Effects of Therapy on Nutritional Status of the Pediatrie Cancer Patient1

Children with cancer are at high risk for major nutritional problems both from the tumor itself and from the treatment administered. Overt malnutrition is seen in as many as 17% of children with newly diagnosed localized tumors and 37% of those with metastatic disease. Weight loss in children with cancer is directly correlated with a poor nutritional status at the time of diagnosis and with a low serum albumin. Massive surgical resections are a common source of nutritional prob lems and are usually not indicated as primary therapy in chil dren with cancer. Both radiotherapy and chemotherapy are associated with recognized acute and long-term complications which may have an impact upon the nutritional status of the child. The majority of childhood cancers are best managed by a multidisciplinary approach including limited surgery, irradia tion, and chemotherapy. This combined modality approach requires careful management including monitoring for known sequelae such that optimistic cure rates can be achieved without compromising the nutritional status of a child with cancer. There is a paucity of information relating to the nutritional status of children with cancer, and few data differentiating the nutritional impact of the disease itself from that of the treatment administered. Modern pediatrie cancer treatment affects nor mal tissues as well as malignant tissues and in so doing has the potential to create specific nutritional problems. In addition, a significant number of children are found to be malnourished at the time when their malignant disease is diagnosed Thus, nutritional problems from the disease itself may soon be inten sified by iatrogenic nutritional problems resulting from surgery, chemotherapy, and/or radiotherapy used to treat the cancer. The purpose of this review is to identify the effects of these modalities in an attempt to elucidate the areas of clinical and laboratory research which still require investigation with re spect to nutritional studies in children with cancer. Effects of Malignant Disease on Nutritional Status While pediatrie tumors are, as a group, responsive to ther apy, it is well recognized that children with cancer often be come ill rapidly and usually respond to treatment rapidly. A relatively brief period of symptoms related to the tumor may contribute to major nutritional sequelae leading to overt mal nutrition in a surprisingly high percentage of children. Malnu trition in the pediatrie population is generally considered to be ' Presented at the Pediatrie Cancer and Nutrition Workshop, December 11 and 12. 1980. Bethesda, Md. Supported in part by Contract NO1-CP-65825 from the Diet. Nutrition, and Cancer Program, National Institutes of Health, Bethesda. Md. present if there is inadequate growth, with a weight:height ratio below the 20th percentile of the national standard and/or a serum albumin value <3.0 g/dl (53). The Diet, Nutrition, and Cancer Program of the NIH spon sored a cooperative randomized clinical trial which tested the value of hyperalimentation among 2 groups of children with cancer. One group included newly diagnosed children known to have abdominal or pelvic tumors. The incidence of malnutri tion among these children was 7 of 40 (1 7.5%) (50). The second group included children known to have metastatic disease to or from the bone. Among 40 children in this group, overt malnutrition was diagnosed in 15 (37.5%) (50). Thus, overt malnutrition is not uncommon among children with can cer. The incidence is higher among those with advanced dis ease, but it is not limited to this group. Thus, at the outset, even before therapeutic programs are initiated, a significant number of children are found to be malnourished from the effects of malignant disease. Thus, these unfortunate children often enter aggressive therapeutic programs with the additional insult of little or no nutritional reserve. The etiology of protein calorie malnutrition is inadequate intake for one's caloric demands. Inadequate intake in a child with cancer often relates to the symptoms of the disease. A review of 244 pediatrie cancer patients studied with respect to their nutritional status at the time of referral to pediatrie cancer centers revealed a correlation between initial signs and symp toms of the disease and nutritional status. Various variables were evaluated as shown in Chart 1. It was seen that relation ships among variables connected with a solid line were corre lated positively, with the presence of one factor being associ ated with the presence of another. Thus, weight loss was directly correlated with a low nutritional status and with a low serum albumin. However, a low serum albumin and nutritional status at the time of first referral were not correlated. Fever and fatigue were directly correlated as common presenting symptoms of leukemia but were inversely correlated with ab dominal mass. The constellation of symptoms of weight loss, anorexia, and poor nutritional intake (early satiety) as direct correlates relate to all pediatrie tumors. Other causes of mal nutrition in children include psychological factors, with learned food aversions associated with chemotherapy; malabsorption from radiotherapy or chemotherapy; excessive nutrient loss as with persistent nausea and vomiting, severe renal protein loss or steroid-induced diabetes; and major increases in caloric demands from the tumor itself. Finally, the location of the tumor itself may have an impact on nutritional status. As the hypothalamus controls the regu lation of food intake, it can be shown experimentally that destruction of the ventromedial hypothalamus causes hyperphagia and obesity, while destruction of the ventrolateral hy pothalamus causes aphagia (2). Thus, tumors impinging in these areas produce similar results; children with hypothalamic