radhnakrishnan N, Dinand V, Yadav SP, Sachdeva A. Nutritional status as a prognostic factor in response to treatment and survival of pediatric acute lymphoblastic leukemia: A single centre experience. Pediatr Blood Cancer 2011;57:766-7. [Abstract PA 026].  Back to cited text no. 34
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