What is the role of nutrition in pediatric patients with cancer?

Role of Nutrition in Children with Cancer

Families of children with cancer must work closely with dietitians and rehabilitation specialists to implement early nutritional assessment and tailored support that maintains normal growth and development during treatment, as this is a modifiable prognostic factor that directly impacts survival, treatment tolerance, and quality of life. 1

Critical Importance of Nutrition in Pediatric Oncology

Nutritional status is a potentially modifiable prognostic factor that affects overall survival, event-free survival, treatment tolerance, infection risk, and quality of life in children with cancer. 2, 3 Children with solid tumors and lymphomas who are malnourished at diagnosis have significantly worse outcomes compared to well-nourished counterparts. 4

Key Evidence on Survival Impact

• A study comparing two 3-year periods demonstrated that intensified nutrition support with mandatory malnutrition risk screening reduced time from diagnosis to treatment completion (802 vs. 512 days, p<0.001) and improved overall survival from 60.3% to 75.0%. 5
• Decrease in weight-for-height percentile during treatment is a significant predictor of less favorable survival. 5
• Regular postdiagnosis exercise in childhood cancer survivors showed significant reductions in all-cause mortality and cancer recurrence risk. 1

Immediate Actions at Diagnosis

Nutritional assessment and counseling must begin immediately after diagnosis with the goal of preventing nutrient deficiencies, preserving muscle mass, and managing treatment side effects. 1

Essential Initial Assessment Components

• Document current body mass index (BMI), extent of weight loss (% of original weight) during preceding 2-6 months, and performance status. 1
• Measure height, weight, premorbid weight to establish baseline nutritional status. 6
• Nutritional support is mandatory when patients have lost >10% of usual body weight over 6 months. 6, 7
• Quantify nutritional intake (calories, proteins, frequency of meals) and identify nutrition-impact symptoms (stomatitis, dysphagia, early satiety, abdominal pain, constipation). 1

Specific Nutritional Targets for Pediatric Cancer Patients

Target energy intake of 25-30 kcal/kg/day and protein intake of minimum 1.2-1.5 g/kg/day, with higher requirements in malnourished patients. 6, 7

Fortification Strategy

• Fortify every meal and snack to maximize calorie and protein density rather than relying on standard formulas. 6, 7
• Add powdered milk to regular milk, soups, casseroles, and mashed potatoes. 7
• Incorporate full-fat dairy products, eggs, nut butters, oils, and fatty fish rich in omega-3s. 7
• Use protein powders to fortify beverages, oatmeal, yogurt, and pudding. 7

Treatment Phase Considerations

During Active Treatment

The unique concern for children is maintaining normal growth and development during and after treatment, which requires close collaboration with dietitians, rehabilitation specialists, and physical therapists. 1

• Enteral nutrition is effective in low nutritional risk groups but ineffective in preventing or reversing protein-energy malnutrition in high-risk groups. 4
• For high-risk groups, central parenteral nutrition is a relatively short-term but important support measure allowing children to grow despite extended periods of intense oncologic treatment. 4
• Nutritional status may affect bone marrow suppression and ability to tolerate aggressive chemotherapeutic treatment. 4

Perioperative Management

Initiate early enteral nutrition within 24 hours after gastrointestinal surgery rather than prolonged nil-by-mouth approach, as this is safe and improves outcomes. 6

• Preoperative nutritional support maintains better nutritional status and reduces number and severity of postoperative complications. 1
• Surgery induces hypercatabolism, and severe malnutrition increases mortality, local morbidity, and infectious complications. 6

Long-Term Survivorship Considerations

Childhood cancer survivors are at higher risk of developing chronic health conditions such as cardiovascular disease and second cancers at earlier ages, making healthy weight maintenance, dietary choices, and regular physical activity especially important. 1

• Current 5-year survival rates are 85% among children and 86% among adolescents, with more than 400,000 survivors living in the United States. 1
• These recommendations align with the Children's Oncology Group Long-Term Follow-Up Guidelines, which recommend maintaining healthy body weight and making healthy choices about diet and exercise. 1

Critical Pitfalls to Avoid

Increase nutrition slowly over several days in severely depleted patients while monitoring and supplementing phosphate, potassium, and magnesium—refeeding syndrome can be fatal. 6, 7

• Never rely on albumin alone as it reflects inflammatory response more than nutritional status; always interpret alongside C-reactive protein. 6, 7
• Do not focus solely on weight gain without considering lean body mass preservation—cancer cachexia involves muscle wasting requiring adequate protein and anti-inflammatory strategies. 7
• Do not delay nutritional intervention—early counseling and support prevent progression to severe cachexia, which is much harder to reverse. 7
• Do not use standard nutritional formulas without anti-inflammatory ingredients—systemic inflammation prevents effective nutrient utilization. 7

Multimodal Approach

Nutritional therapy must be combined with moderate-intensity physical activity to maintain muscle mass and improve quality of life, as nutritional therapy alone may be clinically ineffective if other needs are not addressed. 1, 6, 7

• Physical activity assessment and counseling should begin immediately after diagnosis to help patients prepare for treatments, tolerate treatments, and manage symptoms. 1
• Aerobic and resistance exercise are effective strategies to improve muscle strength more than usual care. 1
• Nutritional support should be part of comprehensive supportive care including psychological counseling and optimal pain control. 1

Monitoring Requirements

Regular reassessment of nutritional status, weight, functional performance, and inflammatory markers is essential throughout treatment and follow-up. 7, 2

• Measure weight with examination for edema or ascites at each visit. 6
• Determine calorie-nitrogen ratio intake regularly. 6
• Consistent longitudinal nutritional assessment from diagnosis through treatment and long-term follow-up is required so interventions can be implemented and evaluated. 2, 3

Evidence Quality Note

While the American Cancer Society 2022 guidelines provide the most recent comprehensive framework 1, research specific to pediatric populations remains limited compared to adult cancer survivors. 1 However, the available evidence consistently demonstrates that nutrition is a modifiable prognostic factor with direct impact on survival and quality of life in children with cancer. 2, 3, 8, 5