الفهرس 
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Abstract
Cancer is one of the leading causes of morbidity and mortality worldwide. The diagnosis of cancer in children and adolescents is a life-altering event for them as well as their families. It is important that survivors of childhood and adolescent cancer are monitored for long-term and late effects. Malnutrition has been reported to be a common problem in pediatric patients with cancer in numerous publications and its clinical relevance has been widely accepted by professionals. Accordingly nutritional management should be an integral part in the management protocol for those children.
Nutritional management comprises several components with assessment constituting the first and foremost step critical for guiding nutritional therapy. A comprehensive assessment of nutritional status is usually based on demographics (specific consideration to age), anthropometric measures, biochemical or laboratory tests, medical history including co-morbidities, clinical indicators, and assessment of cancer and cancer-related symptoms; dietary assessment, functional assessment including physical activity; and most importantly an assessment of patient and family
The present study was conducted to assess the nutritional status of the children who attended the POU, to calculate the prevalence rate of preexisting malnutrition among children with cancer who attended the POU prior to cancer treatment and also to calculate the prevalence rate of malnutrition cases among cancer patients at follow up points during the study period.
This research also aimed at investigating the association of some patient-related, tumor-related and therapy-related variables with malnutrition, to reveal the effect of malnutrition on response to cancer treatment and to identify the effect of malnutrition on cancer outcomes as complications, survival, relapse or death.
The present study included 170 pediatric oncology patients who attended the POU, Main Alexandria university hospital .More than half of the enrolled children (55.3%) were males while the rest (44.7%) were females. More than half (60.6 %) of the studied children were rural dwellers while the remaining 39.4% were urban ones. The age of the enrolled children ranged from 1 to 18 years with a mean of 5.9 ± 3.7 years. More than two thirds (64.7%) of the studied children were enrolled in education. Half of the enrolled children (50%) were in Nursery, 14.5% were in kindergarten, and 23.6 % were in primary school while only a small percentage (8.2%) were enrolled in secondary education.
About one third of the children’s fathers (32.4%) were illiterate and 31.2% were just able to read and write while half of the mothers (50%) were illiterate while less than one fourth (23.5%) can just read and write and 14.7 % of the mothers accomplished their basic education. The majority of the fathers were working (98.8 %); manual workers represented 67.1% of the studied children and about three quarters of the children’s mothers were house wives (77.1 %). Only 22.9% were employed. About half of the families of the studied children (50.6 %) had an income between 500 to 1000 LE, more than one third (40 %) had an income less than 500 LE. Less than one third (9.4%) had an income more than 1000 LE.
Regarding the quality of life style, more than half of the studied children don’t currently go to school while the remaining do (45.3%) and also the majority of the patients (84.7%) were dependent to perform their daily activities on their parents or relatives while the rest (15.3%) were independent. The mean duration of night sleep was 7.3 ± 2.1 hours. Less than two thirds (62.9%) of the enrolled children didn’t walk for a distance more than 1 km while the rest of the children do (37.1%).
Regarding the assessment of dietary habits of the enrolled children, the majority of the studied children (86.5%) had irregular daily meals during the initial assessment compared with 95.9 % and 96.4% during the 3rd and 6th follow up respectively. These differences were statistically significant for initial and 3rd follow up and for the initial assessment and 6th follow up where, P=0.002 and P=0.001 respectively.
As for the numbers of meals per day, the percentage of children who reduce their number of meals increase significantly in the follow up points which may reflect the effect of treatment during the follow up period. For skipping meals, breakfast was the most skipped meal in the initial assessment (78.8%) while lunch was the most skipped meal in the 3rd and 6th follow up points (74.7% and 79.8% respectively).
The intake of different food items was studied in the enrolled children, where more than one third (34.1%) of the children had from 1 to 2 teaspoons of sugar per day in the initial assessment compared to 32.4% and 33.9% in the 3rd and 6th follow ups respectively. These differences were not statistically significant. Regarding the type of oil added to diet, more than three fourth (75.3%) of the studied children consumed vegetable oil in the initial assessment compared to 75.3 and 61.3% in the 3rd and 6th assessment respectively. More than two tenth (22%) of the enrolled children consumed olive oil in the 6th follow up compared to 7.1% in both the initial assessment and 3rd follow up. The percentage of children who ate nuts once or more than once daily significantly increase from initial assessment (0.6% and 0% respectively) to the 3rd month assessment (17% and 37.6% respectively).
There was a significant reduction of the percentage of children who drink enough fluids in the initial assessment (27.1%) compared to 6th month follow up point (13.1%). A positive point in the current study was the improvement in certain dietary practices concerning processed and junk food intake. A significant reduction was noticed in the percentages of children who consume processed and junk food in the initial assessment compared to follow up points. Regarding the consumption of sweets, candies and soft drinks, More than one third (33.5%) of the enrolled children consumed soft drink more than once daily in the initial assessment compared to 12.9% and 4.2 % in the 3rd and 6th follow ups respectively.
Initially the percentage of children (84.7%) who met the recommendations of the food guide pyramid for the carbohydrate group intake (5 or more servings) significantly decreased in the follow up period to reach only 22.4% after 6 months. The study reveals that the majority of studied children at the initial assessment as well as in the follow up assessment points were below the recommended servings for fruits, vegetables and dairy products (1 to 2 servings). There were significant differences in animal protein intake between time points of the study, which indicate protein intake reduction among studied children.
Regarding physical activity, less than two thirds (62.9%) of the studied children didn’t walk for long distance in the initial assessment compared to 84.1% and 89.3% in the 3rd and 6th follow ups. These differences were statistically significant for the initial assessment and 3rd follow up and for the initial assessment and 6th follow up where, P<0.0001 and P<0.0001 respectively.
Concerning anthropometric measurements in the current study, the mean and SD for all indices (weight-related indices and arm anthropometry) declined significantly from the initial point and along the follow up period. In the present study, the mean for ideal body weight percentage decreased from the initial assessment (98.04 ±9.0 %) to reach 73.2 ±10.4 % in the 6th follow up. These differences were statistically significant where, P <0.0001. Weight loss percentage increased from a mean of 14.0±9.4 % compared to a mean of 25.2±10.0 % in the 6th month follow up point. These differences were statistically significant where, P <0.0001. The percentages of body fat of the studied children reached a range of 5 to 20% in the initial assessment with a mean of 11.4±2.7% in comparison to a range of 3 to 19% with a mean of 10.3±2.7% after 6 months of follow up.
The most common abnormal physical finding among the studied children in the current study at 6th month follow up point were in the hair (32.7%), gums and teeth (29.2%), tongue and skin of face and neck (28.6%).
As regards the results of the laboratory investigations, the present study revealed mean hemoglobin of 10.3±1.8 g/dl in the initial assessment, which reached 9.3±1.3g/dl after 6 months, which indicate the occurrence of anemia. An important laboratory indicator of under-nutrition is the level of serum albumin. The current study revealed a range of serum albumin of 1.3 to 5.5 g/dl with a mean of 3.2±0.8 g/dl in the initial and 3rd follow up compared to (1.5 to 4.5g/dl and a mean of 2.7±0.6 g/dl) in the 6th follow up. The blood glucose level of the enrolled children ranged from 70 to 210 mg/dl in the initial assessment with a mean of 113.4 ± 33.8 mg/dl compared to ( 114.9 ±35.3 ) in the 3rd month follow up and a range of 60 to 190 mg /dl with a mean and SD of 106.0 ± 30.2 mg/dl in the 6th month follow up.
Nutritional assessment is an essential component of the initial assessment of children with cancer. In the present study, prevalence rate of malnutrition significantly increased from 4.1% at initial point to reach 40% and 78.6% of studied subjects in 3rd and 6th month follow up points respectively. In in the 3rd month follow up point, the majority of children who had pre-existing malnutrition remained malnourished (85.7%. Moreover, 40.3% of children with normal nutritional status at diagnosis became malnourished. At the final point of nutritional assessment (6th month), the majority of children were malnourished at the initial point remained malnourhsied till the end of the study (83.3%) whereas, the majority of children who were normal at the beginning became malnourished at the end of study (83%).
In comparing group one (undernourished) and group two ( normally nourished).The percentage of malnourished children who didn’t go to school was significantly higher than those who didn’t go to school and assessed as 5th percentile or more (59.8% and 36.1% respectively where, P=0.011, X2 =6.434. The majority (85.6%) of the patients in the first group and second group (83.3%) were dependent in performing their daily activities. These differences were not statistically significant where, P=0.734, X2 =0.115. The mean duration of night sleep for children below the 5th percentile (7 ± 2.2) was significantly less than that of children with 5th percentile or more 8 ± 1.7 where, P=0.006, t =2.848. The majority of the children in the first and second groups ( 90.9% and 83.3% respectively ) didn’t walk for a distance more than one km .These differences were not statistically significant where, P=0.193, X2=1.697.
Regarding the anthropometric, TSFT ranged from 5.0 to 12.5 mms with a mean of 8.6 ±1.3 mms in the group below the 5th percentile compared to a range of 7.0 to 11.0 mms with a mean of 8.9 ±1.2 mms in the second group. These differences were not statistically significant where, P=0.168, t=1.385. The mean MAC was significantly lower in malnourished children (157.5 ±13.8 mm) than that of children in the 2nd group (178.7±27.7 mm) where, P<0.0001, t=4.429. The percentage of body fat ranged from 3.0 to 19.0 % with a mean of 10.0 ±2.7 % in the group below the 5th percentile compared to a range of 4.0 to 18.0 mm with a mean of 10.9 ±2.9 mm in the second group.
Regarding the Hemoglobin (g/dl) , it ranged from 6.0 to 13.0 mg/dl with a mean of 9.3 ±1.4 mg/dl in the group below the 5th percentile compared to range of 6.5 to 11.0 g/dl with a mean of 9.4 ±1.2 g/dl in the second group. These differences were not statistically significant where, P=0.556, t=0.590. The albumin (g/dl) was lower in the first group (2.6 ±0.5 g/dl ) compared to the 2nd (2.7 ± 0.6 g/dl) in the second group.
The blood glucose level (mg/dl), it ranged from 60.0 to 190.0 mg/dl with a mean of 107.5 ±31.3 mg/dl in the group below the 5th percentile compared to range of 70.0 to 190.0 mg/dl with a mean of 100.6 ± 25.2 mg/dl in the second group. These differences were not statistically significant where, P=0.221, t=1.221.
More than half (53.8%) of the enrolled children in the group below the 5th percentile had intermediate tumor grade compared to 58.3% of children in the group of 5th percentile and more. Higher tumor grade was encountered among 34.8 % of first group and 19.4 % 2nd group. Only three cases (2.3 %) had metastasis in the first group compared to none of children in the second group. These differences were not statistically significant where, MCP=0.080, X2=6.485.
All children in the two groups had chemotherapy. More than one third (36.4%) of children in the first group had surgery compared to 41.7% of children in the second group. A minority (3.8%) of children in the first group had radiotherapy compared to 2.8 % of children in the second group. These differences were not statistically significant where, P=0.620, FEP=1.0, X2=0.25.
More than quarter (28.0%) of children in the first group had recurrence of their tumors compared to 36.1% of children in the second group. These differences were not statistically significant where, P=0.279, X2=1.171.
Regarding the effects of malnutrition on cancer outcomes. The percentage of children who stopped treatment was significantly higher in the malnourished group than the 2nd normally nourished group (36.4% and 16.7% respectively) where, P=0.022, X2=5.275. Two cases in the study died, one of them was in the group below 5th percentile and the other was in the second group of the 5th percentile and more. These differences were not statistically significant where, FEP=0.389. More than quarter (28.6%) of children in the first group had recurrence of their tumors compared to 37.8% of children in the second group. These differences were not statistically significant where, P=0.279, X2=1.171.
The study recommends the following
Screening of the children with cancer is an essential part of broadening efforts to reduce the effect of malnutrition in children with cancers with all its consequences.
Due to high prevalence of malnutrition in children diagnosed with cancer in POU, we recommend that a nutritional clinic should be instituted within the oncology department that is expected to help children whether at risk or those having frank malnutrition who seeks medical help in the clinic to nutritionally counsel these patients in order to improve their outcome of oncology management.
Developing training programs aiming that the health care provider should be able to conduct a simple screening test for the children with cancer to assess their status of malnutrition and refer them to the nutrition clinic for in depth assessment and management. Furthermore, they should be trained to provide education in an effective way to improve the knowledge of their parents about the complications of malnutrition and its effect on oncology management outcome.