Introduction
In Mexico, childhood cancer stands as a public health problem, being the leading cause of disease-related death among 5-14 year-olds1. The National Center for Child and Adolescent Health (CeNSIA, by its initials in Spanish), reported an estimated overall 5-year survival rate stands at 56%. Mexico falls below the standards observed in high-income countries, where an 80% cure rate is anticipated for patients1.
Based on data sourced from the National Registry of Childhood and Adolescent Cancer, the cancer incidence rates per million individuals until 2017 were documented as follows: Nationally, the rate was 89.6; with specific rates of 111.4 in children aged 0-9 years and 68.1 in adolescents aged 10-19 years2. Among specific age groups, those aged 0-4 years exhibited the highest incidence rate at 135.8, whereas adolescents aged 15-19 years had the lowest recorded incidence at 52.6. In terms of gender distribution, the data showed that 56% of the registered cases pertained to males, while 44% were attributed to females.
Between the 1st and 4th years of life, Central Nervous System tumors, retinoblastoma, renal tumors, and hepatic tumors prevail. From 10 to 19 years (adolescence), the types of cancer occurring most frequently are akin to those observed in adults and tend to be more aggressive.
Pediatric oncology patients are susceptible to developing malnutrition due to tumor characteristics, localization, stage, and the side effects of treatment3. The prevalence of malnutrition in children and adolescents with cancer ranges from 10.8% to 76%, depending on the disease stage at the time of diagnosis and the parameters used to assess nutritional status4. In a study involving Mexican children with acute lymphoblastic leukemia, with an average age of 5 years, the prevalence of malnutrition was 12%5. Malnutrition reduces treatment tolerance and increases infection rates, morbidity, and patient mortality4.
The ABC Medical Center, a nonprofit private institution, operates a Pediatric Oncology Center Program, dedicated to treating children and teens with cancer from all over Mexico, particularly those from underprivileged backgrounds. The Program represents a tripartite model of altruism funded by physicians, major donors, and institutional resources. Care is provided by pediatric oncologists, pediatric oncology surgeons, pediatricians, nutritionists, psychologists specialized in pediatric oncology, social workers, pediatric nursing professionals, and pediatric dentistry.
Evaluating the nutritional status of children and adolescents is crucial, primarily through pivotal markers such as weight and height. These indicators are readily accessible in clinical settings and demand minimal training for healthcare staff. Grasping the prevalence of underweight and stunted growth enables prompt interventions to avert malnutrition. The study aims to evaluate the nutritional status by determining the prevalence of low weight and short stature and their relationship with age among children and adolescents diagnosed with cancer at the tertiary level of care.
Materials and methods
An analytical, retrospective, and cross-sectional study was conducted. The study included patients admitted to the Pediatric Oncology Center Program at the ABC Medical Center between 2018 and 2023, under 18 years of age, of both sexes, socioeconomically vulnerable, without any affiliation to medical services, and originating from Mexico, with a diagnosis of cancer but no prior treatment. Patients with complete data for information analysis were included, after approval of the protocol by the Ethics Committee of CMABC with the registration number ABC-2332.
Data for the database with study variables were collected from patients’ medical records. The gathered data included sex, age, weight, height, date of birth, date of program entry, and cancer diagnosis.
The hospital follows standardized procedures for patient admission, including weight and height measurements performed by nursing staff. Precise measurements with an accuracy of 0.5 cm and 0.1 kg were taken using the Inbody 230 analyzer scale and SECA 206 wall stadiometer6. Measurements were taken after a 4-h fast and in disposable gowns.
Once patient information regarding weight, height, sex, and age was input into the database, percentile values were identified using the somatometric profile tables of Mexican children by Ramos Galván and Flores Huerta7.
The dependent variables of the study were: (1) underweight for age (UW/A), (2) underweight for height (UW/H), and (3) short stature for age (SS/A). The independent variable was the type of cancer (solid tumors and hematological neoplasms). Solid tumors encompassed brain tumors, retinoblastoma, germ cell tumors, sarcomas, neuroblastoma, Wilms tumor, Ewing’s sarcoma, and hepatoblastoma. Hematological neoplasms included acute lymphoblastic leukemia, Hodgkin lymphoma, and non-Hodgkin lymphomas.
Data analysis was performed using the statistical package for the social sciences version 24. Prevalence rates of UW/A, UW/H, and SS/A were estimated. The Mann–Whitney U test was utilized to compare percentiles between groups, and odds ratios were calculated. The statistical significance level was set at < 0.05.
Results
The sample comprises 80 children and adolescents diagnosed with cancer. Table 1 presents their general characteristics. As observed, 58.75% (n = 47) are male, and 42.5% are aged 11 years and older. Concerning the type of cancer, 68.8% (n = 55) of the patients have been diagnosed with solid tumors, while 31.3% (n = 25) have hematological neoplasms. Regarding their nutritional status, the prevalence rates of UW/A and UW/H (33.8% and 30.1%) exceed that of SS/A (13.8%).
Table 1. General characteristics of the study sample
| Groups of age (y.o.) | Study sample (n = 80) | Female (n = 33) | Male (n = 47) | |
|---|---|---|---|---|
| No. (%) | No. (%) | No. (%) | ||
| 0–5 | 28 (35) | 12 (36.4) | 16 (48.5) | |
| 6-10 | 18 (22.5) | 6 (18.2) | 12 (25.5) | |
| 11-18 | 34 (42.5) | 15 (45.5) | 19 (40.4) | |
| Cancer diagnosis | Total sample | UW/Aa | UW/Hb | SS/Ac |
| No. (%) | No. (%) | No. (%) | No. (%) | |
| Solid tumors | 55 (68.8) | 17 (21.3) | 15 (18.8) | 8 (10) |
| Hematological neoplasms | 25 (31.1) | 10 (12.5) | 9 (11.3) | 3 (3.8) |
| Total | 80 (100) | 27 (33.8) | 24 (30.1) | 11 (13.8) |
|
a UW/A: underweight for age; b UW/H: underweight for height; c SS/A: short stature for age. |
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In Table 2, the comparison between percentile groups of W/A, W/H, and H/A in children and adolescents is presented. It is observed that in the group of children aged < 10 years, the medians of the W/A, W/H, and H/A percentiles are lower than those of children > 11 years. Specifically, the median weight/height is notably lower in a statistically significant manner (p = 0.017).
Table 2. Comparison between percentile groups of W/A, W/H, and H/A in children and adolescents
| Variables | Group < 10 y.o. (n = 46) | Group > 11 y.o. (n = 34) | pa |
|---|---|---|---|
| Median (minimum-maximum) | Median (minimum-maximum) | ||
| Weight/age | 17.5 (3.0-97.0) | 37.5 (3.0-97.0) | 0.230 |
| Weight/height | 10.0 (3.0-97-0) | 37.5 (3.0-97.0) | 0.017 |
| Height/age | 37.5 (3.0-97.0) | 50.0 (3.0-97.0) | 0.557 |
|
a Mann–Whitney U test. UW/A: underweight for age; UW/H: underweight for height; SS/A: short stature for age. |
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Finally, the risk for children with low weight to present short stature is 12.75 times higher compared to those with normal weight (95% confidence interval [CI]: 2.513-64.665).
Discussion
The objective of this study was to determine the prevalence rates of nutritional status through low weight, low weight/height, and short stature in children and adolescents with cancer. In our study, the prevalence of low weight was 33%, and short stature was 13%. When compared to other countries, malnutrition prevalence rates in children and adolescents with cancer have been reported between 10% and 70%8. This wide range in malnutrition rates is due to differences in disease stages and diagnostic criteria. In Mexico, the prevalence of low weight and short stature in children under 5-year-old in the general population is 4.1% and 12.8%, respectively. In our study, the prevalence of low weight surpasses that of Mexican children in the same age group, likely due to the clinical condition of our study’s patients. Weight serves as an effective indicator to identify changes in the cancer patient’s condition9.
In a study conducted by Radhakrishnan et al.10, in India among oncology patients under 16 years old, the prevalence of low weight for age of 44% was reported, which exceeds our study’s findings. These differences may be attributed to socioeconomic disparities between populations. India has the highest number of children with growth stunting globally, primarily due to poor hygiene and inadequate access to sanitation11.
Prevalence rates of low weight in Mexican children with cancer reported in previous studies are lower. In a study conducted by Jaime-Pérez et al. in 2008 in children from the Northern region of the country, with an average age of 5 years and acute lymphoblastic leukemia, the prevalence of low weight was 12%, whereas, in our study, it was 33%.
In the Radhakrishnan et al. study, no significant differences were observed in nutritional status between patients with hematological neoplasms and solid tumors. This coincides with our results.
Moreover, in our study, it was observed that the group of children < 10 years old had lower average weight-for-height percentiles compared to those in the > 11 years old group (p = 0.017), indicating that this group may be more susceptible to malnutrition. At this age, children rely on parents and/or caregivers for their nutrition, and it is possible that they lack adequate information regarding the nutritional demands required due to the illness. The issue of malnutrition exacerbates with cancer as nutritional requirements increase and treatment toxicity is associated with decreases in intake12.
Furthermore, our study shows that children with low weight have a 12.75 times higher risk of having short stature compared to those with normal weight (95% CI: 2.513-64.665). Having short stature is an indicator of growth delay, which may be due to nutritional deficiencies and can trigger neurological development alterations, cognitive impairment, weakened immune system, and susceptibility to chronic diseases13.
Based on the obtained results, we suggest prioritizing health education initiatives and recommend implementing timely educational strategies for parents and caregivers of children and adolescents with cancer. Identifying factors related to nutritional status in this population is crucial, such as timely cancer diagnosis, type of treatment depending on the neoplasm, socioeconomic status, availability of support networks, access to adequate nutrition, and psychological and emotional factors14.
Nutritional status is an important prognostic factor that determines treatment response and the possibility of recovery in pediatric oncology. The nutritional status of the pediatric oncology patient is dynamic and can change during treatments.
Regarding the limitations of this study, it was conducted retrospectively based on clinical records, and it was not feasible to apply nutritional screening tests on patients’ admission.
Nutritional status is a potentially modifiable prognostic factor in pediatric cancer patients. Continuous longitudinal nutritional evaluation of patients during diagnosis, treatment, and long-term follow-up is required to implement effective nutrition interventions15. For newly admitted patients, applying nutritional screening tests upon admission and during follow-up is proposed.
Conclusion
The frequency of low weight and short stature in children and adolescents diagnosed with cancer at the time of diagnosis is high. This results from both the impact of the disease and the socio-economic circumstances of the patients. It is important to design multidisciplinary strategies optimizing disease treatment and prognosis.
Acknowledgments
The authors would like to thank the social workers for their diligent work and commitment to patient and family-centered care.
Funding
The authors declare that this study was funded by the Pediatric Oncology Center at the ABC Medical Center.
Conflicts of interest
The authors declare no conflicts of interest.
Ethical disclosures
Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.
Confidentiality of data. The authors declare that no patient data appear in this article. Furthermore, they have acknowledged and followed the recommendations as per the SAGER guidelines depending on the type and nature of the study.
Right to privacy and informed consent. The authors declare that no patient data appear in this article.
Use of artificial intelligence for generating text. The authors declare that they have not used any type of generative artificial intelligence for the writing of this manuscript or for the creation of images, graphics, tables, or their corresponding captions.
