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\begin{document}

\title{DETERMINING THE APPETITE AND NUTRITIONAL STATUS OF CHILDREN UNDERGOING
STEM CELL TRANSPLANTATION}



\author[1]{Derya Suluhan}%
\author[2]{Hilal  Koacaerkek}%
\author[1]{Dilek Yildiz}%
\author[3]{Nevra   Koç}%
\author[2]{İkbal  Ok Bozkaya}%
\author[4]{Orhan   Gürsel}%
\author[2]{Namık Yaşar Özbek}%
\affil[1]{University of Health Sciences Turkey, Gülhane Faculty of Nursing}%
\affil[2]{Ankara City Hospital}%
\affil[3]{University of Health Sciences Turkey, Gulhane Health Sciences Faculty}%
\affil[4]{Gülhane Training and Research Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Aim: To determine pre- and post-transplant appetite and nutritional
status of children undergoing stem cell transplantation. Methods: This
study was conducted between November 2018 and November 2020 with 25
children, aged 8-18 years, diagnosed with cancer without secondary
disease and scheduled for stem cell transplantation. Time points: seven
days pre-stem cell transplant (T1); transplant day (T2); Day 1
post-transplantation (T3); Day 14 post-transplantation (T4); and Day 30
post-transplantation (T5). Measurements for treating pediatric anorexia
and cachexia include: height, mid-upper arm circumference (MUAC); body
mass index (BMI); and the Pediatric Functional Assessment Scale
(Peds-FAACT). Results: 52\% of patients were female, and mean age was
13.2 years. Acute lymphoblastic leukemia was diagnosed in 32\% of the
children. There was a statistically significant difference between the
means of body weight over time (p\textless{}0.001). By Day 14
post-transplantation, 61\% of subjects (n=14) had lost \textgreater{}
5\% of body weight. There was a statistically significant difference
between distributions of change in food taste over time, and
distribution of change in food smell (p\textless{}0.001,
p\textless{}0.001, respectively). Conclusions: Clinical nutrition teams
should closely follow the children's nutritional status, plan
appropriate nutritional treatment, perform nutritional care, and
evaluate anthropometric measurements.%
\end{abstract}%



\sloppy


\textbf{DETERMINING THE APPETITE AND NUTRITIONAL STATUS OF CHILDREN
UNDERGOING STEM CELL TRANSPLANTATION}

\textbf{ABSTRACT}

\textbf{Aim:} To determine pre- and post-transplant appetite and
nutritional status of children undergoing stem cell transplantation.

\textbf{Methods:} This study was conducted between November 2018 and
November 2020 with 25 children, aged 8-18 years, diagnosed with cancer
without secondary disease and scheduled for stem cell transplantation.
Time points: seven days pre-stem cell transplant (T1); transplant day
(T2); Day 1 post-transplantation (T3); Day 14 post-transplantation (T4);
and Day 30 post-transplantation (T5). Measurements for treating
pediatric anorexia and cachexia include: height, mid-upper arm
circumference (MUAC); body mass index (BMI); and the Pediatric
Functional Assessment Scale (Peds-FAACT).

\textbf{Results:} 52\% of patients were female, and mean age was 13.2
years. Acute lymphoblastic leukemia was diagnosed in 32\% of the
children. There was a statistically significant difference between the
means of body weight over time (p\textless{}0.001). By Day 14
post-transplantation, 61\% of subjects (n=14) had lost \textgreater{}
5\% of body weight. There was a statistically significant difference
between distributions of change in food taste over time, and
distribution of change in food smell (p\textless{}0.001,
p\textless{}0.001, respectively).

\textbf{Conclusions:} Clinical nutrition teams should closely follow the
children's nutritional status, plan appropriate nutritional treatment,
perform nutritional care, and evaluate anthropometric measurements.

\textbf{Key words:} Child, Hematopoietic stem cell transplant, appetite,
nutritional status

\textbf{What's known}

Multidisciplinary approach to the nutritional care of children is vital
for improving nutritional status after HSCT, as recommended
in\emph{Improving Outcomes Guidance for Children and Young People with
Cancer} (National Institute for Health and Clinical Excellence (NICE,
2005).

Healthcare professionals need to be aware that malnutrition will lead to
more complications in children scheduled for transplantation in stem
cell transplant units.

\textbf{What's new}

A nutritional assessment to detect malnourished patients or patients at
risk of malnutrition, which includes anthropometric measurements, and
observation of changes to smell and taste, should be performed on
children in stem cell transplant units.

Nurses need to evaluate changes to smell and taste of children in
transplantation units and use of validated scale for appetite of
children in stem cell transplant units.

\textbf{INTRODUCTION}

Malnutrition is very common in children who are receiving treatment for
cancer.\textsuperscript{1} This is due to numerous factors, which may
include: changes in taste sensation, side effects of cancer treatment
drugs on the gastrointestinal system, increase in metabolic rate and
calorie requirement, decrease in food intake due to mucositis, cytokines
released, and resulting metabolic disorders.\textsuperscript{2,3} Poor
nutritional status in children with cancer is associated with increased
infections, poor survival, and impaired health-related
quality-of-life.\textsuperscript{4,5}

The American Society for Parenteral and Enteral Nutrition workgroup
defined pediatric malnutrition-undernutrition as an imbalance between
nutrient requirement and intake resulting in cumulative deficits of
energy, protein, or micronutrients that may negatively affect growth,
development, and other relevant outcomes.\textsuperscript{6} While the
malnutrition rate in pediatric oncology patients ranges widely, from of
6 - 50\%, due to the type, stage, location of the tumor, and treatment
intensity\textsuperscript{1}, this rate changes to 18-31\% following
transplantation.\textsuperscript{4,5} Some examples of tumors with high
risk of malnutrition among pediatric oncology patients are Wilms tumor,
neuroblastoma stage III and IV rhabdomyosarcoma, Ewing sarcoma,
medulloblastoma, multiple relapsed leukemia and
lymphoma.\textsuperscript{7}

Loss of appetite, which is one of the factors leading to malnutrition,
and is associated with cachexia (muscle and fat loss), is a common
symptom in children with cancer who are undergoing stem cell
transplantation.\textsuperscript{7-,9} Complications of treatment, such
as changes in taste and smell, and oral mucositis, can cause
anorexia.\textsuperscript{10} A study by Skolin et al. demonstrated that
malnutrition occurred in children due to taste change, pain, lack of
appetite, nausea and vomiting, fever or a feeling of illness, aversion
to hospital food, the ward environment, and gaining some control over
the situation were identified as important causes for eating problems by
parents.\textsuperscript{11} Research has also shown that drugs used in
chemotherapy, radiotherapy and stem cell transplant treatment may affect
oral food intake by causing taste changes in children, sometimes leading
to malnutrition.\textsuperscript{11}

The deterioration of nutritional status in a child during cancer
treatment negatively affects that child and her family in many ways. For
example, it may be associated with biochemical disorders, decreased
immune functions, delayed wound healing, and deterioration of drug
metabolism. Malnutrition may also impact prognosis, and cause delay in
growth and development.\textsuperscript{1,12, 13} In addition, decrease
in food intake and body weight associated with anorexia and cancer
cachexia can create conflict between the child, the family, and health
professionals about eating, changes in body image, and decreased quality
of life.\textsuperscript{1,9,14}

Since anorexia and cachexia are complex problems, a multidisciplinary
team approach is required to determine the underlying causes, to support
nutrition, and to keep the child's anthropometric measurements within
normal range.\textsuperscript{1,12} A multidisciplinary approach is
recommended in \emph{Improving Outcomes Guidance for Children and Young
People with Cancer} , a guidance developed by the National Institute for
Health and Clinical Excellence.\textsuperscript{15}

It is the responsibility of the team, consisting of physicians,
dieticians, and pediatric oncology nursesm to evaluate the nutritional
status and anthropometric measurements of the child before and during
the stem cell transplant.\textsuperscript{16} Pediatric oncology nurses
have direct responsibility for physical and developmental assessment,
treatment, education, and anticipatory guidance.\textsuperscript{7} They
are specifically trained to recognize and manage the complications of
childhood cancer and its treatment, including malnutrition and
associated symptoms of nausea, vomiting, mucositis, pancytopenia,
immunodeficiency, infection, pain, and psychosocial issues.
Advanced-practice nurses often have additional responsibility for the
comprehensive medical management of children with cancer, coordinating
care across inpatient, outpatient, and home settings, while providing
preventive services, therapeutic procedures for patients, and education
for professional staff.

Nutritional screening and assessment is vital to identifying and
managing any cancer-related nutritional problems.\textsuperscript{16}For
example, pediatric allogeneic hematopoietic stem cell transplant (HSCT)
is a lifesaving procedure and curative treatment for hematologic
disorders\textsuperscript{17}, but some symptoms after transplantation
can be difficult for children to tolerate, sometimes making nutrition
problemmatic.\textsuperscript{18}

Evaluation of nutrition in children in the first days after
transplantation can be challenging. The daily calorie requirement
suitable for the age period of the child, determining which food to
include during treatment, and managing of symptoms such as nausea, taste
changes, oral mucositis, diarrhea, constipation, and pain affect the
treatment process positively by providing better nutrition of the
child.\textsuperscript{1,8,19,20}

Although there are many studies evaluating anthropometric measurements
in children over time during the stem cell transplantation process,
there are only a limited number on the relationship between appetite and
eating disorder.\textsuperscript{20} In this study, the objective was to
determine the pre- and post-transplant appetite and nutritional status
of children with stem cell transplantation.

\textbf{PATIENT AND METHODS}

\textbf{Study design and Setting}

This descriptive study was carried out between November 2018 and
November 2020 in Ankara, Turkey at the Bone Marrow Transplantation Unit
of Gulhane Training and Research Hospital, and at Ankara Pediatric
Hematology Oncology Training and Research Hospital.

\textbf{Patients}

\textbf{Inclusion criteria:} Children between the ages of 8-18 years,
who did not have a secondary disease (such as diabetes, metabolic
disease), were diagnosed with cancer, and who were scheduled for stem
cell transplantation were included in the study.

\textbf{Measuring tools}

Seven days before stem cell transplant (T1); transplant day (T2); Day 1
post-transplant (T3), Day 14 post-transplant (T4); and Day 30
post-transplant (T5); body weight for age; height for age; MUAC
measurement; BMI, and Pediatric Functional Assessment of Anorexia and
Cachexia Treatment (Peds-FAACT). World Health Organization (2007) growth
charts were used for weight, height, and BMI
evaluation.\textsuperscript{21} Percentages of weight-for-age (WFA),
height-for-age (HFA), BMI and MUAC were calculated. All the cases were
evaluated according to the Waterlow and Gomez
classifications.\textsuperscript{22,23}

\textbf{2.3.1. Body weight for age:} Body weight was measured using an
SC-105 model electronic body scale from Bari-Med. Weight was recorded to
the nearest 0.1 kg. The literature describes two methods that are
frequently used to evaluate risk of malnutrition. In the current study,
first is Gomez classification that was used for evaluation of weight for
age ratio.\textsuperscript{23} The body weight percentile that is below
the 90th is considered risky in terms of nutrition. Second, a decrease
of more than 5\% body weight in a month was considered a nutritional
risk.\textsuperscript{1} Both of two methods were used in our study.
World Health Organization (WHO) growth charts were used for weight
evaluation.\textsuperscript{21}

\textbf{2.3.2. Height for age (HFA):} Height was measured using the
Stadiometer model S100 height rod from Ayrton (Frankfurt, Germany).
Height was recorded to the nearest 0.1 cm. The anthropometric indices
were calculated using a reference median and classified according to
percentiles based on the World Health Organization (WHO) child growth
standards.\textsuperscript{21} All the cases were evaluated according to
the Waterlow classification.\textsuperscript{23} For the evaluation of
acute and chronic malnutrition, classification was made taking HFA into
consideration on the Waterlow classification. A HFA within the ranges
90-95\%, 85-90\% or below 85\% corresponds to mild malnutrition,
moderate malnutrition, and severe malnutrition, respectively.

\textbf{2.3.3. Mid Upper Arm Circumference (MUAC):} Arm soft tissue
includes subcutaneous adipose tissue and muscle tissue. For this reason,
the arm circumference narrows as a result of the reduction of one or
both of these two tissues. Upper middle arm circumference is an
anthropometric measurement frequently used in children with
cancer.\textsuperscript{24-27} In this study, the researcher made the
measurement while the child was standing upright, and with his or her
arm bent 90 degrees at the elbow and the palm facing the ground. A mark
was placed on the acromion. The point between the olecranon and the
acromion was determined, and the arm was then released. The graduated
arm was held at a right angle to the arm. The mid-upper arm
circumference was measured with flexible tape to the nearest 0.1 cm at
the halfway point between the acromion and olecranon process of the
right upper arm.

The anthropometric indices were calculated using a reference median and
classified according to percentiles based on the WHO child growth
standards.\textsuperscript{21}

\textbf{2.3.4. Body Mass Index (BMI) :} BMI was calculated from the
weight and height measurements in kg/m\textsuperscript{2}. World Health
Organization (WHO) growth charts were used for BMI
evaluation.\textsuperscript{21}

\textbf{2.3.5. Pediatric Anorexia and Cachexia Functional Assessment
Scale (Peds-FAACT scale):} Children's anorexia-eagerness to eat was
evaluated using the Peds-FAACT scale, a useful tool developed by Lai et
al. for evaluating anorexia and cachexia in children with
cancer.\textsuperscript{28} In this scale, the score varies between
''0'' and ''40'', with a low value indicating that the risk of anorexia
and cachexia is high, and higher values indicating that the nutritional
status of the patient is better and the risk of anorexia is low.

\textbf{Procedure}

Weight and height for age were measured and recorded as T1, T2, T3, T4,
and T5 by the same researcher. After anthropometric measurements were
taken at each time point, the Peds-FAACT scale was completed. Among the
anthropometric measurement results, such as height for age, weight for
age, and BMI for age, values were evaluated using 2007 standards in the
AnthroPlus computer program created for children aged 5-19
years.\textsuperscript{21} In current study, \textgreater{}5\% loss of
weight for age was accepted as undernutrition in pediatric cancer
patients undergoing stem cell transplantation.\textsuperscript{29}

\textbf{Research hypotheses}

In this current study research hypotheses were:

H\textsubscript{0}: There is no difference between pre- and
post-transplant appetite and nutritional status in children with stem
cell transplantation.

H\textsubscript{1}: There is a difference between pre- and
post-transplant appetite and nutritional status in children with stem
cell transplantation.

\textbf{Data Analysis}

Data were analyzed with IBM SPSS V23. Conformity to normal distribution
was examined using the Shapiro-Wilk test. Repeated analysis of variance
was used to compare normally distributed data over three or more times.
The Pearson correlation coefficient was used to examine the relationship
between normally distributed data. The Friedman test was used to compare
triple and categorized data according to time. Analysis results were
presented as mean \selectlanguage{ngerman}± standard deviation and median (minimum-maximum) for
quantitative data, and as frequency (percentage) for categorical data.
The significance level was defined as p \textless{}0.050.

\textbf{Ethical Considerations}

The study obtained approval from the Ethics Committee (25-46418926), and
permission for the study was obtained from both two hospitals. All the
participants were informed about the aim and method of this study by the
researcher, and gave written informed consent.

\textbf{RESULTS}

Fifty-two percent (52\%) of patients were female, and 32\% were
diagnosed with acute lymphoblastic leukemia. The patients ranged from
age eight to age 18, with a mean age of 13.2 years (\emph{+} 3.5 months)
(Table 1).

There was a statistically significant difference between the means of
body weight over time (p \textless{}0.001). The average body weight for
age at first hospitalization was 47.80 kg \emph{+} 19.79; the mean
weight on day of transplant was 46.46 kg \emph{+} 19.20; on Day 1 after
transplantation, the mean weight was 46.21 kg \emph{+} 19.48; on Day 14
after transplantation, mean weight was 44.92 kg \emph{+} 18.92; and 30
days post-transplantation, mean weight was 45.79 kg + 18.29 (Table 2).

There was a statistically significant difference between the means of
BMI values according to time (p\textless{}0.001). At first
hospitalization, BMI averaged 19.69 \emph{+} 4.19. Other results appear
in Table 2. There was also a statistically significant difference
between the means of MUAC values according to time (p\textless{}0.001).
The mean MUAC at first hospitalization was 25.31 \emph{+} 6.07. (Other
results appear in Table 2).

At Day 14 post-transplantation, there was a loss of more than 5\% of
body weight in 61\% of the children (n=14) as compared to weight at Day
1 of hospitalization post-transplantation (Table 3).

Fifty-two percent (52\%) of patients had no change in their food taste
at the time of first hospitalization; 64\% of patients had minimal
change in food taste on the day of transplantation; 44\% had a slight
and slightly change in food taste on Day 1 post-transplantation; at Day
14, 40\% stated that there was some change in food taste; and at Day 30
post-transplantation, 40\% had very little change in food taste. There
was a statistically significant difference between the distributions of
change in food taste over time (p\textless{}0.001) (Table 4).

Regarding food smell, 56\% of patients experienced no change. Table 4
shows the rest of the results at the various time points. There was no
statistically significant difference between the distributions of other
variables over time (p\textgreater{}0.05).

\textbf{DISCUSSION}

In this study, the pre- and post-transplant appetite and nutritional
status of children who underwent stem cell transplantation were
evaluated over the first month. The fact that the treatment regimen
after stem cell transplantation causes symptoms for vomiting, anorexia,
oral mucositis, diarrhea, pain, change in taste, and decreased oral
intake in children poses a risk for the development of
malnutrition.\textsuperscript{25,27} Although there are many studies
showing decreased appetite associated with cancer and its treatment in
children.\textsuperscript{27,30,31}, there are only a limited number of
studies analyzing appetite following stem cell
transplantation.\textsuperscript{32} The qualitative study by Loves et
al. of children with cancer treatment and children with stem cell
transplantation found that appetite decreased in children after
chemotherapy treatment and stem cell
transplantation.\textsuperscript{33} In the study by Koç, et al., which
evaluated nutritional status after stem cell transplantation, a 46\%
decrease in energy intake and a 47\% decrease in protein intake were
found two weeks after the transplant.\textsuperscript{26} In our study,
which aligns with Koç's work, the average number of meals eaten by the
children decreased versus the number both before and the day of
transplantation. Also, the number of meals was \textless{} 2 on the 14th
day after the transplant, and the children skipped at least one meal Day
1 post-transplant and on Day 30 after the transplant. Parenteral
nutrition therapy was initiated in patients who could not be fed
enterally due to insufficient oral intake resulting from mucositis,
skipping meals and lack of appetite, posing a risk for malnutrition.
This process could be managed effectively.

\textbf{Anthropometric measurements over time}

The malnutrition rate in children after transplantation ranges between
20-50\%.\textsuperscript{3,25-27,30} In the study of Koç, et al., which
compared the nutritional status of a study group of 40 children who
underwent hematopoietic stem cell transplantation against a control
group of 20 healthy children, malnutrition was detected in almost half
of the study group.\textsuperscript{26} But in determining malnutrition
during the transplant process, it is not sufficient to consider body
weight as the only anthropometric measurement.\textsuperscript{7,24}Body
weight may also be affected by hydration during chemotherapy and does
not identify any long-term changes in body cell
mass.\textsuperscript{34} Therefore, in our study, body weight was used
as a measurement tool in evaluating growth with height, BMI,
MUAC.\textsuperscript{1,7,16}

In a study of Zemrani et al. (2020), which evaluated the nutritional
status and anthropometric measurements of 27 children who underwent stem
cell transplantation, researchers found that the body weight of the
children decreased in the first and third months after transplantation
as compared to the pre-transplant period.\textsuperscript{34} Moreover,
at the end of the first year, the body weight z score was higher than
the pre-transplant value. In our study, it was determined that the
decrease in the average body weight of children on Day 14
post-transplantation was statistically significant. This early
recognition of the change in the nutritional status and anthropometric
measurements of the children, especially on that 14th day, contributed
to the determination of needed nutritional supportren. Daily monitoring
of body weight by nurses who care for children after transplantation is
an important indicator, as well as other methods, for the nutritional
team to assess the need for nutritional support.\textsuperscript{20} In
the study by Koç et al., which compared the upper middle arm
circumference as an indicator of the nutritional status of healthy
children with transplantation, there was no difference between the two
groups in post-transplant follow-up
controls.\textsuperscript{26}However, prior to transplantation, the
upper middle arm circumference in children to be transplanted was lower
than that of the healthy children.

Factors affecting anorexia/cachexia include, but are not limited to,
treatment cycle, duration after receiving treatment, and disease
severity. As for the peds-FAACT scale, which was developed to detect
anorexia/cancer cachexia, the authors stated that scale could not
clearly distinguish between patients in different clinical groups due to
the limited sample size in each subgroup of the
scale.\textsuperscript{28} Therefore, the authors suggested conducting
studies using the peds-FAACT scale according to treatment regimens,
duration after treatment, and disease severity.

\textbf{Change in sense of taste and smell}

Taste change associated with treatment may affect nutritional status and
cause malnutrition in pediatric cancer patients undergoing
treatment.\textsuperscript{10,11,34,35} Children defined food as tasting
''funny'', ''not right'', or ''different'' in the qualitative study by
Loves et al., which evaluated the taste changes of children during
cancer treatment and HCT process.\textsuperscript{33} In the same study,
the change in taste caused children to modify their food preferences.
One child expressed the change in taste as ''{[}I was{]} less
{[}hungry{]} because nothing tasted''. In the study by Skolin et al.,
children who received chemotherapy treatment for cancer and their
parents stated that taste change was the key source of nutritional
problems.\textsuperscript{11}

In addition to taste changes, the smell function can also be
affected.\textsuperscript{33} In the study by van den Brink et al, which
compared the taste and smell functions of 24 healthy controls with 31
children receiving cancer treatment, researchers found that the smell
function was affected similarly to our study
finding.\textsuperscript{10,18} In the same study, approximately
one-third of the children reported a decrease in appetite, and 12\%
stated that there was a bad change in the sense of
taste.\textsuperscript{10,18} Consistent with the literature, which
describes a change in the taste of food on the 14th day
post-transplantation, a change in the smell of food on the first and
14th days post-transplantation, and a decrease in the number of meals on
the 14th day, the nurses caring for transplanted children should guide
the nutrition team to meet the necessary support.

\textbf{CONCLUSION}

Considering that the changes in food taste and odor by the children
increase on Day 14 post-transplantation, according to our study results,
the health team members in the clinic should closely follow the changes
in the nutritional status of the child to ensure timely access to the
clinical nutrition team for starting nutritional support. In addition,
as part of this effort, it is recommended that anthropometric
measurements be evaluated.

A nutritional assessment to detect malnourished patients or patients at
risk of malnutrition, which includes anthropometric measurements, and
observation of changes to smell and taste, should be performed on
children in transplantation units. The current study showed that a
multidisciplinary approach to the nutritional care of children is vital
for improving nutritional status after HSCT, as recommended
in\emph{Improving Outcomes Guidance for Children and Young People with
Cancer} (National Institute for Health and Clinical Excellence (NICE,
2005). Healthcare professionals should be aware that malnutrition will
lead to more complications in children scheduled for transplantation in
stem cell transplant units.

The study has several limitations. First, this study evaluated the
nutritional status and appetite status of children for only 30 days
post-transplantation. In contrast, the studies in the literature that
evaluated the long-term nutritional status of children after
transplantation found that anthropometric measurements reached the
pre-transplant level approximately one year after transplantation. Since
the peds-FAACT scale was used in children with stem cell
transplantation, it is recommended that long-term studies be conducted
to determine whether there is a relationship between nutritional status
and the peds-FAACT scale. Second, considering that the sample group was
small, and was not homogenous according to diagnoses, it is difficult to
generalize the findings. Thus, it is recommended that a study being
planned using a homogeneous sample or a sample grouped according to
diagnosis and the type of transplant. Fourth, while the changes in taste
and smell were considered, other important factors, such as oral
mucositis and nausea were not included in the study. Finally, we
recommend that studies be conducted to investigate the relationship
between Children's International Mucositis Evaluation Scale (ChIMES)---a
scale for detecting oral mucositis before and after
transplantation---and Peds-FAACT.

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2. Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition
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3. Papadopoulou A. Nutritional considerations in children undergoing
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4. Marín Caro MM, Laviano A, Pichard C. Nutritional intervention and
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5. Khan, A. U., Sheikh, M. U., \& Intekhab, K. (2006). Effect of
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6. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric
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7. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric
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8. Hoffmeister PA, Storer BE, Macris PC, Carpenter PA, Baker KS.
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9. Arpaci T, Toruner EK, Altay N. Assessment of Nutritional Problems in
Pediatric Patients with Cancer and the Information Needs of Their
Parents: A Parental Perspective. \emph{Asia Pac J Oncol
Nurs.}2018;5(2):231-236.

10. van den Brink M, IJpma I, van Belkom B, Fiocco M, Havermans RC,
Tissing WJE. Smell and taste function in childhood cancer patients: a
feasibility study. \emph{Support Care Cancer.} 2021;29(3):1619-1628.

11. Skolin I, Hursti UK, Wahlin YB. Parents' perception of their child's
food intake after the start of chemotherapy. \emph{J Pediatr Oncol
Nurs.} 2001;18(3):124-136.

12. Fox MK, Devaney B, Reidy K, Razafindrakoto C, Ziegler P.
Relationship between portion size and energy intake among infants and
toddlers: evidence of self-regulation. \emph{J Am Diet Assoc.}2006;106(1
Suppl 1):S77-S83.

13. Muscaritoli M, Grieco G, Capria S, Iori AP, Rossi Fanelli F.
Nutritional and metabolic support in patients undergoing bone marrow
transplantation. \emph{Am J Clin Nutr.} 2002;75(2):183-190.

14. Angelucci E, Matthes-Martin S, Baronciani D, et al. Hematopoietic
stem cell transplantation in thalassemia major and sickle cell disease:
indications and management recommendations from an international expert
panel. \emph{Haematologica.} 2014;99(5):811-820.

15. National Institute for Health and Clinical Excellence (2005).
Improving outcomes in children and young people with cancer: an
assessment of need for child and adolescent cancer services. Available
online at www.nice.org.uk/Guidance/CSGC YP (Last accessed: March 1,
2021).

16. Selwood K, Ward E, Gibson F. Assessment and management of
nutritional challenges in children's cancer care: a survey of current
practice in the United Kingdom. \emph{Eur J Oncol
Nurs.}2010;14(5):439-446.

17. Fuji S, Mori T, Khattry N, et al. Severe weight loss in 3 months
after allogeneic hematopoietic SCT was associated with an increased risk
of subsequent non-relapse mortality. \emph{Bone Marrow
Transplant.}2015;50(1):100-105.

18. Fuji S, Mori T, Khattry N, et al. Severe weight loss in 3 months
after allogeneic hematopoietic SCT was associated with an increased risk
of subsequent non-relapse mortality. \emph{Bone Marrow Transplant} .
2015;50(1):100-105.

19. Baumgartner A, Hoskin K, Schuetz P. Optimization of nutrition during
allogeneic hematologic stem cell transplantation. \emph{Curr Opin Clin
Nutr Metab Care.} 2018;21(3):152-158.

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associated with worse health-related quality of life in children with
cancer. \emph{Support Care Cancer.} 2015;23(10):3043-3052.

21. WHO Multicentre Growth Reference Study Group. 2007.

22. Gomez F, Galvan RR, Frenk S, Munoz JC, Chavez R, Vazquez J.
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(Lond).} 1956;2(2):77-83.

23. Waterlow JC. Classification and definition of protein-calorie
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24. Mosby TT, Barr RD, Pencharz PB. Nutritional assessment of children
with cancer. \emph{J Pediatr Oncol Nurs.} 2009;26(4):186-197.

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North Am.} 1998;27(2):347-369.

26. Koç N, Gündüz M, Tavil B, et al. Beneficial Effect of the
Nutritional Support in Children Who Underwent Hematopoietic Stem Cell
Transplant. \emph{Exp Clin Transplant.} 2017;15(4):458-462.

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concerns of survivors of childhood cancer: A ''First World''
perspective. Pediatr Blood Cancer. 2020;67 Suppl 3:e28193.

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Anorexia/cachexia-related quality of life for children with
cancer.\emph{Cancer.} 2005;104(7):1531-1539.

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malignancy in childhood: common but mostly missed. \emph{Eur J
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study. \emph{Am J Clin Nutr.} 1997;65(1):95-100.

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a new meal system in a children's cancer ward{]}. \emph{Ugeskr
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35. Bechard LJ, Guinan EC, Feldman HA, Tang V, Duggan C. Prognostic
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Parenter Enteral Nutr.} 2007;31(4):295-301.

Table 1. Frequency distribution of demographic data (n=25)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Characteristic}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Characteristic}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Number (n)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Percent (\%)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Gender}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Gender}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Gender}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Gender}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Female\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
52.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Male\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
48.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Diagnosis}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Diagnosis}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Diagnosis}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Diagnosis}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Acute lymphoblastic leukemia(ALL)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
48.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Acute myeloid leukemia (AML)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
28.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Aplastic anemia\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
16.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Thalassemia\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Clinical variables}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Source of hematopoietic stem cell}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Source of hematopoietic stem cell}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Source of hematopoietic stem cell}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Source of hematopoietic stem cell}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Peripheral stem cell\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
52.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Bone marrow\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
48.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Relationship to donor}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Relationship to donor}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Relationship to donor}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Relationship to donor}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Related\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
32\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Unrelated\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
17\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
68\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Outcome}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Alive\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
100\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Age} (mean \selectlanguage{ngerman}± Standard Deviation / Median (min. -- max.)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Age} (mean \selectlanguage{ngerman}± Standard Deviation / Median (min. -- max.)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13.2 \selectlanguage{ngerman}± 3.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
15.0 (8.0 -- 18.0)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2. Comparison of quantitative variables according to time (n=25)\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
& \textbf{T1} & \textbf{T2} & \textbf{T3} & \textbf{T4} & \textbf{T5} &
\textbf{Test statistics} & \textbf{p}\tabularnewline
\midrule
\endhead
& Mean\selectlanguage{ngerman}±SD Median (min. -- maks.) & Mean\selectlanguage{ngerman}±SD Median (min. -- maks.) &
Mean\selectlanguage{ngerman}±SD Median (min. -- maks.) & Mean\selectlanguage{ngerman}±SD Median (min. -- maks.) &
Mean\selectlanguage{ngerman}±SD Median (min. -- maks.) & &\tabularnewline
Height for age & 152.12 \selectlanguage{ngerman}± 20.46 & 152.16 \selectlanguage{ngerman}± 20.44 & 152.16 \selectlanguage{ngerman}± 20.44 &
151.44 \selectlanguage{ngerman}± 20.15 & 152.12 \selectlanguage{ngerman}± 20.51 & F=1.685 & 0.207\tabularnewline
& 156.00 (118.00 -- 182.00) & 156.00 (118.00 -- 182.00) &
156.00(118.00-- 182.00) & 152.00 (118.00- 182.00) & 156.00 (118.00 --
182.00) & &\tabularnewline
Weight for age & 47.80 \selectlanguage{ngerman}± 19.79\textsuperscript{c} & 46.46 \selectlanguage{ngerman}±
19.20\textsuperscript{b} & 46.21 \selectlanguage{ngerman}± 19.48\textsuperscript{b} & 44.92 \selectlanguage{ngerman}±
18.92\textsuperscript{a} & 45.79 \selectlanguage{ngerman}± 18.29\textsuperscript{ab} & F=15.566
& \textbf{\textless{}0,001}\tabularnewline
& 45.00 (20.00 -- 88.00) & 45.20 (19.00 -- 86.00) & 45.00 (18.00 --
86.00) & 42,00 (17.00 -- 84.00) & 46.00 (18.00 -- 85.00) &
&\tabularnewline
BMI & 19.69 \selectlanguage{ngerman}± 4.19\textsuperscript{c} & 19.20 \selectlanguage{ngerman}±
4.48\textsuperscript{abc} & 19.01 \selectlanguage{ngerman}± 4.15\textsuperscript{b} & 18.47 \selectlanguage{ngerman}±
3.91\textsuperscript{a} & 18.82 \selectlanguage{ngerman}± 3.84\textsuperscript{ab} & F=7.727 &
\textbf{\textless{}0.001}\tabularnewline
& 20.00 (12.00 -- 27.00) & 19.68 (11.00 -- 30.00) & 20.00 (11.00 --
26.00) & 19.40 (11.00--25.00) & 20.00 (11.00 -- 26.00) &
&\tabularnewline
MUAC & 25.31 \selectlanguage{ngerman}± 6.07\textsuperscript{c} & 24.14 \selectlanguage{ngerman}± 5.70\textsuperscript{b}
& 24.12 \selectlanguage{ngerman}± 6.05\textsuperscript{b} & 22.92 \selectlanguage{ngerman}± 5.57\textsuperscript{a} &
22.94 \selectlanguage{ngerman}± 5.16\textsuperscript{a} & F=23.686 &
\textbf{\textless{}0.001}\tabularnewline
& 25.00 (15.00 -- 34.00) & 24.00 (15.00 -- 33.00) & 24.00 (13.00 --
33.00) & 23.00 (13.00--31.00) & 24.00 (13.00 -- 31.00) &
&\tabularnewline
Number of meal/day & 2.88 \selectlanguage{ngerman}± 0.44\textsuperscript{a} & 2.48 \selectlanguage{ngerman}±
0,71\textsuperscript{a} & 2.64 \selectlanguage{ngerman}± 0.49\textsuperscript{a} & 1.88 \selectlanguage{ngerman}±
0.60\textsuperscript{b} & 2.68 \selectlanguage{ngerman}± 0.48\textsuperscript{a} & F=18.246 &
\textbf{\textless{}0.001}\tabularnewline
& 3.00 (2.00 -- 4.00) & 3.00 (1.00 -- 3.00) & 3.00 (2.00 -- 3.00) & 2.00
(1.0--3.00) & 3,00 (2.00 -- 3.00) & &\tabularnewline
Peds-FAACT Scale & 16.60 \selectlanguage{ngerman}± 5.12 & 17.44 \selectlanguage{ngerman}± 4.23 & 17.24 \selectlanguage{ngerman}± 4.51 & 19.24 \selectlanguage{ngerman}±
5.31 & 18.04 \selectlanguage{ngerman}± 3.23 & F=1.459 & 0.235\tabularnewline
& 16.00 (9.00 -- 27.00) & 18.00 (9.00 -- 24.00) & 17.00 (9.00 -- 27.00)
& 19.00 (12.00--31.00) & 18.00 (13.00 -- 25.00) & &\tabularnewline
T1: First hospitalization; T2: Transplantation day; T3: First day after
transplantation; T4: Day 14 after transplantation; T5: Day 30 after
transplantation; F: Repeated variance analysis test statistics, a-c:
There is no difference between times with the same letter, MUAC: Mid
upper arm circumference & T1: First hospitalization; T2: Transplantation
day; T3: First day after transplantation; T4: Day 14 after
transplantation; T5: Day 30 after transplantation; F: Repeated variance
analysis test statistics, a-c: There is no difference between times with
the same letter, MUAC: Mid upper arm circumference & T1: First
hospitalization; T2: Transplantation day; T3: First day after
transplantation; T4: Day 14 after transplantation; T5: Day 30 after
transplantation; F: Repeated variance analysis test statistics, a-c:
There is no difference between times with the same letter, MUAC: Mid
upper arm circumference & T1: First hospitalization; T2: Transplantation
day; T3: First day after transplantation; T4: Day 14 after
transplantation; T5: Day 30 after transplantation; F: Repeated variance
analysis test statistics, a-c: There is no difference between times with
the same letter, MUAC: Mid upper arm circumference & T1: First
hospitalization; T2: Transplantation day; T3: First day after
transplantation; T4: Day 14 after transplantation; T5: Day 30 after
transplantation; F: Repeated variance analysis test statistics, a-c:
There is no difference between times with the same letter, MUAC: Mid
upper arm circumference & T1: First hospitalization; T2: Transplantation
day; T3: First day after transplantation; T4: Day 14 after
transplantation; T5: Day 30 after transplantation; F: Repeated variance
analysis test statistics, a-c: There is no difference between times with
the same letter, MUAC: Mid upper arm circumference & T1: First
hospitalization; T2: Transplantation day; T3: First day after
transplantation; T4: Day 14 after transplantation; T5: Day 30 after
transplantation; F: Repeated variance analysis test statistics, a-c:
There is no difference between times with the same letter, MUAC: Mid
upper arm circumference & T1: First hospitalization; T2: Transplantation
day; T3: First day after transplantation; T4: Day 14 after
transplantation; T5: Day 30 after transplantation; F: Repeated variance
analysis test statistics, a-c: There is no difference between times with
the same letter, MUAC: Mid upper arm circumference\tabularnewline
\bottomrule
\end{longtable}

Table 3. Malnutrition rates according to different assessments by time
(n=25)\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
& & T1 & T1 & T2 & T2 & T3 & T3 & T4 & T4 & T5 & T5\tabularnewline
\midrule
\endhead
& & n & \% & n & \% & n & \% & n & \% & n & \%\tabularnewline
Height for age* & Severe malnutrition & 10 & 40 & 10 & 40 & 10 & 40 & 10
& 40 & 10 & 40\tabularnewline
& Modarete malnutrition & 12 & 48 & 12 & 48 & 12 & 48 & 12 & 48 & 12 &
48\tabularnewline
& Mild malnutrition & 3 & 12 & 3 & 12 & 3 & 12 & 3 & 12 & 3 &
12\tabularnewline
& Normal & - & - & - & - & - & - & - & - & - & -\tabularnewline
Weight for age** & Severe malnutrition & 11 & 44 & 13 & 52 & 13 & 52 &
13 & 52 & 14 & 56\tabularnewline
& Moderate malnutrition & 9 & 36 & 7 & 28 & 7 & 28 & 9 & 36 & 9 &
36\tabularnewline
& Mild malnutrition & 3 & 12 & 3 & 12 & 3 & 12 & 1 & 4 & 1 &
4\tabularnewline
& No malnutrition & 2 & 8 & 2 & 8 & 2 & 8 & 2 & 8 & 1 & 4\tabularnewline
Change & Increased & - & - & 3\textsuperscript{a} & 12 &
2\textsuperscript{b} & 8 & 1\textsuperscript{c} & 4 &
5\textsuperscript{d} & 20\tabularnewline
of & Stable & - & - & 3\textsuperscript{a} & 12 & 2\textsuperscript{b} &
8 & 1\textsuperscript{c} & 4 & 2\textsuperscript{d} & 8\tabularnewline
weight & Decreased & - & - & 19\textsuperscript{a} & 76 &
21\textsuperscript{b} & 84 & 23\textsuperscript{c} & 92 &
18\textsuperscript{d} & 72\tabularnewline
for age & \textless{}5\% & & & 17 & 89.5 & 19 & 90.5 & 9 & 39 & 10 &
55.5\tabularnewline
& More than 5\% & & & 2 & 10.5 & 2 & 9.5 & 14 & 61 & 8 &
44.5\tabularnewline
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: Day 30
post-transplantation; a: differences between T1 and T2; b: differences
between T1 and T3; c: differences between T1 and T4; d: differences
between T1 and T5; * The cases were evaluated according to the Waterlow
classification; ** The cases were evaluated according to the Gomez
classification. & T1: First hospitalization; T2: Transplantation day;
T3: Day 1 post-transplantation, T4: Day 14 post-transplantation; T5: Day
30 post-transplantation; a: differences between T1 and T2; b:
differences between T1 and T3; c: differences between T1 and T4; d:
differences between T1 and T5; * The cases were evaluated according to
the Waterlow classification; ** The cases were evaluated according to
the Gomez classification. & T1: First hospitalization; T2:
Transplantation day; T3: Day 1 post-transplantation, T4: Day 14
post-transplantation; T5: Day 30 post-transplantation; a: differences
between T1 and T2; b: differences between T1 and T3; c: differences
between T1 and T4; d: differences between T1 and T5; * The cases were
evaluated according to the Waterlow classification; ** The cases were
evaluated according to the Gomez classification. & T1: First
hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: Day 30
post-transplantation; a: differences between T1 and T2; b: differences
between T1 and T3; c: differences between T1 and T4; d: differences
between T1 and T5; * The cases were evaluated according to the Waterlow
classification; ** The cases were evaluated according to the Gomez
classification. & T1: First hospitalization; T2: Transplantation day;
T3: Day 1 post-transplantation, T4: Day 14 post-transplantation; T5: Day
30 post-transplantation; a: differences between T1 and T2; b:
differences between T1 and T3; c: differences between T1 and T4; d:
differences between T1 and T5; * The cases were evaluated according to
the Waterlow classification; ** The cases were evaluated according to
the Gomez classification. & T1: First hospitalization; T2:
Transplantation day; T3: Day 1 post-transplantation, T4: Day 14
post-transplantation; T5: Day 30 post-transplantation; a: differences
between T1 and T2; b: differences between T1 and T3; c: differences
between T1 and T4; d: differences between T1 and T5; * The cases were
evaluated according to the Waterlow classification; ** The cases were
evaluated according to the Gomez classification. & T1: First
hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: Day 30
post-transplantation; a: differences between T1 and T2; b: differences
between T1 and T3; c: differences between T1 and T4; d: differences
between T1 and T5; * The cases were evaluated according to the Waterlow
classification; ** The cases were evaluated according to the Gomez
classification. & T1: First hospitalization; T2: Transplantation day;
T3: Day 1 post-transplantation, T4: Day 14 post-transplantation; T5: Day
30 post-transplantation; a: differences between T1 and T2; b:
differences between T1 and T3; c: differences between T1 and T4; d:
differences between T1 and T5; * The cases were evaluated according to
the Waterlow classification; ** The cases were evaluated according to
the Gomez classification. & T1: First hospitalization; T2:
Transplantation day; T3: Day 1 post-transplantation, T4: Day 14
post-transplantation; T5: Day 30 post-transplantation; a: differences
between T1 and T2; b: differences between T1 and T3; c: differences
between T1 and T4; d: differences between T1 and T5; * The cases were
evaluated according to the Waterlow classification; ** The cases were
evaluated according to the Gomez classification. & T1: First
hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: Day 30
post-transplantation; a: differences between T1 and T2; b: differences
between T1 and T3; c: differences between T1 and T4; d: differences
between T1 and T5; * The cases were evaluated according to the Waterlow
classification; ** The cases were evaluated according to the Gomez
classification. & T1: First hospitalization; T2: Transplantation day;
T3: Day 1 post-transplantation, T4: Day 14 post-transplantation; T5: Day
30 post-transplantation; a: differences between T1 and T2; b:
differences between T1 and T3; c: differences between T1 and T4; d:
differences between T1 and T5; * The cases were evaluated according to
the Waterlow classification; ** The cases were evaluated according to
the Gomez classification. & T1: First hospitalization; T2:
Transplantation day; T3: Day 1 post-transplantation, T4: Day 14
post-transplantation; T5: Day 30 post-transplantation; a: differences
between T1 and T2; b: differences between T1 and T3; c: differences
between T1 and T4; d: differences between T1 and T5; * The cases were
evaluated according to the Waterlow classification; ** The cases were
evaluated according to the Gomez classification.\tabularnewline
\bottomrule
\end{longtable}

Table 4. Distribution of appetite and nutritional status by time (n=25)\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{T1} \textbf{n \%}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{T2} \textbf{n \%}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{T3} \textbf{n \%}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{T4} \textbf{n \%}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{T5} \textbf{n \%}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Test statistics}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Change in sense of taste\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is little change\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (24)\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
16 (64)\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
11 (44)\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\textsuperscript{ab}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (40)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\(\chi^{2}\)=23.068\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is some change\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
11 (44)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (40)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is a lot of change\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5 (20)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2 (8)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8 (32)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is no change in taste\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
13 (52)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8 (32)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Change in sense of smell\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is little change\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (24)\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
15 (60)\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (40)\textsuperscript{ab}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (24)\textsuperscript{ab}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\(\chi^{2}\)=20.083\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is some change\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2 (8)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12 (48)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14 (56)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9 (36)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is a lot of change\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3 (12)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2 (8)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5 (20)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is no change in taste\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14 (56)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2 (8)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9 (36)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Appetite\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is no loss of appetite\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12 (48)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8 (32)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (40)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5 (20)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9 (36)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\(\chi^{2}\)=8.804\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.066\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is little loss of appetite\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14 (56)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
13 (52)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (40)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9 (36)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There is a modarete loss of appetite\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (24)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3 (12)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2 (8)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9 (36)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
There are a lot of loss of appetite\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
T1: First hospitalization; T2: Transplantation day; T3: Day 1
post-transplantation, T4: Day 14 post-transplantation; T5: day 30
post-transplantation; \selectlanguage{greek}χ\selectlanguage{english}2: Friedman test statistic; a-b: There is no
difference between times with the same letter.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\selectlanguage{english}
\FloatBarrier
\end{document}

