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INTRODUCTION

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A child with cancer faces nutritional challenges. The nutritional well-being of that child is a principal concern of parents and caregivers during all phases of treatment. Management of cancer and related diseases generally includes chemotherapy, radiation, and hematopoietic stem cell transplantation (HSCT) for resistant diseases. The disease itself, as well as its treatment, often lead to an immunocompromised state, thus increasing risk for critical illness and morbidity.

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A detailed nutrition assessment is imperative to inform an individualized nutrition care plan that considers the unique concerns raised by a critically ill child with cancer. Limitations to the provision of nutrition may be related to organ function—especially gastrointestinal (GI) feeding tolerance—renal function, and cardiovascular status. Endocrine abnormalities, including hyperglycemia and hypertriglyceridemia, often result from steroids or calcineurin inhibitors used in cancer and HSCT treatment, and may be exacerbated by critical illness. Respiratory failure and sepsis are frequent reasons for admission to a pediatric intensive care unit (PICU) for children with oncologic diseases or following HSCT.1 Multisystem organ failure may further affect adherence to a planned nutritional regimen.

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NUTRITIONAL STATUS

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Children and adolescents are at higher risk for development of malnutrition than are adults during cancer treatment due to the proportionally higher nutritional requirements during periods of growth and development. It is difficult to estimate the prevalence of malnutrition during treatment due to lack of uniform criteria and adequate studies.2 Undernutrition at the time of diagnosis is relatively uncommon in high-income countries, but it continues to be a frequent problem in low-income countries.3 Malnutrition during treatment depends on many factors, such as the specific tumor, extent of the disease, hospital resources, and treatment strategies. It is estimated that the rate of malnutrition in children with cancer is 0% to 10% for leukemia, 20% to 50% for neuroblastoma, and 0% to 30% for other malignancies.2

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Nutritional status at diagnosis has prognostic implications. Well-nourished children tolerate intensive cancer treatment better than those who are malnourished and thus have better chances of survival and lower relapse rates.4 Undernutrition is associated with higher rates of death due to abandonment of therapy, treatment failure,5 and infectious complications.6 Malnourished children are at an increased risk for treatment-related complications, reduced tolerance to therapy, altered drug metabolism, increased susceptibility to infection, and poorer treatment outcome. The impact of malnutrition may be more severe in younger children.

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Obesity is an increasing problem among children undergoing treatment for cancer and related diseases.7 A detailed account of childhood obesity, its associated morbidities, and nutritional management during critical illness are provided in chapter 21. Childhood obesity may be associated with hyperlipidemia, hypertension, acanthosis nigricans, diabetes and insulin resistance, hepatic steatosis, cholelithiasis, pseudotumor celebri, sleep apnea, and orthopedic abnormalities.8 Children and adolescents who are obese are at increased risk for coronary heart disease, stroke, high blood pressure, diabetes, and other chronic diseases ...

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