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.
INTRODUCTION
Malnutrition is very common in children who are receiving treatment for
cancer.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.2,3 Poor
nutritional status in children with cancer is associated with increased
infections, poor survival, and impaired health-related
quality-of-life.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.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
intensity1, this rate changes to 18-31% following
transplantation.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.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.7-,9 Complications of treatment, such
as changes in taste and smell, and oral mucositis, can cause
anorexia.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.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.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.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.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.1,12 A multidisciplinary approach is
recommended in Improving Outcomes Guidance for Children and Young
People with Cancer , a guidance developed by the National Institute for
Health and Clinical Excellence.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.16 Pediatric oncology nurses
have direct responsibility for physical and developmental assessment,
treatment, education, and anticipatory guidance.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.16For example, pediatric allogeneic hematopoietic stem cell transplant
(HSCT) is a lifesaving procedure and curative treatment for hematologic
disorders17, but some symptoms after transplantation
can be difficult for children to tolerate, sometimes making nutrition
problemmatic.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.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.20 In this study, the objective was to
determine the pre- and post-transplant appetite and nutritional status
of children with stem cell transplantation.
PATIENT AND METHODS
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.
Patients
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.
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.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.22,23
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.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.1 Both of two methods were used in our study.
World Health Organization (WHO) growth charts were used for weight
evaluation.21
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.21 All the cases were evaluated according to
the Waterlow classification.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.
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.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.21
2.3.4. Body Mass Index (BMI) : BMI was calculated from the
weight and height measurements in kg/m2. World Health
Organization (WHO) growth charts were used for BMI
evaluation.21
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.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.
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.21 In current study, >5% loss of
weight for age was accepted as undernutrition in pediatric cancer
patients undergoing stem cell transplantation.29
Research hypotheses
In this current study research hypotheses were:
H0: There is no difference between pre- and
post-transplant appetite and nutritional status in children with stem
cell transplantation.
H1: There is a difference between pre- and
post-transplant appetite and nutritional status in children with stem
cell transplantation.
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 ± standard deviation and median (minimum-maximum) for
quantitative data, and as frequency (percentage) for categorical data.
The significance level was defined as p <0.050.
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.
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 (+ 3.5 months)
(Table 1).
There was a statistically significant difference between the means of
body weight over time (p <0.001). The average body weight for
age at first hospitalization was 47.80 kg + 19.79; the mean
weight on day of transplant was 46.46 kg + 19.20; on Day 1 after
transplantation, the mean weight was 46.21 kg + 19.48; on Day 14
after transplantation, mean weight was 44.92 kg + 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<0.001). At first
hospitalization, BMI averaged 19.69 + 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<0.001).
The mean MUAC at first hospitalization was 25.31 + 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<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>0.05).
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.25,27 Although there are many studies
showing decreased appetite associated with cancer and its treatment in
children.27,30,31, there are only a limited number of
studies analyzing appetite following stem cell
transplantation.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.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.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 < 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.
Anthropometric measurements over time
The malnutrition rate in children after transplantation ranges between
20-50%.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.26 But in determining malnutrition
during the transplant process, it is not sufficient to consider body
weight as the only anthropometric measurement.7,24Body weight may also be affected by hydration during chemotherapy and
does not identify any long-term changes in body cell
mass.34 Therefore, in our study, body weight was used
as a measurement tool in evaluating growth with height, BMI,
MUAC.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.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.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.26However, 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.28 Therefore, the authors suggested conducting
studies using the peds-FAACT scale according to treatment regimens,
duration after treatment, and disease severity.
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.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.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.11
In addition to taste changes, the smell function can also be
affected.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.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.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.
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 inImproving 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.