Child Nutrition and Health [1 ed.] 9781622579822, 9781622579815

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Copyright © 2013. Nova Science Publishers, Incorporated. All rights reserved. Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

Copyright © 2013. Nova Science Publishers, Incorporated. All rights reserved. Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

CHILDREN'S ISSUES, LAWS AND PROGRAMS

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CHILD NUTRITION AND HEALTH

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Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

CHILDREN'S ISSUES, LAWS AND PROGRAMS

CHILD NUTRITION AND HEALTH

GREGOR CVERCKO AND

LUKA PREDOVNIK

Copyright © 2013. Nova Science Publishers, Incorporated. All rights reserved.

EDITORS

New York

Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

Copyright © 2013 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Child nutrition and health / [edited by] Gregor Cvercko and Luka Predovnik. pages cm Includes bibliographical references and index. ISBN:  (eBook) 1. Children--Nutrition. 2. Children--Health and hygiene. I. Cvercko, Gregor. II. Predovnik, Luka. RJ206.C513 2013 618.92--dc23 2012035888

Published by Nova Science Publishers, Inc.  New York

Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

Contents Preface Chapter I

Nutrition in Children and Adolescents with Cancer Terezie Tolar Mosby and Ronald D. Barr

Chapter II

Calcium Supplementation in Young Children in Asia: Prevalence, Benefits and Risks Shu Che, Colin Binns and Bruce Maycock

Chapter III

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vii

Chapter V

Chapter VI

Exposure of Slovenian Preschool Children to Preservatives and Polyphosphates Elizabeta Mičović, Mario Gorenjak, Gorazd Meško and Avrelija Cencič The Breakfast Experience in Low Socioeconomic Families with Overweight Children Simone Pettigrew and Melanie Pescud Early Vitamin D Supplementation, Immune Modulation and Allergy Gian Vincenzo Zuccotti and Valeria Manfredini Factors Associated with Overweight and Obesity among Kuwaiti Young Children A. N. Al-Isa, Nadeeja Wijesekara, Ediriweera Desapriya and Yamesha Ranatunga

Index

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Copyright © 2013. Nova Science Publishers, Incorporated. All rights reserved. Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

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Preface In this book, the authors have gathered and present current research in the study of child nutrition and health from across the globe. Topics discussed include the exposure of Slovenian preschool children to preservatives and polyphosphates; the breakfast experience in low socioeconomic families with overweight children; nutrition in children and adolescents with cancer; calcium supplementation in young children in Asia; early vitamin D supplementation, immune modulation and allergy; and the factors associated with overweight and obesity among Kuwaiti young children. Chapter I - Cancer is the most common cause of disease-related death in children and adolescents in the United States, and it is becoming a proportionately more common cause of death among young people in developing countries as well. However, cancer is highly curable in young people. In high income countries, the survival rate of children and adolescents with cancer is 80% or higher. However, more than 80% of children live in low and middle income countries where the survival rate may be as low as 5%. Nutrition plays an important role in many aspects of cancer development, treatment and long term survival. Nutritional status at diagnosis has prognostic implications. Well-nourished children have a better tolerance of intensive cancer therapy, improved chances of survival, and lower relapse rates. Children and adolescents with cancer are at higher risk for the development of malnutrition than adults during treatment due to the relatively higher nutritional needs demanded by their continuous growth and organ development. Nutritional assessment is important for the prevention, recognition, and early treatment of malnutrition. Proper assessment of the nutritional status of a patient is necessary for the determination of appropriate nutritional therapy. The goals of nutritional therapy for patients undergoing anticancer treatment are to maintain weight and to achieve age-appropriate growth and weight gain after treatment. These goals can be achieved by dietary modifications, use of dietary supplements, appetite stimulants, or nutritional support. Patients undergoing chemotherapy, radiation and hematopoietic stem cell transplantation can experience any or all of the following side effects: nausea, vomiting, mouth sores, constipation, diarrhea, altered taste, loss of appetite. Any of these side effects could result in undesirable weight loss, protein energy malnutrition or cancer cachexia. Food poisoning can occur if a person eats or drinks something that contains harmful germs. Food consumed by immunocompromised patients should be prepared in a manner to minimize bacterial growth.

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Gregor Cvercko and Luka Predovnik

Survivors of cancer in childhood and adolescence are at risk for many long-term adverse effects of therapy. Lifestyle changes, including dietary modification, may help with the management of some of those sequelae. The three nutrition-related key areas to reduce cancer risk are weight, diet, and physical activity. There are numerous gaps in our knowledge concerning the interaction of nutrition with cancer in children and adolescents. These include the effects of nutritional interventions on cancer outcomes and the influence of such interventions on co-morbidities; all providing rich opportunities for good clinical research. Chapter II - Calcium is essential for maintaining bone health in infants and young children. The calcium intakes of weaning infants and children in Asia are relatively low in comparison to their Western counterparts. This is an increasing concern for Asian parents and is one reason the Asia Pacific region is becoming a large market for vitamins and dietary supplements. However, there is a lack of data on the long-term benefits to early calcium supplementation of healthy infants and young children. The objective of this chapter is to discuss the appropriate calcium intakes for infants and young children, the risks and benefits of calcium supplementation and to review the proportion of children in Asia who are taking calcium supplements. To achieve our objective a literature review was undertaken of the English language databases PubMed and Web of Knowledge. Studies were selected that reported outcomes of calcium intake in infants and young children, as well as systematic reviews of such studies. Studies were undertaken of children in China and a comparison group of Chinese children living in Australia to document the use of calcium supplements. The prevalence of dietary supplementation among children under five years old in China (30.0%) was higher than in Australia (21.6%). In supplement users in China, 60.3% of them took calcium supplementation while only a small number in Australia (8%) took calcium supplements. Age and feeding method of the child (ever breastfed or not) were associated with nutritional supplementation in Australia, while household income and mother’s educational status were significantly related to the use of dietary supplements including calcium supplements in China. More than half of the children took supplemental calcium in the form of calcium gluconate (51.8%) and the average intake from supplements was 131 mg per day. There is little evidence to support the general use of calcium supplements in infants who were exclusively breastfed or formula fed. Evidence from recent studies does not support the use of calcium supplementation in healthy children as a public health intervention. However, for weaning infants and children with low calcium intakes, increased intake of calcium-rich foods should be encouraged. If adequate calcium cannot be achieved through food sources, supplementation may be an effective alternative. More studies are required in infants and young children with low calcium intakes, particularly those living in Asian countries or children of Asian ethnic origin. Chapter III - The purpose of this chapter is to present exposure of preschool children to daily consumed food preservatives and polyphosphates: sorbic acid, benzoic acid, nitrate, nitrite, sulphur dioxide and polyphosphates. For exact exposure of chemicals in food, data of consumed food intake and concentration of observed chemicals in food are needed. Methodology: Among the randomly selected regions in Slovenia, we randomly selected kindergartens and children aged from 2-6 years. The study included 190 children, 98 boys and 92 girls. Anthropometric measurements of children were conducted, so data on the sex, age, measured weight and height of the children were available. The dietary intake was based on

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Preface

ix

the 3-day-weighed record method. The data from databases obtained from the official control and monitoring of food additive content in consumed food were used to calculate estimated daily intake (EDI). Such estimated exposure of each preservative and polyphosphates EDI was compared with acceptable daily intake (ADI) and expressed as % of ADI. Results: average exposure to each preservative and polyphosphates EDI was not exceeding ADI. It is evident that average exposure to nitrites and sulphur dioxide is relatively high, while intake of benzoic acid, sorbic acid, nitrates and polyphosphates is not so high. The mean daily exposure of children to nitrites ranged from 12.8 % to 28.3 % ADI, to sulphur dioxide from 14.3 % to 21.4 % ADI, while to sorbic acid from 3.8 % to 4.5 % ADI and polyphosphates from 1.8 % to 3.9 % ADI. It is apparent that such exposure does not present any harm or threat to observed children although we should consider the fact that ADI for sum of preservatives and polyphosphates have not been set yet. Chapter IV - Dietitians emphasise the importance of a healthy breakfast as part of a balanced diet. As well as providing energy to fuel physical and mental activity, there is increasing evidence that eating breakfast assists individuals manage their food intake to prevent excessive weight gain. Parents play a critical role in determining if their children eat breakfast and, if so, the kinds of foods that are consumed at this meal. Limited previous research has specifically examined parents’ beliefs and behaviours in relation to this aspect of their children’s diets. Such information is especially important in the context of low socioeconomic families given that disadvantaged children have significantly higher rates of overweight and obesity and poorer academic performance relative to their more advantaged peers. In the present study, parents’ attitudes to breakfast and its role in children’s health were explored. A range of qualitative data collection methods was employed over an extended period (12 months) with low socioeconomic status parents of overweight children. Insights were generated into the barriers, motivators, and facilitators influencing whether parents provide their children with healthy breakfasts. Numerous factors were listed as making it difficult to ensure children eat a healthy breakfast. These included time constraints, children’s taste preferences, a lack of appetite upon waking, and a reluctance among some parents to model recommended breakfast consumption behaviours. The findings indicate that future efforts to improve children’s nutrition could (i) build on parents’ existing belief that breakfast is important and (ii) suggest coping strategies for parents to overcome the identified barriers to selecting and serving healthy breakfast foods. Chapter V - A daily Vitamin D (VitD) intake of at least 400 IU/day is recommended nowadays by most updated guidelines during the first year of life. However, it is not known whether such an intake is enough to provide all the health benefits associated with VitD and a consensus is still missing stating the serum vitD levels appropriate for global health and the cutoffs for deficiency in younger individuals. Potent immune-modulating effects of VitD have been reported in vitro and, in particular, its potential ability to influence both innate and adaptive immunity, reducing the inflammatory response associated with Th1 and Th17 cells and skewing the T cell balance towards a Th2-phenotype. VitD immune-modulation activities could thus play a role in controlling infections and reducing inflammatory responses toward viral pathogens in both children and adults. However, the evidence in relation to vitD and allergic diseases is controversial.

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Most evidence report a protective effect of vitD against allergy. Some studies, however, suggest that VitD supplementation can be a risk factor for asthma and atopic disorders, assuming that VitD could induce sensitization against allergens during infancy. In this chapter, published data on the relationship between vitamin D and asthma and allergy will be discussed, emphasizing the need for controlled, prospective studies on vitamin D supplementation to clarify whether it has a role in the prevention of and treatment for asthma and allergic conditions. Chapter VI - Background. Childhood obesity is becoming a global epidemic which may result in increased morbidity and mortality during young adulthood. Objectives. To identify common factors associated with overweight and obesity among Kuwaiti intermediate school children aged 10-14 years to support Kuwaiti obesity prevention policy making. Methods. Weights and heights of 343 female and 340 male students were collected to obtain body mass index (BMI). Results. The prevalence of overweight and obesity were 21.9 and 6.4% among females and 22.9 and 7.6% among males, respectively. Risk factors for obesity in males and females vary considerably and also differ between age groups. Conclusion. Health education programs focused on reducing obesity in Kuwait must be multifactorial in nature and should be defined by gender and age group.

Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

In: Child Nutrition and Health Editors: G. Cvercko and L. Predovnik

ISBN: 978-1-62257-981-5 © 2013 Nova Science Publishers, Inc.

Chapter I

Nutrition in Children and Adolescents with Cancer Terezie Tolar Mosby1 and Ronald D. Barr2, 1

St Jude Children’s Research Hospital, Memphis, TN, US 2 Departments of Pediatrics, Pathology and Medicine, McMaster University, Hamilton, Ontario, Canada

Abstract

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Cancer is the most common cause of disease-related death in children and adolescents in the United States, and it is becoming a proportionately more common cause of death among young people in developing countries as well. However, cancer is highly curable in young people. In high income countries, the survival rate of children and adolescents with cancer is 80% or higher. However, more than 80% of children live in low and middle income countries where the survival rate may be as low as 5%. Nutrition plays an important role in many aspects of cancer development, treatment and long term survival. Nutritional status at diagnosis has prognostic implications. Wellnourished children have a better tolerance of intensive cancer therapy, improved chances of survival, and lower relapse rates. Children and adolescents with cancer are at higher risk for the development of malnutrition than adults during treatment due to the relatively higher nutritional needs demanded by their continuous growth and organ development. Nutritional assessment is important for the prevention, recognition, and early treatment of malnutrition. Proper assessment of the nutritional status of a patient is necessary for the determination of appropriate nutritional therapy. The goals of nutritional therapy for patients undergoing anticancer treatment are to maintain weight and to achieve age-appropriate growth and weight gain after treatment. These goals can be achieved by dietary modifications, use of dietary supplements, appetite stimulants, or nutritional support. Patients undergoing chemotherapy, radiation and hematopoietic stem cell transplantation can experience any or all of the following side effects: nausea, vomiting, mouth sores, constipation, diarrhea, altered taste, loss of appetite. Any of these side effects could result in undesirable weight loss, protein energy malnutrition or cancer 

Room 3N27, Health Sciences Centre. McMaster University, 1200 Main Street West, Hamilton, Ontario, L8S 4J9, Canada, Tel: 1-905-521-2100 X 73428, Fax: 1-905-521-1703, E-mail: [email protected].

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Terezie Tolar Mosby and Ronald D. Barr cachexia. Food poisoning can occur if a person eats or drinks something that contains harmful germs. Food consumed by immunocompromised patients should be prepared in a manner to minimize bacterial growth. Survivors of cancer in childhood and adolescence are at risk for many long-term adverse effects of therapy. Lifestyle changes, including dietary modification, may help with the management of some of those sequelae. The three nutrition-related key areas to reduce cancer risk are weight, diet, and physical activity. There are numerous gaps in our knowledge concerning the interaction of nutrition with cancer in children and adolescents. These include the effects of nutritional interventions on cancer outcomes and the influence of such interventions on comorbidities; all providing rich opportunities for good clinical research.

A. Introduction

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Prevalence of Cancer and Access to Care in High Income and Low Income Countries Cancer is the most common cause of disease-related death in children and adolescents in the United States [1] [2] and it is becoming a proportionately more common cause of death among young people in developing countries. In the U.S. every year more than 12,000 children (less than 15 years of age) are diagnosed with cancer, with an incidence of 155 new cases per million [3] In all high income countries combined, 50,000 children are diagnosed with cancer each year [4]. In low and middle income countries, more than 200,000 children are diagnosed with cancer annually [4]. Therefore, the great majority of children with cancer live in the developing world [5]. The most common types of cancers in children in the US are acute leukemia and brain tumors, which together account for half of all cases [6]. There are some regional and ethnic differences in cancer incidence which are not well understood but may suggest genetic predisposition or infectious etiologies [7]. Some examples are the high incidence of Burkitt lymphoma and retinoblastoma in some African regions [5], the low incidence of neuroblastoma in Blacks and of Ewing sarcoma in Chinese, and the high incidence of Kaposi sarcoma in eastern and southern Africa [7]. Malnutrition is the condition that results from an unbalanced diet in which certain nutrients are lacking - undernutrition, in excess (too high an intake) - overnutrition, or in the wrong proportions [8], although the term malnutrition is interchanged with undernutrition in common usage. Undernutrition (malnutrition) is one of the most common causes of death in children in the developing world. However, it is uncommon in the general population of children in the United States. Complications of undernutrition before a diagnosis of cancer are frequent in low-income countries, whereas childhood overnutrition is the more frequent problem among young people in high-income countries. Both undernutrition and obesity can affect treatment outcome.

Treatment Outcome Cancer is highly curable in children and adolescents. In high income countries, their survival rate is 80% or higher [5]. However, more than 80% of children live in low and middle income countries where the survival rate may be as low as 5% [5]. Unfortunately, the

Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

Nutrition in Children and Adolescents with Cancer

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difference in survival for children diagnosed with cancer between high income and low income countries continues to widen as more advanced therapies are developed in the former but not implemented in the latter [9]. The low survival rate in low income countries is multifactorial in origin and includes limited availability and access to care, abandonment of treatment, malnutrition and advanced disease at the time of diagnosis. In high income countries, treatment outcome depends on such factors as the type and extent of disease, and the method of treatment used.

1. Nutritional Status at Diagnosis Impact of Over and Undernutrition Nutritional status at diagnosis has prognostic implications. Well-nourished children have a better tolerance of intensive cancer treatment, improved chances of survival, and lower relapse rates [10]. Both undernutrition and overnutrition at the time of diagnosis are associated with poorer treatment outcome [11] [12]. Malnourished children are at an increased risk for treatment-related complications, reduced tolerance of therapy, altered drug metabolism, increased susceptibility to infection, and poorer treatment outcome. They are also at higher risk for improper physical and psychological development [13] [14]. As they age, malnourished children may have permanent mental and physical disabilities [15]. The younger the child, the more severe the effects of malnutrition may be.

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I. Undernutrition (Underweight) It is estimated that the prevalence of malnutrition in children in the general population in low income countries can range up to 32% in some parts of Africa and up to 43% in India [16]. The prevalence of malnutrition in low income countries at the time of diagnosis of cancer depends on the geographical region, type of cancer and method used to diagnose undernutrition. For example, in Central America, more than 70% of children had some type of nutritional depletion at the time of diagnosis [17]. Undernutrition was associated with higher rates of death due to abandonment of therapy and treatment failure [12].

II. Overnutrition (Overweight and Obesity) Obesity is an increasing problem among children, not just in high income countries but also in low income countries. It is estimated that, in the US, 20% of children are obese. Overweight children are taller than their peers, have earlier onset of puberty and are presumed to be more mature [18]. Childhood obesity is associated with hyperlipidemia, hypertension, diabetes and insulin resistance, hepatic steatosis, cholelithiasis, pseudotumor cerebri, sleep apnea, and orthopedic abnormalities [18]. All of those problems can affect treatment outcome. With only a small number of pharmacological investigations regarding the half-life, volume of distribution, and clearance of drugs in obese patients, there is the risk of under dosing and/or over-dosing patients considered to be obese [11].These risks can result in poorer treatment outcome and/or greater toxicities in these patients [11].

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Terezie Tolar Mosby and Ronald D. Barr

2. Nutritional Status during Treatment Children and adolescents are at higher risk for the development of malnutrition than adults during cancer treatment due to the relatively higher nutritional needs demanded by their continuous growth and organ development. Anti-cancer treatment itself affects the nutritional status of patients and contributes to malnutrition. It is difficult to estimate the prevalence of malnutrition during treatment due to the lack of uniform criteria and adequate studies [19] but rates are estimated to be 0-10% for leukemia, 20-50% for neuroblastoma and 0-30% for other malignancies [19]. Suspected contributing factors are energy deficit, including low energy intake and increased metabolic rate, inflammation related to cachexia and malabsorption related to intestinal and other organ damage. The severity and variety of side effects depends on the nature of the disease and the treatment used. Common side effects interfering with nutrition are nausea, vomiting, loss of appetite, alteration of taste, mucositis, pancreatitis, pneumatosis intestinalis, and colitis. In those who have undergone hematopoietic stem cell transplantation (HSCT), graft versus host disease (GVHD) may result in an additional nutritional challenge. On the other hand, prolonged steroid use, physical inactivity and certain changes in metabolism predispose children with cancer to obesity. Malnutrition precludes optimal healing and recovery from therapy; therefore maximal effort should be focused on its prevention and treatment.

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B. Nutritional Assessment Nutritional assessment is important for the prevention, recognition, and early treatment of malnutrition. Proper assessment of the nutritional status of a patient is necessary for the determination of appropriate nutritional therapy. Special attention should be paid to metabolic derangements of macronutrients, leading to protein energy malnutrition (PEM), and micronutrients such as deficiencies of vitamin D, vitamin K, zinc, copper and selenium. There are many techniques that can be used to evaluate the nutritional status of adolescents and children. The choice of technique will depend on hospital resources, diagnosis, type of treatment, and other factors. In any case, both objective and subjective data should be used to complete the nutritional assessment. One measure alone should not be used to evaluate nutrition; therefore, healthcare providers should use critical thinking skills to assess nutritional status.

1. Screening Screening should be performed within 24-72 hours of admission for every patient and repeated regularly depending on the patient’s age, diagnosis, treatment, and other risk factors. Nutritional screening should include weight history, usual body weight, and a subjective history of current symptoms that includes, but is not limited to, nausea, vomiting, diarrhea, and appetite. Questions about food availability and who is responsible for food preparation should be asked as well. Such screening can identify children who are at risk of malnutrition

Child Nutrition and Health, edited by Gregor Cvercko, and Luka Predovnik, Nova Science Publishers, Incorporated, 2013. ProQuest Ebook Central,

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and need a more comprehensive nutritional assessment. See Table 1. for an example of a screening form used in St Jude Children’s Research Hospital. Table 1. Nutritional screening for nurses: inpatients done at admission; outpatients done at diagnosis and every 6 months at St Jude Children's Research Hospital

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Are you currently being seen by the clinical nutrition service? YES/NO Nutritional Screen Allergies to food Weight loss > 5% over 1 month Weight loss > 2 % over 1 month for infants Recent unexpected weight gain (please comment) Nausea/vomiting > 3 days Nil by mouth or poor oral intake > 3 days Total parenteral nutrition/tube feedings Problems or pain with chewing, swallowing, sucking Modified diet/dietary restrictions (please comment) Currently being breastfed Currently taking complementary/alternative medications (please comment) Other Nutritional Consult No nutritional concerns identified at this time Nutritional consult requested Comments

2. Data Collection, Evaluation and Interpretation In depth nutritional assessment should be provided anytime patients are at risk of malnutrition. Patients can be identified as at risk by medical personnel, other caregivers, or by periodic screenings. Unlike nutritional screening, nutritional assessment should be performed by a professional trained in nutritional assessment, such as a dietitian, trained nurse or a medical doctor. Nutritional assessment consists of 3 parts: data collection, data evaluation, and interpretation of findings [20]. Data collection should include diagnosis, historical data, nutrition-focused physical examination, anthropometry and measures of body composition, biochemical and hematological indices, and diet [21]. Nutritional assessment is a dynamic process performed to measure body size and composition for comparison with standards, to estimate nutritional needs, and to evaluate nutritional status and intake adequacy [22]. Diagnosis Oncologic diagnoses predispose patients to increased risks for malnutrition. Patients with cancers of the digestive tract (e.g., esophageal, gastric, pancreatic, liver, gallbladder, bile duct, and small and large intestine) especially may have severe weight loss due to changes in

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normal digestion and absorption [23]. Cancers posing high nutritional risks in children are advanced/metastatic solid tumors (e.g. neuroblastoma), non-Hodgkin lymphoma (stages III, IV and relapsed disease), acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL) with poor prognosis (high risk categories and relapsed disease), medulloblastoma and other brain tumors. All patients undergoing allogeneic HSCT are also at high risk for the development of malnutrition.

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Historical Data Historical data may include a medical history (acute and chronic illnesses, surgical and diagnostic procedures and medication use), diet history (use of dietary supplements), oral intake history, use of alternative or complementary medicine and weight history. Questions about the psychological status of patients should be asked with special attention to stress and depression. Patients should be asked about the use of over-the-counter medication, vitamins, and dietary and herbal supplements. Nutrition-Focused Physical Examination The nutrition-focused physical examination of an adolescent and child with cancer is an integral part of nutritional assessment and should never be omitted. It should include the general appearance and activity level of the patient. The clinician should focus on the presence of edema, ascites, cachexia, obesity, skin changes, dry mucous membranes, petechiae or ecchymoses, healing of wounds, glossitis, stomatitis, and cheilosis [24]. The physical examination should include an evaluation of body composition, including fat and muscle stores. Places to assess fat stores are overlying the lower ribs, orbital fat pads, groins, and armpits. Places to assess muscle stores are temples, clavicles, calves, and quadriceps (thighs) [25][26]. Other physical signs of malnutrition are liver enlargement and changes in skin, hair, eyes, face, lymph glands, mouth, teeth, and psychological status [27][28][29]. Nutritional skin disorders are also common as part of vitamin or mineral deficiencies [30]. Anthropometry and Measures of Body Composition These measures can be divided by level of resources needed for accomplishment and by the need for accuracy and precision as routine, midlevel and advanced. Routine measures include weight, height/length, head circumference (in children 25-30 Kg/m²) and with obesity (BMI>30 Kg/m²) among Kuwaiti intermediate school children aged 10-14 years from a chi-squared analysis of female and male data. For females these factors were age (p