Consensus Recommendations for the Nutritional Management of Children with Cancer in Limited Resource Settings: A Report from the International Initiative for Pediatrics and Nutrition

Karina Viani¹Jullyana Alves²Erika Damasco-Avila³Mariana Murra⁴Judy Schoeman^5,6Michelle Walters³Elena J Ladas^3*

• ¹Instituto de Tratamento do Câncer Infantil, Department of Pediatrics, School of Medicine, University of São Paulo, São Paulo, Brazil
• ²Department of Pediatrics, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brazil
• ³Department of Pediatrics, Division of Hematology/Oncology/Stem Cell Transplantation, Columbia University Irving Medical Center, New York, United States
• ⁴Department of Pediatrics, Hospital de Amor, Barretos, Brazil
• ⁵Division of Paediatric Oncology and Haematology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Pretoria, Pretoria, South Africa
• ⁶Research fellow, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa

Introduction: Malnutrition (under-and over-nutrition) is a critical challenge in pediatric oncology, particularly in low-and middle-income countries (LMIC), where supportive care resources are scarce. It negatively impacts treatment toxicity, survival rates, and quality of life. Despite the availability of broad guidelines, there is a lack of practical, context-adapted protocols for nutritional assessment and intervention in LMIC. The International Initiative for Pediatrics and Nutrition (IIPAN) developed adapted consensus-based protocols to address this gap. Methods: A multidisciplinary panel of experts in pediatric oncology and nutrition from high-income and LMIC settings collaborated to develop adapted nutrition assessment and intervention manuals. The process involved literature reviews, iterative expert consultations, field testing in LMIC hospitals, and subsequent revisions based on realworld application feedback. Training programs were designed to ensure implementation, including in person and virtual mentorship. Results: Two comprehensive manuals and one complementary material were developed: (1) Nutritional Assessment: A Training Manual in Anthropometry, (2) Nutritional Intervention: A Training Manual for Pediatric Oncology, and (3) Appendix for Nutritional Intervention. These resources provide structured detailed guidance on nutrition assessment, interventions, and the management of nutrition-related complications. Their scalability and accessibility are crucial for optimizing nutritional management and improving clinical outcomes in limited resource settings. Conclusion: These evidence-based, expert-designed adapted protocols address critical gaps in nutritional care for children with cancer in LMIC.