Nutritional status of children and adolescents at diagnosis of hematological and solid malignancies

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rev bras hematol hemoter. 2014;36(6):420–423

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

w w w . r b h h . o r g

Original

article

Nutritional

status

of

children

and

adolescents

at

diagnosis

of

hematological

and

solid

malignancies

Priscila

dos

Santos

Maia

Lemos

∗

_,

_Fernanda

_Luisa

_Ceragioli

_de

_Oliveira,

Eliana

Maria

Monteiro

Caran

UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received4May2013 Accepted31March2014 Availableonline9July2014

Keywords:

Pediatrics Adolescent Weightloss Nutritionalstatus Neoplasms

a

b

s

t

r

a

c

t

Objective:Toassessthenutritionalstatusofchildandadolescentpatientswithcancerat

diagnosis.

Methods:A totalof1154patientswereincludedanddividedintotwogroups:solidand

hematological malignancies. The parameters used for nutritional assessment were weight, height, triceps skinfold thickness, mid-upper arm circumference, arm muscle circumference,bodymassindexandpercentageweightloss.

Results:Atdiagnosis,belowadequate bodymassindex wasobservedby

anthropomet-ricanalysisin10.85%ofthepatients–12.2%inthesolidtumorgroupand9.52%inthe hematologicgroup.Theaverageweightlossadjustedforaperiodof7dayswas−2.82%in thehematologicgroupand−2.9%inthesolidtumorgroup.

Conclusions:Theprevalenceofmalnutritionishigheramongpatientswithmalignancies

thaninthegeneralpopulation,eventhoughnodifferencewasobservedbetweenthetwo groups.

Introduction

Pediatricmalignanciesaccountforbetween1%and3%of can-cerdiagnosedworldwide.1_However,_in_developing_countries,

wherethe proportionof childrenand adolescents isabout 50%ofthepopulation,thesetumorscorrespondtofrom3%to 10%ofallmalignantneoplasms;2_in_developed_countries_this

rateisabout 1%.AccordingtothePopulation-BasedCancer

∗ _{Corresponding}_author_at_:_Instituto_de_Oncologia_Pediátrica,_Departamento_de_Pediatria,_Universidade_Federal_de_São_Paulo_(UNIFESP),

RuaBotucatu,743,VilaClementino,04020-060SãoPaulo,SP,Brazil. E-mailaddress:pri.nutri@gmail.com(P.d.S.M.Lemos).

Registers(RCBP),theincidenceofpediatrictumorsinBrazil isbetweendevelopinganddevelopedcountries,accounting for3%ofallmalignancies.Asnearly30%ofthepopulationis 19yearsoldorless,itisestimatedthatapproximately11,530 newcasesofcanceroccurredinthepediatricandadolescent populationsin2012.3

The prevalence of malnutrition among these patients variesfrom10%to50%dependingontheassessmentmethod

http://dx.doi.org/10.1016/j.bjhh.2014.06.001

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revbrashematolhemoter.2 0 1 4;36(6):420–423

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used,timeofevaluation(atdiagnosis,duringchemotherapy, etc.),tumorstageandhistologytype,andpatient socioeco-nomicstatus.4–12

Consideringtheimportanceofknowingthenutritional sta-tusofpediatricpatientswithmalignantneoplasms,thisstudy wasperformedwiththefollowingobjectives:

- Toevaluatethenutritionalstateofunder20-year-oldcancer patientsatdiagnosis;

- To compare the nutritional status ofpatients with solid tumors(ST)tothosewithhematologicalmalignancies(HM); - Tocorrelatethediagnosiswiththenutritionalstatusofthe patient, the caregiver’slevel ofeducation,family income andplaceoforigin.

Methods

Thistransversalobservationalstudyevaluatedthenutritional statusof1154consecutivechildrenandteenagerswith malig-nantneoplasmstreatedintheoutpatientclinicoradmitted asinpatientsonthewardsorintheintensivecareunitsof thePediatricOncologyInstituteofthePediatricsDepartment, UniversidadeFederaldeSãoPaulo(UNIFESP),fromMarch2006 toMarch2012.ThisstudywasapprovedbytheResearchEthics CommitteeofUNIFESP.

Patientsaged0–19yearswithdiagnosisofmalignant neo-plasms or benign tumors of the central nervous system with malignant behavior (i.e. craniopharyngioma, astrocy-toma,etc.)wereenrolledinthisstudy.Patientswithhistory oftreatmentoftheneoplasm,receivingcorticosteroids,those withchronicpre-existentdiseasesorwithphysicallimitations thatwouldhinderadequatemeasurementofstudyvariables (inparticularheightandweight)wereexcluded.

Thepatientswere divided into two groupsaccording to diagnosis:HM group,comprising lymphomaand leukemia, andtheSTgroup,whichincludedallothertumors.

The Anthrosoftware of the World Health Organization (version3.0.1; DepartmentofNutrition,WHO) wasused to calculatethe nutritionalstatusaccordingtothebody mass index(BMI)ofupto5-year-oldpatientsandtheWHO Anthro-Plus software(version1.0.2) forpatients agedmorethan 5 years.NutritionalstatuswasclassifiedaccordingtotheWHO criteria13,14_and_then_categorized_into_three_groups:

- Below adequate– patientswithaz-scoremorethantwo standarddeviations(SD)belowthemeanBMIforage;

- Adequate–patientswithaz-scorebetweentwoSDbelow andoneSDabovethemeanBMIforage;

- Aboveadequate–patientswithaz-scoremorethanoneSD abovethemeanBMIforage.

The parameters used for nutritional assessment were weight,height,tricepsskinfoldthickness(TSFT),mid-upper arm circumference (MUAC)and arm muscle circumference (AMC),BMIandpercentageweightloss.TSFT,MUACandAMC wereclassifiedaccordingtotheclassificationofFrisancho15

asfollows:

- Belowadequate:≤5thpercentile;

- Adequate:between5thand95thpercentiles; - Aboveadequate:≥95thpercentile.

Weightlosswasqualitativelyevaluatedbyquestioningthe patientorcaregiveraboutwhethertheyhadnoticedweight loss andquantitatively assessedbythe absolutedifference betweentheusualweightofthepatient(asreportedbythe patient/caregiver)andtheweightonadmission.Therelative weightlosswasobtainedbydividingtheweightlostbythe usual weightandclassified accordingtothetime of occur-rence(asreportedbythecaregiver)usingtheBlackburnetal. formula,16_adjusted_for_a_7-day_period.

Statisticalanalysis

The Chi-square test was used to assess the association between oncologic diagnosis and prevalence of nutritional deficitasidentifiedbytheTSFT,MUAC,andAMCexams.

ThenonparametricKruskal–Wallistestwasusedtoassess the association between diagnosis and weight loss and between diagnosis and nutritional deficit as measured by the BMI. The significance threshold (˛) was set at 5% (p

-value<0.05).

Results

Atotalof1317patientswereadmittedtotheintensivecare unitsandinpatientfacilitiesortreatedintheoutpatientclinic duringthe study period.Ofthose, 163were excludedfrom analysisduetodifficultiesinweighingortheimprecisionof the result. Thus, 1154patients were included inthe study of which 53.09% were male and the mean age was 10.24 years.Thedistributionoftumortypes(HMandST),age, fam-ilyincomeandeducationlevelofthecaregiverisshownin

Table1.

Table1–Demographicdataofpatientswithcanceratthetimeofdiagnosis(n=1154).

Hematologicaltumors Solidtumors Total

n(%) 373(32.49) 781(67.51) 1154(100.00)

Age–median(mean±standarddeviation) 8.90(10.33±9.51) 7.85(9.84±10.85) 8.10(10.08±10.05)

Gender–male(%) 54 52 53

Meanfamilyincome(R$) 129.00 147.00 202.50

Illiteracyrateofcaregiver–n(%) 13(3.48) 29(3.71) 42(3.63)

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Table2–Percentageofmalnutritionaccordingto anthropometricparameters(n=1154).

Anthropometricparameters

Hematological tumors(%)

Solidtumors (%)

Total(%)

Bodymassindex

<Adequate 9.52 12.2 10.85 Adequate 75.05 63.23 69.15 >Adequate 15.43 24.57 20.00

Tricepsskinfoldthickness

Mid-upperarmcircumference

Armmusclecircumference

Chi-squaredtest:groupsdidnotdifferwithrespecttothe diagno-sisofnutritionalstatusaccordingtothedifferentanthropometric parameters.

According to anthropometric analysis, 10.85% of the patientspresentedwithbelowadequate BMIatadmission. However,whentheTSFT,MUACandAMCexamswereused, theprevalenceofmalnutrition increasedto27.02%, 24.74% and13.83%,respectively.Theprevalencesofmalnutritionby typeoftumorand anthropometricparameterare shownin

Table2.

Table 3 shows the mean weight loss adjusted to 7-day

periods:−2.82%inthepatientsoftheHMgroup,and−2.9% inthe patientsofthe ST group(p-value=0.11). No statisti-callysignificantdifferenceswereobservedinrespecttousual weight (p-value=0.18) and current weight (p-value=0.11) betweenthetwogroups.

Table3–Weightlossatdiagnosisofpatientswith hematologicalandsolidtumors(n=1154).

Hematological tumors

Solid tumors

Usualweight(kg) Median(mean±SD)

28.00(33.88±_19.00) _25.00_(32.08±_21.00)

Weightatdiagnosis (kg)

Median(mean±SD)

27.05(32.66±19.18) 24.5(30.57±20.39)

Weightloss(%) (mean±SD)

−2.82±1.38 −2.90±5.8

SD:Standarddeviation.

Chi-squaredtest:thegroupsdidnotdifferinmeanusualweight, weightatdiagnosisandpercentageweightloss.

Discussion

A significant drop in the prevalence of malnutrition was observedinBrazilduringrecentdecades.Theproblemoflow weightforagehasbeenpracticallyovercomeinunder 5-year-oldchildrenandthelowheightforageinthisagegroupwill followasimilartrendoverthenext10yearsifthecurrentrate ofreductionismaintained.17–24

Oneofthemainreasonsforthisevolutionisthe improve-mentintheorganizationofbasiccarebytheBrazilianNational HealthcareSystemwiththeFamilyHealthcareStrategy.The evolutionofprimaryhealthcareiscentraltoguaranteeaccess andpromoteequitythroughclosercontactofthepopulation withhealthcareservicesandmeasurestopromotehealthand diseaseprevention.18–24

Inthisstudy,accordingtotheBMI,theprevalenceof malnu-tritionatthetimeofdiagnosiswashigherthaninthegeneral Brazilianpopulation.Thisisprobablyduetothecatabolism causedbythedisease.Theprevalenceofmalnutritionisalso higherthanreportedintheinternationalliterature,probably duetothelowincomeofthepopulation.

Between2000and2012,a30%increaseinthepercapita incomewasobservedintheBrazilianpopulation.In2010,the BrazilianpercapitaincomewasR$767.02,80%higherthanthe mediumpercapitaofourpatients.19–22_{Interestingly,}_besides

thelowincome,theilliteracyrate(3.63%)amongcaregivers waslowerthaninthegeneralpopulation(9.3%).20–23

Theresultsofthecurrentstudysuggestthatsometypesof tumorscanmaskmalnutrition,mainlywhenonlytheBMIis usedforevaluation.Therefore,otheranthropometrical mea-surementsbasedonTSFandMUACmeasurementsmustbe combined,astheymoreefficiently evaluatebody composi-tion and diagnose malnutrition in patients with pediatric cancer.18–24

Thepatientsincludedinthisstudywerenotevaluatedfrom thebeginningofthesymptomsuptoadmissioninourservice. Therefore,manywouldhavebeenevaluatedbyother profes-sionalsinotherhealthcenters,beforetheirfinaldiagnosisand theirfirstoncologicalconsultation.Inthisstudy,nutritional evaluationwasperformedatthetimeofdiagnosis,whichis supposedlythemostadequatetimetopreventworseningof thenutritionalstatus.Inotherwords,at‘onset’ofthedisease, whichisideallythetimewhentheoncologicaldiagnosisis made,thelevelofmalnutritionisexpectedtobesimilarto othersinthepopulationtowhichthepatientbelongs. Mal-nutritionworsensasthetumorevolves,thatis,thelaterthe diagnosis,thehigheristheriskofmalnutrition.25

Hence, the lack ofprotocols toevaluate and treat mal-nutrition, aswell asthe limitedinvolvementofhealthcare professionalsinrelationtoearlynutritionalinterventionsare importantfactorscontributingtothehighincidenceof malnu-tritionfoundintheliterature.Thus,diagnosisofmalnutrition and early intervention must be prioritized by all oncology teamsinanattempttosolveatleastpartoftheproblem.

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therealityofourpopulationshouldbeimmediately imple-mented in all Brazilian oncologic centers, so that these patientshaveatleastthechanceofreceivingadequate treat-ment to avoid the need of reducing drug doses, delaying chemotherapycyclesorsurgicalprocedures,anddecreasing theriskoftoxicity,infectionsanddeath.

Conclusion

Theprevalenceofmalnutritioninourstudypopulationwas almostthreetimeshigherthaninthegeneralpopulationof Brazil.Accordingly,itisessentialthatpoliciesthatallowfor earlierdiagnosisandimplementationofnutritional interven-tions andtreatment areurgently requiredinorder tooffer moreeffectivetreatmentforpediatriccancer.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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