Keywords
malnutrition - incidence - pediatric cancer - WHO norms - acute lymphoblastic leukemia
- prevalence
Introduction
Malnutrition is a critical concern among patients with pediatric cancer, with its
impact varying across cancer types and treatment stages.[1] Several studies have explored malnutrition and undernutrition in patients with pediatric
cancer. These studies underscore the critical role of nutritional status in influencing
both the immediate treatment outcomes and the long-term prognosis in patients with
pediatric cancer.
However, only three studies in the Indian context have been conducted in the past
decade,[2]
[3]
[4] and these are limited by small sample sizes. Therefore, it is crucial to examine
malnutrition among patients with pediatric cancer using a larger sample size, particularly
with a focus on the North Indian population. This study focuses on patients with pediatric
cancer receiving care at two major public sector hospitals in Delhi.
Materials and Methods
Study Design and Setting
This is a retrospective study analyzing data from patients with pediatric cancer who
received treatment at two major hospitals in Delhi—Safdarjung Hospital and Kalawati
Saran Children's Hospital. These patients were also supported through Cankids with
other required supplementary cancer care services. The study covers data from the
past 6 years, spanning from April 2018 to April 2024.
Inclusion Criteria
Children in the age group up to 18 years diagnosed for the first time with cancer,
availing treatment from these hospitals, and supported through CanKids during the
period under study were included.
Exclusion Criteria
Those patients with incomplete records were excluded.
The information collected for each patient are date of birth, date of diagnosis, and
anthropometric measurements (weight, height, and body mass index [BMI]) at baseline
(i.e., at the time of first contact). Anthropometric data were collected by professional
dietitians using calibrated and standardized equipment. The data are maintained in
Google spreadsheets with in-built auto-computation of BMI and nutritional status categorization.
Age at diagnosis was calculated as the difference between the date of birth and the
diagnosis date. The average height, weight, and BMI were calculated for each age separately
for boys and girls. These have been compared with the Indian Academy of Pediatrics
(IAP) and World Health Organization (WHO) median norms/standards. Importantly, WHO
growth standards are used for children younger than 5 years[5], while IAP growth charts are applied for children aged 5 to 17 years. The nutritional
status grading was done using the WHO classification of nutritional status of infants
and children.[6]
[7] These are given in [Tables 1] and [2].
Table 1
Nutritional status grading as per the WHO classification for 0 to 59 months
|
Grade
|
Nutritional status markers
|
|
Normal
|
Weight-for-length/height or BMI-for-age 0 (median) to −2 SD
|
|
Moderate acute malnutrition
|
Weight-for-length/height or BMI-for-age < − 2 SD and ≥ − 3 SD of the median
|
|
Severe acute malnutrition
|
Weight-for-length/height or BMI-for-age < − 3 SD of the median
|
Table 2
Nutritional status grading as per the WHO classification for 5 to 18 years
|
Grade
|
Nutritional status markers
|
|
Normal
|
BMI-for-age 0 (median) to −2 SD
|
|
Thinness
|
BMI-for-age < − 2 SD and ≥ − 3 SD of the median
|
|
Severe thinness
|
BMI-for-age <− 3 SD of the median
|
Statistical Analysis
An analysis of nutritional status was conducted based on gender, age group, and type
of cancer. An appropriate test of significance (Chi-square test) was applied to assess
differences in nutritional status between gender, age groups, and cancer types. A
p-value of less than 0.05 was considered statistically significant. The analysis was
conducted using SPSS version 24.
Ethical Approval
Since this is a retrospective study, ethical permission and consent from patients
and their guardians were not needed.
Results
The sample consisted of 1,042 patients with pediatric cancer, of whom 707 (67.8%)
were boys and 335 (32.2%) were girls. Regarding age distribution, 498 (47.8%) were
younger than 5 years, 426 (40.8%) were pre-adolescents (ages 5–11), and 118 (11.3%)
were adolescents (ages 12–17). A significantly large proportion of the sample, 872
(83.7%), were diagnosed with hematological malignancies ([Table 3]).
Table 3
Profile of study subjects according to gender, age groups, and cancer type
|
Category
|
Frequency
|
Percentage
|
|
Gender
|
|
Male
|
707
|
67.8
|
|
Female
|
335
|
32.1
|
|
Age groups
|
|
0–59 mo
|
429
|
41.1
|
|
5–11 y
|
488
|
46.8
|
|
12–17 y
|
125
|
11.9
|
|
Cancer type
|
|
Hematological malignancies
|
872
|
83.7
|
|
Solid tumors (except CNS tumors)
|
78
|
7.5
|
|
CNS tumors
|
92
|
8.8
|
Abbreviation: CNS, central nervous system.
Comparison of Anthropometric Parameters with WHO and IAP Norms
The average height, weight, and BMI of boys and girls were compared against the standard
median norms of the WHO for children younger than 5 years and the norms of IAP for
children 5 to 17 years to calculate growth achievement. This was assessed as the ratio
of the observed mean values to the median norms for height, weight, and BMI, separately
for boys and girls.
It was observed that the average height of patients with pediatric cancer was ∼94.2%
of the expected values for boys and 96.3% for girls ([Table 4]). Similarly, the average weight was ∼79.1% of the reference values for boys and
80.2% for girls ([Table 5]). Furthermore, the average BMI was 89.6% of the corresponding benchmarks for boys
and 86.6% for girls ([Table 6]).
Table 4
Comparison of average height with standard median norm by gender
|
Age (years)
|
Height (in cm)
|
|
Gender
|
|
Male
|
Female
|
|
Mean
|
Standard norms
|
Achievements of growth norms
|
Mean
|
Standard norms
|
Achievements of growth norms
|
|
1
|
77
|
75.7
|
101.7
|
78
|
74
|
105.4
|
|
2
|
84
|
87.1
|
96.4
|
87
|
85.7
|
101.5
|
|
3
|
89
|
96.1
|
92.6
|
89
|
95.1
|
93.6
|
|
4
|
95
|
103.3
|
92.0
|
94
|
102.7
|
91.5
|
|
5
|
104
|
108.9
|
95.5
|
105
|
107.5
|
97.7
|
|
6
|
110
|
114.8
|
95.8
|
102
|
113.5
|
89.9
|
|
7
|
114
|
120.7
|
94.4
|
118
|
119.4
|
98.8
|
|
8
|
123
|
126.4
|
97.3
|
124
|
125.4
|
98.9
|
|
9
|
122
|
131.8
|
92.6
|
127
|
131.4
|
96.7
|
|
10
|
132
|
137.2
|
96.2
|
129
|
137.4
|
93.9
|
|
11
|
137
|
142.7
|
96.0
|
139
|
143.3
|
97.0
|
|
12
|
139
|
148.4
|
93.7
|
136
|
148.4
|
91.6
|
|
13
|
140
|
154.3
|
90.7
|
146
|
152.2
|
95.9
|
|
14
|
136
|
159.9
|
85.1
|
149
|
154.7
|
96.3
|
|
15
|
152
|
164.5
|
92.4
|
146
|
156.1
|
93.5
|
|
16
|
160
|
168.1
|
95.2
|
–
|
–
|
|
|
17
|
160
|
171.0
|
93.6
|
156
|
157.4
|
99.1
|
|
Average
|
|
|
94.2
|
|
|
96.3
|
Note: WHO growth standards are used for children younger than 5 years, while IAP growth
charts are applied for children aged 5 to 17 years.
Table 5
Comparison of average weight with standard median norm by gender
|
Age (years)
|
Weight (in kg)
|
|
Gender
|
|
Male
|
Female
|
|
Mean
|
Standard norms
|
Achievements of growth norms
|
Mean
|
Standard norms
|
Achievements of growth norms
|
|
1
|
8.7
|
9.6
|
90.6
|
8.9
|
8.9
|
100.0
|
|
2
|
9.9
|
12.2
|
81.1
|
10
|
11.5
|
87.0
|
|
3
|
12.7
|
14.3
|
88.8
|
11.7
|
13.9
|
84.2
|
|
4
|
14.2
|
16.3
|
87.1
|
12.5
|
16.1
|
77.6
|
|
5
|
15.6
|
18.3
|
85.2
|
15
|
18.2
|
82.4
|
|
6
|
16.7
|
19.3
|
86.5
|
15.5
|
18.7
|
82.9
|
|
7
|
18
|
21.9
|
82.2
|
19
|
21.2
|
89.6
|
|
8
|
20.7
|
24.8
|
83.5
|
20.2
|
24.0
|
84.2
|
|
9
|
22.9
|
27.9
|
82.1
|
23
|
27.2
|
84.6
|
|
10
|
25.8
|
31.1
|
83.0
|
23.9
|
31.0
|
77.1
|
|
11
|
26.5
|
34.7
|
76.4
|
27
|
35.4
|
76.3
|
|
12
|
27.4
|
39.0
|
70.3
|
25.1
|
39.8
|
63.1
|
|
13
|
28.7
|
43.3
|
66.3
|
33.8
|
43.6
|
77.5
|
|
14
|
34.3
|
48.2
|
71.2
|
32.3
|
46.4
|
69.6
|
|
15
|
36.3
|
53.1
|
68.4
|
29
|
48.4
|
59.9
|
|
16
|
43
|
56.8
|
75.7
|
–
|
–
|
|
|
17
|
40
|
59.5
|
67.2
|
44.1
|
50.9
|
86.6
|
|
Average
|
|
|
79.1
|
|
|
80.2
|
Note: WHO growth standards are used for children younger than 5 years, while IAP growth
charts are applied for children aged 5 to 17 years.
Table 6
Comparison of average BMI for age with standard median norm by gender
|
Age (years)
|
BMI
|
|
Gender
|
|
Male
|
Female
|
|
Mean
|
Standard norms
|
Achievements of growth norms
|
Mean
|
Standard norms
|
Achievements of growth norms
|
|
1
|
14.7
|
16.8
|
87.5
|
14.6
|
16.4
|
89.0
|
|
2
|
14.0
|
16.0
|
87.5
|
13.2
|
15.7
|
84.1
|
|
3
|
16.0
|
15.6
|
102.6
|
14.8
|
15.4
|
96.1
|
|
4
|
15.7
|
15.3
|
102.6
|
14.1
|
15.3
|
92.2
|
|
5
|
14.4
|
14.7
|
98.0
|
13.6
|
14.3
|
95.1
|
|
6
|
13.8
|
14.9
|
92.6
|
14.9
|
14.5
|
102.8
|
|
7
|
13.9
|
15.1
|
92.1
|
13.6
|
14.9
|
91.3
|
|
8
|
13.7
|
15.5
|
88.4
|
13.1
|
15.3
|
85.6
|
|
9
|
15.4
|
15.9
|
96.9
|
14.3
|
15.8
|
90.5
|
|
10
|
14.8
|
16.4
|
90.2
|
14.4
|
16.5
|
87.3
|
|
11
|
14.1
|
17.0
|
82.9
|
14.0
|
17.2
|
81.4
|
|
12
|
14.2
|
17.7
|
80.2
|
13.6
|
18.0
|
75.6
|
|
13
|
14.6
|
18.2
|
80.2
|
15.9
|
18.8
|
84.6
|
|
14
|
18.5
|
18.7
|
98.9
|
14.5
|
19.4
|
74.7
|
|
15
|
15.7
|
19.3
|
81.3
|
13.6
|
19.9
|
68.3
|
|
16
|
16.8
|
19.9
|
84.4
|
–
|
–
|
|
|
17
|
15.6
|
20.5
|
76.1
|
18.1
|
20.6
|
87.9
|
|
Average
|
|
|
89.6
|
|
|
86.6
|
Note: WHO growth standards are used for children younger than 5 years, while IAP growth
charts are applied for children aged 5 to 17 years.
Nutritional Status
Nutritional status was graded using the WHO classification.
Measured in terms of sigma limits and categorized as normal, moderately malnourished,
or severely malnourished, the following findings emerged ([Table 7]):
-
Overall, 414 children (39.7%) were found to be malnourished, including a significant
202 children (19.3%) with weight-for-length/height or BMI-for-age ≤ − 3 SD of the
median (i.e., severely malnourished).
-
The prevalence of malnutrition was similar among boys (39.4%) and girls (40.3%), with
the difference not being statistically significant (p = 0.94).
-
Malnutrition increased with age: 32.9% among children younger than 5 years, 41.9%
among pre-adolescents, and 55.5% among adolescents. Among the severely malnourished,
there were 69 (16.1%) children younger than 5 years, 92 (18.9%) pre-adolescents, and
42 (33.3%) adolescents. The differences were statistically significant (p < 0.001).
-
The prevalence of severe malnutrition was lower among patients with hematological
malignancies compared with those with other cancers, with the differences being statistically
significant (p = 0.0005).
Table 7
Nutritional status according to gender, age group, and cancer type
|
Nutritional status grade
|
|
Category
|
Normal
|
Weight-for-length/height or BMI-for-age < − 2 SD and ≥ − 3 SD of the median
|
Weight-for-length/height or BMI-for-age <− 3 SD of the median
|
|
Number
|
%
|
Number
|
%
|
Number
|
%
|
|
Overall
|
|
628
|
60.3
|
212
|
20.30
|
202
|
19.30
|
|
Gender
|
|
Male
|
428
|
60.5
|
144
|
20.3
|
136
|
19.2
|
|
Female
|
200
|
59.7
|
68
|
20.3
|
67
|
20.0
|
|
χ
2 = 0.09; p = 0.94
|
|
Age group
|
|
0–59 mo
|
288
|
67.1
|
72
|
16.8
|
69
|
16.1
|
|
5–11 y
|
284
|
58.2
|
112
|
23.0
|
92
|
18.9
|
|
12–17 y
|
56
|
44.4
|
28
|
22.2
|
42
|
33.3
|
|
χ
2 = 28.54; p < 0.001
|
|
Cancer type
|
|
Hematological malignancies
|
546
|
62.61
|
191
|
21.90
|
131
|
15.02
|
|
Solid tumors (except CNS tumors)
|
37
|
47.44
|
17
|
21.79
|
24
|
30.77
|
|
CNS tumors
|
46
|
50.00
|
17
|
18.48
|
24
|
26.09
|
|
χ
2 = 19.96; p = 0.0005
|
Abbreviations: CNS, central nervous system.
Discussion
The study represents the longest cohort in India specifically covering childhood cancer
and nutrition, highlighting the prevalence of malnutrition among children with cancer.
Overall, 39.7% of the children were malnourished, with 20.3% moderately malnourished
and 19.3% severely malnourished. The prevalence of malnutrition varied by cancer type,
with hematological malignancies showing 37% malnutrition (21.9% MAM, 15.02% SAM),
solid tumors (except CNS tumors) having the highest burden at 52.56% malnutrition
(21.79% MAM, 30.77% SAM), and CNS tumors at 50.00% malnutrition (18.48% MAM, 26.09%
SAM). A statistical review by Ward et al[8] provides a detailed breakdown of childhood cancer incidence rates, with acute lymphoblastic
leukemia consistently showing the highest prevalence among leukemias and solid tumors,
which aligns with our findings that hematological malignancies constituted the largest
subgroup in our cohort.
Furthermore, a review study by Diakatou and Vassilakou[9] found that malnutrition is common at diagnosis and is linked to poor health-related
quality of life and nutritional issues in survivors, reinforcing the need for early
nutritional assessment and interventions to mitigate long-term complications in childhood
cancer survivors.
The 39.7% prevalence of malnutrition observed in this study is comparable to the 56.8%
reported by Jain et al using weight-for-age criteria.[2] In their study, they also assessed nutritional status using hematological and biochemical
markers, with malnutrition reflected through low hemoglobin (82%), low total proteins
(25%, i.e., <5.7 g/dL), low serum albumin (20.5%, i.e., <3.2 g/dL), low serum transferrin
(27.3%, i.e., <210 mg/dL), and low serum iron (16.3%, i.e., <60 μg/dL). However, this
is much higher than the level of 37.2% as reported by Sakthikumar et al in another
Indian study.[3] This study suggested that early nutritional intervention should be an essential
part of the multidisciplinary treatment protocol.[3]
In another Indian study by Radhakrishnan et al, undernutrition was seen in 44% of
patients at diagnosis. He also reported that active nutritional intervention and education
were able to significantly reduce the prevalence of undernutrition in patients by
the end of treatment.[4]
Maia-Lemos et al evaluated 1,154 children and adolescents with cancer using various
measures like weight, height, BMI, and arm measurements. They found that 10.85 to
27.32% of patients were malnourished at diagnosis, highlighting the need for early
nutritional monitoring in pediatric cancer care.[10] A study in the Netherlands by Brinksma et al reported that 40 to 50% of patients
with pediatric cancer experienced malnutrition during treatment. It emphasized the
adverse effects of malnutrition on treatment outcomes and suggested the need for routine
nutritional assessments and interventions in oncology care.[11] Another study by Lemos et al concluded that the prevalence of malnutrition was higher
in malignancies.[12]
In our study, the prevalence of malnutrition increased with age, which aligns with
the study by Huibers et al, where it was reported that malnutrition was more common
in children aged ≥5 years (70.0%) compared with children aged <5 years.[13]
The study by Zimmermann et al, though reporting a low prevalence of malnutrition at
diagnosis, showed a steady increase in malnutrition during anticancer therapy.[14] A review study by Barr mentioned that the prevalence and severity of malnutrition
in children with cancer in LMICs demand attention.[15] Opportunities exist to conduct studies in India to examine the effects of nutritional
interventions, including on the overall well-being of survivors.[15]
The findings of this study align with prior research emphasizing the critical impact
of malnutrition on pediatric cancer outcomes. Zimmermann et al demonstrated that while
the prevalence of malnutrition at diagnosis was relatively low, it worsened during
therapy due to treatment-induced side effects such as reduced appetite and gastrointestinal
complications. Similarly, a study by Brinksma et al identified that malnutrition during
cancer therapy adversely affected treatment tolerance and recovery rates, underscoring
the necessity for routine nutritional assessment.[11]
[12]
[13]
[14] Peccatori et al mentioned that nutritional support considerably improved 1-year
event-free survival (EFS) by ∼13% compared with a historical cohort in their study.[16] Schoeman, Pedretti et al, and Bauer et al found that proactive nutritional management
significantly improves treatment tolerance, reduces complications, and enhances overall
outcomes for children undergoing cancer treatment.[17]
[18]
[19] Another study by Fabozzi et al provided practice recommendations for systematic
nutritional management in pediatric oncology, reinforcing the importance of structured
nutritional interventions to improve treatment outcomes and quality of life.[20]
While survival and toxicity data were not the focus of the current study, previous
evidence strongly links poor nutritional status to both increased treatment toxicity
and reduced survival. These insights highlight the importance of integrating tailored
nutritional support into treatment protocols to mitigate therapy-associated nutritional
deterioration and improve overall outcomes.
Strengths
This is one of the largest Indian studies on pediatric patients with cancer and malnutrition,
analyzing data from 1,042 patients over 6 years. It draws from two major public hospitals,
ensuring real-world relevance. Standardized anthropometric assessments and comparisons
with WHO/IAP norms enhance data reliability. Stratified analysis by age, gender, and
cancer type offers actionable insights for targeted nutritional interventions. The
study fills a critical gap in Indian literature and supports the integration of nutrition
into pediatric oncology care.
Limitations
Malnutrition can be assessed using various well-established indicators, such as mid-upper
arm circumference (MUAC), height-for-age, weight-for-age, weight-for-height, BMI-for-age,
and triceps skinfold thickness (TSF). In this study, malnutrition was measured using
weight-for-height and BMI-for-age. However, incorporating additional measures, such
as MUAC and TSF, could enhance the comprehensiveness and accuracy of the assessment,
providing a more nuanced understanding of the nutritional status of pediatric patients.
Future Prospects and Gray Areas for Research
The study focuses primarily on two government hospitals, highlighting the need for
data on additional measures of malnutrition to provide a more comprehensive understanding.
Generalizability of Study
Generalizability of Study
To ensure proper generalization, it would be beneficial to include data from private
hospitals and healthcare facilities in other regions of the country.
Conclusion
The considerably high prevalence of malnutrition among patients with pediatric cancer
observed in this study underscores the urgent need for routine nutritional assessment
and timely intervention as part of standard oncology care. Our findings highlight
that nearly 40% of children were either moderately or severely malnourished at the
time of diagnosis, with variation by cancer type and age group. This emphasizes the
necessity for proactive nutritional planning and individualized care strategies to
identify and support at-risk patients early. While this study did not directly assess
clinical outcomes, therapy tolerability, or quality of life, the findings reinforce
the importance of integrating structured nutritional support into multidisciplinary
pediatric oncology care. Future research should aim to explore how early nutritional
interventions may influence treatment outcomes, therapy adherence, and the overall
well-being of patients with pediatric cancer.
