The nutritional risks of children with cancer

Nutrition is a major concern in paediatric cancer, increasing the risk of co-morbidities, affecting tolerance of therapies and influencing survival. Despite this, very few studies have aimed to identify the nutritional risks of children treated for cancer in the western world. A unique retrospective study was therefore proposed to assess the degree of nutritional risk in paediatric cancer using the need for nutrition support (NS) as a proxy for high nutritional risk. Of 168 patients, seventy four (44%) required NS of whom 50 (67%) and 24 (33%) had solid and haematological malignancies. These findings underline the common need for NS in this childhood cancer cohort. A prospective study was consequently designed to assess the effect of cancer and its treatment on nutritional status, using commonly used assessment techniques. Measurements were taken regularly at six time points over a period of up to 18 months. 26 patients, 18 (69%) male and 8 (31%) female (median age 5.1; IQR 2.3, 7.9) volunteered for the study. At recruitment and during the first three months of treatment, those with solid tumour demonstrated nutritional deprivation, low BMI (median 25.5, IQR 5.5-60.5; median 18.0, IQR 7.5-54.2 respectively), low fat mass %(median 76.3, IQR 48.5-99.1; median 70.8, IQR 62.6-124.8 respectively), low energy intake (median kcal/d 1200, IQR 866-1970; median 1305 kcal/d, IQR 901-1488) and a high need for NS. In contrast, those with haematological cancer demonstrated an excess BMI (median 66.0, IQR 41.5-82.2; median 79.5; IQR 70- 94.2 respectively), high fat mass % (median 102.0, IQR 78.6- 153.0; median 129.4, IQR 96.5-202.6,respectively) and excessive energy intake (median kcal/d 2076; IQR 1453-2525, median kcal/d 1078, IQR 919-1206 respectively) These results suggest that children undergoing cancer therapy are at high risk of both undernutrition and obesity and they indicate apparent differences in nutritional risk according to diagnosis and treatment.sub_dnbsunpub1587_ethesesunpu

5-Hydroxyvitamin D concentration in paediatric cancer patients from Scotland:a prospective cohort study

Children with cancer are potentially at high risk of plasma 25-hydroxyvitamin D [25(OH)D] inadequacy and despite UK vitamin D supplementation guidelines their implementation remains inconsistent. Thus, we aimed to investigate 25(OH)D concentration and factors contributing to 25(OH)D inadequacy in paediatric cancer patients. A prospective cohort study of Scottish children aged <18 years, diagnosed with and treated for cancer (patients) between Aug 2010-Jan 2014 was performed, with control data from Scottish healthy children (controls). Clinical and nutritional data were collected at defined periods up to 24 months. 25(OH)D status was defined by the Royal College of Paediatrics and Child Health (2013); inadequacy [<50 nmol/L: deficiency (<25 nmol/L), insufficiency (25-50 nmol/L)], sufficiency (51-75 nmol/L), optimal (>75 nmol/L). Eighty-two patients [median(IQR) age 3.9(1.9-8.8); 56% males)] and 35 controls [median(IQR) age (6.2(4.8-9.1); 49% males] were recruited. 25(OH)D inadequacy was highly prevalent in the controls (63%; 22/35), and in the patients (64%; 42/65) at both baseline and during treatment (33-50%). Non-supplemented children had the highest prevalence of 25(OH)D inadequacy at every stage with 25(OH)D median(IQR) ranging from 32.0 (21.0-46.5) nmol/L to 45.0(28.0-64.5) nmol/L. Older age at baseline [R=-0.46; p<0.001], overnutrition (BMI ≥85th centile) at 3 months [p=0.005; RR=3.1] and not being supplemented at 6 months (p=0.04; RR=4.3) may have contributed to lower plasma 25(OH)D. Paediatric cancer patients are not at higher risk of 25(OH)D inadequacy than healthy children at diagnosis; however prevalence of 25(OH)D inadequacy is still high and non-supplemented children have a higher risk. Appropriate monitoring and therapeutic supplementation should be implemented

Low Plasma Vitamin D (25-Hydroxycholecalciferol) in Children and Adolescents Diagnosed with Cancer: A Case-Control Study

Introduction: Children and young people with cancer are less likely to spend time outdoors and they may also have a limited dietary intake. In addition, some cancer treatments can increase vitamin D catabolism. Objectives: This study aimed to investigate if there was an increased risk of poor vitamin D status in newly diagnosed childhood cancer patients compared to healthy controls in Scotland. Methods: Plasma 25 (OH) D was measured in children and adolescents during initial cancer treatment and compared to 33 healthy controls. Vitamin D deficiency was classified as plasma 25 (OH) D &lt;25 nmol/l, with a plasma 25 (OH) D of 25-49 nmol/l classified as insufficient. Results: Forty-one patients (median age 3.8 years, IQR 1.9-8.0) were diagnosed with cancer, 63% were male. Twenty-three (56 %) had solid tumours, 18 (44%) had haematological cancers. Median (IQR) plasma 25 (OH) D at recruitment was 37.0 nmol/l (23.7-58.2). Ten patients (24%) had vitamin D deficiency and 17 (41%) patients were classified as insufficient. The median (IQR) plasma 25 (OH) D in the control group (n = 33) was 37.5 nmol/l (29.0-58.0). Six controls (18%) had vitamin D deficiency and 14 (42%) were classified as having insufficient results. Plasma 25 (OH) D did not differ (p &gt; 0.05) between the patients and the controls. Conclusions: Almost three in four Scottish children treated for cancer had vitamin D deficiency or insufficiency; there was no increased risk of poor vitamin D status compared to healthy controls. Assessment of vitamin D status at diagnosis and in response to the course of treatment appears necessary to optimise nutritional management.sch_dieThe determinants of nutritional risk in children and young people with cancer3pub4423pub

Effects of pediatric cancer and its treatment on nutritional status: A systematic review

Context: Malnutrition in pediatric cancer is common worldwide, yet its prevalence and effects on clinical outcomes remain unclear. Objective: The aim of this review was to evaluate primary research reporting the prevalence of malnutrition in pediatric cancer patients and to assess the effects of pediatric cancer and its treatment on nutritional status. Data Sources: Electronic databases of MEDLINE, CINHAL, and PubMed were searched (January 1990-February 2013). Study Selection: Studies of patients aged <18 years who were diagnosed with and treated for cancer and for whom measurements of anthropometry were reported were included. The primary outcome was the prevalence of malnutrition (undernutrition and overnutrition), expressed as body mass index (BMI), in children diagnosed with and treated for cancer. Data Extraction: Evidence was appraised critically by employing the Critical Appraisal Skills Program tool, and data was extracted from original articles. Data Synthesis: A total of 46 studies were included, most of which were considered to be of low quality on the basis of heterogeneity in both the criteria and the measurements used to define malnutrition. Undernutrition was identified by measuring BMI, weight loss, mid-upper arm circumference, and triceps skinfold thickness, while overnutrition was assessed using BMI. Overall, the prevalence of undernutrition ranged from 0% to 65% and overnutrition from 8% to 78%. Finally, undernutrition in pediatric cancer at diagnosis was associated with poor clinical outcomes in 6 of 9 studies. Conclusion: The possibility of a high prevalence of malnutrition in childhood cancer, indicated by the studies reviewed, highlights the need for high-quality, populationbased, longitudinal studies using standard criteria to identify malnutrition.sch_die1. Cancer Research UK. 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Brennan BM. Sensitive measures of the nutritional status of children with cancer in hospital and in the field. Int J Cancer Suppl. 1998;11:10-13. 7. van Eys J, Copeland EM, Cangir A, et al. A clinical trial of hyperalimentation in children with metastatic malignancies. Med Pediatr Oncol. 1980;8:63-73. 8. Lange BJ, Gerbing RB, Feusner J, et al. Mortality in overweight and underweight children with acute myeloid leukemia. JAMA. 2005;293:203-211. 9. Reilly JJ, Odame I, McColl JH, et al. Does weight for height have prognostic significance in children with acute lymphoblastic leukemia? Am J Pediatr Hematol Oncol. 1994;16:225-230. 10. Butturini AM, Dorey FJ, Lange BJ, et al. Obesity and outcome in pediatric acute lymphoblastic leukemia. J Clin Oncol. 2007;25:2063-2069. 11. Sala A, Pencharz P, Barr RD. Children, cancer, and nutrition - a dynamic triangle in review. Cancer. 2004;100:677-687. 12. Viana MB, Murao M, Ramos G, et al. Malnutrition as a prognostic factor in lymphoblastic leukaemia: a multivariate analysis. Arch Dis Child. 1994;71:304-310. 13. International Union against Cancer: Nutritional Morbidity in Children with Cancer: Mechanisms, Measures and Management. UICC International Workshop, November 13-15, 1997. New York: Wiley-Liss; 1998. 14. van Eys J. Malnutrition in children with cancer: incidence and consequence. Cancer. 1979;43:2030-2035. 15. Wallace WHB, Thompson L, Anderson RA. Long term follow-up of survivors of childhood cancer: summary of updated SIGN guidance. BMJ. 2013;346:f1190. doi: 10.1136/bmj.f1190. 16. Hubert HB, Feinleib M, McNamara PM, et al. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983;67:968-977. 17. Bauer J, Jurgens H, Fruhwald MC. Important aspects of nutrition in children with cancer. Adv Nutr. 2011;2:67-77. 18. Sala A, Rossi E, Antillon F, 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;48:243-252. 19. Antillon F, de Maselli T, Garcia T, et al. Nutritional status of children during treatment for acute lymphoblastic leukemia in the Central American Pediatric Hematology Oncology Association (AHOPCA): preliminary data from Guatemala. Pediatr Blood Cancer. 2008;50:502-505. 20. Odame I, Reilly JJ, Gibson BE, Donaldson MD. Patterns of obesity in boys and girls after treatment for acute lymphoblastic leukaemia. Arch Dis Child. 1994;71: 147-149. 21. Reilly JJ. Obesity during and after treatment for childhood cancer. Endocr Dev. 2009;15:40-58. 22. Jaime-Perez JC, Gonzalez-Llano O, Herrera-Garza JL, et al. Assessment of nutritional status in children with acute lymphoblastic leukemia in northern Mexico: a 5-year experience. Pediatr Blood Cancer. 2008;50:506-508. 23. Brinksma A, Huizinga G, Sulkers E, et al. Malnutrition in childhood cancer patients: a review on its prevalence and possible causes. Crit Rev Oncol Hematol. 2012;83: 249-275. 24. Brouwer CAJ, Gietema JA, Kamps WA, et al. Changes in body composition after childhood cancer treatment: impact on future health status - a review. Crit Rev Oncol Hematol. 2007;63:32-46. 25. Reilly JJ, Weir J, McColl JH, et al. Prevalence of protein-energy malnutrition at diagnosis in children with acute lymphoblastic leukemia. J Pediatr Gastroenterol Nutr. 1999;29:194-197. 26. Agostoni C, Axelson I, Colomb V, et al. The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr. 2005;41:8-11. 27. ESPGHAN committee on nutrition. The need for nutrition support teams in paediatric units: commentary by the ESPGHAN Committee on Nutrition. J Paediatr Gastroenterol Nutr. 2010;41:8-11. 28. Barr R, Collins L, Nayiager T, et al. Nutritional status at diagnosis in children with cancer. 2. An assessment by arm anthropometry. J Pediatr Hematol Oncol. 2011; 33:e101-e104. 29. Collins L, Nayiager T, Doring N, et al. Nutritional status at diagnosis in children with cancer I. An assessment by dietary recall - compared with body mass index and body composition measured by dual energy X-ray absorptiometry. J Pediatr Hematol Oncol. 2010;32:e299-e303. 30. Green GJ, Weitzman SS, Pencharz PB. Resting energy expenditure in children newly diagnosed with stage IV neuroblastoma. Pediatr Res. 2008;63: 332-336. 31. Donaldson SS, Wesley MN, DeWys WD, et al. A study of the nutritional status of pediatric cancer patients. Am J Dis Child. 1981;135:1107-1112. 32. Lobato-Mendizabal E, Ruiz-Arguelles GJ, Mar_n-Lopez A. Leukaemia and nutrition. I: Malnutrition is an adverse prognostic factor in the outcome of treatment of patients with standard-risk acute lymphoblastic leukaemia. Leuk Res. 1989;13: 899-906. 33. Mej_a-Arangure JM, Fajardo-Gutierrez A, Reyes-Ru_z NI, et al. Malnutrition in childhood lymphoblastic leukemia: a predictor of early mortality during the induction-to-remission phase of the treatment. ArchMed Res. 1999;30:150-153. 34. Weir J, Reilly JJ, McColl JH, et al. No evidence for an effect of nutritional status at diagnosis on prognosis in children with acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 1998;20:534-538. 35. Pedrosa F, Bonilla M, Liu A, et al. Effect of malnutrition at the time of diagnosis on the survival of children treated for cancer in El Salvador and northern Brazil. J Pediatr Hematol Oncol. 2000;22:502-505. 36. Robison LL, Bhatia S. Late-effects among survivors of leukaemia and lymphoma during childhood and adolescence. Br J Haematol. 2003;122:345-359. 37. Iughetti L, Bruzzi P. Obesity and craniopharyngioma. Ital J Pediatr. 2011;37:38. doi: 10.1186/1824-7288-37-38. 38. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. J Clin Epidemiol. 2009;62: 1006-1012. 39. Steliarova-Foucher E, Stiller C, Lacour B, et al. International classification of childhood cancer, third edition. Cancer. 2005;103:1457-1467. 40. Gonzalez A, Cortina L, Gonzalez P, et al. Longitudinal assessment of nutritional status in children treated for acute lymphoblastic leukaemia in Cuba. Eur J Cancer. 2004;40:1031-1034. 41. Elhasid R, Laor A, Lischinsky S, et al. Nutritional status of children with solid tumors. Cancer. 1999;86:119-125. 42. Gofman I, Ducore J. Risk factors for the development of obesity in children surviving ALL and NHL. J Pediatr Hematol Oncol. 2009;31:101-107. 43. Baillargeon J, Langevin A, Lewis M, et al. Demographic correlates of body size changes in children undergoing treatment for acute lymphoblastic leukemia. Pediatr Blood Cancer. 2007;49:793-796. 44. Baillargeon J, Langevin A, Lewis M, et al. Therapy-related changes in body size in Hispanic children with acute lymphoblastic leukemia. Cancer. 2005;103: 1725-1729. 45. Reilly JJ, Kelly A, Ness P, et al. Premature adiposity rebound in children treated for acute lymphoblastic leukemia. J Clin Endocrinol Metab. 2001;86:2775-2778. 46. Delbecque-Boussard L, Gottrand F, Ategbo S, et al. Nutritional status of children with acute lymphoblastic leukemia: a longitudinal study. Am J Clin Nutr. 1997;65: 95-100. 47. Arguelles B, Barrios V, Buno M, et al. Anthropometric parameters and their relationship to serum growth hormone-binding protein and leptin levels in children with acute lymphoblastic leukemia: a prospective study. Eur J Endocrinol. 2000; 143:243-250. Nutrition ReviewsVR Vol. 0(0):1-20 19 48. Barbosa-Cortes L, Tapia-Rojas M, Lopez-Aguilar E, et al. Body composition by dilution of deuterium oxide in Mexican children with lymphoma and solid tumors. Nutrition. 2007;23:739-744. 49. Murphy AJ, Wells JCK, Williams JE, et al. Body composition in children in remission from acute lymphoblastic leukemia. Am J Clin Nutr. 2006;83:70-74. 50. Bond SA, Han AM, Wootton SA, et al. Energy intake and basal metabolic rate during maintenance chemotherapy. Arch Dis Child. 1992;67:229-232. 51. Halton JM, Atkinson SA, Barr RD. Growth and body composition in response to chemotherapy in children with acute lymphoblastic leukemia. Int J Cancer Suppl. 1998;11:81-84. 52. Skolin I, Axelsson K, Ghannad P, et al. Nutrient intake and weight development in children during chemotherapy for malignant disease. Oral Oncol. 1997;33: 364-368. 53. Smith DE, Stevens MC, Booth IW. Malnutrition at diagnosis of malignancy in childhood: common but mostly missed. Eur J Pediatr. 1991;150:318-322. 54. Uderzo C, Rovelli A, Bonomi M, et al. Nutritional status in untreated children with acute leukemia as compared with children without malignancy. J Pediatr Gastroenterol Nutr. 1996;23:34-37. 55. Bakish J, Hargrave D, Tariq N, et al. Evaluation of dietetic intervention in children with medulloblastoma or supratentorial primitive neuroectodermal tumors. Cancer. 2003;98:1014-1020. 56. Pietsch JB, Ford C. Children with cancer: measurements of nutritional status at diagnosis. Nutr Clin Pract. 2000;15:185-188. 57. Schiavetti A, Fornari C, Bonci E, et al. Nutritional status in childhood malignancies. Nutr Cancer. 2002;44:153-155. 58. Ahmed SF, Wallace WH, Kelnar CJ. An anthropometric study of children during intensive chemotherapy for acute lymphoblastic leukaemia. Horm Res. 1997;48: 178-183. 59. Sala A, Rossi E, Antillon F. Nutritional status at diagnosis in children and adolescents with cancer in the Asociacion de Hemato-Oncologia Pediatrica de Centro America (AHOPCA) countries: preliminary results from Guatemala. Pediatr Blood Cancer. 2008;50:499-501. 60. van der Sluis IM, van den Heuvel-Eibrink MM, Hahlen K, et al. Altered bone mineral density and body composition, and increased fracture risk in childhood acute lymphoblastic leukemia. J Pediatr. 2002;141:204-210. 61. Muller HL, Gebhardt U, Teske C, et al. Post-operative hypothalamic lesions and obesity in childhood craniopharyngioma: results of the multinational prospective trial KRANIOPHARYNGEOM 2000 after 3-year follow-up. Eur J Endocrinol. 2011; 165:17-24. 62. Tamminga RY, Kamps WA, Drayer NM, et al. Longitudinal anthropometric study in children with acute lymphoblastic leukaemia. Acta Paediatr. 1992;81:61-65. 63. Groot-Loonen J, Otten BJ, vant Hof MA, et al. Influence of treatment modalities on body weight in acute lymphoblastic leukemia. Med Pediatr Oncol. 1996;27:92-97. 64. Murphy AJ, White M, Davies PSW. Body composition of children with cancer. Am J Clin Nutr. 2010;92:55-60. 65. Oguz A, Karadeniz C, Pelit M, et al. Arm anthropometry in evaluation of malnutrition in children with cancer. Pediatr Hematol Oncol. 1999;16:35-41. 66. Wessels G, Hesseling PB, Van Ommeren KH, et al. Nutrition, morbidity, and survival in South African children with Wilms tumor. Pediatr Hematol Oncol. 1999; 16:321-327. 67. Koskelo EK, Saarinen UM, Siimes MA. Skeletal muscle wasting and protein-energy malnutrition in children with a newly diagnosed acute leukemia. Cancer. 1990;66: 373-376. 68. Baillargeon J, Langevin A, Lewis M, et al. Obesity and survival in a cohort of predominantly Hispanic children with acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2006;28:575-578. 69. Mej_a-Arangure JM, Fajardo-Gut_errez A, Bernaldez-R_os R, et al. Nutritional state alterations in children with acute lymphoblastic leukemia during induction and consolidation of chemotherapy. Arch Med Res. 1997;28:273-279. 70. Caruso-Nicoletti M, Mancuso M, Spadaro G, et al. Growth and growth hormone in children during and after therapy for acute lymphoblastic leukaemia. Eur J Pediatr. 1993;152:730-733. 71. Israels T, Damen CWN, Cole M, et al. Malnourished Malawian patients presenting with large Wilms tumours have a decreased vincristine clearance rate. Eur J Cancer. 2010;46:1841-1847. 72. Muller HL, Bueb K, Bartels U, et al. Obesity after childhood craniopharyngioma - German multicenter study on pre-operative risk factors and quality of life. Klin Padiatr. 2001;213:244-249. 73. Zimmermann K, Ammann RA, Kuehni CE, et al. Malnutrition in pediatric patients with cancer at diagnosis and throughout therapy: a multicenter cohort study. Pediatr Blood Cancer. 2013;60:642-649. 74. Carter P, Carr D, van Eys J, et al. Nutritional parameters in children with cancer. J Am Diet Assoc. 1983;82:616-622. 75. Tobias J, Hochhauser D. Cancer and its Management. 6th ed. Oxford: Wiley- Blackwell; 2010. 76. Chan HSL. Understanding Cancer Therapies. 1st ed. Jackson, MS: University Press of Mississippi; 2007. 77. Holm K, Nysom K, Hertz H, et al. Normal final height after treatment for acute lymphoblastic leukemia without irradiation. 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Systematic review and meta-analysis: Prevalence and possible causes of vitamin D deficiency and insufficiency in pediatric cancer patients

Background and aims: Vitamin D inadequacy is now an internationally recognized health problem and pediatric cancer patients may be at even higher risk than healthy children. We aimed to evaluate primary research to establish the prevalence of vitamin D inadequacy and to explore its possible causes in pediatric cancer patients. Methods: Electronic databases were searched (no restriction-Aug 2013) with no language restrictions and keywords related to cancer and vitamin D. We included studies of patients aged <18 years, diagnosed with and treated for cancer and reporting plasma vitamin D status. Evidence was critically appraised employing the CASP tool. Meta-analysis was performed when appropriate. Results: We included 19 studies, which were mainly of moderate-quality and heterogeneous in the definitions of vitamin D deficiency and insufficiency. The median (range) prevalence of vitamin D deficiency was 14% (0-61.5%) and insufficiency 23% (0-83%). Finally, a significant effect of younger age with vitamin D inadequacy was shown (effect size:-0.132; 95%CI-0.203,-0.060). Conclusion: There is a possibility of a high prevalence of vitamin D inadequacy in pediatric cancer patients, especially older children, urging the need for high-quality population-based longitudinal studies using standard definitions.sch_die35pub3716pub