Research Article

iMedPub Journals Archives in Cancer Research 2017

http://www.imedpub.com/ Vol.5 No.1:128
ISSN 2254-6081
DOI: 10.21767/2254-6081.1000128

Nutritional Assessment of Children with Acute Lymphoblastic Leukemia

Rula Ahmed Abdul Kadir, Janan G Hassan and Mohammed K Aldorky
Department of Pediatrics, College of Medicine, University of Basra, Iraq
Corresponding author: Janan G Hassan, Department of Pediatrics, College of Medicine, University of Basra, Iraq, Tel: 9647801000820; E-mail:
[email protected]
Received: 25 May 2016; Accepted: 27 January 2017; Published: 31 January 2017
Citation: Kadir RAA, Hassan JG, Aldorky MK. Nutritional Assessment of Children with Acute Lymphoblastic Leukemia. Arch Can Res. 2017, 5: 1.

with P value (0.005). During induction, there is decrease

in serum calcium with P value (0.001), and a significant
Abstract decrease in serum albumin with P value (0.005), also in
this study there is a significant decrease in serum
Background: The high prevalence of malnutrition in adult cholesterol during induction with P value (0.001). There is
and pediatric cancer patients has been appreciated for no significant increase in random blood sugar during
decades and continues to be documented. Although the induction.
prognostic significance of nutritional status among
patients with cancer remains controversial, it is generally Conclusion: Malnutrition exists in a significant proportion
accepted that the nutritional support is an important of children with acute lymphoblastic leukemia. So,
aspect of medical therapy. adequate nutrition is an important in such children, to
ensure optimal treatment and outcome.
Objective: Assess the nutritional status of children with
acute lymphoblastic leukemia at time of diagnosis of Keywords: Lymphoblastic Leukemia; malnutrition;
disease, assess the nutritional status of the same children Pediatric cancer
during induction of chemotherapy and after induction by
3-6 weeks.

Patients and methods: A prospective study was carried Introduction

out on thirty children their age ranged from (1-14 year)
The high prevalence of malnutrition in adult and pediatric
with newly diagnosed acute lymphoblastic leukemia, (16)
of them were males and (14) were females, who were cancer patients has been appreciated for decades and
admitted to the oncology pediatric Unit in Basrah continues to be documented. Although the prognostic
Maternity and children Hospital, from the first of January significance of nutritional status among patients with cancer
to the end of October -2010). This study has been done to remains controversial, it is generally accepted that the
determine the nutritional status of children with newly nutritional support is an important aspect of medical therapy.
diagnosed acute lymphoblastic leukemia before, during Parents of children with cancer are often quite concerned
and after induction by (3-6 weeks). Full history was taken about issues of appetite and other gastrointestinal symptoms
from each patient regarding chief compliant, dietary even when death is imminent [1]. The incidence of
history, also clinical examination and anthropometric malnutrition at the time of diagnosis of cancer in children
measurement by measure weight, height, mid upper arm appears to be less than adult. Some children were
circumference and body mass index, in addition malnourished at the time of diagnosis and their
investigation in form of Hb, serum albumin, serum malnourishment was reported to have increased during the
cholesterol, and random blood sugar. therapy for malignancy, especially if their treatment involved
intensive chemotherapy or bone marrow transplantation.
Results: This study has revealed that among 30 patients
with newly diagnosed ALL, 15 (50%) of them are Children treated for leukemia underwent changes in
underweight according to weight for age, 8 of them are nutritional status, as manifested by a reduction in growth,
male and 7 are females. Twelve (40%) of these 30 patients weight gain and weight losses. A child with newly diagnosed
are wasted, 7 of them are male and 5 are female. cancer appears to have the same average nutritional status as
Fourteen (46.7%) of the total 30 patients are seen in the population from which the child come, if the
malnourished according to body mass index, 6 of them diagnosis is made in a reasonably timely manner [2].
are male and 8 are female, ten (33.3%) are malnourished
according to mid upper arm circumference, five of them In the last decade, improved chemotherapy strategies for
are male and 5 are female. The study has revealed that children with leukemia have resulted in a dramatic
there is a statistically significant increase in mean body improvement in the survival rates. Malnutrition more often
weight during induction with P value (0.046) and a develops during intensive induction therapy but it less
statistically increase in body mass index during induction commonly apparent at diagnosis [3].

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The occurrence of wasting among cancer patients is Children from developing countries are at risk for primary
determined by host susceptibility, tumor type and location, malnutrition. Children undergoing anticancer therapy are at
and anticancer regimen. The rational for identifying, treating, higher risk for secondary malnutrition, including obesity and
and preventing malnutrition among pediatric cancer patients growth retardation. Objective and subjective data should be
may be summarized as follows: Malnutrition is common used to complete the nutritional assessment. Different parts of
among patients with cancer both on presentation and with nutritional assessment include medical history; physical
subsequent antitumor therapy, weight loss, deficits in weight examination; biochemical and hematological data,
for height (wasting), and deficits in height for age (stunting) anthropometric measurements and food and nutrition history.
are observed [1]. There are no known disease processes where Malnutrition can lead to a decreased immune function, in
malnutrition is advantageous to the host. There is an increased already immune compromised patients; delay wound healing
morbidity from malnutrition in hospitalized patients, including and reduce drug metabolism. Also, as mentioned earlier it can
delayed wound healing, increased infectious complications, be a contributing factor to death and poor prognosis [1,8,9].
decreased immune competence, reduced respiratory and
Biochemical data: Serum proteins serum albumin became
other muscle strength, and increased length of stay. The
the gold standard for indicating nutritional status in patients.
nutrition literature in pediatrics confirm wasting as an
important risk factor for early death, Moreover, acute Blood glucose levels: Malnutrition can cause glucose
malnutrition is marked by depression and apathy, and chronic intolerance and impairment of insulin secretion
malnutrition by delayed neurodevelopment. All the
Lipid profile: A diet high in saturated fats and transfers can
morbidities named above are common in pediatric cancer
increase total cholesterol levels. Plant based diets high in fiber
patients [1]. Malnutrition in pediatric cancer patients has been
and unsaturated fatty acids can lower total cholesterol.
associated Within tolerance to chemotherapy [1].
Hemoglobin/Hematocrit in state of malnutrition, hemoglobin
Early recognition of patients at risk for malnutrition can and hematocrit tend to decrease because of inadequate
obviate the need for more aggressive supports subsequently in amount of protein consumption and possibly iron deficiency
the patients course [1]. [9].
Insufficient energy and nutrients intake (due to anorexia, Aims of the study: This prospective study was carried out to
taste changes, pain, nausea; adverse effect of cancer therapy, assess the nutritional status of children with acute
psychological problems), Pathologic alterations in nutrient lymphoblastic leukemia at time of diagnosis of disease, assess
metabolism (e.g. increase protein turnover, decrease muscle the nutritional status of the same children during induction of
protein synthesis, increase lipolysis, increase fatty acid chemotherapy and after induction by 3-6 weeks.
oxidation, increase hepatic glucose production, increase
hepatic protein synthesis, increase acute phase proteins)
[4], the side effects of the cancer treatment can also affect
Patients and Methods
dietary input by triggering nausea, vomiting and mucositis, ALL
patients take steroids during their treatment, this can cause an Patients
increase appetite and weight gain. This has been linked to the A prospective study has been carried out on children and
escalation of obesity in pediatric ALL survivors, which is four to adolescents with newly diagnosed acute lymphoblastic
five times more likely than expected, Leukemia and lymphoma leukemia over ten months (from the first of January till the end
patients can have an enlarged spleen, this effect on the of October -2010).
patient's stomach thus reducing their appetite [5]. Nutrition is
a supportive care modality that has associated with improved The data was collected from oncology pediatric ward in
tolerance to chemotherapy, improved survival, increased Basrah Maternity and Children Hospital. A total of 30 newly
quality of life, and decreased risk of infection in children diagnosed ALL patients, their ages range from 1-14 years were
undergoing anticancer therapy [6]. The goal of nutritional included in this study.
assessment in childhood is to prevent nutritional disorders and
the increased morbidity and mortality that accompany them. Data collection
Nutritional assessment is the quantitative evaluation of
nutritional status. A comprehensive nutritional assessment has A special questionnaire was designed for the study. The
five components: following information were taken: name, age, sex, date of
admission, diagnosis, and residence.
1. Growth, anthropometric and body composition
measurements. ALL classification according to:

2. Physical examination. 1. Risk group (Standard Risk and High Risk)

3. Growth, anthropometric and body composition 2. Morphology (L1, L2, L3).
measurements. High risk ALL: Age at presentation less than 1 year and more
4. Laboratory tests. than 10, Sex: male, W.B.C >50,000/mm3 at diagnosis, C.N.S
manifestation at time of presentation, Platelet count
5. Intervention and monitoring [7].

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<50,000/mm3 at time of presentation Immunophenotyping: The anthropometric indices were calculated by using
pro B ALL cell type. reference median as recommended by the National Centre for
Health Statistics (NCHS) (WHO) and classified according to
Morphological subtypes standard deviation units termed as Z score based on World
Health Organization (WHO) criterion. Children who were less
Acute lymphoblastic leukemia divided into 3 groups than 2standard deviations below the reference median (-2SD)
according to FAB classification: L1, L2, L3. This classification were considered as under-weight (weight for age), and wasted.
depends on size of nucleus, amount of cytoplasm, cytoplasm
basophilic and nuclear cytoplasm ratio [1]. Hematological and biochemical data
L1 comprises 85%of ALL in childhood while L2 comprises
Four milliliters of venous blood were withdrawn from each
14%, and L3 comprises 1%, the L1 morphology has been
patient. One milliliter was put in (EDTA) containing tube and
associated with higher remission rate and a better event free
send for Hb %.
survival (EFS) than L2 morphology which appears to convey
poor prognosis and patient with L3 have the worst over all The remaining 3 milliliters of blood were put in plain tube
prognoses [10]. without EDTA, centrifuged and send for: Random blood sugar
(RBS), total serum protein and serum albumin, Serum calcium
Clinical data and Serum Cholesterol.

Pallor, bleeding, fever, wasting, edema, abdominal Statistical analysis

distension, irritability or apathy, bone or joint pain, hair
changes, lymph node enlargement, vomiting, skin lesion due Statistical analysis was done using SPSS program [11], data
to infection or vitamin deficiency such as vitamin A and D, were expressed by means ± Standard Deviation. Comparisons
constipation or diarrhea. of proportions was performed by crosstab using Chi-Square
test. The t-test used for quantitative comparisons of
Full examination was done to all patients including general
anthropometric measurement, hematological and biochemical
and systemic examination. An informed consent was obtained
variables before, during and after induction of chemotherapy.
from one or both parents, for recruitment in the study.
For all tests, P value of <0.05 was considered as statistically
Methods significant.

Anthropometric measurement Results

The basic anthropometric measurements for which Table 1 reveals A total of 30 children with newly diagnosed
reference data exist for comparison are weight, stature (length ALL were included in this study, their age range from (1-14)
or height), mid arm circumference. years, mean age (5.4 ± 3.4SD). Sixteen were males and
fourteen were females, reveals that 16 (53.3%) of patients
Weight: Weight loss is a good indicator of acute nutritional included in this study were males and 14 (46.6%) were
insult in children, reflecting loss of fat, muscle, other soft females. More than (60%) of patients lies in the age group (1-
tissue, and water taken to the nearest 0.1 Kg. Electronic scale <5) for both males and females.
SEGA was used to measure weight of children wearing
minimum clothing. Table 1 Age and sex distribution of patients with Acute
lymphoblastic Leukemia.
Height or length: Height or length generally correlates
better with socioeconomic status than soft tissue
Age Sex
measurement such as weight. Length is usually indicated for
children up to 24 months of age, and height is used thereafter. Male Female Total
Height of the children were measured by using SEGA
No % No % No %
Stadiometer. The reading was taken to the nearest 0.1 cm.
1- < 5 10 62.5% 7 50% 17 56.6%

Mid-upper arm circumference 5 - 3 18.75% 4 28.58% 7 23.3%

<10
An advantage of the MUAC is that there is very little change
10-14 3 18.75% 3 21.42% 6 20%
between ages 1 and 4 years. MUAC measurement done by
using tape measure. Total 16 100% 14 100% 30 100%

Body mass index Table 2 shows past feeding history in early life include
breast, bottle and mixed feeding (breast and bottle feeding)
Body mass index (BMI) calculated by using norm gram based shows that nineteen patients with newly diagnosed ALL with
on {Weight (Kg)/Height (m)2}. BMI assess adiposity status.

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breast feeding and ordinary diet. Seven patients with mixed during induction with chemotherapy and after induction. that
feeding and ordinary diet. the body weight increase during induction of chemotherapy
than before induction and statistically significant with P value
Table 2 Distribution of patients according to the type of of 0.045. Body mass index was increase during induction and
feeding. statistically significant with P value of 0.005. There is no
difference in MUAC in both groups and it is statistically not
Type of feeding Frequency % significant, P value of 0.083. There is no change in growth
Breastfeeding and ordinary diet 19 63.3% parameters during and after induction of chemotherapy by six
weeks.
Bottle feeding and ordinary diet 4 13.3%

Mixed feeding and ordinary diet 7 23.3%

Table 4 Indices of malnutrition at presentation.

Indices At presentation Sex

Table 3 shows the two main risk groups of ALL are standard
risk and high risk, according to morphology ALL subdivided No. % Male Female
into L1, L2 and L3. Two third of patients according to risk group
Under nutrition 15 50% 8 7
are with high risk, according to morphology twenty five out of
thirty newly diagnosed ALL with L2. Wasting 12 40% 7 5

BMI<5th centile 14 46.7% 6 8

Table 3 ALL Classification according to risk group and
morphology. MUAC<5th centile 10 33.3% 5 5

ALL Risk No.30 Standard Risk (%) High Risk (%) Table 6 shows hemoglobin, total serum protein, serum
9 (30%) 21 (70%)
albumin, serum calcium, serum cholesterol and blood sugar
were assessed for all patients included in the study before,
ALL Morphology No. L1 (%) L2 (%) L3 (%) during and after induction and the result are that the Hb level
30
3 (10%) 25 (83.3%) 2 (6.6%) was significantly higher during induction than before induction
with P value of 0.000, also show that the serum calcium level
Table 4 shows nutritional indices of children with ALL were was decrease during induction with significant P value of
studied and present that half of the patients are underweight 0.001. Serum protein and albumin decrease during induction
at presentation and one third of the thirty newly diagnosed with significant P value of 0.000 and 0.005 respectively. Serum
patients are malnourished according to mid upper arm cholesterol was decrease during induction with significant P
circumference. value of 0.001. There was no statistical significant difference
between blood sugar before and during induction with P value
Tables 3-5 show thirty patients with newly diagnosed ALL of (0.771). There was no statistical significant difference
underwent somatometric measurement at initial presentation, between all the above indices during and after induction.

Table 5 Growth parameters before, during and after induction.

Indices No. 30 Before‫ ٭‬induction During‫ ٭‬induction P value During‫ ٭‬induction After‫ ٭‬induction P Value

Weight 18.806 ± 19.4567 ± 0.046 19.4567 ± 18.9967 ± 0.141

9.7107 9.3958 9.3958 9.3958

Height 107.9 ± 107.9 ± 1.000 107.9 ± 107.9 ± 1.000

21.7721 21.7721 21.7721 21.7721

Mid arm circumference 15.26 ± 15.5966 ± 0.083 15.5966 ± 15.0083 ± 0.357

2.6400 2.8229 2.8229 3.50473

Body mass index 15.37 ± 16.07 ± 0.005 16.07 ± 15.7323 ± 0.056

2.1115 2.0983 2.0983 2.0983

*Values were expressed as mean ± SD

Table 7 shows sixteen males from the total number (30) no significant relation between sex and body weight and body
patients and fourteen female were assessed for body mass index before and during induction of chemotherapy.
measurement before and during induction and the result was

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Table 8 shows Hb and same biochemical investigations there is no significant relation between sex and hematological
(serum protein, serum cholesterol, serum calcium) were and biochemical data before and during induction.
studied in relation to sex before and during induction that

Table 6 Hematological and biochemical data before, during and after induction.

Indices Before During induction‫٭‬ P value During induction‫٭‬ After induction‫٭‬ P value
No.30 Induction*

Hb 6.5033 ± 9.3000 ± .000 9.3000 ± 12.1100 ± 15.2856 0.324

1.9031 0.6988 0.6988

Serum calcium 2.2600 ± 2.0300 ± .001 2.0300 ± 2.1267 ± 0.1701 0.102

0.2621 0.3282 0.3282

Serum protein 6.7767 ± 0.9104 5.8167 ± .000 5.8167 ± 6.0033 ± 0.8202 0.06
0.7724 0.7724

Serum albumin 4.04 ± 0.91 3.55 ± 0.49 0.005 3.55 ± 0.49 3.68 ± 0.43 0.07

Serum 172.5333 ± 144.9333 ± .001 144.9333 ± 147.6667 ± 30.343 0.705

cholesterol
35.2378 30.1741 30.1741

R.B.S 4.9867 ± 5.8700 ± 0.077 5.8700 ± 4.7700 ± 0.9025 0.201

0.9402 1.174 1.174

*Values were expressed as mean ± SD

Table 7 Body measurement and sex before and during induction.

Indices Before induction‫٭‬ During induction‫٭‬ P value

Male (16) Female (14) Male (16) Female (14)

Body weight 19.7313 ± 17.7500 ± 20.1438 ± 18.6714 ± NS >0.05

10.6378 8.8050 9.7992 9.2136

Body mass index 15.6925 ± 15.0086 ± 16.3512 ± 15.7571 ± NS >0.05

1.9256 2.3235 2.1856 2.0267

*Values were expressed as mean ± SD, NS (not significant)

Table 8 Hematological and biochemical data in relation to sex before and during induction.

Indices ‫٭‬Before induction ‫٭‬During induction P value

Male (16) Female (14) Male (16) Female (14)

Hb 6.7813 ± 2.1037 6.1857 ± 1.6640 9.3188 ± 0.8224 9.2786 ± 0.5549 NS >0.05

Serum protein 6.7813 ± 0.6685 6.7714 ± 1.1545 5.8687 ± 0.8700 5.7571 ± 0.6711 NS >0.05

Serum Calcium 2.2875 ± 0.2754 2.2286 ± 0.2525 2.0250 ± 0.3435 2.0357 ± 0.3225 NS >0.05

Serum 170.8750 ± 174.4286 ± 142.3750 ± 147.8571 ± NS >0.05

Cholesterol
33.5477 38.2637 27.5097 33.7727

*Values were expressed as mean ± SD, NS (not significant)

Table 9 shows nine patients with standard risk ALL and Table 10 shows no significant relation between risk group
21with high risk ALL their body weight and body mass index and hematological and biochemical data before and during
were evaluated before and during therapy no significant induction.
relation between body measurement and ALL risk group
Table 11 shows twenty-five patients belong to L2 subtype, 3
before and during therapy.
were L1 subtype, their weight and body mass index were
evaluated before and during induction in relation to
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morphological subtypes and the result was shown no

significant relation between morphological subtypes and body
measurement before and during induction.

Table 9 Body measurement and risk group before and during induction.

ALL Risk Group. NO. Bodyweight‫٭‬ P value Body mass index‫٭‬ P Value

Before Standard Risk (9) 15.6889 ± 3.0937 0.249 14.2900 ± 1.7384 0.053
Therapy
High Risk (21) 20.1429 ± 11.2540 15.8376 ± 2.1216

During Standard Risk (9) 17.0778 ± 3.5113 0.371 15.5743 ± 2.1247 0.409
Therapy
High Risk (21) 20.4762 ± 10.9287 16.2881 ± 2.1019

*Values were expressed as mean ± SD

Table 10 Hematological and biochemical data in relation to risk group before and during induction.

ALL Risk ‫٭‬Hb P value ‫٭‬Serum P value ‫٭‬Serum P value ‫٭‬Serum P value
Protein Calcium Cholesterol

Before Standard Risk 6.9556 ± 0.425 6.5222 ± 0.382 2.1444 ± 0.018 175.3333 ± 0.98
Therapy (9) 2.4790 0.7918 0.2128 33.0038

High Risk (21) 6.3095 ± 6.8875 ± 2.3095 ± 171.3333 ±

1.6315 0.9536 0.2700 36.8746

During Standard Risk 9.0778 ± 0.354 5.4556 ± 0.068 2.0778 ± 0.528 131.6667 ± 0.125
Therapy (9) 0.3528 0.8819 0.2333 23.8965

High Risk (21) 9.3952 ± 5.9714 ± 2.0095 ± 150.6190 ±

0.7915 0.6857 0.3646 31.2833

‫٭‬Values were expressed as mean ± SD

Table 11 Body measurement in relation to morphological subtypes before and during induction.

ALL No Body Weight‫٭‬ P value Body Mass Index‫٭‬ P value

Morphological Type

Before Therapy L1 3 10.6 ± 1.5 0.143 13.4 ± 0.11 0.112

L2 25 19.6 ± 10.0 15.5 ± 2.17

During Therapy L1 3 11.8 ± 2.4 0.144 14.8 ± 1.2 0.200

L2 25 20.4 ± 9.8 16.4 ± 2.0

*Values were expressed as mean ± SD

Table 12 shows hematological and biochemical data of prevent over nutrition which may in some instances be
patients with subgroups L1 and L2 were studied before and detrimental to the treatment of cancer [12-14].
during induction and the result revealed no significant relation
Children with cancer represent a high-risk group for protein
between morphological subtype and hematological and
energy malnutrition due to side effect associated with
biochemical data before and during chemotherapy.
treatment, mild to moderate malnutrition is common in
leukemia patients at diagnosis and relapse [15].
Discussion This prospective study was carried out on thirty patients
Nutritional assessment is the first step of nutritional support with newly diagnosed ALL. Of these thirty patients 15 (50%)
which will not improve the child's sense of well-being but also are underweight at presentation, while twelve (40%) are
maintain normal growth, promote wound healing, improve wasted at presentation. In this study 14 (46.7%) of the total 30
tumor response to therapy and enable the child to better newly diagnosed ALL are malnourished according to BMI
withstand the effects of therapy. Assessment will also help (BMI<5th centile), ten (33.3%) are malnourished according to
MUAC (MUAC<5th centile). A similar survey in India by Rajesh
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et al. was carried out on study group comprised 25 children shown that 21.2% of ALL patients evaluated had evidence of
with newly diagnosed ALL, their age range from (1-12) year, malnutrition, relatively less than Rajesh et al. and less than this
eighteen of them are male and seven are females [16]. In this study, which is explained by Delbecque –Boussard et al., as
Indian study show that there is 13 (52%) patients out of these there is low intake of energy, carbohydrate, and protein in case
25 newly diagnosed ALL were underweight at presentation, of ALL at time of diagnosis [18]. In the study by Tamminga et
twelve patients (48%) were wasted. Nine (36%) of them were al. observed that at the time of diagnosis, Wt, Ht, wt for ht and
malnourished according to MUAC [16]. Our study is mid arm circumference were normal in all patients with ALL in
comparable Rajesh et al. study [17]. Sgarberie et al., showed their study [19].
that 30% of affected children with ALL were wasted on
admission [2], while survey from Mexico by Delbecque et al.

Table 12 Hematological and biochemical data in relation to morphological subtypes before and during induction.

ALL Morphological ‫٭‬Hb P value *Serum P value *Serum P value *Serum P value
subtype No. Protein Calcium Cholesterol

Before L1 (3) 6.10 ± 1.93 0.707 7.50 ± 0.51 0.085 2.23 ± 0.25 0.857 192.6 ± 31.0 0.335
Therapy
L2 (25) 6.55 ± 1.96 6.63 ± 0.69 2.26 ± 0.27 170.8 ± 36.6

During L1 (3) 9.26 ± 0.46 0.941 6.33 ± 1.41 0.274 2.5 ± 0.45 0.08 168.6 ± 17.2 0.184
Therapy
L2 (25) 9.30 ± 0.79 5.80 ± 0.69 2.1 ± 0.26 143.4 ± 31.0

*Values were expressed as mean ± SD

In this study changes in body parameters before and during body mass index during induction, this due to same effect of
induction show that there is overall increase in body weight steroid on body weight. In this study, there was no change in
during induction (mean increasing 0.6 kg), while Rajesh et al. all body parameters in comparison between during and after
show that there is overall increase in body weight of (0.3 kg) induction by 6 weeks. This may be due to short duration post
with a P value of (0.05) [17]. induction. Also, Delbecque et al. documented no change in
body composition during and after induction [18]. The most
There was a great effect of prednisolone during the weeks
presenting feature of children in this study at time of
of induction by increase food intake, which related to relieve
presentation was pallor, comprising 14 (46.6%) of the total
of symptoms and euphoria, over caring for children during
patients with mean Hb of (6.5 g/dl). Induction of
illness period and over introduction of best food by the
chemotherapy was not started unless stabilization of general
parents [16].
condition of the patients by supportive measure such as blood
Corticosteroid therapy causes alteration in fat metabolism, transfusion, platlate transfusion, treatment of infection, it is
which had a net effect of increase body fat and redistribution expected that Hb increases during induction. Similar result was
of body fat causing truncal obesity [16]. obtained by Carriottee et al. [13]. Serum calcium was
significantly decrease during induction. This is in agreement
In the current study one patient had severe weight loss
with a study by Chariotte [13] e t al. The explanation for this
during induction of chemotherapy. His body weight on
decrease due to effect of drug during induction such as steroid
admission was 27 kg, during induction his body weight was 22
(predinsolone induce calcium loss), antibiotics, prolonged
kg, he lost about 5 kg during induction. During induction, he
immobilization also induce calcium loss. In tumor lyses
was complaining from severe gastroenteritis with high grade
syndrome, there is hypercalciuria and loss of calcium in the
fever and severe oral mucositis which lead to decrease oral
urine result in hypocalcaemia [13].
intake and lead to weight loss. While in the study by Rajesh et
al. show that 9 cases have demonstrated loss of weight during The use of steroid and nephrotoxic agent may worsen
induction range from (0.2-5.8 kg). These patients had hypercalciuria putting the patient at high risk of osteopenia
complicated course during induction of chemotherapy such as and fractures [1].
(gastroenteritis, severe oral mucosities, bleeding, febrile
In this study, there was significant decrease in total serum
neutropenia, pneumonia and sepsis) which can lead to
protein and serum albumin during induction.
decrease oral intake and severe weight loss during induction
[17]. Similar result was obtained by Charriotte et al. The
explanation for that decrease due to effect of drugs that used
In this study, there is increase in mid upper arm
during induction such as L- Asparginase induce
circumference during induction by (0.3 cm) than before
hypoproteinemia, steroid induce protein muscle loss,
induction, although statistically not significant.
antibiotics decrease protein synthesis [13].
A study by Delbecque et al. also found no significant change
Albumin concentration decreases in acutely or chronically ill
in MUAC during induction [18], this may be due to large
patients because of the effects of inflammatory mediators on
amount of protein in diet. There was a significant increase in
hepatic protein synthesis. Severe liver and renal disease,
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intravascular volume overload and zinc deficiency decrease insulin secretion and action. Malnutrition can cause glucose
serum albumin levels [19]. In cancer patients, there is intolerance and impairment of insulin secretion [1,12].
derangement of macronutrient metabolism such as the However, insulin resistance caused by disease or medication
presence of protein catabolism, hypoalbuminemia is common. used during treatment, including glucocorticiods and L-
An increase in muscle protein breakdown and decrease Asparginase is more common [21,22]. When hyperglycemia
skeletal muscle protein synthesis seems to be of primary occurs, synthesis of very low density lipoprotein is driven up,
importance. A net loss of skeletal muscle protein is a common and both triglyceride and cholesterol level rise (19). According
finding with malignancy and is particularly problematic in the to changes in hematological and biochemical data during and
growing child. Furthermore, there is disturbance of whole after induction, there is no significant change in any one of
protein homeostasis with net catabolism, negative nitrogen these data. In this study, there is no significant association
balance, increase in blood urea nitrogen, and fall in serum exists between body measurement and hematological and
albumin [1]. biochemical data in relation to sex, ALL risk group, ALL
morphological subtypes.
There is clinical impression that cancer patients especially
when undergoing chemotherapy, ingest lower amount of
nutrient than age based standard, these dietary changes Conclusion
therefore place them at risk of negative energy balance [1].
Malnutrition exists in a significant proportion of children
Another important reason for decreased nutrient intake is with acute lymphoblastic leukemia so adequate nutrition is an
anorexia and other gastrointestinal side effects of important in such children, to ensure optimal treatment.
chemotherapy. Mucosal damage is generally dose related, with
increased risk of mucosal toxicity with high dose induction
therapy, escalating dose pattern and combination
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