Pediatr Blood Cancer 2008;50:517

POSITION PAPERExperience in Developing Countries

Guillermo Ruiz-Arguelles, MD*

Marcos Borato-Viana presented detailed data on height deficits

during and many years after treatment of children with acute

lymphoblastic leukemia (ALL). In a cohort of Brazilian children,

and in a review of the literature from the past 20 years, it was clear

that significant height deficit occurs in childrenwhowere given only

chemotherapy, but it was greater in thosewho had additional cranial

irradiation. Young age at the time of treatmentwas an additional risk

factor. Providing human growth hormone to these children improves

their growth without risking leukemic relapse, though there is a

slightly increased risk of second malignancies, notably brain

tumors. These data indicate the need for long-term monitoring,

until achievement of final height, with therapeutic intervention

when required.

In the Summary of the First Workshop held in Puebla in

November, 1997, it is clearly stated that malnutrition is an adverse

prognostic factor in children with cancer. Socioeconomic dis-

advantage and poor compliancewith treatment are inter-relatedwith

malnutrition in this regard. In this Second Workshop, preliminary

information presented by Jose Carlos Jaime-Perez suggests that, by

intervening in the nutritional status of children with ALL, it may

be possible to improve their compliance with treatment. The

hypothesis is that malnutrition and poor compliance contribute

synergistically to the compromised delivery of scheduled chemo-

therapy to socioeconomically disadvantaged children in developing

countries. The prospective study which is being conducted in the

Hospital Universitario de Nuevo Leon, in addition to measuring

in detail the nutritional status of children with ALL, including

measures of body composition, involves close interactions of the

patients and relatives with nutritionists who, in addition to making

recommendations about diet and nutritional supplements, actively

promote compliance with anti-leukemic therapy. Other studies

to examine the impact of nutritional intervention on treatment

compliance are encouraged.

The studies reported by Federico Antillon, which are being

conducted in Guatemala, may reflect conditions common to

other developing countries and were designed after a meeting of

the Central American consortium AHOPCA in Guatemala City.

Preliminary data show a prevalence of some degree of nutritional

depletion in up to 58% of newly diagnosed children with all types of

cancer. For ALL the prevalence of malnutrition at diagnosis was

55%. Abandonment of therapy and treatment failure were more

common in under-nourished than in well-nourished children when

nutritional status was determined by arm anthropometry (mid upper

arm circumference and triceps skin fold thickness). Given that these

measures are less subject to variation between racial/ethnic groups

than is the case with height and weight, it is recommended that arm

anthropometry become part of the standard of care for children with

cancer in developing countries.

� 2007 Wiley-Liss, Inc.DOI 10.1002/pbc.21395

——————Centre for Hematology and Internal Medicine, Puebla, PUE, Mexico

*Correspondence to: Guillermo Ruiz-Arguelles, Centre for

Hematology and Internal Medicine, 8B Sur 3710, 72530, Puebla,

PUE, Mexico. E-mail: gruiz1@clinicaruiz.com

Received 17 September 2007; Accepted 17 September 2007