and Mhamed Harif2
(1)
South African Medical Research Council, Cape Town, South Africa
(2)
Université Mohammed VI des Sciences de la Santé Cheikh Khalifa Hospital, Casablanca, Morocco
Keywords
MalnutritionWeight lossNutritional statusAnthropometryWHO classificationBiochemical markersDiet historyEnergyFatProteinCaloriesCase Scenario
A 2-year 4-month-old girl diagnosed with AML on admission presented with a weight-for-height ratio that appears clinically normal and on par with the age-appropriate stages of development. See measurements below. Further investigation of her Road to Health booklet (RTHB) or individual growth chart shows her birth weight was 3 kg and she since followed her own expected normal growth curve. The RTHB shows she started to present with failure to thrive (FTT) 2 months ago and according to the mother this is caused by an unexplained loss in appetite.
Measurements | Interpretation |
|---|---|
Birth weight: 3 kg | On 0 z-score |
Birth Length: 47 cm | Just above the-2 z-score |
Weight-for-height at birth | On the 0 z-score |
Head circumference at birth: 35 cm | Just above the 0 z-score |
Admission weight: 13.0 kg | Above 0 z-score |
Admission length: 87 cm | Just below 0 z-score |
Weight-for-height at admission | On the +1 z-score |
What other information would you like to have? | |
Description of growth trends wrt weight and length/height | Following normal growth curve since birth with slight plato/FTT in the last 2 months of life |
MUAC on admission: 14.4 cm | Normal |
Introduction: The Role of Nutrition
Children with cancer are especially at risk for developing malnutrition because they require elevated substrate needs as a result of the disease and its treatment [1, 2]. At the same time, they need to grow and develop optimally, and therefore, have even higher nutritional needs to facilitate the process [2, 3]. An optimal nutritional status in children has also been described to help them better recover from illness and trauma [1].
Malnutrition can affect tolerance of cancer therapy (disturbed drug metabolism), increase the risk of comorbidities (decreased immune function and delayed wound healing) and ultimately, adversely influence overall survival and prognosis [1, 2, 4]. The younger the child, the more severe the effects of malnutrition can be [5].
Therefore, nutrition plays a very important role in the management of the child with cancer!
What Is Malnutrition?
The term malnutrition is a very unspecific description of an impaired nutritional state, and is characterized by either a deficiency or excess intake of energy that has a negative impact on a person’s clinical outcome [2]. Malnutrition, that encompasses both extremes of the weight spectrum , if not present at diagnosis, may develop throughout the course of treatment [3, 4].
The occurrence of malnutrition in children with childhood tumors is multifactorial, and the prevalence will vary according to its vague definition and different diagnostic techniques used to assess nutritional status [2, 4] (Fig. 26.1).
Fig. 26.1
Prevention of malnutrition is important to facilitate growth in young children and adolescents
Factors that Influence Nutritional Status [4]
- (a)
Cancers associated with high risk of developing malnutrition
Advanced disease during initial intense treatment
Wilms tumor (metastatic) and Neuroblastoma
Soft tissue sarcomas (Ewing or Rhabdomyosarcoma)
Some non-Hodgkin lymphoma and advanced Hodgkin disease
Relapsed Leukemia
Acute Myeloid Leukemia
Poor prognosis ALL (infants diagnosed <12 months, certain chromosomal abnormalities)
Brain tumors , especially those with decreased level of consciousness
- (b)
Low-risk nutrition based on less intensive chemotherapy protocols
Good prognosis ALL
Non-metastatic solid tumors
Advanced diseases in remission during maintenance treatment
- (c)
Factors that can further deplete nutritional stores
Anorexia—either related to treatment-induced nausea and vomiting or to presence of psychological factors
Infection
Stomatitis/Mucositis
Diarrhea
Nausea and vomiting
Malabsorption
Blood loss and iron deficiency
Renal damage and nutrient loss
Mechanical gut problems
Xerostomia and dysgeusia
Psychological factors like acquired food aversion, depression
Mechanisms of Weight Loss
Anorexia is defined as the loss of a desire to eat. Cachexia is a syndrome of progressive and profound wasting of equal amounts of lean body mass and body fat in relation to total body weight [2] and associated with both anorexia and metabolic alterations [3]. The metabolic and body composition changes in cancer cachexia are similar to those in people with polytrauma, acute sepsis, burns, and AIDS [2]. In contrast to simple starvation, wasting induced by cancer cachexia cannot be prevented or reversed by increasing nutrient ingestion alone [2].
The pathogenesis of malnutrition during chronic diseases, such as cancer, is the direct result of diminished intake, enhanced losses (like malabsorption) and increased needs [1]. Changes in metabolism of macronutrients take place, which results in a net energy loss clinically that presents as weight loss, particularly lean body mass [1, 2]:
Increased lipid breakdown via lipolysis that result in depletion of fat stores
Altered (energy consumptive) carbohydrate metabolism
The body uses glucose from dietary sources as well as glucose gained from the liver converting muscle-derived proteins via gluconeogenesis, which results in increased energy expenditure
Increased Cori cycle—glucose is transformed into lactate by the tumor and recycled by the liver at a high energy cost
Insulin resistance and elevated secretion of growth hormone occur
Increased total body protein turnover (likely mediated by cytokines), reduced muscle protein synthesis, and increased hepatic protein synthesis that result in loss of lean body mass.
Nutrient deficiencies tend to develop over a period of time, and the extent will depend on the patient’s substrate reserves [1]. Metabolic changes are not necessarily uniformly altered in all patients with cancer [2]. A review by Bauer et al. investigated studies that suggested the changes in macronutrient metabolism can be attributed to a cancer-host rivalry. They discovered that recent trials do not support this theory indicating no positive correlation between tumor size or extension and the severity of host depletion [2].
Which aspects would one consider when assessing the nutritional status of a newly diagnosed child with childhood cancer, such as this 28-month-old patient?
Assessment of Nutritional Status
Children living with childhood cancer are at higher risk of developing malnutrition during cancer treatment than adults, because they have higher nutritional requirements to facilitate optimal growth and development [3]. Some children may already present with malnutrition at diagnosis, but others may develop this during the course of their treatment. Determining a patient’s nutritional status at diagnosis is important as it has prognostic implications [5]. Therefore, nutritional assessment is an important part of caring for this patient population, and imperative to recognizing and preventing the development of malnutrition by implementing early nutritional interventions before cancer treatment starts and further depletes stores [2, 5]. Assessing a patient’s nutritional status is tough because there is no gold standard and little information is still available on formal comparisons of different measures on how to best define nutritional status [1].
Anthropometry
Nutritional assessments previously relied heavily on height and weight measurements. However, these measurements may be misleading because of large masses of solid tumors masking a patient’s real weight, influencing the weight-for-height ratio. Other factors influencing weight include edema, organ congestion, and amputations, as seen in osteosarcoma cases [1, 2, 4].
Measurement of body compartments provides useful information at diagnosis, and presents additional information from that obtained through anthropometry and subjective nutritional assessments. Changes in body composition can also occur as a direct result of chemotherapy treatment, resulting in a reduction in lean body mass and an increase in fat mass. Body composition can affect the distribution, absorption, metabolism, and elimination of cytostatic drugs. Steroids may also increase fat mass and cause insulin resistance [2] (Fig. 26.2).
Fig. 26.2
Measuring the mid-upper arm circumference
The upper limbs are not usually directly affected by edema or tumor mass and arm anthropometry can be used as an additional method to provide an accurate evaluation of body composition [1, 4]. Biceps and triceps skinfold measurements provide an estimate of the body’s fat reserves, whereas calculating the arm muscle area will help estimate muscle protein reserves. Measuring the mid-upper arm circumference (MUAC) is another cost-effective and reliable way to assess nutritional status and proven most practical as this can be performed anywhere [1, 4].
General consensus supports that one marker alone is not sufficient to fully evaluate nutritional status and diagnostic criteria should be used together [4, 5]. Recommendations are that arm anthropometry, together with weight or height indexes are completed in all patients with solid tumors and repeated weekly during the course of their treatment [1, 4]. The RTHB is a valuable tool to assess a patient’s pre-tumor growth trends in children <5 years old [4]. In 2010, the World Health organization (WHO) released new standardized growth charts based on z-scores for interpreting growth and identifying malnutrition [6, 7].
Monitoring schedule for anthropometrical evaluations
Daily | Weight |
|---|---|
Weekly | Height/length |
MUAC | |
Triceps, biceps, and subscapular skinfolds. Indirect calorimetry | |
Monthly | Head circumference |
Trends in % EWA, % EWH, % EHA and z-scores |
Classification of Nutritional Status Based on Anthropometrical Findings [6]
Tables 26.1 and 26.2.
Table 26.1
The new WHO classifications using Z-scores
Z-scores | Classification |
|---|---|
Length/height for age: | |
Above 3 | Child very tall—rarely endocrine disorder |
Below 2 | Stunted |
Weight for age: | |
Below 2 | Underweight |
Below 3 | Severely underweight |
Weight for L/H: | |
Above 3 | Obese |
Above 2 | Overweight |
Above 1 | Possible risk of overweight |
Below 2 | “Wasted” |
Below 3 | “Severely wasted” |
Table 26.2
The MUAC reference ranges for moderate-to-severe malnutrition, ages 6 months to 14 years [7]
Infants 12 months | MUAC < 110 mm | Severe malnutrition |
MUAC < 115 mm | Moderate malnutrition | |
Children 1–5 years | MUAC < 110 mm | Severe malnutrition |
MUAC < 135 mm | Moderate malnutrition | |
Children 6–9 years | MUAC < 135 mm | Severe malnutrition |
MUAC < 155 mm | Moderate malnutrition | |
Children 10–14 years | MUAC < 160 mm | Severe malnutrition |
MUAC < 185 mm | Moderate malnutrition |
Overweight (Not Common in Africa) [5]
The detrimental effects of obesity in children are well described and may include the development of hyperlipidemia, hypertension, diabetes and insulin resistance, hepatic steatosis, cholelithiasis, sleep apnea, and orthopedic abnormalities. While having increased risk for developing chronic diseases of lifestyle later in life, they are also proposed to be more susceptible to certain cancers (esophagus, colon and rectum, and breast when postmenopausal). In obese children and adolescents with childhood cancer, there are also risks for over- or underdosing with treatment that could result in poorer treatment outcome and greater toxicities. In pediatric acute myeloblastic leukemia (AML) , obese patients have a higher treatment-related mortality and inferior survival compared to those who are not obese.
Survivors of common childhood malignancies are at risk for adult-onset diseases such as obesity that is in turn associated with a high risk for cardiovascular and endocrine diseases [2] (Table 26.3).
BMI-for-age | Classification |
|---|---|
Above +2 SD | Obesity (at 19 years: >30 kg/m2) |
Above +1 SD | Overweight (at 19 years: >25 kg/m2 for girls) |
Below −2 SD | Thinness |
Below −3 SD | Severe thinness |
Screening Tools for Early Detection of Malnutrition [8]
Although many malnutrition screening tools exist there are no screening tools specifically designed for the assessment of oncology patients.
The Screening Tool for Assessment of Malnutrition in Pediatrics (STAMP) was developed in the UK and is quite useful for nutritional assessment of the general at-risk patient. This can be downloaded from the website www.stampscreeningtool.org.
A work group formed at the Royal College of Nursing (2010) compiled a supplementary diagnostic section to STAMP, specific to pediatric oncology and suggested this section replace section one of the original STAMP tool . To note: This supplementary section was not audited or evaluated by the time of publication. They recommend one should combine the score for this tool with the STAMP score for nutritional intake, weight, and height. A total score of >4 should be referred to the dietician for further nutritional management [3] (Table 26.4).
Table 26.4
Supplementary tool for identifying malnutrition in pediatric oncology patients, for use with the STAMP document (step one) [3]
High nutritional risk (definite nutritional implications: score 3) | Low nutritional risk (possible nutritional implications: score 2) |
|---|---|
• Advanced disease during initial intense treatment | • ALL—regimen A patients |
• High-risk neuroblastoma | • Non-metastatic solid tumors |
• Stage 3 and 4 Wilms tumor | • Retinoblastoma |
• Rhabdomyosarcoma | • Hodgkin’s disease |
• Ewing sarcoma/primitive neuroectodermal tumor (PNET) | • Germ cell tumors |
• Osteosarcoma | • Advance diseases in remission |
• Medulloblastoma/CNS PNET | • During maintenance treatment |
• Nasopharyngeal tumors | |
• B-cell non-Hodgkin’s lymphoma | |
• Acute myeloid leukemia | |
• Acute lymphoblastic leukemia (ALL)
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