Malnutrition at the diagnosis of cancer is not an uncommon finding in the developing world.
Malnutrition describes the consequences of insufficient protein-energy intake. Malnutrition is an unspecific term used to define an inadequate nutritional condition. It is characterized by either a deficiency or an excess of energy with measurable adverse effects on clinical outcome.
Malnutrition describes the consequences of insufficient protein-energy intake. An adequate protein-energy balance is a prerequisite for age-appropriate growth and maintenance.
Nutrition is very important for Children with Cancer, because the presence of the tumour as well as the treatments that they undergo play havoc with their immune systems as well as various other systems in their little bodies.
The occurrence of malnutrition in children with cancer is multifactoral. While some children arrive at the hospital already malnourished due to personal home circumstances, between 40-80% of children will become malnourished during their treatment.
The prevalence of malnutrition is also related to the type of tumour the child is diagnosed with as well as the extent of the disease. Malnutrition is more commonly seen in patients with advanced Neuroblastoma, Wilms Tumour, Ewing Sarcoma and advanced Lymphomas.
Malnutrition is more severe with aggressive tumours in the later stages of malignancy; the more intensive treatment regimens, the more chance there is of the child becoming malnourished.
A malignant tumour leads to changes in a child’s metabolism; their system is unable to regulate the expenditure of energy according to the reduced energy intake, leading to an ineffective use of nutrients and contributing to the development of malnutrition.
Children with a poor nutritional status have lower survival rates than those with a good nutritional status. One study conducted on 18 children with newly diagnosed stage IV Neuroblastoma found that malnourished paediatric cancer patients were more likely to relapse and or die 1 year into the treatment than those who were well-nourished. The median survival for the group who was malnourished was 5 months versus 12 months for the well-nourished group.
Children with cancer, especially those with solid tumours, have reduced body protein stores due to whole body protein breakdown. This may occur as a result of the cancer itself, the treatment they are undergoing for their tumour, or complications of the disease. The breakdown of lean body mass is a common effect of cancer, making the assessment of body composition a critical part of the nutritional assessment.
Tumour types associated with malnutrition
for Paediatric Oncology Patients
|High risk for undernourishment||Moderate risk for undernourishment||High risk for
|Solid tumours with advanced stages||Nonmetastatic solid tumours||Acute Lymphoblastic Leukemia receiving cranial irradiation|
|Wilms tumours||Uncomplicated Acute Lymphoblastic Leukemia||Craniopharyngeoma|
|Neuroblastoma stage III and IV Rhabdomyosarcoma||Advanced diseases in remission during maintenance treatment||Malignancies with large and prolonged doses of cortisone therapy or other drugs increasing body fat stores|
|Ewing Sarcoma||Total body or abdominal or cranial irradiation|
According to the American Academy of Paediatrics, children may be considered obese on the basis of a BMI standard deviation score (BMI-SDS) of greater than the 95th percentile
Obesity at diagnosis has been associated with lower survival rates in children with cancer, especially those with ALL, AML, or Brain Tumours. Obesity at diagnosis of cancer is also associated with increased risk of obesity at the end of the treatment and in survivorship
Obesity in survivorship can lead to an impaired glucose tolerance, diabetes mellitus, hypertension, cardiovascular disease, higher risk of developing certain forms of cancer, and less of a chance of survival should they develop cancer again late in life.
Obese children with cancer have significantly lower survival rates compared with other patients. Overweight children diagnosed with cancer after age 10 have a significantly lower mean 5-year event-free survival rate and a higher mean risk of relapse than normal weight children.
Mechanisms underlying the association between obesity and cancer are only starting to be understood. Most studies to date regarding obesity in children with cancer during and after treatment have concentrated on those with ALL or brain tumours due to the high risk of hypothalamic-pituitary axis damage caused by the treatment regimens or the location of the tumour. Several studies have shown that children who were obese at diagnosis became between 30% and 40% more overweight by the end of treatment.
This excessive weight-gain has been attributed to reduced physical activity, exposure to corticosteroids, growth hormone (GH) deficiency/hypothalamic-pituitary axis damage due to cranial Radiation Treatment (RT), and poor dietary habits.
How to Ensure Adequate Nutrition for your Child with Cancer
Nutritional intervention for children with cancer is challenging, especially for those who do not have the means to employ the use of a qualified nutritionist, but there are many things that one can do at home to ensure that your child with cancer is getting adequate nutrition.
Children with cancer need protein, carbohydrates, fat, water, vitamins, and minerals. Your child’s cancer itself as well as the treatment s they undergo will often cause changes in their eating habits or desire to eat. Not eating can lead to weight loss, and can cause weakness and fatigue. Helping your child eat as well as they can is an important part of helping them through their treatment and increasing their chances of survival.
Use Healthy Fats
Including healthy dietary fats in your child’s diet during their cancer treatment is important in treating their brain cancer:
Avoid saturated fats and hydrogenated oils (Whole milk products, Butter and margarine, High fat red meat (except grass-fed), Processed meats (like bacon, hot dogs), French fries and other deep-fried foods, Partially hydrogenated oils in pastries, crackers, processed foods);
Use healthy oils like olive oil and fish oil, which can boost the immune system while reducing inflammation and swelling. Healthy fats include Fish (salmon, flounder, herring, sardines); Olive oil, canola oil, flax oil, and coconut oil; Nuts and natural nut butters; Ground flax-seed; Chia seeds; Wheat germ; Avocado and Olives;
Omega-3 fats, found in fish and flax-seed oil, are extremely advantageous in reducing tumour resistance to therapy;
Olive oil is an Omega-9 fat and a healthy source of dietary fat – use moderately in food preparation.
Decrease Sugar Intake
Sugar feeds cancerous cells and suppresses the immune system during cancer treatment;
Cancer cells can consume 10 to 15 times more sugar than normal cells do, which increases the chances of inflammation;
During brain cancer treatment, you should reduce your child’s intake of refined sugar and carbohydrates.
Replace the refined sugars with a selection of whole-grain breads, pastas etc and rather give them naturally sweet vegetables such as sweet potatoes to reduce any cravings for sweets.
Increase Fibre Intake
A diet high in fibre can decrease your child’s chances of becoming constipated or getting diarrhoea, lower their cholesterol and triglyceride levels, and regulate their blood sugar level;
Your child may get a good amount of fibre from whole grain breads and cereals, but fresh fruits, vegetables, and legumes (such as peas, beans or lentils) provide a higher intake of fibre.
Your child should try to eat 4 to 5 servings of vegetables and 1 to 2 servings of fruit;
If your child is not getting enough fibre via their diet, mix one to two tablespoons of ground flaxseed into their yoghurt, porridge, salads, or smoothies.
Fruits & Vegetables
The more fruits and vegetables your child eats the better for them. Select Vegetables and Fruits with Vivid Colours because they will appeal more to your child, but also because the more intense the colour, the higher the nutritional content.
Try the “3-colours-a-day” trick as an easy way of ensuring your child eats enough variety of fruits and vegetables. For example, blueberries (1) with breakfast, dark leafy lettuce (2) on the lunch sandwich, and red peppers (3) with chicken at dinner.
Don’t shy away from canned vegetables, especially if they make your life easier right now. Frozen fruits and vegetables are also a healthy alternative.
“Phyto” means plant, and phytochemicals are nutrients derived from plants. Although phytochemicals have not yet been classified as nutrients (substances necessary for sustaining life), they are healthy buzzwords in both nutrition and cancer research.
Phytochemicals have been identified as containing properties for aiding in the prevention and/or treatment of at least four of the leading causes of death in Western countries – cancer, diabetes, cardiovascular disease, and hypertension.
Phytonutrients appear to stimulate the immune system, exhibit antibacterial and antiviral activity, decrease cholesterol levels, prevent cancer cell replication, and generally, help your body fight cancer.
For more information on Phytochemicals, you can download America’s Phytonutrient Report in PDF form HERE
Make sure that your child drinks sufficient fluids, as additional fluids are needed to replace fluid lost during chemotherapy and through treatment side effects.
The human body needs water for the following essential functions:
Remove waste and toxins
Transport nutrients and oxygen
Control heart rate and blood pressure
Regulate body temperature
Protect organs and tissue, including the eyes, ears, and heart
Children often lose a lot of water from vomiting, diarrhoea, or by just not drinking enough. This can lead to dehydration, but it can be handled by making sure your child gets plenty of fluids. Children get some water from foods, especially fruits and vegetables, but they need to drink liquids as well to be sure that all the body cells get the fluid they need.
Tap, filtered, or bottled water is best, but your child can also get necessary fluids from other sources like sports drinks, juices (100% juice is best), and clear broths.
The use of supplements is rather controversial, but according to Dr. Wallace, who holds a PhD in nutrition and is a nutrition consultant, a diet rich in natural supplementation will reduce side effects of treatments.
Supplements that are currently recommended for brain cancer patients include:
Vitamin D – Vitamin D deficiency that occurred before birth may have set the stage for brain tumour formation later in life. Vitamin D deficiency during gestation causes long-term effects on brain development (Levenson CW et al 2008). Vitamin D remains important after birth, as it activates chemical pathways, in particular the sphingomyelin pathway, which kills glioblastoma cells (Magrassi L et al 1998).
Melatonin – There is growing evidence suggesting melatonin may be useful in treating primary brain tumours. An in vitro experiment showed that melatonin, at physiologic concentrations, inhibits growth of neuroblastoma cells (Cos S et al 1996). A 2006 paper published in Cancer Research reported that melatonin stopped the growth of gliomas that had been implanted into rats (Martín V et al 2006). As a result, some researchers suggest melatonin might be useful in treating glioma (Wion D et al 2006). The strongest evidence for the use of melatonin in brain cancer is in treating pituitary tumours (Gao L 2001). and (Yang QH et al 2006).
Folic Acid and 5-MTHF – Natural folate from food and folic acid from supplements must be converted into the active form, 5-MTHF (5-methyltetrahydrofolate), by the enzyme 5,10-methylenetetrahydrofolate reductase (MTHFR). In certain people the gene that codes for this enzyme produces a less effective enzyme. In some studies, the risk for glioma in these people is increased by about 23% while meningioma risk is more than doubled (Sirachainan N et al 2008, Bethke L et al 2008, Kafadar AM et al 2006).
Selenium – antioxidant that patients with brain tumours should consider. Exposing brain cancer cells to selenium makes them more sensitive to, and more likely to die after, radiation therapy (Schueller P et al 2004). Selenium inhibits growth and invasion, and induces apoptosis in various types of brain tumour cells, including malignant cell lines (Sundaram N et al 2000, Rooprai HK et al 2007).
Vitamin E – antioxidant of particular interest in connection with brain cancer; enhances chemotherapy treatment of drug resistant glioblastoma cells, increasing effectiveness (Kang YH et al 2005)
Consult your child’s Oncology Team before giving him or her any supplements.
Managing Side Effects with Nutrition
It may be hard for your child to eat a balanced diet during their cancer treatment. Various side effects of their treatment such as nausea, vomiting, diarrhoea, constipation, fatigue, and mouth sores (mucositis) can make eating very difficult.
The following tips may help:
- Nausea: Try a low-fat, bland diet of cold foods, products containing ginger, peppermint or sea bands to combat nausea;
- Diarrhoea: Try a diet of bananas, white rice, applesauce and toast; it will help minimise irritation to the digestive tract. Water soluble fibre supplements may help form firmer a stool;
- Constipation: Increase your child’s fibre intake and keep them hydrated by making sure they drink sufficient liquids;
- Fatigue: Give your child small meals of protein-rich foods often; decrease their sugar intake to give them more energy. Certain iron and folic acid supplements may also help boost red blood cell count, but DO NOT give your child any vitamins or supplements without their oncologist’s permission.
“Nutrition is an important part of the health of all children, but it is especially important for children getting cancer treatment. This guide can help you learn about your child’s nutritional needs and how cancer and its treatment may affect them. We also offer suggestions and recipes to help you ensure your child is getting the nutrition he or she needs.”
Source: Nutrition for Children with Cancer: American Cancer Society
This Report offers a vast array of information regarding nutrition for the child with cancer, and even includes some great recipes.
Download the Full PDF Report HERE
“Children more commonly present with protein energy malnutrition (PEM) at diagnosis of cancer in developing countries than in developed countries, depending on the type of cancer and extent of the disease.” PHM at cancer diagnosis is associated with delays in treatment, increased infections and a negative outcome.’ [here is still controversy regarding the ideal criteria to use to describe PEM as there are many methods and cut-off points.]“
Source: Malnutrition in Paediatric Oncology Patients: South African Study Published 1 August, 2010:
- JUDITH SCHOEMAN, BDietetics, BCompt, MSc Dietetics Principal Dietitian: Oncology. Steve Biko Academic Hospital Oncology Complex.
- ANDRE DANNHAUSER, BSc Dietetics, MSc Dietetics, PhD Professor and Head, Department of Nutrition & Dietetics. University of the Free State
- MARIANA KRUCER, MB ChB, MMed Paed, MPhil (Applied Ethics), PhD Professor and Executive Head, Department of Paediatrics and Child Health. Stellenbosch University and Tygerberg Hospital, W.Cape
Download the Full PDF Report HERE
“Study results of children (8-15.8 years) with solid tumors showed that they had a higher basal metabolic rate (BMR) at the time of diagnosis, when compared to reference values. BMR is defined as the minimum amount of energy required to maintain all essential bodily functions. The increase in BMR indicates that the tumor is more than an inert mass requiring removal. It consists of metabolically active tissue initially increasing basal energy requirements, which should be accounted for when determining requirements for nutritional support.”
Source: Nutrition in the Paediatric Oncology Patient: South African Study Published in April 2007; Reviewed in 2009: Red Cross Children’s Hospital
Download the Full PDF Report HERE