A compromised nutritional status (NS) jeopardizes positive clinical outcomes, treatment tolerance, the risk of developing infections, and quality of life (QoL). Globally, the reported incidence of malnutrition at diagnosis in children with cancer varies from 6% to as high as 50%, whereas in India, the prevalence is very high, with 84% of children having undernourishment. NS is a modifiable prognostic determinant that can be used to improve the outcomes in these patients. To study the change in anthropometric and biochemical parameters related to nutrition at diagnosis and post-intensive chemotherapy in pediatric cancer patients. A prospective observational study was conducted on ninety patients aged 1-12 years with newly diagnosed hematological malignancies admitted to Safdarjung Hospital for chemotherapy. Anthropometric and biochemical parameters were assessed at initiation, one month, and three months after chemotherapy. Our study revealed a significant increase in weight for age and height/length for age at 1 and 3 months (p value <0.05). Acute and severe acute malnutrition was present in 23.33% and 5.56% of patients at 3 months, respectively, compared to 20% and 3.33% at initiation. Significant differences in the distribution of anemia at initiation (53.33%), 1 (8.89%), and 3 months (7.78%) were noted and mucositis was significantly increased at 3 months as compared to initiation (p-value <0.05). Standardized guidelines and a methodical approach to dietary management for children with cancer are currently lacking. A crucial component of the care pathway ought to be nutritional follow-up.

Excellent outcomes of pediatric cancer are still limited to high-income countries whereas a large majority of children with cancer reside in low and middle-income countries where undernutrition still has high concurrence and is a modifiable risk factor for the outcome of pediatric malignancy. Undernutrition is directly linked to poorer survival in both hematological and solid tumors as is demonstrated by Loeffen et al.^[8], in a heterogeneous childhood cancer population (269 patients, including 139 with hematological malignancy, 86 with solid tumors and 44 with brain tumors), where survival was significantly worse in patients who were malnourished at diagnosis or at 3 months after initiation of treatment as compared to those who were adequately nourished at diagnosis. This is significant because, unlike malnourishment at diagnosis, malnourishment at 3 months after initiation of treatment is preventable with close follow-up of NS and rapid intervention if needed.

Despite the high percentage of malnourishment among pediatric cancer patients, no uniform protocols exist for monitoring nutrition in children with cancer. As per a study on nutritional practices for children in India, out of 108 respondents, only half of them used some nutritional assessment method routinely while more than 40% of respondents used it only when clinically indicated where the assessment was most commonly done by a dietician 68%) followed by doctors (28%), nurses and social workers and nutritional assessment was most commonly done using height (81%) and weight (82%)and MUAC (36%) and TSFT (23%) were less commonly used.^[9]

In our study mean weight for age (in kgs) was significantly increased at 1 month (p=0.022) and 3 months (p=0.013) as compared to initiation by 0.3 kg and 0.45 kg respectively. Similar results were obtained in a study done by Kadir et al.^[7] on 30 patients with ALL who noticed an overall significant increase in mean body weight during induction by 0.6 kg and after induction by 0.19 kg. This could be explained by the fact that the intensive, individualized dietary counseling approach as done by the dieticians and social workers in our study has had a positive impact on the weight maintenance of the cancer patients during the treatment.

Prevalence of underweight in our study at initiation was present in 46.67% of patients, while Kadir et al.^[7] reported an underweight prevalence of 50 % at diagnosis. The increase in body weight despite initiation of chemotherapy in the initial phase could be explained by the effect of prednisolone in the treatment of leukemia patients, which causes euphoric behavioral changes as well as increases the overall appetite, as overcaring attitude of patients and nutritional counseling by dietician could be responsible factors.^[10]

In our study, stunting was present in 35.56% out of which only 5.56% were severely stunted at initiation as per WHO standards which were lesser than the prevalence of stunting reported in a study done by Sundersandas et al.^[11] where the percentage of stunting was 66% while another study done by mouroge et al.^[12], children with a height below 95th centile were 25%. Moreover, stunting is a marker of chronic malnutrition and is expected to be more profound in cancer survivors than those started on treatment. By the end of 3 months, stunting in our study was reduced to 27.77%, out of which only 3.33% were severely stunted. This could be due to regular, intensified nutritional counseling, close follow-up, and management of any diet-related issues.

Wasting at presentation was present in 32.22 % comparable to results in a study done on children with ALL by Rajesh et al.^[13] where 48% were wasted at diagnosis. Weight for height with age-related cut-offs can be used for children without a tumor mass to assess nutritional status but in children with a tumor mass weight is a misleading measure and can be distorted by organomegaly, large tumor mass, and hydration status. Clinical assessment of wasting is important in these patients but for quantitative assessment, SIOP PODC recommends the use of MUAC as an anthropometric measurement in children with cancer as it is independent of tumor mass. The only disadvantage in the use of MUAC as a screening tool is the lack of WHO reference standards above 5 years of age where above guidelines of SIOP PODC can be used for rapid screening into SAM and AM.^[14]

In our study, the prevalence of undernutrition (moderately and severely depleted) was 32.22% which was comparable to the 38 % prevalence of malnutrition as per BMI at diagnosis in Indian patients studied by Shah et al.^[15]

The mean value of hemoglobin (gm/dl) was significantly increased at 1 month and 3 months as compared to initiation. (p-value <0.05) from 7.38 at initiation to 9.06 at 1 month and 9.09 at 3 months. The proportion of patients at initiation with severe anemia was 53.33% of patients which was significantly higher as compared to severe anemia after 1 month (8.89% of patients) and after 3 months (7.78% of patients). Similar results were obtained in a study done by Kadir et al.^[7] where mean hemoglobin levels increased during and after induction to 9.3 g/dl and 12.11 g/dl as compared to that before induction in pediatric ALL patients. Chemotherapy is not started unless the general condition of the patient is stabilized with transfusion of blood products and control of infection hence hemoglobin levels are expected to increase after initiation of chemotherapy.

Our study revealed no significant change in the mean value of total calcium (mg/dL) or phosphate at 1 month and 3 months as compared to initiation. Although Kadir et al.^[7] reported a significant decrease in serum calcium during induction as an effect of steroids, immobilization, or antibiotics while chemotherapy-induced lysis is expected to cause a rise in serum calcium levels.

After treatment for ALL Parson et al.^[3] reported mild hypercholesterolemia and low HDL levels while Halton et al.^[16] did not report cholesterol concentration more than normal for age in any child rather children had lower mean values of cholesterol and low HDL levels as compared to the control group. In our study, a significant difference was seen in the distribution of serum HDL between initiation as compared to values after 1 month (p-value <0.05) where HDL levels less than 35 mg/dl were present in 20% at initiation and 38.89% at one month respectively while lower HDL values were present in 30% patients after three months. Serum triglyceride and cholesterol were acceptable within the normal range in the majority of patients with no significant difference at initiation and one and three months. Lipid abnormalities observed in oncology patients can be explained by altered nutritional status and lipid metabolism attributed to L-asparaginase therapy.^[16]

In our study, complaints related to nutritional status as faced by parents at diagnosis, one month, and three months were noted which included weight loss (perceived by parents), nausea, decreased oral intake, mucositis, diarrhea, and edema. Clinical complaints of mucositis were significantly increased at 3 months as compared to initiation (p <0.05). Similar results were obtained in a study done by Arpaci et al. ^[17] on nutritional problems from a parental perspective where they reported loss of appetite (85.5%), nausea (84.1%), vomiting (81.2%), fatigue (79.7%), and mucositis (66.7%) were most common nutritional problems in children with cancer.

Nutritional advice was uniformly provided to all patients as a part of the unit’s treatment protocol where a well-formed nutrition policy was followed including nutritional assessment by doctors and nutritionists, regular assessment of weight and height, dietary advice in the form of personalized diet chart, neutropenic diet and advice on enhancement of locally available food was given to all children. In our study dietary history by 24-hour recall reported combined protein and caloric deficit in 57.78% at initiation, 56.67% after 1 month, and 64.44% after 3 months which validated the need for routine nutritional assessment with special emphasis on dietary intake in every patient. Very few studies in the literature attempt to correlate malnutrition in pediatric cancer patients as an outcome of various socio-demographic factors and most of the available studies are done in developed countries which are difficult to extrapolate to our study.

A significant association was noted between delay due to intercurrent illness and malnutrition where children whose treatment delay was present had significantly higher malnutrition (p=0.001). Delay due to intercurrent illness in cancer chemotherapy is attributed mainly to febrile neutropenia for which malnutrition is a potential predictor of mortality which explains the greater incidence of malnutrition amongst children with treatment delay.^[17]

Nutritional follow-up should aim at identifying children with cancer who are at a higher risk of malnutrition at an early stage, considering their baseline nutritional evaluation, underlying pathology, and the necessary treatment. Education of the families and healthcare professionals on the nutrition of children with cancer, as well as the adoption of tools and algorithms for nutritional interventions, should be promoted. Early screening of the NS should be a priority and a close interdisciplinary collaboration between the oncological team and nutritional specialist is strongly required. In the therapeutic management of these patients, a customized nutrition plan that considers dietary variability would be revolutionary. Proteomics, metabolomics, and nutritional genomics could all help achieve this.^[5]

Conclusion

Assessing NS should become an essential component of cancer care therapy as it is a modifiable risk factor and any alterations in NS can have adverse effects not only at diagnosis but also during survivorship. Routine assessments during and after cancer treatment are necessary to ensure normal growth and development and to provide appropriate and timely interventions to improve the QoL, immunological status, treatment response, and survival of children with cancer.

Acknowledgments

None

Conflict of interest

None

Financial support

None

Ethics statement

None