Impact of Malnutrition on Survival and Treatment-Related Morbidity of Cancer in Children

Main Article Content

Saira Uzma
Raheela Mansoor
Bakht Jamal
Luqman Khan


Background: Malnutrition is a prevalent and severe issue in pediatric oncology, affecting treatment outcomes and survival rates significantly. In developing countries, where access to comprehensive healthcare is limited, malnutrition's impact is even more profound, complicating treatment protocols and increasing morbidity and mortality rates among children with cancer.

Objective: To evaluate the effects of malnutrition on survival rates and treatment-related morbidity in pediatric cancer patients, and to assess the efficacy of nutritional interventions in improving these outcomes.

Methods: This retrospective study was conducted at SKMCH & RC, involving 160 newly diagnosed cancer patients aged between one and eighteen years. Patients were followed from January 2021 through March 2023. Malnutrition was assessed using WHO growth charts and defined using BMI and weight/height Z-scores. Data analysis was performed using SPSS software, version 25, focusing on survival rates, incidence of febrile neutropenia (FN), and nutritional status changes over time. Statistical significance was set at a p-value of 0.025.

Results: At diagnosis, 42.5% (n=68) of the children were malnourished. After six months, 35% (n=56) remained malnourished, indicating some improvement. Malnourished children showed significantly lower survival rates, with those having a BMI Z-score ≤ -2 at six months post-diagnosis having a mortality rate HR of 4.05 (95% CI= 1.58-6.33, P = 0.009). Children experiencing a weight/height loss of >10% had an HR of 1.98 (95% CI= 1.23-6.91, P=0.04) for increased mortality. Increased episodes of FN were correlated with severe malnutrition (HR 7.32, 95% CI=1.98-10.14, P=0.0007).

Conclusion: Malnutrition significantly impacts the survival rates and treatment-related morbidity in pediatric cancer patients. Early and aggressive nutritional interventions can improve survival outcomes and reduce the rate of hospitalizations due to complications like febrile neutropenia.

Article Details

How to Cite
Uzma, S., Mansoor, R., Jamal, B., & Khan, L. (2024). Impact of Malnutrition on Survival and Treatment-Related Morbidity of Cancer in Children. Journal of Health and Rehabilitation Research, 4(2), 696–701.
Author Biographies

Saira Uzma, Shaukat Khanum Memorial Cancer Hospital and Research Centre Peshawar Pakistan.

Paedtric Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre Peshawar Pakistan.

Raheela Mansoor, Shaukat Khanum Memorial Cancer Hospital and Research Centre Peshawar Pakistan.

Paedtric Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, Pakistan.

Bakht Jamal, Shaukat Khanum Memorial Cancer Hospital and Research Centre Peshawar Pakistan.

Paedtric Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, Pakistan.

Luqman Khan, Shaukat Khanum Memorial Cancer Hospital and Research Centre Peshawar Pakistan.

Hospital Administration, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, Pakistan.


Meshram II, Arlappa N, Balakrishna N, Rao KM, Laxmaiah A, Brahmam GNV. Trends in the Prevalence of Undernutrition, Nutrient and Food Intake and Predictors of Undernutrition Among Under Five-Year Tribal Children in India. Asia Pac J Clin Nutr. 2012;21:568-576.

Demissie S, Worku A. Magnitude and Factors Associated with Malnutrition in Children 6–59 Months of Age in Pastoral Community of Dollo Ado District, Somali Region, Ethiopia. Sci J Public Health. 2013;1:175-183. doi: 10.11648/j.sjph.20130104.12.

Bryce J, Boschi-Pinto C, Shibuya K, Black RE; WHO Child Health Epidemiology Reference Group. WHO Estimates of the Causes of Death in Children. Lancet. 2005;365:1147-1152. doi: 10.1016/S0140-6736(05)71877-8.

Surveillance, Epidemiology and End Results (SEER) Program. SEER 9 Area. Based on Follow-Up of Patients into 2012, 2012.

Bauer J, Jürgens H, Frühwald MC. Important Aspects of Nutrition in Children with Cancer. Adv Nutr. 2001;2:67-77.

Pietsch JB, Ford C. Children with Cancer: Measurements of Nutritional Status at Diagnosis. Nutr Clin Pract. 2000;15:185-188.

Barron MA, Pencharz PB. Nutritional Issues in Infants with Cancer. Pediatr Blood Cancer. 2007;49:1093-1096.

Jain V, Dubey AP, Gupta SK. Nutritional Parameters in Children with Malignancy. Indian Pediatr. 2003;40:976-984.

Shamvil A. Annually 8000 Pakistani Children Fall Prey to Cancer The Indus Hospital Pakistan Observes International Childhood Cancer Day; 2019 February [cited 2024 Jan 03]. Available from:

Gabriela V, Jessica B, Silvia R, Ana LM, Nidia L, et al. Nutritional Status at Diagnosis of Cancer in Children and Adolescents in Guatemala and Its Relationship to Socioeconomic Disadvantage: A Retrospective Cohort Study. Pediatr Blood Cancer. 2019;66(6):e27647. doi: 10.1002/pbc.27647.

Ghafoor T, Ahmed S, Khalil S, Farah T. Impact of Malnutrition on Treatment Outcome of Pediatric Acute Myeloid Leukemia. J Coll Physicians Surg Pak. 2020;30(10):1021-1025. doi: 10.29271/jcpsp.2020.10.1021.

Loeffen EA, Brinksma A, Miedema KG, de Bock GH, Tissing WJ. Clinical Implications of Malnutrition in Childhood Cancer Patients--Infections and Mortality. Support Care Cancer. 2015;23:143-150.

Pribnow AK, Ortiz R, Báez LF, Mendieta L, Luna-Fineman S. Effects of Malnutrition on Treatment-Related Morbidity and Survival of Children with Cancer in Nicaragua. Pediatr Blood Cancer. 2017;64.

Norman K, Pichard C, Lochs H, Pirlich M. Prognostic Impact of Disease-Related Malnutrition. Clin Nutr. 2008;27:5-15.

Rogers PC. Nutritional Status as a Prognostic Indicator for Pediatric Malignancies. J Clin Oncol. 2014;32:1293-1294.

Sala A, Rossi E, Antillon F, Molina AL, de Maselli T, Bonilla M, Hernandez A, Ortiz R, Pacheco C, Nieves R, Navarrete M, Barrantes M, Pencharz P, Valsecchi MG, Barr R. Nutritional Status at Diagnosis Is Related to Clinical Outcomes in Children and Adolescents with Cancer: A Perspective from Central America. Eur J Cancer. 2012;48:243-252.

Murry DJ, Riva L, Poplack DG. Impact of Nutrition on Pharmacokinetics of Anti-Neoplastic Agents. Int J Cancer Suppl. 1998;11:48-51.

Cunningham-Rundles S, McNeeley DF, Moon A. Mechanisms of Nutrient Modulation of the Immune Response. J Allergy Clin Immunol. 2005;115:1119-1128.

Schaible UE, Kaufmann SH. Malnutrition and Infection: Complex Mechanisms and Global Impacts. PLoS Med. 2007;4:e115.

Taj MM, Pearson AD, Mumford DB, Price L. Effect of Nutritional Status on the Incidence of Infection in Childhood Cancer. Pediatr Hematol Oncol. 1993;10:281-287.

Crokaert F. Febrile Neutropenia in Children. Int J Antimicrob Agents. 2000;16:173-176.

Kebudi R, Kizilocak H. Febrile Neutropenia in Children with Cancer: Approach to Diagnosis and Treatment. Curr Pediatr Rev. 2018;14:204-209.

Ge KY, Chang SY. Definition and Measurement of Child Malnutrition. Biomed Environ Sci. 2001 Dec;14(4):283-91. PMID: 11862608.

Shah P, Jhaveri U, Idhate TB, Dhingra S, Arolkar P, Arora B. Nutritional Status at Presentation, Comparison of Assessment Tools, and Importance of Arm Anthropometry in Children with Cancer in India. Indian J Cancer. 2015 Apr 1;52(2):210-15. doi: 10.4103/0019-509X.175838.

Brinksma A, Sanderman R, Roodbol PF, Sulkers E, Burgerhof JG, de Bont ES. Malnutrition Is Associated with Worse Health-Related Quality of Life in Children with Cancer. Support Care Cancer. 2015;23:3043-3052.

WHO and UNICEF. WHO Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants and Children A Joint Statement by the World Health Organization and the United Nations Children’s Fund. Geneva: WHO; 2009.

Huibers MHW, Ganda M, Silverstein A, Wanda W, Mtete I, Makuti S. The Burden of Malnutrition in Childhood Cancer in Malawi-Risk Regardless of Age. Nutrition and Cancer. 2022;74:3322-3328.

The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies, Version 2. NutritionWorks, Emergency Nutrition Network, Global Nutrition Cluster; 2011.

Triarico S, Rinninella E, Cintoni M, Capozza MA, Mastrangelo S, Mele MC, Ruggiero A. Impact of Malnutrition on Survival and Infections Among Pediatric Patients with Cancer: A Retrospective Study from European Review for Medical and Pharmacological Sciences. 2019;23:1165-1167.

Inaba H, Surprise HC, Pounds S, Cao X, Howard SC, Ringwald-Smith K, Buaboonnam J, Dahl G, Bowman WP, Taub JW, Campana D, Pui CH, Ribeiro RC, Rubnitz JE. Effect of Body Mass Index on the Outcome of Children with Acute Myeloid Leukemia. Cancer. 2012;118:5989-5996.

Zimmermann K, Ammann RA, Kuehni CE, De Geest S, Cignacco E. Malnutrition in Pediatric Patients with Cancer at Diagnosis and Throughout Therapy: A Multicenter Cohort Study. Pediatr Blood Cancer. 2013;60:642-649.

Andrassy RJ, Chwals WJ. Nutritional Support of the Pediatric Oncology Patient. Nutrition. 1998;14:124-129.

Schoeman J. Nutritional Assessment and Intervention in a Pediatric Oncology Unit. Indian J Cancer. 2015;52:186-190.