Development and evaluation of a nutritional support protocol for pediatric cancer patients during chemotherapy: A mixed-method study based on nutritional ecology

Development and evaluation of a nutritional support protocol for pediatric cancer patients during chemotherapy: A mixed-method study based on nutritional ecology | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and evaluation of a nutritional support protocol for pediatric cancer patients during chemotherapy: A mixed-method study based on nutritional ecology Yuan Zhang, Xin Yu, Sijia Gao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9491500/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Malignant neoplasms are the leading cause of disease‑related mortality in children. Although chemotherapy remains the primary treatment for pediatric malignancies, it frequently causes highly prevalent and challenging nutritional problems. Given that nutritional issues during chemotherapy represent a complex systemic challenge, this study aimed to develop a nutritional support protocol based on nutritional ecology theory for children undergoing chemotherapy and to evaluate its clinical application effects. Methods: A mixed-methods design was employed, comprising four phases: Phase 1 involved a systematic literature search and quality evaluation to synthesize evidence on nutritional support for children with cancer undergoing chemotherapy. Phase 2 comprised semi-structured interviews with pediatric cancer patients, family caregivers, and healthcare providers to explore multi‑stakeholder perspectives on internal and external systemic factors influencing nutritional status. Based on the findings of Phases 1 and 2, an initial nutrition support protocol was developed, which was then refined and finalized through a Delphi expert consultation in Phase 3, incorporating multiple ecological determinants. In Phase 4, a quasi‑experimental study was performed from January to October 2025 at a tertiary grade A hospital, enrolling 148 pediatric cancer patients. The experimental group received the nutritional support protocol, while the control group received routine care. Following a 12‑week intervention period, the two groups were compared regarding body mass index (BMI) z‑scores, STRONGkids scores, serum albumin (ALB), and prealbumin (PA) levels. Results: The protocol comprised 5 first‑level, 19 second‑level, and 44 third‑level items. After implementation, the experimental group showed significantly higher BMI‑Z scores, STRONGkids scores, serum ALB, and PA than the control group ( P <0.05). Conclusion: This scientifically rational, safe, and feasible nutritional support protocol reduces malnutrition risk and improves nutritional status in pediatric cancer patients, and can serve as a reference for clinical nursing practice. Trial registration: Not applicable. Pediatric oncology Chemotherapy Nutritional ecology Nutrition support Best evidence Qualitative research Delphi Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Childhood cancer represents a formidable global health burden. According to the World Health Organization (WHO), approximately 400,000 children and adolescents (aged 0–19) are diagnosed with cancer annually worldwide, establishing malignant neoplasms as the leading cause of disease-related mortality in this age group [ 1 ]. A spectrum of therapeutic modalities—including chemotherapy, radiotherapy, immunotherapy, surgery, and emerging RNA-based therapeutics—has been deployed in oncological management. Despite these advances, chemotherapy remains the cornerstone of pediatric cancer treatment [ 2 , 3 ]. While contemporary treatment protocols have propelled five-year survival rates to exceed 85% for many pediatric malignancies, the intensification of chemotherapeutic regimens has concomitantly escalated the burden of treatment-related toxicities, profoundly impacting patients’ quality of life and long-term health outcomes [ 4 ]. Gastrointestinal complications, such as nausea, vomiting, mucositis, and diarrhea, represent some of the most prevalent and clinically consequential adverse effects of cytotoxic therapy. These complications frequently result in inadequate nutrient intake, impaired absorption, and progressive nutritional decline [ 5 ]. This nutritional deterioration spans a continuum from subclinical deficiencies to overt malnutrition, rendering affected children more vulnerable to treatment interruptions, infectious complications, and diminished quality of life [ 6 , 7 ]. The intricate relationship between nutritional status and treatment outcomes in pediatric oncology has garnered increasing scholarly attention. Epidemiological data indicate that malnutrition affects approximately 24% – 55.4% of cancer patients overall, with pediatric populations experiencing disproportionately higher rates, reaching approximately 75% [ 8 , 9 ]. Strikingly, malnutrition, rather than the malignancy itself, accounts for mortality in 10%–20% of cancer patients, underscoring nutrition as an independent prognostic determinant in oncological care [ 10 ]. Recognizing the critical role of nutrition, several authoritative organizations—including the European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN)—have issued clinical practice guidelines providing evidence-based recommendations for nutritional support in pediatric oncology [ 10 – 12 ]. While these guidelines offer valuable frameworks for screening, assessment, and intervention, significant gaps remain between existing evidence and routine clinical practice. First, most guidelines tend to present general principles, making it challenging to translate them into context-specific, operational protocols tailored to the unique needs of children undergoing chemotherapy, particularly within local healthcare setting [ 13 , 14 ]. Second, implementation barriers—such as inconsistent workflows, limited staff training, and insufficient interdisciplinary collaboration—are frequently reported yet seldom explicitly addressed in protocol development. In parallel, traditional research approaches have largely concentrated on unidirectional causal pathways of insufficient nutrient intake, with corresponding interventions often limited to nutritional supplementation. However, nutritional compromise in pediatric cancer patients undergoing chemotherapy is better understood as a multifaceted systemic challenge. Multiple factors interact dynamically, including chemotherapy-induced gastrointestinal toxicity, enteral feeding modalities, institutional screening and intervention protocols, developmental nutritional requirements, and culturally embedded feeding practices. Collectively, these elements highlight the ecological complexity inherent in nutritional management during chemotherapy [ 15 , 16 ]. Taken together, an integrated and context-specific approach is needed in pediatric oncology nutrition practice, one that bridges clinical evidence with the realities of treatment delivery. Nutritional ecology theory conceptualizes nutritional status as an emergent property of complex systems, arising from dynamic interactions between the individual's internal environment (biological characteristics, disease status, metabolic demands) and external environment (family support systems, healthcare infrastructure, sociocultural contexts) [ 17 ]. This theoretical framework offers novel insights for addressing clinical nutritional challenges, facilitating systematic elucidation of multidimensional determinants of nutritional status, and providing conceptual foundations for developing comprehensive nutritional management protocols integrating medical intervention, family engagement, and sociocultural considerations [ 18 , 19 ]. To date, no study has been identified that applies nutritional ecology theory to the field of pediatric oncology nutrition. Existing research has largely focused on individual components of the nutrition care continuum, with few studies systematically integrating the complex interplay of biological, familial, and sociocultural factors that shape nutritional outcomes in this vulnerable population. This theoretical and practical gap highlights the need for a comprehensive, theoretically informed approach to nutritional support that addresses the unique challenges faced by pediatric cancer patients and their families throughout the treatment trajectory. Accordingly, this study seeks to develop a scientifically rigorous, systematic nutrition support protocol for pediatric cancer patients receiving chemotherapy, grounded in nutritional ecology theory, and to explore its clinical applicability. It is hoped that this theoretically informed approach may provide useful insights for researchers, clinicians, and nurses in pediatric oncology, particularly in the development of tailored nutrition support protocols for children with tumors. Materials and methods This study employed a four-phase mixed-methods design. Phase 1 involved a systematic literature search and quality evaluation to synthesize evidence on nutritional support for children with cancer undergoing chemotherapy. Phase 2 comprised semi-structured interviews with pediatric cancer patients, family caregivers, and healthcare providers to explore multi‑stakeholder perspectives on internal and external systemic factors influencing nutritional status. Based on the findings of Phases 1 and 2, an initial nutrition support protocol was developed, which was then refined and finalized through a Delphi expert consultation in Phase 3, incorporating multiple ecological determinants. Phase 4 was a quasi‑experimental study conducted from January to October 2025 at a tertiary grade A general hospital in Jilin Province, China – the only institution in Northeast China with a dedicated pediatric oncology ward – to evaluate the effectiveness of the finalized protocol in improving nutritional outcomes in this population. The study process is shown in Fig. 1 . 1.Evidence synthesis 1.1 Formulating an Evidence‑Based Question The evidence-based problem was constructed using the PIPOST model [ 20 ]. As “P” (population): pediatric cancer patients; “I” (intervention): strategies for nutritional support; “P” (professionals): nutrition support teams, patients, and their caregivers; “O” (outcomes): incidence of malnutrition, BMI-Z score, serum ALB and PA concentrations; “S” (setting): home and hospitals; “T” (types of evidence): clinical decisions, clinical guidelines, evidence summaries, expert consensus, systematic reviews, meta-analyses, and randomized controlled trial (RCT). 1.2 Literature Search Strategy Following the “6S” classification model for evidence-based resources [ 21 ], a comprehensive search was conducted in UpToDate, BMJ Best Practice, WHO guidelines, Guidelines International Network (GIN), National Guideline Clearinghouse (NGC), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), Medlive, European Society for Clinical Nutrition and Metabolism (ESPEN), American Society for Parenteral and Enteral Nutrition (ASPEN), Chinese Nutrition Society, Chinese Society of Clinical Oncology, Chinese Anti-Cancer Association, Web of Science, Cochrane Library, Embase, PubMed, CINAHL, CBM, CNKI, and Wanfang Data. The search timeframe was from January 2012 to January 2025. The search strategy combined MeSH terms and free-text keywords as follows: (tumor/cancer/oncology/neoplasms/“Neoplasms”[Mesh]) AND (child/children/pediatric/pediatrics/“Pediatrics”[Mesh]) AND (chemotherapy/antitumor therapy/drug therapy/“Drug Therapy”[Mesh]) AND (nutritional support/nutrition supplementation/nutritional assessment/nutrition/family support/health system/health education/patient education/social support/psychosocial support/continuity of care/“Nutritional Support”[Mesh]/“Nutrition Assessment”[Mesh] /“Nutrition Therapy”[Mesh]). 1.3 Evidence inclusion and exclusion criteria Studies were included for those involved children (aged ≤ 18 years) diagnosed with hematologic or solid malignancies and receiving chemotherapy; implemented nutritional interventions specifically targeting this population; were conducted in contexts where healthcare professionals served as evidence implementers; reported outcomes related to malnutrition incidence, anthropometric indicators, or laboratory parameters in pediatric cancer patients; and were published as clinical decisions, clinical guidelines, expert consensus, evidence summaries, systematic reviews, meta-analyses, or RCTs in English or Chinese. Studies were excluded if they had incomplete data, were conference abstracts or had unavailable full texts, were duplicate publications, or received low-quality ratings during critical appraisal. 1.4 Literature quality assessment criteria The quality of included literature was assessed using established tools. Clinical practice guidelines were evaluated using the AGREE II [ 22 ], clinical decisions were assessed using the Critical Appraisal for Summaries of Evidence (CASE) [ 23 ], and expert consensuses, systematic reviews, meta-analyses, and RCTs were assessed using the Joanna Briggs Institute (JBI) checklists [ 24 ]. All appraisals were conducted independently by trained researchers, with guidelines assessed by four researchers and other document types by two. Disagreements were resolved through team discussion. 1.5 Evidence synthesis and grading Two authors (XY, YZ) independently extracted, synthesized, and graded the evidence using the JBI evidence pre-grading and recommendation level system (2014 version), which categorizes evidence into levels 1–5 [ 25 ]. Final evidence grades were determined through discussion within the research team. 2. Qualitative interview A descriptive qualitative study was undertaken to understand the experiences, needs, and perceptions of multiple stakeholders regarding nutritional support for pediatric cancer patients undergoing chemotherapy. This phase was grounded in stakeholder theory [ 26 ], which acknowledges that incorporating perspectives from all relevant parties is essential for developing contextually appropriate interventions. 2.1 Participants Participants were recruited from January to April 2025. A purposive sampling strategy was employed, with an emphasis on maximum variation sampling to ensure diversity across key characteristics. Three participant groups were enrolled: Pediatric cancer patients, their family caregivers, and clinical healthcare providers. Inclusion and exclusion criteria were shown in Fig. 2 . Sample size was determined by data saturation, defined as the point at which no new themes emerged from subsequent interviews. 2.2 Interview procedure Data were collected through individual, semi-structured interviews. Interview guides, tailored to each participant group, were developed based on study objectives and relevant literature, as shown in Fig. 3 . All interviews were conducted by the first author in private settings — hospital rooms for children and families, and offices for healthcare professionals. Prior to each interview, the researcher explained the study’s purpose and confidentiality. Children and caregivers were interviewed separately to ensure data independence. Interviews lasted 20–40 minutes. The researcher employed active listening, open-ended questioning, and behavioral observation, maintaining neutrality and clarifying ambiguous statements in real time. Interviews were audio-recorded, with non-verbal information documented manually. Transcripts were verified against recordings, anonymized using pseudonyms, and stripped of identifying information. Written informed consent was obtained from all participants. 2.3 Data Analysis and Rigor Thematic analysis was conducted using Colaizzi's seven-step method [ 27 ]. Transcripts were imported into NVivo 12 for data management. Coding was performed independently by two researchers, with discrepancies resolved through discussion and team consensus. Member checking was conducted with a subset of participants to verify the accuracy of interpretations. To ensure trustworthiness, we employed independent coding by two trained researchers (with consensus on discrepancies), maintained reflexive journals to facilitate bracketing, conducted member checking for participant validation, and held regular peer debriefing meetings. 3. Delphi expert consensus 3.1 Identify consulting experts Experts were selected based on the Delphi method [ 28 ] and the content of the consultation. The selection criteria included current employment at a tertiary Grade A hospital, holding a mid-level or higher professional title, having a bachelor’s degree or above, possessing at least 10 years of clinical experience in pediatric oncology or clinical nutrition (in either medicine or nursing), demonstrating recognized academic influence in the fields of pediatric oncology and clinical nutrition, and showing strong commitment by voluntarily participating in this study. 3.2 Procedure Based on gaps identified through evidence synthesis and qualitative interviews, a draft nutrition support protocol for pediatric cancer patients undergoing chemotherapy was developed via multiple team discussions under the framework of nutritional ecology, to bridge the evidence–practice gap. A corresponding Delphi consultation questionnaire was then constructed based on this draft protocol. The full questionnaire is provided as Supplementary File 1. Experts were asked to rate the importance of each item using a 5-point Likert scale (1 = very unimportant to 5 = very important). Open-ended comment boxes were provided after each item and at the end of each dimension to solicit qualitative feedback, including suggestions for item modification, addition, or deletion. The Delphi procedure was conducted from May to June 2025. Questionnaires were distributed and returned via email. Each round remained open for two weeks, with reminders sent at the beginning and end of the second week, and a two-week interval between rounds. Descriptive statistics were used for analysis. Items were retained if mean importance > 3.50 and coefficient of variation < 0.25 [ 29 ]. Qualitative comments were systematically reviewed and synthesized. The protocol was revised by integrating quantitative and qualitative feedback to form the next-round questionnaire. The process concluded when consensus was reached and no new substantive suggestions emerged. 4. Quasi-experimental study 4.1 Participants Children with histopathological confirmed malignant tumors requiring chemotherapy were enrolled. The inclusion criteria were as follows: (1) age between 6 and 16 years; (2) ability to communicate effectively; (3) normal blood counts and liver and renal function prior to chemotherapy; and (4) written informed consent obtained from both the child and the caregiver. The exclusion criteria were: (1) concurrent radiotherapy and chemotherapy; (2) use of corticosteroids as part of the chemotherapy regimen; (3) pre-existing severe feeding difficulties or malabsorption prior to chemotherapy resulting from tumor-related factors or surgical sequelae; and (4) terminal malignancy. Participants were withdrawn from the study if they were lost to follow-up, developed severe treatment-related complications, or voluntarily withdrew consent. The sample size was estimated using G Power software based on a comparison of two independent means with a 1:1 allocation ratio. The primary outcome was BMI-Z score. Assuming a two-tailed α = 0.05, power (1-β) = 0.80, and an effect size of d = 0.49 derived from a previous study [ 30 ], the required sample size was calculated to be 67 participants per group. After accounting for a 10% attrition rate, the sample size was inflated to 74 participants per group, resulting in a total target sample of 148 children. A convenience sampling method was employed due to clinical and logistical constraints. To minimize contamination between groups, a temporal separation design was implemented. The control group comprised 74 children receiving regular chemotherapy from January to May 2025. Following a washout period for staff training and protocol implementation, the experimental group comprised 74 children receiving regular chemotherapy from August to December 2025. Both groups were recruited from the same pediatric oncology department. 4.2 Interventions. Participants in the experimental group received the newly developed nutrition support protocol for pediatric cancer patients during chemotherapy (Table 7 ). The protocol integrated five dimensions established in previous phases: Organization and management, standardized screening and assessment, nutritional intervention strategies, health education, and transitional care. To ensure implementation consistency, the research team developed a systematic training program delivered through a blended approach (online and face-to-face). The curriculum covered protocol implementation procedures, standardized screening and assessment techniques, principles of nutritional intervention (including indications for enteral and parenteral support), health education delivery, and transitional care. Training included theoretical lectures, scenario-based simulations, and case analyses, with two online and two face-to-face sessions (approximately 30 minutes each). Following training, all team members completed a competency assessment to verify proficiency before participating in the experimental group, ensuring intervention fidelity. The control group received standard nutritional care per hospital protocols, consisting of three phases. During screening and assessment, height and weight were measured, dietary intake assessed, and STRONGkids screening performed upon admission; high-risk cases were reported to the attending physician. In the intervention phase, nutritional support was initiated when weight loss exceeded 5% of baseline or intake fell below 50% of estimated requirements for more than five days, with the route and goals determined by laboratory parameters and physician judgment. During monitoring and follow-up, weight, serum ALB, and PA levels were assessed during hospitalization, with biweekly telephone follow-up after discharge to track weight and dietary status. Measurements Demographic and clinical characteristics: Baseline data, including age, sex, diagnosis, StrongKids score, BMI‑Z score, serum ALB, and PA levels, were collected for all participants. Nutritional risk screening: Nutritional risk was assessed using the STRONGkids tool, which evaluates subjective clinical assessment, presence of high-risk disease, nutritional intake, and weight loss or poor weight gain [ 31 ]. Total scores are categorized as: 0 = low risk (routine reassessment); 1–3 = medium risk (further assessment and intervention); 4–5 = high risk (in-depth evaluation and individualized treatment). Nutritional status assessment: Nutritional status was evaluated using anthropometric and laboratory indicators: BMI‑Z scores calculated based on WHO growth standards (adjusted for age and sex), and serum AL and PA levels as indicators of protein nutritional status. Protocol feasibility: Feasibility of protocol implementation was evaluated through: (1) protocol execution rates; (2) correct operation rates for key procedures; (3) execution efficiency (time required for completion); and (4) qualitative feedback from medical staff regarding barriers and facilitators. Data Collection Data were collected at baseline (within 24 hours of admission) and 12 weeks post-intervention. Prior to data collection, two designated data collectors received standardized training. Inter-rater reliability was established through independent evaluation of five pilot cases, with discrepancies discussed and resolved to ensure consistency. Throughout the data collection period, the principal investigator conducted spot checks every 1–2 weeks to review data quality and ensure protocol adherence until sample collection was complete. Ethical considerations The study was approved by the institution's Research Ethics Committee under No.25K350-001. Prior to enrollment, all participants received a clear explanation of the study’s purpose and provided written informed consent. They were explicitly informed of the voluntary nature of their participation and their right to withdraw at any time without consequence. Furthermore, participants were assured of the confidentiality of their personal information and the anonymous use of all data and experiences. Statistical Analysis Statistical analyses were conducted using the SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were computed for all variables: continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as frequencies and percentages. For between-group comparisons, independent samples t-tests were used for continuous variables meeting normality assumptions, and chi-square tests or Fisher's exact tests for categorical variables as appropriate. BMI-Z scores were calculated using R software (version 4.3.2; R Foundation for Statistical Computing, Vienna, Austria) with the “Z-scorer” package. Statistical significance was set at P < 0.05 (two-tailed). In the analyses of the Delphi phase, the expert positive coefficient, expert authority coefficient, and coordination coefficient were calculated. The expert positive coefficient was calculated with the formula (number of questionnaires returned/ number of questionnaires given) 100. Kendall’s W value was calculated for coordination coefficient calculation and P < 0.05 was accepted as significant. Results Findings of literature screening A preliminary search produced 601 articles. After a systematic literature search and screening process, as shown in Fig. 4 , 11 articles met the inclusion criteria. There are comprising 2 clinical decisions [ 32 , 33 ], 3 clinical practice guidelines [ 10 , 34 , 35 ], 2 expert consensus [ 36 , 37 ], 2 systematic reviews [ 38 , 39 ], and 2 randomized controlled trials [ 40 , 41 ]. The basic characteristics of the included literature are summarized in Table 1 . Table 1 Basic characteristics of included studies. Author Literature source Literature type Publication date Literature title Baker et al. UpToDate Clinical decision-making 2024 Parenteral nutrition in infants and children Jatoi et al. UpToDate Clinical decision-making 2024 The role of parenteral and enteral/oral nutritional support in patients with cancer CSNO Medlive Guideline 2023 Updated guideline for oral nutritional supplements Muscaritoli M et al. ESPEN Guideline 2021 ESPEN practical guideline: clinical nutrition in cancer CSPEN Medlive Guideline 2017 Guidelines on nutritional support in patients with tumor Agnieszka Budka-Chrzęszczyk et al. PubMed Expert consensus 2024 Managing Undernutrition in Pediatric Oncology: A Consensus Statement Developed Using the Delphi Method by the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology The Hematology Group of the Pediatric Section of the Chinese Medical Association et al. Medlive Expert consensus 2024 Nutrition Management Standard Process for Children with Blood/Tumor Diseases Iniesta et al. PubMed Systematic review 2023 Systematic review and meta-analysis: prevalence and possible causes of vitamin D deficiency and insufficiency in pediatric cancer patients Hawes et al. PubMed Systematic review 2023 The effect of oral nutrition supplements and appetite stimulants on weight status among pediatric cancer patients: a systematic review Ramezani et al. PubMed Randomised controlled experiments 2018 The Effect of Soy Nut Compared to Cowpea Nut on Body Weight, Blood Cells, Inflammatory Markers and Chemotherapy Complications in Children with Acute Lymphoblastic Leukemia: A Randomized Controlled Clinical Trial Rocha et al. PubMed Randomised controlled experiments 2016 Impact of Selenium Supplementation in Neutropenia and Immunoglobulin Production Findings of literature quality evaluation The quality evaluation results of the guidelines are presented in Table 2 . Two clinical decisions were included, both [ 32 , 33 ] were rated “no” for “transparent and comprehensive search,” and one of them [ 33 ] was rated “no” for “clear evidence grading”; all other items were rated “yes.” Two expert consensuses were included. For one consensus [ 36 ], the rating for Item 2 (“Do the opinions originate from influential experts in the field?”) was “unclear”, whereas all other items were rated “yes”. For the other consensus [ 37 ], the rating for Item 6 (“Are the proposed opinions inconsistent with previous literature?”) was “uncertain”, and all other items were rated “yes”. The quality of these two expert consensuses was deemed to be high, and therefore they are worthy of consideration. Two systematic reviews were included. For the review by Hawes et al. [ 38 ], all items were rated as “yes”. For the review by Iniesta et al. [ 39 ], the ratings for all items were “yes” except for Item 5 (“Was the quality of the included studies appropriately assessed?”) and Item 6 (“Was the quality of the included studies assessed by two or more independent reviewers?”), which were rated as “unclear”. Both systematic reviews demonstrated a relatively complete study design and high overall quality, and were therefore included. Two RCTs were also included. The trial by Ramezani et al. [ 41 ] received a rating of “yes” for all items. The trial by Rocha et al. [ 40 ] received a rating of “unclear” for the item “Was blinding of intervention providers implemented?” and “yes” for all other items. Both of these randomized controlled trials were all included due to their relatively sound study designs and high overall quality. Table 2 Quality evaluation results of included guidelines. Studies Standardized scores in various domains (%) ≥ 60% 30%-60% Quality Scope and purpose Stakeholder involvement Rigor of development Clarity of presentation Applicability Editorial independence CSNO 94.44 72.2 89.58 91.67 75.00 83.33 6 6 A Muscaritoli M et al. 94.44 88.89 87.50 88.89 79.17 95.83 6 6 A CSPEN 93.52 84.72 78.13 94.44 38.54 50.00 4 2 B A total of five key themes were identified, encompassing organizational management, standardized screening and assessment, nutritional intervention strategies, health education and transitional care. This led to the identification of 38 pieces of best evidence, as outlined in Table 3 . Table 3 Summary of the best evidence on nutritional support for children with tumors during chemotherapy. Theme Evidence content Level of evidence Organizational Management 1. Establish a multidisciplinary nutrition support team (hematologists/oncologists, dietitians, nurses, pharmacists) to monitor energy, protein, trace elements, minerals, and vitamins [ 10 , 37 ]. 1a 2. Perform nutritional risk screening and assessment immediately upon cancer diagnosis [ 36 ]. 5b 3. Formulate and implement a nutritional treatment plan based on nutritional diagnosis [ 37 ]. 5b Nutritional Screening and Assessment 4. Conduct comprehensive nutritional assessment to identify the etiology, mechanism, and severity of malnutrition [ 32 ]. 1b 5. Use the “ABCDEF” method: Anthropometry, Biochemistry, Clinical assessment, Dietary assessment, Environment/Family information [ 32 , 37 ]. 1b 6. Include weight, height, BMI, and mid-upper arm circumference in anthropometry; reference WHO standards [ 37 ]. 5b 7. Include serum ALB, PA, anemia status, inflammatory markers, and specific trace elements/vitamins in biochemical tests [ 37 ]. 5b 8. Clinically assess dietary intake, muscle wasting, subcutaneous fat, edema, and skin/mucous membrane/hair condition [ 37 ]. 5b 9. Use STAMP or SCAN tool for nutritional risk screening [ 37 ]. 5b 10. STAMP ≥ 4 or SCAN ≥ 3 indicates high nutritional risk; conduct detailed assessment and regular re-screening [ 37 ]. 5b Nutritional Requirements 11. Use Nutritional Risk Index (NRI) to assess nutritional status: NRI = 1.519 × serum albumin (g/L) + 0.417 × (current weight/usual weight) × 100. Classify as well-nourished (NRI > 97.5), moderately malnourished (97.5 ≥ NRI ≥ 83.5), or severely malnourished (NRI < 83.5) [ 33 ]. 1b 12. For stable children, follow energy, protein, and micronutrient recommendations for healthy peers per Chinese Dietary Reference Intakes [ 36 ]. 5b 13. Supplement soy protein during chemotherapy to improve nutritional status [ 41 ]. 1c 14. Supplement vitamins C, D, E, and selenium to improve nutritional status and reduce treatment-related side effects [ 39 , 40 ]. 1a 15. Administer micronutrients in appropriate amounts to avoid toxicity [ 10 ]. 1b 16. Oral fish oil may improve appetite, muscle mass, and reduce inflammation in hematologic malignancies [ 10 ]. 1b Nutritional Intervention 17. Indications for nutritional therapy: High nutritional risk/malnutrition; crossing down two major percentile curves; weight loss > 5% [ 37 ]. 5b 18. Follow the five-step ladder: Diet and education → diet + ONS → EN → partial EN + partial PN → total PN. Advance if current step fails to meet ≥ 60% of target energy for 3–5 days [ 37 ]. 5b 19. Individualize interventions based on patient needs, clinical status, and gastrointestinal function [ 36 ]. 5b 20. Provide nutritional support for at-risk children and monitor efficacy and complications [ 34 ]. 1b 21. Prefer EN if gastrointestinal function is intact; prioritize diet and education for those able to eat orally [ 10 ]. 1b 22. Provide ONS when intensified counseling improves but does not meet nutritional requirements [ 38 ]. 1b 23. ONS selection: Standard whole-protein formula for most cases; elemental formula for severe intestinal dysfunction; diabetes-specific for diabetes/glucose intolerance; specialized for chronic kidney disease with electrolyte abnormalities; high-energy-density for fluid restriction; immunomodulating may benefit major surgery. Routine enrichment with ω-3 fatty acids, β-hydroxy-β-methylbutyrate, arginine, glutamine, branched-chain amino acids, or probiotics is not recommended [ 34 ]. 5b 24. Whey protein-fortified ONS may improve albumin, immunoglobulins, and nutritional status scores [ 34 ]. 1b 25. Initiate artificial nutrition support when oral intake is impossible or ONS insufficient [ 35 ]. 1b 26. EN indications: Oral intake < 50% of standard for 5 consecutive days; severe wasting/malnutrition (BMI or MUAC <5th percentile or z-score 5% or MUAC reduction > 10% from diagnosis [ 37 ]. 5b 27. EN includes oral and tube feeding; use tube feeding when oral intake is inadequate [ 37 ]. 5b 28. Tube selection: Nasogastric for short-term ( 4 weeks) when feasible [ 37 ]. 5b 29. Initiate EN at low dose and concentration, with gradual progression [ 35 ]. 1b 30. EN administration: Maintain formula at 37–40°C; osmolality < 330 mmol/L to reduce diarrhea; continuous pump infusion; head of bed elevated 30–45°; maintain semi-recumbent position for 30 minutes post-infusion [ 37 ]. 5b 31. EN monitoring: Gastrointestinal symptoms (measure gastric residual volume if vomiting/distension); fluid input/output; nutritional adequacy (daily intake percentage); laboratory indicators (complete blood count and biochemistry every 1–2 days initially, then every 1–2 weeks) [ 37 ]. 5b 32. EN is preferred for hematologic malignancies. Use PN for critically ill or high-dose chemotherapy patients when oral/enteral intake is insufficient, and discontinue upon gastrointestinal recovery [ 10 ]. 1b 33. PN indications: EN contraindicated or fails to meet ≤ 60% of target energy for 3–5 days, per ESPEN guidelines and five-step ladder [ 10 , 37 ] 5b 34. Monitor PN complications: Mechanical/device-related issues, infections, metabolic complications, electrolyte/acid-base imbalances, drug-nutrient interactions, intestinal failure-associated liver disease, and refeeding syndrome [ 32 , 35 ]. 1b 35. Initiate nutritional therapy at low doses and gradually increase to target levels [ 35 ]. 1b Education and Follow-up 36. Provide individualized nutrition education [ 10 ]. 5b 37. Encourage physical activity to maintain and improve appetite, adjusting intensity according to health status and function [ 10 ]. 5b 38. Conduct regular monitoring and follow-up during and after treatment to implement and evaluate interventions [ 36 ]. 5b Qualitative interview Thematic analysis of the interviews with 10 pediatric cancer patients, 12 family caregivers, and 12 healthcare professionals (5 physicians and 7 nurses) yielded five central themes that capture their experiences, needs, and perceptions of nutritional support during chemotherapy. Demographic and clinical data of patients, caregivers and healthcare professionals were collected in Table 4 . Table 4 Demographic and clinical characteristics of participants. Variables Pediatric Patients with Cancer (n = 10) Family caregivers (n = 12) Healthcare Professionals (n = 12) Gender, n (%) Male 4 (40) 5 (41.67) 1 (8.33) Female 6 (60) 7 (58.33) 11 (91.67) Age, years, Mean ± SD 12.00 ± 2.40 35.50 ± 6.57 40.40 ± 3.57 Education, n (%) Junior high school or below — 4 (33.3) — High school / technical secondary school — 1 (8.33) — Junior college — 2 (16.67) — Bachelor’s degree — 4 (33.3) 7 (58.33) Master’s degree or above — 1 (8.33) 5 (41.67) Occupation, n (%) civil servant — 2 (16.67) — teacher — 1 (8.33) — nurse — 1 (8.33) — pharmacist — 1 (8.33) — salesman — 1 (8.33) — famer — 3 (25.00) — others — 3 (25.00) — Professional title, n (%) Junior — — — Intermediate — — 8 (66.67) Sub-senior — — 4(33.33) Senior — — — Years of working experience, n (%) — — 16.40 ± 3.57 5–10 4 (33.33) 10–15 1 (8.33) ≥ 15 7 (58.33) Illness leading to hospitalization (medical specialty), n (%) Lymphoma 3 (30.00) 3 (25.00) — Leukemia 1 (10.00) 2 (16.67) — Neuroblastoma 2 (20.00) 2 (16.67) — Medulloblastoma 1 (10.00) 2 (16.67) — Rhabdomyosarcoma 1 (10.00) 1 (8.33) — Hepatoblastoma 1 (10.00) — — Wilms' tumor 1 (10.00) 1 (8.33) — Teratoma — 1 (8.33) — Disease duration, months, Mean ± SD 6.90 ± 3.60 6.83 ± 3.10 — Degree of kinship, n (%) Father — 5 (41.67) — Mother — 7 (58.33) — Note: Data are presented as mean ± standard deviation for continuous variables and as number (percentage) for categorical variables. “—” indicates that the variable was not applicable to the respective participant group. Interviews were transcribed verbatim within 48 hours, yielding 127,600 Chinese characters of transcribed text from a total interview duration of 896 minutes. The themes and sub-themes derived from the analysis of the interview data are presented in Fig. 5 . Analyze the gaps between clinical practice and the best evidence. Based on the theory of nutritional ecology, specific supplements were made to the initial draft of the plan. The specific strategies are collected in Table 5 . Table 5 Integration of evidence–practice gaps and protocol development strategies. Gap Category Evidence-Based Recommendation Current Clinical Practice Ecological Disconnection Protocol Development Response Screening gap Standardized nutritional risk screening using validated tools (e.g., STRONGkids), with regular reassessment throughout treatment Screening performed only at admission; no systematic follow-up. High-risk children faced > 24-hour delays awaiting formal assessment Fragmented approach failed to capture dynamic changes in the child’s internal environment (e.g., deteriorating nutritional status due to treatment toxicity), delaying early intervention Nutritional Risk Screening dimension restructured to ensure systematic monitoring throughout treatment trajectory. Established clear escalation pathways with specified reassessment and response timelines, enabling standardized dynamic surveillance of the child’s internal environment Intervention gap Preventive nutritional interventions for anticipated chemotherapy-induced toxicities (e.g., mucositis, nausea, vomiting, diarrhea) Reactive management: interventions initiated only after symptoms became clinically significant Temporal misalignment between internal system changes (emergence of gastrointestinal toxicity) and external system responses (nutritional support), reflecting lack of ecological synergy Nutritional Management of Chemotherapy-Related Adverse Effects module developed to shift from reactive to proactive paradigm. Integrated fragmented guidance into timeline-based framework, including defined eating windows relative to chemotherapy (e.g., 3 hours before, 4 hours after) and stepwise escalation for oral mucositis initiated before symptom onset Information gap Personalized, actionable health education tailored to caregivers’ needs Overly generic educational content delivered in standardized formats; no consideration of health literacy, cultural background, or specific concerns Inadequate allocation of educational resources within the external system (hospital) to address families’ complex, individualized nutritional challenges Health Education dimension reconfigured into modular packages aligned with treatment phases (diagnosis, active chemotherapy, myelosuppression, maintenance). Assigned clear accountability: Primary nurses for delivery; dietitians for quality control, ensuring tailored information transfer throughout treatment journey Coordination gap The multidisciplinary nutrition support team is composed of hematologists/oncologists, clinical nutritionists/nutritionists, nurses/pharmacists, etc., and is a multi-disciplinary team that jointly participates. Poorly defined role boundaries among physicians, nurses, and dietitians; no clear mechanism for collaboration Systemic fragmentation reflected absence of effective communication channels and collaboration mechanisms among subsystems, preventing an integrated support system Standardized Training added to define standardized operating procedures for screening, education delivery, and escalation protocols. Specified distinct responsibilities of physicians, nurses, and dietitians to optimize information flow and create a cohesive external support system Delphi expert consensus A total of 20 experts consented to participate in this study, and all of them completed both rounds of the Delphi survey. All participating experts were female and engaged in clinical practice. The characteristics of the experts are presented in Table 6 . Table 6 Demographics of the experts that participated in the Delphi-study. Characteristic Round 1–2 (n = 20) N (%) MEAN (SD) Age (years) 40.40 ± 3.57 Years of professional experience 16.4 ± 3.57 Province of experts Jilin Province 15 (75) Shanghai Municipality 1 (5) Hubei Province 2 (10) Hunan Province 2 (10) Field of expertise Pediatric oncology clinical experts 3 (15) Pediatric oncology nursing experts 10 (50) Nutritional nursing experts 3 (15) Adult oncology nursing experts 4 (20) Educational background Doctorate 3 (15) Master's degree 15 (75) Bachelor's degree 2 (10) Professional title Senior 2 (10) Associate senior 16 (80) Intermediate 2 (10) In the Delphi survey, two rounds of expert consultation were conducted. In each round, 20 questionnaires were distributed, and all 20 were returned valid, resulting in a 100% effective response rate. The expert authority coefficients were 0.903 in the first round and 0.895 in the second round. In the first round, the coefficients of variation (CV) for individual items ranged from 0 to 0.312, the full-score rate was 82.94%, and Kendall’s coefficient of concordance (Kendall’s W) was 0.229 ( P < 0.001). In the second round, the CVs ranged from 0 to 0.183, the full-score rate was 96.76%, and Kendall’s W was 0.227 ( P < 0.001). Round 1 18 experts provided 20 substantive modification suggestions. Based on the predefined retention criteria and team discussion, the following revisions were made: Item Additions: (1 second-level items) “Nutritional strategies for chemotherapy-related adverse effects” ; (4 third-level items): “Medical social workers are responsible for providing medical play therapy and social support to children and their caregivers” “Nutritional strategies for nausea and vomiting after chemotherapy” “Nutritional strategies for chemotherapy-induced oral mucositis” “Nutritional strategies for Chemotherapy-induced diarrhea”. Item Deletions: (2 third-level items) “Assess nutritional status using the Nutritional Risk Index (NRI)”—experts noted limited validation of this tool in pediatric oncology populations; “Consider supplementing with soy protein to improve nutritional status”—concerns were raised regarding potential interactions with chemotherapy and lack of pediatric-specific safety data. Item Modifications: Three second-level items and 13 third-level items were revised. Key modifications included: Relocating “Nutritional Requirements” to the “Standardized Screening and Assessment” dimension to improve logical flow; merging original items “Health Education Formats” and “Health Education Channels” into a single item “Health Education Methods” to reduce redundancy; (3) Renaming original “Transitional Care Formats” to “Transitional Care Methods” for terminological consistency; (4) Expanding “Use telephone or WeChat follow-up” to “Use diversified follow-up modes selected based on patient circumstances: video consultations, telephone follow-up, home visits, etc.,” reflecting experts' emphasis on individualized transitional care. After incorporating the expert feedback, the second-round questionnaire was finalized. The complete questionnaire is presented in Supplementary File 2. Round 2 After this round of consultation, none of the experts proposed any modification opinions to the intervention program. The statistical analysis of the second round of consultation revealed that all the items had a mean of 4.50 or more. The nutrition support protocol was designed and finalized accordingly (Table 7 ) since the experts’ opinions tended to be consistent, and the consultation ended. Table 7 Nutrition support protocol for pediatric cancer patients during chemotherapy (Final version). Item Round 1 (n = 20) Round 2 (n = 20) 1. Organization and management 20 (100) 20 (100) 1.1 Establish a multidisciplinary nutrition management team 20 (100) 20 (100) 1.1.1 Team members include pediatric oncology specialists and nurses, dietitians, rehabilitation physicians, psychotherapists, and medical social workers 20 (100) 20 (100) 1.2 Define roles and responsibilities 20 (100) 20 (100) 1.2.1 Pediatric oncology clinician: Responsible for disease assessment, formulation and implementation of treatment plans, and health education 18 (90) 20 (100) 1.2.2 Dietitian: Responsible for nutritional screening, assessment, and diagnosis; formulation and adjustment of individualized nutrition plans; nutritional monitoring; and health education 18 (90) 20 (100) 1.2.3 Primary nurse: Performs initial screening, supervises daily nutritional support, provides guidance and consultation, observes and reports adverse reactions, coordinates team communication, and establishes and manages nutrition records for patients at high nutritional risk 20 (100) 20 (100) 1.2.4 Psychotherapist: Provides psychological counseling for patients and their family caregivers 20 (100) 20 (100) 1.2.5 Rehabilitation physician: Develops individualized exercise plans for patients 20 (100) 20 (100) 1.2.6 Medical social worker: Provides medical play guidance and social support for patients and their family caregivers — 18 (90) 1.3 Conduct standardized training and assessment 20 (100) 20 (100) 1.3.1 Organize periodic professional nutrition training and assessments, with different training focuses for each team member to ensure standardization of core content 20 (100) 17 (85) 2. Standardized screening and assessment 20 (100) 20 (100) 2.1 Nutritional requirements 20 (100) 20 (100) 2.1.1 Individualized assessment of target energy and protein requirements: For children in a stable disease phase, reference the recommended intake of energy, protein, and micronutrients for healthy children of the same age as outlined in the Chinese Dietary Reference Intakes published by the Chinese Nutrition Society, with dynamic adjustments based on treatment response, metabolic status, and weight trends 20 (100) 20 (100) 2.2 Nutritional risk screening 20 (100) 20 (100) 2.2.1 Use the STRONGkids tool to screen for nutritional risk in children diagnosed with cancer 20 (100) 20 (100) 2.2.2 Timing of screening: Routine screening at admission and discharge; no nutritional intervention required for a score of 0, with weekly rescreening; for scores of 1–3, nutritional intervention is required, with weight monitored twice weekly and rescreening performed weekly; for scores of 4–5, children are identified as being at high nutritional risk, requiring initial nutritional assessment within 24 hours and comprehensive assessment within 72 hours to confirm the diagnosis. Reassessment is performed weekly thereafter, with frequency adjusted based on changes in clinical status 20 (100) 20 (100) 2.3 Nutritional status assessment 20 (100) 20 (100) 2.3.1 Use the “ABCDEF” approach for nutritional assessment, which includes: Anthropometry (A), biochemistry (B), clinical assessment (C), diet assessment (D), and environment/family information (E/F) 20 (100) 20 (100) 2.3.2 A (Anthropometry): Weight, height, body mass index (BMI), mid-upper arm circumference, and triceps skinfold thickness (referencing WHO standards) 20 (100) 20 (100) 2.3.3 B (Biochemistry): ALB, PA, anemia status, inflammatory markers, and specific minerals and vitamins 20 (100) 20 (100) 2.3.4 C (Clinical assessment): Dietary intake, muscle wasting, subcutaneous fat, skin and mucous membranes, edema, and hair condition 20 (100) 20 (100) 2.3.5 D (Diet assessment): Documentation of dietary intake 20 (100) 20 (100) 2.3.6 E/F (Environment/Family): Assessment of family support and environmental factors 20 (100) 20 (100) 3. Nutritional intervention strategies 20 (100) 20 (100) 3.1 Timing and methods of intervention 20 (100) 20 (100) 3.1.1 Timing: Screening and assessment indicate high nutritional risk and/or malnutrition; growth trajectory shows a decline crossing two major percentile curves in a short period; recent weight loss exceeding 5% 18 (90) 20 (100) 3.1.2 Methods: Follow the five-step treatment ladder for malnourished patients (oral diet and nutrition education → diet plus oral nutritional supplements → enteral nutrition → partial enteral nutrition plus partial parenteral nutrition → total parenteral nutrition). Advance to the next step when the current step fails to meet 60% of target energy requirements for 3–5 days 20 (100) 20 (100) 3.1.3 Nutritional interventions should be individualized based on the child's specific needs, clinical condition, and gastrointestinal function 20 (100) 20 (100) 3.2 Oral nutritional supplements (ONS) 20 (100) 20 (100) 3.2.1 ONS is preferred when gastrointestinal function is present 20 (100) 20 (100) 3.2.2 ONS is indicated when oral intake does not improve sufficiently with nutrition education to meet nutritional needs 20 (100) 20 (100) 3.2.3 ONS formulations should be selected based on the medical condition (e.g., whole protein, elemental, diabetes-specific, renal-specific, high-energy-density, or immune-enhancing formulas). Whey protein-fortified formulas are recommended to improve nitrogen balance (assess renal function and allergy status first). In the absence of contraindications, supplementation with vitamins C, D, E, and selenium is recommended to improve nutritional status and alleviate treatment-related side effects 20 (100) 20 (100) 3.3 Enteral nutrition (EN) 20 (100) 20 (100) 3.3.1 Timing of initiation: When oral intake is not possible or ONS is insufficient, or in cases of absorption disorders, metabolic abnormalities, food allergies, pancreatitis, etc. 20 (100) 20 (100) 3.3.2 Tube feeding route selection: For short-term ( 4 weeks), percutaneous endoscopic gastrostomy/jejunostomy is recommended when conditions permit 20 (100) 20 (100) 3.3.3 Administration method: Choose bolus or intermittent feeding based on tolerance; formula temperature at 37–40°C, osmolality < 330 mmol/L; use an infusion pump; elevate the head of the bed to 30–45°; maintain a semi-recumbent position for 30 min after infusion 20 (100) 20 (100) 3.3.4 Monitoring and complication management: Monitor gastrointestinal symptoms, intake and output, achievement rate of nutritional targets, and laboratory parameters; promptly manage complications such as diarrhea, nausea, vomiting, and constipation 20 (100) 20 (100) 3.4 Parenteral nutrition (PN) 20 (100) 18 (90) 3.4.1 Timing of PN: PN is indicated when EN is contraindicated, when EN fails to meet ≥ 60% of target energy requirements for 3–5 days, or when critically ill children or those receiving high-dose chemotherapy cannot meet nutritional needs via oral and enteral routes. Transition to EN as soon as gastrointestinal function recovers 20 (100) 20 (100) 3.4.2 Monitor PN-related complications: Mechanical or equipment-related complications, infections, metabolic complications, electrolyte and acid-base imbalances, drug interactions, intestinal failure-associated liver disease, and refeeding syndrome 20 (100) 20 (100) 3.5 Exercise intervention 18 (90) 20 (100) 3.5.1 Exercise type: Under the guidance of a rehabilitation physician, choose individualized resistance and/or aerobic exercises (e.g., radio calisthenics, aerobic exercises) 18 (90) 18 (90) 3.5.2 Exercise intensity: Under caregiver supervision, low-to-moderate intensity training is recommended, with adjustments based on health status and physical function 18 (90) 18 (90) 3.5.3 Exercise frequency: Individualized approach is recommended, with sessions 3 times per week, 10–30 minutes each session, starting with low intensity and short duration, and progressing gradually 18 (90) 20 (100) 3.6 Psychological care 20 (100) 18 (90) 3.6.1 Continuously monitor the emotional status of children and their caregivers, especially in the early post-diagnosis period; provide psychological support, counseling, and lectures 20 (100) 20 (100) 3.6.2 Medical social workers regularly organize medical play activities and relaxing activities such as flower arranging, crafts, and picture book reading 20 (100) 16 (80) 3.7 Nutritional strategies for chemotherapy-related adverse effects 20 (100) 20 (100) 3.7.1 Chemotherapy-induced nausea and vomiting: It is recommended to have breakfast 3 hours before chemotherapy, consisting of high-protein, high-energy, low-fat, vitamin-rich, light, and easily digestible foods, with intake limited to approximately two-thirds of usual volume; start eating 4 hours after chemotherapy, with a light diet and small, frequent meals. In cases of severe vomiting, fasting for 4–8 hours (may be extended to 24 hours if necessary), with gradual resumption of intake after symptom relief — 20 (100) 3.7.2 Oral mucositis: During chemotherapy, avoid foods that are excessively hot, rough, hard, spicy, or irritating. Choose high-protein, high-energy, soft, and easily digestible foods such as high-protein and high-energy milkshakes, pureed foods, or liquid diets. Small, frequent meals are recommended to reduce mucosal irritation. For children with severe symptoms who cannot eat orally, EN or PN should be administered as prescribed — 20 (100) 3.7.3 Chemotherapy-induced diarrhea: Choose light, easily digestible foods; avoid spicy, irritating, and hyperosmolar dietary supplements. Limit lactose intake in cases of lactose intolerance. Appropriately restrict raw vegetables and fresh fruits rich in dietary fiber based on gastrointestinal tolerance. In severe cases with insufficient energy intake, EN or PN should be administered as prescribed — 20 (100) 4. Health education 20 (100) 20 (100) 4.1 Timing 20 (100) 20 (100) 4.1.1 Design modular education packages for different treatment phases (diagnosis, chemotherapy, myelosuppression, and maintenance phases) and implement targeted health education 18 (90) 20 (100) 4.2 Content 20 (100) 20 (100) 4.2.1 Provide detailed guidance covering the entire nutrition management process, focusing on both daily diet and therapeutic diet. When EN and PN are administered, inform patients and family caregivers about monitoring and handling of complications such as diarrhea, constipation, nausea, vomiting, infection, and metabolic issues 18 (90) 20 (100) 4.3 Methods 20 (100) 18 (90) 4.3.1 Establish an online (internet) and offline (inpatient ward/outpatient clinic) dual-track information service platform; regularly share professional lectures; conduct daily evening Q&A sessions via WeChat groups 18 (90) 20 (100) 4.3.2 Conduct various health education activities, including patient-caregiver meetings, parent education classes, peer education, and distribution of nutrition education videos and illustrated materials 18 (90) 18 (90) 5. Transitional care 20 (100) 20 (100) 5.1 Timing 20 (100) 20 (100) 5.1.1 Initiate the day after discharge; consultation with caregivers regarding the frequency of transitional care based on the child's nutritional status and treatment plan 18 (90) 20 (100) 5.2 Content 20 (100) 20 (100) 5.2.1 Monitor dietary intake and weight changes during home stay; assess current caregiving status and needs; address questions and concerns regarding nutritional care. For children receiving home EN, closely monitor gastrointestinal symptoms (vomiting, abdominal pain, bloating, diarrhea), fluid intake and output, nutritional target achievement, and laboratory parameters; instruct caregivers to seek timely follow-up in case of abnormalities 20 (100) 20 (100) 5.3 Methods 20 (100) 20 (100) 5.3.1 Employ diverse follow-up models, selecting video consultations, telephone follow-up, or home visits based on the child’s condition 18 (90) 20 (100) Quasi-experimental study Characteristics of the participants A total of 148 children were initially enrolled, with 74 allocated to each group. During the intervention period, one child in the experimental group was transferred to the intensive care unit due to sudden clinical deterioration, and three caregivers voluntarily withdrew. In the control group, two children were lost to follow-up due to transfer to other hospitals. The final analysis included 70 children in the experimental group and 72 children in the control group, yielding a completion rate of 94.6% and 97.3%, respectively. The age of children in the control group was (7.83 ± 4.11) years, while that in the experimental group was (7.86 ± 4.13) years. No statistically significant differences were observed between the two groups in terms of demographic and clinical characteristics, including age, sex, disease diagnosis, STRONGkids scores, BMI-Z scores, serum ALB, and PA (all P > 0.05) (Table 8 ). Table 8 Comparison of baseline characteristics between the two groups. Variable Control group (n = 72) Experimental group (n = 70) χ² / t P Gender Boy 38 41 0.483 0.487 Girl 34 29 Age (years) 7.83 ± 4.11 7.86 ± 4.13 0.034 0.973 Diagnosis Lymphoma 15 18 2.179 0.975 Leukemia 9 8 Hepatoblastoma 2 2 Rhabdomyosarcoma 3 2 Neuroblastoma 14 15 Germ cell tumor 9 10 Wilms tumor 9 8 Osteosarcoma 1 0 Medulloblastoma 10 7 Strongkids score 2.92 ± 0.75 3.00 ± 0.80 0.643 0.521 BMI-Z score (-2) (6/66) (6/64) 0.003 0.095 PA (g/L) 0.21 ± 0.07 0.21 ± 0.07 0.104 0.917 ALB(g/L) 39.40 ± 5.12 39.49 ± 5.05 0.094 0.925 Risk of malnutrition and nutritional status After the 12-week intervention period, the experimental group showed significant improvements in multiple nutritional indicators compared to the control group: Nutritional risk: STRONGkids scores in the experimental group were significantly higher than those in the control group ( P < 0.05), indicating reduced nutritional risk. Laboratory Indicators: Both serum PA and ALB levels were significantly elevated in the experimental group compared to controls ( P < 0.05). An thropometric indicator: The incidence of emaciation (defined as BMI-Z score<-2) was significantly lower in the experimental group (2.9%, 2/70) than in the control group (12.5%, 9/72) ( P < 0.05). These findings demonstrate that implementation of the nutrition support protocol effectively improved nutritional outcomes for pediatric cancer patients undergoing chemotherapy (Table 9 ). Table 9 Comparison of risk indicators and nutritional status of malnutrition between the two groups. Variable Control group (n = 72) Experimental group (n = 70) χ²/t P STRONGkids score 2.89 ± 0.74 2.56 ± 0.53 3.061 0.003 BMI z-score (<-2 / ≥-2) (9/63) (2/68) 4.618 0.032 PA (g/L) 0.21 ± 0.07 0.24 ± 0.07 2.617 0.099 ALB (g/L) 38.89 ± 3.75 40.68 ± 5.05 2.410 0.017 Note: Data are presented as mean ± standard deviation or n (%). The t-test was used for continuous variables, and the chi-square (χ²) test was used for categorical variables. Protocol implementation feasibility The protocol demonstrated high implementation feasibility, with consistently high execution and accuracy rates across all core components. Efficiency metrics showed seamless integration into routine workflows, and stakeholder feedback indicated strong clarity and acceptance. The specific data is presented in Table 10 . Table 10 Summary of feasibility indicators for the nutrition support protocol. Domain Indicator Result / Data Notes Execution Rates Admission nutritional risk screening execution rate 100% (74/74) All children in the experimental group completed initial screening within 24 hours of admission Comprehensive nutritional assessment execution rate 97.7% (42/43) One incomplete assessment due to sudden clinical deterioration and transfer to the ICU Nutritional follow-up completion rate 95.9% (70/73) Three missed follow-ups due to voluntary withdrawal from the study Correct Execution Rates Screening documentation completeness 100% Completed by primary nurses using the standardized STRONGkids tool Screening scoring accuracy 100% Standardization rate for anthropometric data collection 100% Comprehensive nutritional assessments led by nutritionists Adverse event rate 0% No adverse events related to nutritional support documented during the intervention Execution Efficiency Admission screening time 5.5 ± 3.2 min/patient Completed by primary nurses Bedside reassessment time 4.1 ± 2.4 min/patient Subsequent nutritional re-examination Health education time 11.5 ± 5.1 min/patient Using standardized patient education materials Workflow integration No substantial increase in task duration Combined with routine post-chemotherapy assessments Stakeholder Feedback Nurse clarity rating > 90% (14/15) Rated the protocol as “clear” or “very clear” Family comprehension rate 85.7% (60/70) Reported nutritional guidance as “easy to understand” Nurse qualitative feedback Structured protocol provided a “clear sense of purpose” Enhanced confidence and role clarity Note : Data are presented as n (%) or mean ± standard deviation. ICU, intensive care unit. Discussion In this study, a theory-driven, multilevel nutrition support protocol for pediatric cancer patients undergoing chemotherapy was developed based on the theory of nutritional ecology and validated in a quasi-experimental trial. The final protocol comprised 5 first-level, 19 second-level, and 44 third-level items. Implementation of the protocol significantly improved nutritional outcomes, as evidenced by higher BMI‑Z scores, lower STRONGkids risk scores, and elevated serum albumin and prealbumin concentrations in the experimental group compared with the control group (all P < 0.05). To our knowledge, this is the first study to operationalize the nutritional ecology framework into a clinical nutrition support protocol for this vulnerable population, bridging best evidence, multi‑stakeholder perspectives, and real‑world feasibility. In this study, the best available evidence was identified through a systematic literature search, and a draft nutrition support protocol was developed based on this evidence. This draft is generally consistent with current guidelines and expert consensuses, such as the “ABCDEF” method for nutritional assessment [ 42 ], the “five‑step approach” for nutritional support [ 37 ], and the gradual increase of nutritional treatment from a low dose to the target value [ 43 , 44 ]. However, the present study also incorporates the theory of nutritional ecology as a guiding framework, which may offer a somewhat different analytical perspective on nutritional problems. Nutritional ecology views humans as complex biological systems interacting with internal and external environments and suggests that nutritional status is shaped by interactions across multiple levels [ 45 ]. To our knowledge, this study represents one of the initial attempts to apply this theoretical framework to nutritional support for pediatric cancer patients, moving beyond a sole focus on individual nutrient intake and symptom management. Through qualitative interviews, we incorporated the perspectives of multiple stakeholders, including patients, family caregivers, and healthcare professionals, on the current status of clinical nutritional support. Based on these insights, we integrated three ecological levels into a unified analytical and interventional framework. The individual level encompasses chemotherapy‑induced taste alterations, nausea, vomiting, diarrhea, and other direct symptoms that impair nutritional intake. The interpersonal level addresses caregivers’ feeding anxiety, knowledge, and practical skills. The organizational or system level involves standardized hospital workflows, multidisciplinary collaboration models, and transitional care after discharge. This theoretical shift may enable the protocol to identify and address certain ecological factors that, although less emphasized in existing guidelines, may still exert an important influence on nutritional outcomes. In the present study, implementation of the nutrition support protocol was associated with a significantly reduced risk of malnutrition, as evidenced by lower STRONGkids scores in the experimental group than in the control group ( P < 0.05). The STRONGkids tool is validated for identifying malnutrition risk in hospitalized children, and up to 62% of children undergoing chemotherapy are classified as high-risk by this instrument [ 31 , 46 ]. From a nutritional ecology perspective, the observed improvement in STRONGkids scores may reflect coordinated interventions acting across multiple levels of influence. At the individual level, the protocol included strategies to manage chemotherapy-induced taste alterations, nausea, vomiting, oral mucositis, and diarrhea. These items were added during the Delphi process based on expert input. Such symptoms are known to be major barriers to adequate oral intake during chemotherapy [ 6 ]. By addressing them directly, the protocol may have enabled children to maintain higher nutrient intake compared with routine care, where symptom management is often reactive. At the interpersonal level, the protocol incorporated health education components that targeted caregivers’ feeding anxiety and practical skills, which were identified as barriers in our qualitative interviews. Empowering caregivers in this way might have helped sustain nutritional intake beyond the hospital setting. At the organizational level, standardized screening workflows and diversified follow-up modes, including video consultations, telephone follow-up, and home visits, may have facilitated early identification of at-risk children and timely intervention, factors considered important for successful malnutrition prevention [ 13 , 47 ]. Therefore, the multi-level nature of the protocol, which addressed individual symptoms, interpersonal support, and organizational workflows, may have produced synergistic effects that surpass the more fragmented approaches typical of routine care. This interpretation is consistent with nutritional ecology theory, which suggests that nutritional status results from interactions across multiple ecological layers rather than from individual factors alone [ 19 ]. Beyond individual and interpersonal factors, the protocol introduced several organizational‑level changes that may have shifted nutritional management from a fragmented, reactive model toward a more systematic and structured approach. This shift aligns with nutritional ecology theory, which proposes that optimizing external systems can enhance the responsiveness of internal biological processes to nutritional support. One such change was embedding nutritional screening into the admission workflow. Early identification of at‑risk children through standardized screening is a prerequisite for timely intervention. This is highly consistent with the international concept of “early identification and full management of nutritional issues in pediatric cancer patients” [ 15 , 36 , 48 ]. By systematizing the timing and criteria for screening, the protocol may have enabled the care team to initiate support before significant nutritional deterioration occurred. Another key change involved clarifying the division of responsibilities among multidisciplinary team members. Effective clinical nutrition management necessitates the establishment of a multidisciplinary nutritional support team [ 48 ]. Explicit role definitions for clinicians, dietitians, nurses, psychotherapists, rehabilitation physicians, and social workers may have reduced communication gaps and helped prevent fragmented care. When each professional understands their specific tasks, the overall care system becomes more coordinated and responsive [ 49 ]. In addition, the protocol established a closed‑loop management pathway that integrated assessment, intervention, and re‑evaluation. This pathway ensured continuous monitoring of nutritional status rather than one‑time assessment at admission. A systematic, cyclical approach has been shown to improve early recognition of malnutrition and facilitate timely adjustments to interventions [ 36 , 50 ]. Taken together, these organizational changes may have optimized the responsiveness of the external care system to the child’s internal nutritional needs. When screening is systematic, roles are clearly defined, and a closed loop connects assessment to intervention and re‑evaluation, the care environment becomes more predictable and responsive. In turn, this improved external system responsiveness may support the child’s internal metabolic and nutritional regulation, creating conditions in which individual‑level dietary strategies and interpersonal caregiver support can be more effective. Consequently, the improved nutritional outcomes observed in the experimental group may reflect not only the content of the protocol but also the system within which it was delivered. This interpretation is consistent with the nutritional ecology premise that external environmental factors shape internal biological outcomes [ 19 ]. The protocol demonstrated satisfactory clinical applicability. First, it provides a structured, evidence‑based, and stakeholder‑endorsed roadmap for nutritional care in pediatric oncology wards. Its feasibility for implementation was validated in a real‑world tertiary hospital setting in China, where core components consistently achieved high rates of execution and accuracy. Efficiency metrics indicated seamless integration into routine workflows, and stakeholder feedback reflected strong clarity and acceptability (Table 10 ). These observations suggest that the protocol is not only effective but also practical for routine clinical use. Second, because the protocol was developed using a rigorous mixed‑methods approach that included summary of the best evidence, qualitative inquiry, and a Delphi consensus process, it may offer greater content validity and contextual relevance than locally developed ad‑hoc practices. Furthermore, the protocol was informed by the perspectives of multiple stakeholders, including children, family caregivers, and healthcare professionals. This multi‑stakeholder foundation may enhance its acceptability among patients, families, and providers, thereby supporting implementation fidelity. Study limitations Several limitations should be acknowledged. Firstly, the quasi‑experimental (non‑randomized) design was conducted at a single tertiary hospital, which limits the ability to infer causality. Although baseline characteristics were comparable between groups ( P > 0.05 for all demographic and clinical variables, Table 8 ), the possibility of selection bias and unmeasured confounding cannot be completely ruled out. Secondly, the final analysis included a relatively small sample (70 children in the experimental group and 72 in the control group) drawn from a single geographic region, which restricts the generalizability of the findings to other populations or healthcare systems. Thirdly, outcome measures were collected only at the end of the 12‑week intervention period; consequently, long‑term effects on treatment completion rates, infection episodes, event‑free survival, and late malnutrition sequelae remain unknown, and extended follow‑up would be needed to assess whether the observed short‑term improvements are sustained over time. Fourthly, given the behavioral nature of the nutritional intervention, blinding of participants and healthcare providers was not feasible. This lack of blinding may have introduced performance and detection bias, although outcome assessors could in principle have been blinded. Readers should therefore interpret the findings with caution. Implications for practice The protocol provides a structured, evidence‑based, and stakeholder‑endorsed framework for nutritional support in pediatric oncology wards. Establishing a closed‑loop assessment‑intervention‑re‑evaluation pathwayrkflows and clarifying multidisciplinary team roles, and can help reduce fragmented care and improve the responsiveness of the care system to children’s nutritional needs. The protocol’s development incorporated perspectives from multiple stakeholders, including children, family caregivers, and healthcare professionals. This multi‑stakeholder foundation may enhance acceptability and adherence among users, thereby supporting implementation fidelity. To further strengthen clinical application, future multicenter, cluster‑randomized controlled trials are needed to confirm the effectiveness of the protocol in diverse settings. Extended follow‑up should be implemented in routine practice to monitor long‑term clinical outcomes, including treatment completion rates, febrile neutropenia episodes, and overall survival. In addition, the protocol may be adapted for use in other treatment contexts, such as radiotherapy or stem cell transplantation, as well as across different pediatric age groups, which could broaden its clinical utility. Conclusion This study, grounded in nutritional ecology theory, systematically developed and evaluated a nutrition management protocol for pediatric cancer patients undergoing chemotherapy. The protocol was formulated through a rigorous multi-method approach encompassing evidence synthesis, qualitative stakeholder interviews, and Delphi expert consensus. Preliminary clinical application demonstrated that the protocol effectively reduced nutritional risk and improved nutritional status during chemotherapy, with favorable clinical applicability and safety profiles. By translating nutritional ecology theory into a structured, implementable protocol, this study not only advances clinical practice by providing an evidence-based framework for systematic nutritional management but also extends the theoretical application of nutritional ecology in pediatric oncology care. Abbreviations ALB albumin PA prealbumin BMI body mass index RCT randomized controlled trial CV the coefficients of variation Kendall’s W Kendall’s coefficient of concordance NRI Nutritional Risk Index Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the First Hospital of Jilin University under No.25K350-001. All participants signed the Informed Consent Form, for child participants, assent was obtained in addition to parental consent, ensuring the principles of autonomy, confidentiality and voluntary participation. Consent for publication Not applicable. Availability of data and materials The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This research was supported by Nursing Research Fund of the First Hospital of Jilin University in 2024 (Project No.: HLKY20240107). Authors' contributions XY: Writing –review& editing, Methodology, Investigation, Resources, Conceptualization. YZ: Writing – original draft, Methodology, Data curation, Formal analysis, Conceptualization, Project administration. SG: Methodology, Investigation, Data curation. Acknowledgements We sincerely thank the children with tumors, their family caregivers, and the medical workers who participated in this research. References World Health Organization. Cancer in Children [Internet]. Who.int. World Health Organization: WHO. 2025. 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Current practices for nutritional evaluation and care during the treatment of pediatric oncology patients: a survey among AIEOP centers. Eur J Pediatrics. 2023;183(3):1137–44. Viani K, Alves J, Damasco-Avila E, Murra MS, Schoeman J, Walters M et al. Consensus recommendations for the nutritional management of children with cancer in limited resource settings: a report from the International Initiative for Pediatrics and Nutrition. Frontiers in Nutrition [Internet]. 2025 Jun 26 [cited 2025 Jul 27];12(40642169). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12240747/ Pedretti L, Massa S, Leardini D, Muratore E, Rahman S, Pession A et al. Role of Nutrition in Pediatric Patients with Cancer. Nutrients [Internet]. 2023;15(3):710. Available from: https://www.mdpi.com/2072-6643/15/3/710 Podpeskar A, Crazzolara R, Kropshofer G, Hetzer B, Rabensteiner E, Meister B, et al. Recommendations for Nutritional Supplementation in Pediatric Oncology: A Compilation of the Facts. Nutrients. 2023;15(14):3239–9. Raiten DJ, Combs GF, Steiber AL, Bremer AA, Perspective. Nutritional Status as a Biological Variable (NABV): Integrating Nutrition Science into Basic and Clinical Research and Care. Advances in Nutrition [Internet]. 2021 Apr 30 [cited 2022 Jan 10];12(5):1599–609. Available from: https://academic.oup.com/advances/article/12/5/1599/6261392 Graif C, Meurer J, Fontana M. An Ecological Model to Frame the Delivery of Pediatric Preventive Care. Pediatrics [Internet]. 2021;148(Supplement 1):s13–20. Available from: https://www.publications.aap.org/pediatrics/article-abstract/148/Supplement%201/s13/179816/An-Ecological-Model-to-Frame-the-Delivery-of?redirectedFrom=fulltext Raiten DJ, Steiber AL, Bremer AA. The Value of Integrating the Nutritional Ecology into the Nutrition Care Continuum—A Conceptual and Systems Approach. Advances in Nutrition [Internet]. 2025;16(3):100385. 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Implementing the GRADE approach in systematic reviews that adhere to JBI methodological conduct. JBI Evid synthesis. 2024;22(3):351–8. Jin C, Shang L. Application of stakeholder theory in chronic disease nursing:a review. J Nurs Sci. 2020;35(23):102–5. Liu M. Using an example to illustrate Colaizzi’s phenomenological data analysis method. J Nurs Sci. 2019;34(11):90–2. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and Reporting the Delphi Method for Selecting Healthcare Quality Indicators: A Systematic Review. Wright JM, editor. PLoS ONE [Internet]. 2011;6(6):e20476. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111406/ Wu L, Tang L, Zhuang L, Xie W, Liu M, Li J. Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method. PLoS ONE. 2023;18(11):e0294606–6. Mao Q, Mao X, Li X, Tang L, Chen Q, Xie S, et al. Application of a specialist nurse-led nutrition management program in children with leukemia during induction remission chemotherapy. Chin J Nurs. 2024;59(23):2900–7. Hulst JM, Zwart H, Hop WC, Joosten KFM. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clin Nutr. 2010;29(1):106–11. Baker RD, Baker SS, Bojczuk G. Parenteral nutrition in infants and children [Internet]. UpToDate. 2024 [cited 2026 Mar 10]. Available from: http://61.153.6.101:11111/contents/parenteral-nutrition-in-infants-and-children Jatoi A. The role of parenteral and enteral/oral nutritional support in patients with cancer [Internet]. UpToDate. 2024 [cited 2026 Mar 10]. Available from: http://61.153.6.101:11111/contents/the-role-of-parenteral-and-enteral-oral-nutritional-support-in-patients-with-cancer Chinese Society of Nutritional Oncology. Updated guideline for oral nutritional supplements. Electron J Metabolism Nutr Cancer. 2023;10(1). Chinese Society for Parenteral and Enteral Nutrition. Guidelines on nutritional support in patients with tumor. Chin J Surg. 2017;55(11):801–29. Agnieszka B-C, Szlagatys-Sidorkiewicz A, Ninela Irga-Jaworska BieńE, Borkowska A, Małgorzata A, Krawczyk et al. Managing Undernutrition in Pediatric Oncology: A Consensus Statement Developed Using the Delphi Method by the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology. Nutrients [Internet]. 2024;16(9):1327–7. Available from: https://pubmed.ncbi.nlm.nih.gov/38732574/ The Subspecialty Group of Hematology, the Society of Pediatrics, Chinese Medical Association. The Subspecialty Group of Oncology, the Society of Pediatrics, Chinese Medical Association, The Professional Committee of Child Nutrition, China Maternal and Child Health Association. Expert recommendations on the standardized procedure for nutritional management in pediatric patients with hematologic and oncologic diseases. J China Pediatr Blood Cancer. 2024;29(6):383–91. Hawes C, Gomes A, Byham-Gray L, Henderson S. The effect of oral nutrition supplements and appetite stimulants on weight status among pediatric cancer patients: a systematic review. Nutr Clin Pract. 2022;36222574(36222574). Revuelta Iniesta R, Rush R, Paciarotti I, Rhatigan EB, Brougham FHM, McKenzie JM, et al. Systematic review and meta-analysis: Prevalence and possible causes of vitamin D deficiency and insufficiency in pediatric cancer patients. Clin Nutr. 2016;35(1):95–108. Alves KCR, Ligia S, Azzalis A et al. Impact of Selenium Supplementation in Neutropenia and Immunoglobulin Production in Childhood Cancer Patients. Journal of Medicinal Food. 2016;19(6):560–8. Ramezani N, Alireza Moafi A, Nadjarzadeh, Yousefian S, Nahid, Reisi. Amin Salehi-Abargouei. The Effect of Soy Nut Compared to Cowpea Nut on Body Weight, Blood Cells, Inflammatory Markers and Chemotherapy Complications in Children with Acute Lymphoblastic Leukemia: A Randomized Controlled Clinical Trial. Nutr Cancer. 2018;70(7):1017–25. Viani K, Manzoli B, Trehan A, Schoeman J. Assessment of nutritional status in children with cancer: A narrative review. Pediatric Blood and Cancer [Internet]. 2020;67(S3). Available from: http://eds.b.ebscohost.com/eds/detail/detail?vid=10&sid=f38f9132-f0d9-4776-b858-58a0d78c86c4%40pdc-v-sessmgr05&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=edselc.2-52.0-85087273089&db=edselc Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F et al. ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition [Internet]. 2016;36(1). Available from: https://www.clinicalnutritionjournal.com/article/S0261-5614(16)30181-9/fulltext Duan JY, Zheng WH, Zhou H, Xu Y, Huang HB. Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis. Crit Care. 2021;25(1). Lihoreau M, Buhl J, Charleston MA, Sword GA, Raubenheimer D, Simpson SJ. Nutritional ecology beyond the individual: a conceptual framework for integrating nutrition and social interactions. Eubanks M, editor. Ecology Letters. 2015;18(3):273–86. Salerno A, Gazineo D, Lanari M, Shehi R, Ricco M, La Malfa E et al. Italian cross-cultural validation of the STRONGkids tool for pediatric nutritional evaluation. Eur J Pediatrics. 2024;184(1). Zhao X, Wang J, Chen L, Xu X, Fu C. Effect of nutritional screening in children with acute lymphoblastic leukemia undergoing the maintenance chemotherapy. BMC pediatrics [Internet]. 2025;25(1):462. Available from: https://pubmed.ncbi.nlm.nih.gov/40481403/ Fabozzi F, Trovato CM, Diamanti A, Mastronuzzi A, Zecca M, Tripodi SI et al. Management of Nutritional Needs in Pediatric Oncology: A Consensus Statement. Cancers [Internet]. 2022;14(14):3378. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9319266/ Díaz C, Egide A, Berry A, Rafferty M, Amro A, Tesorero K, et al. Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study. BMJ Open. 2023;13(12):e075470–0. Damasco-Avila E, Stephany Zelaya Sagastizado, Carrillo M, Blanco J, Fu L, Espinoza D et al. Improving the Quality of the Delivery of Nutritional Care Among Children Undergoing Treatment for Cancer in a Low- and Middle-Income Country. JCO Global Oncol. 2023;37384860(9). Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.docx SupplementaryFile2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 May, 2026 Reviewers agreed at journal 01 May, 2026 Reviewers invited by journal 01 May, 2026 Editor assigned by journal 01 May, 2026 Editor invited by journal 29 Apr, 2026 Submission checks completed at journal 29 Apr, 2026 First submitted to journal 29 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9491500","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635693125,"identity":"6ae652eb-d58f-4305-ab24-8c519b7bcd79","order_by":0,"name":"Yuan Zhang","email":"","orcid":"","institution":"First Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Zhang","suffix":""},{"id":635693134,"identity":"a49b720f-7d48-42e3-a149-0afabf182dca","order_by":1,"name":"Xin Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYJCCAwwVEnLy/O0HH0gUgPgJxGg5Y2NsOONMsoGEAZFaGBhb0hIbDiSYSTAQo8XgRo7h4cKGw4mNDQfSKiwMDjPws+cYMPzcgU9LWsLhmTsOG7czNx67IQHUItnzxoCx9ww+LckHDvOeOSwLsgWsBWivATNjGz4tiQ2HedsOM4L8UgDSYk9YC8iWtjRFkBYGsC0SBLRInnmWcJgHGsgSEgbpPBJnnhUc7MWjhe94jvFnHmhUfpaosJbjb0/e+OAnHi0KB5A4zBIMDDwgxgGsaqFAvgGJw/gBn9JRMApGwSgYsQAA5dZZO0Qa1qIAAAAASUVORK5CYII=","orcid":"","institution":"First Hospital of Jilin University","correspondingAuthor":true,"prefix":"","firstName":"Xin","middleName":"","lastName":"Yu","suffix":""},{"id":635693135,"identity":"ad44d4c1-6420-4891-b0f4-7b784ac9f699","order_by":2,"name":"Sijia Gao","email":"","orcid":"","institution":"First Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Sijia","middleName":"","lastName":"Gao","suffix":""}],"badges":[],"createdAt":"2026-04-22 06:08:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9491500/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9491500/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108975883,"identity":"9d094200-90ea-4dfc-8ab6-a37a188a460e","added_by":"auto","created_at":"2026-05-11 10:58:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2243050,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe flowchart of the different stages of the mixed-methods approach in this study.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003eThis flowchart shows the three phases of the mixed‑methods design. Phase I includes a literature review and qualitative interviews (patients, caregivers, providers) to explore needs and practices, leading to an initial protocol draft based on evidence and clinical practice. Phase II uses a Delphi expert consultation to finalize the nutritional support protocol. Phase III is the intervention stage: nutritional support for pediatric chemotherapy patients, participant enrollment, intervention, post‑outcome assessment, and data analysis. Arrows indicate progression. No abbreviations.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/96310141d5a3addf0a470ddc.png"},{"id":108975912,"identity":"d86e4834-8a82-4d93-8a64-61a0b716ed9b","added_by":"auto","created_at":"2026-05-11 10:58:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2773021,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria for participants in qualitative interviews.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003eThe figure lists the eligibility criteria for three groups of participants: pediatric cancer patients, family caregivers, and healthcare professionals. No abbreviations are used.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/1d9046fb951cc8884e4bd754.png"},{"id":108975910,"identity":"969124a5-7349-465f-ad1a-c20b8e0a5fc8","added_by":"auto","created_at":"2026-05-11 10:58:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2975171,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInterview outlines for different participant groups in qualitative research.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003eThe figure lists the interview outlines for three groups of participants: pediatric cancer patients, family caregivers, and healthcare professionals. No abbreviations are used.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/3b39c9b5b4377eb70cb6014c.png"},{"id":108975870,"identity":"792b75a9-3947-424c-81f0-4c7a91faef11","added_by":"auto","created_at":"2026-05-11 10:58:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":889231,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLiterature screening flowchart.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003eThis flowchart illustrates the study selection process for the systematic literature review. A total of 601 records were initially identified from 12 databases. After removing duplicates, 485 records remained. Following title and abstract screening, 424 records were excluded for reasons including wrong topic, wrong study type, wrong population, or outdated guidelines. The remaining 61 full‑text articles were assessed for eligibility, of which 50 were excluded due to no extractable or low‑quality evidence. Finally, 11 studies were included in the analysis. No abbreviations are used in the figure.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/5627c9dc29b2d2bf795bb7d7.png"},{"id":109203366,"identity":"4c3622ac-827f-49a5-9399-7c445e229b75","added_by":"auto","created_at":"2026-05-13 14:30:36","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":6259949,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe themes and sub-themes reflecting the experience of nutritional management for pediatric cancer patients from the perspective of stakeholders.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003eThe figure lists the major themes and sub‑themes derived from qualitative interviews with patients, caregivers, nurses, and physicians. No abbreviations.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/5a265bf87ea98983a15e3bf3.png"},{"id":108975173,"identity":"f737b1c8-d3d4-48f4-9fa0-5416791d01bf","added_by":"auto","created_at":"2026-05-11 10:54:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":901700,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/c1b240d3-82be-4eed-8946-d2eebe88b503.pdf"},{"id":108975874,"identity":"32671577-c32d-4975-8f18-03ad08ad1504","added_by":"auto","created_at":"2026-05-11 10:58:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40039,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/9f08202b4ffd596e5a789cce.docx"},{"id":108975882,"identity":"7a536e08-9ebc-469a-b219-8dc0051b08ed","added_by":"auto","created_at":"2026-05-11 10:58:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":39484,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9491500/v1/4e58ac742add37e1fe6f8d36.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and evaluation of a nutritional support protocol for pediatric cancer patients during chemotherapy: A mixed-method study based on nutritional ecology","fulltext":[{"header":"Background","content":"\u003cp\u003eChildhood cancer represents a formidable global health burden. According to the World Health Organization (WHO), approximately 400,000 children and adolescents (aged 0\u0026ndash;19) are diagnosed with cancer annually worldwide, establishing malignant neoplasms as the leading cause of disease-related mortality in this age group [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A spectrum of therapeutic modalities\u0026mdash;including chemotherapy, radiotherapy, immunotherapy, surgery, and emerging RNA-based therapeutics\u0026mdash;has been deployed in oncological management. Despite these advances, chemotherapy remains the cornerstone of pediatric cancer treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While contemporary treatment protocols have propelled five-year survival rates to exceed 85% for many pediatric malignancies, the intensification of chemotherapeutic regimens has concomitantly escalated the burden of treatment-related toxicities, profoundly impacting patients\u0026rsquo; quality of life and long-term health outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGastrointestinal complications, such as nausea, vomiting, mucositis, and diarrhea, represent some of the most prevalent and clinically consequential adverse effects of cytotoxic therapy. These complications frequently result in inadequate nutrient intake, impaired absorption, and progressive nutritional decline [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This nutritional deterioration spans a continuum from subclinical deficiencies to overt malnutrition, rendering affected children more vulnerable to treatment interruptions, infectious complications, and diminished quality of life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The intricate relationship between nutritional status and treatment outcomes in pediatric oncology has garnered increasing scholarly attention. Epidemiological data indicate that malnutrition affects approximately 24% \u0026ndash; 55.4% of cancer patients overall, with pediatric populations experiencing disproportionately higher rates, reaching approximately 75% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Strikingly, malnutrition, rather than the malignancy itself, accounts for mortality in 10%\u0026ndash;20% of cancer patients, underscoring nutrition as an independent prognostic determinant in oncological care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecognizing the critical role of nutrition, several authoritative organizations\u0026mdash;including the European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN)\u0026mdash;have issued clinical practice guidelines providing evidence-based recommendations for nutritional support in pediatric oncology [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While these guidelines offer valuable frameworks for screening, assessment, and intervention, significant gaps remain between existing evidence and routine clinical practice. First, most guidelines tend to present general principles, making it challenging to translate them into context-specific, operational protocols tailored to the unique needs of children undergoing chemotherapy, particularly within local healthcare setting [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Second, implementation barriers\u0026mdash;such as inconsistent workflows, limited staff training, and insufficient interdisciplinary collaboration\u0026mdash;are frequently reported yet seldom explicitly addressed in protocol development.\u003c/p\u003e \u003cp\u003eIn parallel, traditional research approaches have largely concentrated on unidirectional causal pathways of insufficient nutrient intake, with corresponding interventions often limited to nutritional supplementation. However, nutritional compromise in pediatric cancer patients undergoing chemotherapy is better understood as a multifaceted systemic challenge. Multiple factors interact dynamically, including chemotherapy-induced gastrointestinal toxicity, enteral feeding modalities, institutional screening and intervention protocols, developmental nutritional requirements, and culturally embedded feeding practices. Collectively, these elements highlight the ecological complexity inherent in nutritional management during chemotherapy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Taken together, an integrated and context-specific approach is needed in pediatric oncology nutrition practice, one that bridges clinical evidence with the realities of treatment delivery.\u003c/p\u003e \u003cp\u003eNutritional ecology theory conceptualizes nutritional status as an emergent property of complex systems, arising from dynamic interactions between the individual's internal environment (biological characteristics, disease status, metabolic demands) and external environment (family support systems, healthcare infrastructure, sociocultural contexts) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This theoretical framework offers novel insights for addressing clinical nutritional challenges, facilitating systematic elucidation of multidimensional determinants of nutritional status, and providing conceptual foundations for developing comprehensive nutritional management protocols integrating medical intervention, family engagement, and sociocultural considerations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, no study has been identified that applies nutritional ecology theory to the field of pediatric oncology nutrition. Existing research has largely focused on individual components of the nutrition care continuum, with few studies systematically integrating the complex interplay of biological, familial, and sociocultural factors that shape nutritional outcomes in this vulnerable population. This theoretical and practical gap highlights the need for a comprehensive, theoretically informed approach to nutritional support that addresses the unique challenges faced by pediatric cancer patients and their families throughout the treatment trajectory.\u003c/p\u003e \u003cp\u003eAccordingly, this study seeks to develop a scientifically rigorous, systematic nutrition support protocol for pediatric cancer patients receiving chemotherapy, grounded in nutritional ecology theory, and to explore its clinical applicability. It is hoped that this theoretically informed approach may provide useful insights for researchers, clinicians, and nurses in pediatric oncology, particularly in the development of tailored nutrition support protocols for children with tumors.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study employed a four-phase mixed-methods design. Phase 1 involved a systematic literature search and quality evaluation to synthesize evidence on nutritional support for children with cancer undergoing chemotherapy. Phase 2 comprised semi-structured interviews with pediatric cancer patients, family caregivers, and healthcare providers to explore multi‑stakeholder perspectives on internal and external systemic factors influencing nutritional status. Based on the findings of Phases 1 and 2, an initial nutrition support protocol was developed, which was then refined and finalized through a Delphi expert consultation in Phase 3, incorporating multiple ecological determinants. Phase 4 was a quasi‑experimental study conducted from January to October 2025 at a tertiary grade A general hospital in Jilin Province, China \u0026ndash; the only institution in Northeast China with a dedicated pediatric oncology ward \u0026ndash; to evaluate the effectiveness of the finalized protocol in improving nutritional outcomes in this population. The study process is shown in Fig. \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.Evidence synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.1 Formulating an Evidence‑Based Question\u003c/p\u003e\n\u003cp\u003eThe evidence-based problem was constructed using the PIPOST model [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. As \u0026ldquo;P\u0026rdquo; (population): pediatric cancer patients; \u0026ldquo;I\u0026rdquo; (intervention): strategies for nutritional support; \u0026ldquo;P\u0026rdquo; (professionals): nutrition support teams, patients, and their caregivers; \u0026ldquo;O\u0026rdquo; (outcomes): incidence of malnutrition, BMI-Z score, serum ALB and PA concentrations; \u0026ldquo;S\u0026rdquo; (setting): home and hospitals; \u0026ldquo;T\u0026rdquo; (types of evidence): clinical decisions, clinical guidelines, evidence summaries, expert consensus, systematic reviews, meta-analyses, and randomized controlled trial (RCT).\u003c/p\u003e\n\u003cp\u003e1.2 Literature Search Strategy\u003c/p\u003e\n\u003cp\u003eFollowing the \u0026ldquo;6S\u0026rdquo; classification model for evidence-based resources [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], a comprehensive search was conducted in UpToDate, BMJ Best Practice, WHO guidelines, Guidelines International Network (GIN), National Guideline Clearinghouse (NGC), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), Medlive, European Society for Clinical Nutrition and Metabolism (ESPEN), American Society for Parenteral and Enteral Nutrition (ASPEN), Chinese Nutrition Society, Chinese Society of Clinical Oncology, Chinese Anti-Cancer Association, Web of Science, Cochrane Library, Embase, PubMed, CINAHL, CBM, CNKI, and Wanfang Data. The search timeframe was from January 2012 to January 2025. The search strategy combined MeSH terms and free-text keywords as follows: (tumor/cancer/oncology/neoplasms/\u0026ldquo;Neoplasms\u0026rdquo;[Mesh]) AND (child/children/pediatric/pediatrics/\u0026ldquo;Pediatrics\u0026rdquo;[Mesh]) AND (chemotherapy/antitumor therapy/drug therapy/\u0026ldquo;Drug Therapy\u0026rdquo;[Mesh]) AND (nutritional support/nutrition supplementation/nutritional assessment/nutrition/family support/health system/health education/patient education/social support/psychosocial support/continuity of care/\u0026ldquo;Nutritional Support\u0026rdquo;[Mesh]/\u0026ldquo;Nutrition Assessment\u0026rdquo;[Mesh] /\u0026ldquo;Nutrition Therapy\u0026rdquo;[Mesh]).\u003c/p\u003e\n\u003cp\u003e1.3 Evidence inclusion and exclusion criteria\u003c/p\u003e\n\u003cp\u003eStudies were included for those involved children (aged\u0026thinsp;\u0026le;\u0026thinsp;18 years) diagnosed with hematologic or solid malignancies and receiving chemotherapy; implemented nutritional interventions specifically targeting this population; were conducted in contexts where healthcare professionals served as evidence implementers; reported outcomes related to malnutrition incidence, anthropometric indicators, or laboratory parameters in pediatric cancer patients; and were published as clinical decisions, clinical guidelines, expert consensus, evidence summaries, systematic reviews, meta-analyses, or RCTs in English or Chinese. Studies were excluded if they had incomplete data, were conference abstracts or had unavailable full texts, were duplicate publications, or received low-quality ratings during critical appraisal.\u003c/p\u003e\n\u003cp\u003e1.4 Literature quality assessment criteria\u003c/p\u003e\n\u003cp\u003eThe quality of included literature was assessed using established tools. Clinical practice guidelines were evaluated using the AGREE II [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], clinical decisions were assessed using the Critical Appraisal for Summaries of Evidence (CASE) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and expert consensuses, systematic reviews, meta-analyses, and RCTs were assessed using the Joanna Briggs Institute (JBI) checklists [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. All appraisals were conducted independently by trained researchers, with guidelines assessed by four researchers and other document types by two. Disagreements were resolved through team discussion.\u003c/p\u003e\n\u003cp\u003e1.5 Evidence synthesis and grading\u003c/p\u003e\n\u003cp\u003eTwo authors (XY, YZ) independently extracted, synthesized, and graded the evidence using the JBI evidence pre-grading and recommendation level system (2014 version), which categorizes evidence into levels 1\u0026ndash;5 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Final evidence grades were determined through discussion within the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Qualitative interview\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA descriptive qualitative study was undertaken to understand the experiences, needs, and perceptions of multiple stakeholders regarding nutritional support for pediatric cancer patients undergoing chemotherapy. This phase was grounded in stakeholder theory [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which acknowledges that incorporating perspectives from all relevant parties is essential for developing contextually appropriate interventions.\u003c/p\u003e\n\u003cp\u003e2.1 Participants\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from January to April 2025. A purposive sampling strategy was employed, with an emphasis on maximum variation sampling to ensure diversity across key characteristics. Three participant groups were enrolled: Pediatric cancer patients, their family caregivers, and clinical healthcare providers. Inclusion and exclusion criteria were shown in Fig. \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Sample size was determined by data saturation, defined as the point at which no new themes emerged from subsequent interviews.\u003c/p\u003e\n\u003cp\u003e2.2 Interview procedure\u003c/p\u003e\n\u003cp\u003eData were collected through individual, semi-structured interviews. Interview guides, tailored to each participant group, were developed based on study objectives and relevant literature, as shown in Fig. \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. All interviews were conducted by the first author in private settings \u0026mdash; hospital rooms for children and families, and offices for healthcare professionals. Prior to each interview, the researcher explained the study\u0026rsquo;s purpose and confidentiality. Children and caregivers were interviewed separately to ensure data independence. Interviews lasted 20\u0026ndash;40 minutes. The researcher employed active listening, open-ended questioning, and behavioral observation, maintaining neutrality and clarifying ambiguous statements in real time. Interviews were audio-recorded, with non-verbal information documented manually. Transcripts were verified against recordings, anonymized using pseudonyms, and stripped of identifying information. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e2.3 Data Analysis and Rigor\u003c/p\u003e\n\u003cp\u003eThematic analysis was conducted using Colaizzi\u0026apos;s seven-step method [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Transcripts were imported into NVivo 12 for data management. Coding was performed independently by two researchers, with discrepancies resolved through discussion and team consensus. Member checking was conducted with a subset of participants to verify the accuracy of interpretations. To ensure trustworthiness, we employed independent coding by two trained researchers (with consensus on discrepancies), maintained reflexive journals to facilitate bracketing, conducted member checking for participant validation, and held regular peer debriefing meetings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Delphi expert consensus\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e3.1 Identify consulting experts\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eExperts were selected based on the Delphi method [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and the content of the consultation. The selection criteria included current employment at a tertiary Grade A hospital, holding a mid-level or higher professional title, having a bachelor\u0026rsquo;s degree or above, possessing at least 10 years of clinical experience in pediatric oncology or clinical nutrition (in either medicine or nursing), demonstrating recognized academic influence in the fields of pediatric oncology and clinical nutrition, and showing strong commitment by voluntarily participating in this study.\u003c/p\u003e\n\u003cp\u003e3.2 Procedure\u003c/p\u003e\n\u003cp\u003eBased on gaps identified through evidence synthesis and qualitative interviews, a draft nutrition support protocol for pediatric cancer patients undergoing chemotherapy was developed via multiple team discussions under the framework of nutritional ecology, to bridge the evidence\u0026ndash;practice gap. A corresponding Delphi consultation questionnaire was then constructed based on this draft protocol. The full questionnaire is provided as Supplementary File 1. Experts were asked to rate the importance of each item using a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;very unimportant to 5\u0026thinsp;=\u0026thinsp;very important). Open-ended comment boxes were provided after each item and at the end of each dimension to solicit qualitative feedback, including suggestions for item modification, addition, or deletion.\u003c/p\u003e\n\u003cp\u003eThe Delphi procedure was conducted from May to June 2025. Questionnaires were distributed and returned via email. Each round remained open for two weeks, with reminders sent at the beginning and end of the second week, and a two-week interval between rounds. Descriptive statistics were used for analysis. Items were retained if mean importance\u0026thinsp;\u0026gt;\u0026thinsp;3.50 and coefficient of variation\u0026thinsp;\u0026lt;\u0026thinsp;0.25 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Qualitative comments were systematically reviewed and synthesized. The protocol was revised by integrating quantitative and qualitative feedback to form the next-round questionnaire. The process concluded when consensus was reached and no new substantive suggestions emerged.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Quasi-experimental study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e4.1 Participants\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eChildren with histopathological confirmed malignant tumors requiring chemotherapy were enrolled. The inclusion criteria were as follows: (1) age between 6 and 16 years; (2) ability to communicate effectively; (3) normal blood counts and liver and renal function prior to chemotherapy; and (4) written informed consent obtained from both the child and the caregiver. The exclusion criteria were: (1) concurrent radiotherapy and chemotherapy; (2) use of corticosteroids as part of the chemotherapy regimen; (3) pre-existing severe feeding difficulties or malabsorption prior to chemotherapy resulting from tumor-related factors or surgical sequelae; and (4) terminal malignancy. Participants were withdrawn from the study if they were lost to follow-up, developed severe treatment-related complications, or voluntarily withdrew consent.\u003c/p\u003e\n\u003cp\u003eThe sample size was estimated using G Power software based on a comparison of two independent means with a 1:1 allocation ratio. The primary outcome was BMI-Z score. Assuming a two-tailed \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05, power (1-\u0026beta;)\u0026thinsp;=\u0026thinsp;0.80, and an effect size of d\u0026thinsp;=\u0026thinsp;0.49 derived from a previous study [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], the required sample size was calculated to be 67 participants per group. After accounting for a 10% attrition rate, the sample size was inflated to 74 participants per group, resulting in a total target sample of 148 children.\u003c/p\u003e\n\u003cp\u003eA convenience sampling method was employed due to clinical and logistical constraints. To minimize contamination between groups, a temporal separation design was implemented. The control group comprised 74 children receiving regular chemotherapy from January to May 2025. Following a washout period for staff training and protocol implementation, the experimental group comprised 74 children receiving regular chemotherapy from August to December 2025. Both groups were recruited from the same pediatric oncology department.\u003c/p\u003e\n\u003cp\u003e4.2 Interventions.\u003c/p\u003e\n\u003cp\u003eParticipants in the experimental group received the newly developed nutrition support protocol for pediatric cancer patients during chemotherapy (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The protocol integrated five dimensions established in previous phases: Organization and management, standardized screening and assessment, nutritional intervention strategies, health education, and transitional care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure implementation consistency, the research team developed a systematic training program delivered through a blended approach (online and face-to-face). The curriculum covered protocol implementation procedures, standardized screening and assessment techniques, principles of nutritional intervention (including indications for enteral and parenteral support), health education delivery, and transitional care. Training included theoretical lectures, scenario-based simulations, and case analyses, with two online and two face-to-face sessions (approximately 30 minutes each). Following training, all team members completed a competency assessment to verify proficiency before participating in the experimental group, ensuring intervention fidelity.\u003c/p\u003e\n\u003cp\u003eThe control group received standard nutritional care per hospital protocols, consisting of three phases. During screening and assessment, height and weight were measured, dietary intake assessed, and STRONGkids screening performed upon admission; high-risk cases were reported to the attending physician. In the intervention phase, nutritional support was initiated when weight loss exceeded 5% of baseline or intake fell below 50% of estimated requirements for more than five days, with the route and goals determined by laboratory parameters and physician judgment. During monitoring and follow-up, weight, serum ALB, and PA levels were assessed during hospitalization, with biweekly telephone follow-up after discharge to track weight and dietary status.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eMeasurements\u003c/h2\u003e\n \u003cp\u003eDemographic and clinical characteristics: Baseline data, including age, sex, diagnosis, StrongKids score, BMI‑Z score, serum ALB, and PA levels, were collected for all participants.\u003c/p\u003e\n \u003cp\u003eNutritional risk screening: Nutritional risk was assessed using the STRONGkids tool, which evaluates subjective clinical assessment, presence of high-risk disease, nutritional intake, and weight loss or poor weight gain [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Total scores are categorized as: 0\u0026thinsp;=\u0026thinsp;low risk (routine reassessment); 1\u0026ndash;3\u0026thinsp;=\u0026thinsp;medium risk (further assessment and intervention); 4\u0026ndash;5\u0026thinsp;=\u0026thinsp;high risk (in-depth evaluation and individualized treatment).\u003c/p\u003e\n \u003cp\u003eNutritional status assessment: Nutritional status was evaluated using anthropometric and laboratory indicators: BMI‑Z scores calculated based on WHO growth standards (adjusted for age and sex), and serum AL and PA levels as indicators of protein nutritional status.\u003c/p\u003e\n \u003cp\u003eProtocol feasibility: Feasibility of protocol implementation was evaluated through: (1) protocol execution rates; (2) correct operation rates for key procedures; (3) execution efficiency (time required for completion); and (4) qualitative feedback from medical staff regarding barriers and facilitators.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected at baseline (within 24 hours of admission) and 12 weeks post-intervention. Prior to data collection, two designated data collectors received standardized training. Inter-rater reliability was established through independent evaluation of five pilot cases, with discrepancies discussed and resolved to ensure consistency. Throughout the data collection period, the principal investigator conducted spot checks every 1\u0026ndash;2 weeks to review data quality and ensure protocol adherence until sample collection was complete.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the institution\u0026apos;s Research Ethics Committee under No.25K350-001. Prior to enrollment, all participants received a clear explanation of the study\u0026rsquo;s purpose and provided written informed consent. They were explicitly informed of the voluntary nature of their participation and their right to withdraw at any time without consequence. Furthermore, participants were assured of the confidentiality of their personal information and the anonymous use of all data and experiences.\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analyses were conducted using the SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were computed for all variables: continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and categorical variables as frequencies and percentages.\u003c/p\u003e\n \u003cp\u003eFor between-group comparisons, independent samples t-tests were used for continuous variables meeting normality assumptions, and chi-square tests or Fisher\u0026apos;s exact tests for categorical variables as appropriate. BMI-Z scores were calculated using R software (version 4.3.2; R Foundation for Statistical Computing, Vienna, Austria) with the \u0026ldquo;Z-scorer\u0026rdquo; package. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed).\u003c/p\u003e\n \u003cp\u003eIn the analyses of the Delphi phase, the expert positive coefficient, expert authority coefficient, and coordination coefficient were calculated. The expert positive coefficient was calculated with the formula (number of questionnaires returned/ number of questionnaires given) 100. Kendall\u0026rsquo;s W value was calculated for coordination coefficient calculation and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was accepted as significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFindings of literature screening\u003c/h2\u003e \u003cp\u003eA preliminary search produced 601 articles. After a systematic literature search and screening process, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, 11 articles met the inclusion criteria. There are comprising 2 clinical decisions [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], 3 clinical practice guidelines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], 2 expert consensus [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], 2 systematic reviews [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and 2 randomized controlled trials [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The basic characteristics of the included literature are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic characteristics of included studies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiterature source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLiterature type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePublication date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature title\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaker et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpToDate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical decision-making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParenteral nutrition in infants and children\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJatoi et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpToDate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical decision-making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe role of parenteral and enteral/oral nutritional support in patients with cancer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSNO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedlive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUpdated guideline for oral nutritional supplements\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscaritoli M et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESPEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eESPEN practical guideline: clinical nutrition in cancer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSPEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedlive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGuidelines on nutritional support in patients with tumor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgnieszka Budka-Chrzęszczyk et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eManaging Undernutrition in Pediatric Oncology: A Consensus Statement Developed Using the Delphi Method by the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe Hematology Group of the Pediatric Section of the Chinese Medical Association et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedlive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNutrition Management Standard Process for Children with Blood/Tumor Diseases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIniesta et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSystematic review and meta-analysis: prevalence and possible causes of vitamin D deficiency and insufficiency in pediatric cancer patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHawes et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe effect of oral nutrition supplements and appetite stimulants on weight status among pediatric cancer patients: a systematic review\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRamezani et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRandomised controlled\u003c/p\u003e \u003cp\u003eexperiments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe Effect of Soy Nut Compared to Cowpea Nut on Body Weight, Blood Cells, Inflammatory Markers and Chemotherapy Complications in Children with Acute Lymphoblastic Leukemia: A Randomized Controlled Clinical Trial\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRocha et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRandomised controlled\u003c/p\u003e \u003cp\u003eexperiments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImpact of Selenium Supplementation in Neutropenia and Immunoglobulin Production\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFindings of literature quality evaluation\u003c/p\u003e \u003cp\u003eThe quality evaluation results of the guidelines are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Two clinical decisions were included, both [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] were rated \u0026ldquo;no\u0026rdquo; for \u0026ldquo;transparent and comprehensive search,\u0026rdquo; and one of them [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] was rated \u0026ldquo;no\u0026rdquo; for \u0026ldquo;clear evidence grading\u0026rdquo;; all other items were rated \u0026ldquo;yes.\u0026rdquo; Two expert consensuses were included. For one consensus [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], the rating for Item 2 (\u0026ldquo;Do the opinions originate from influential experts in the field?\u0026rdquo;) was \u0026ldquo;unclear\u0026rdquo;, whereas all other items were rated \u0026ldquo;yes\u0026rdquo;. For the other consensus [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], the rating for Item 6 (\u0026ldquo;Are the proposed opinions inconsistent with previous literature?\u0026rdquo;) was \u0026ldquo;uncertain\u0026rdquo;, and all other items were rated \u0026ldquo;yes\u0026rdquo;. The quality of these two expert consensuses was deemed to be high, and therefore they are worthy of consideration. Two systematic reviews were included. For the review by Hawes et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], all items were rated as \u0026ldquo;yes\u0026rdquo;. For the review by Iniesta et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], the ratings for all items were \u0026ldquo;yes\u0026rdquo; except for Item 5 (\u0026ldquo;Was the quality of the included studies appropriately assessed?\u0026rdquo;) and Item 6 (\u0026ldquo;Was the quality of the included studies assessed by two or more independent reviewers?\u0026rdquo;), which were rated as \u0026ldquo;unclear\u0026rdquo;. Both systematic reviews demonstrated a relatively complete study design and high overall quality, and were therefore included. Two RCTs were also included. The trial by Ramezani et al. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] received a rating of \u0026ldquo;yes\u0026rdquo; for all items. The trial by Rocha et al. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] received a rating of \u0026ldquo;unclear\u0026rdquo; for the item \u0026ldquo;Was blinding of intervention providers implemented?\u0026rdquo; and \u0026ldquo;yes\u0026rdquo; for all other items. Both of these randomized controlled trials were all included due to their relatively sound study designs and high overall quality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality evaluation results of included guidelines.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStudies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eStandardized scores in various domains (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e30%-60%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eQuality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScope and\u003c/p\u003e \u003cp\u003epurpose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStakeholder\u003c/p\u003e \u003cp\u003einvolvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRigor of\u003c/p\u003e \u003cp\u003edevelopment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClarity of\u003c/p\u003e \u003cp\u003epresentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eApplicability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEditorial\u003c/p\u003e \u003cp\u003eindependence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSNO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e91.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e75.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e83.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscaritoli M et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e88.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e79.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e95.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSPEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e94.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of five key themes were identified, encompassing organizational management, standardized screening and assessment, nutritional intervention strategies, health education and transitional care. This led to the identification of 38 pieces of best evidence, as outlined in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the best evidence on nutritional support for children with tumors during chemotherapy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence content\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLevel of evidence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational Management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Establish a multidisciplinary nutrition support team (hematologists/oncologists, dietitians, nurses, pharmacists) to monitor energy, protein, trace elements, minerals, and vitamins [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2. Perform nutritional risk screening and assessment immediately upon cancer diagnosis [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3. Formulate and implement a nutritional treatment plan based on nutritional diagnosis [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNutritional Screening and Assessment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4. Conduct comprehensive nutritional assessment to identify the etiology, mechanism, and severity of malnutrition [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5. Use the \u0026ldquo;ABCDEF\u0026rdquo; method: Anthropometry, Biochemistry, Clinical assessment, Dietary assessment, Environment/Family information [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6. Include weight, height, BMI, and mid-upper arm circumference in anthropometry; reference WHO standards [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7. Include serum ALB, PA, anemia status, inflammatory markers, and specific trace elements/vitamins in biochemical tests [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8. Clinically assess dietary intake, muscle wasting, subcutaneous fat, edema, and skin/mucous membrane/hair condition [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9. Use STAMP or SCAN tool for nutritional risk screening [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10. STAMP\u0026thinsp;\u0026ge;\u0026thinsp;4 or SCAN\u0026thinsp;\u0026ge;\u0026thinsp;3 indicates high nutritional risk; conduct detailed assessment and regular re-screening [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNutritional Requirements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11. Use Nutritional Risk Index (NRI) to assess nutritional status: NRI\u0026thinsp;=\u0026thinsp;1.519 \u0026times; serum albumin (g/L)\u0026thinsp;+\u0026thinsp;0.417 \u0026times; (current weight/usual weight) \u0026times; 100. Classify as well-nourished (NRI\u0026thinsp;\u0026gt;\u0026thinsp;97.5), moderately malnourished (97.5\u0026thinsp;\u0026ge;\u0026thinsp;NRI\u0026thinsp;\u0026ge;\u0026thinsp;83.5), or severely malnourished (NRI\u0026thinsp;\u0026lt;\u0026thinsp;83.5) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12. For stable children, follow energy, protein, and micronutrient recommendations for healthy peers per Chinese Dietary Reference Intakes [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13. Supplement soy protein during chemotherapy to improve nutritional status [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1c\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14. Supplement vitamins C, D, E, and selenium to improve nutritional status and reduce treatment-related side effects [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15. Administer micronutrients in appropriate amounts to avoid toxicity [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16. Oral fish oil may improve appetite, muscle mass, and reduce inflammation in hematologic malignancies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNutritional Intervention\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17. Indications for nutritional therapy: High nutritional risk/malnutrition; crossing down two major percentile curves; weight loss\u0026thinsp;\u0026gt;\u0026thinsp;5% [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18. Follow the five-step ladder: Diet and education \u0026rarr; diet\u0026thinsp;+\u0026thinsp;ONS \u0026rarr; EN \u0026rarr; partial EN\u0026thinsp;+\u0026thinsp;partial PN \u0026rarr; total PN. Advance if current step fails to meet\u0026thinsp;\u0026ge;\u0026thinsp;60% of target energy for 3\u0026ndash;5 days [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19. Individualize interventions based on patient needs, clinical status, and gastrointestinal function [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20. Provide nutritional support for at-risk children and monitor efficacy and complications [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21. Prefer EN if gastrointestinal function is intact; prioritize diet and education for those able to eat orally [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22. Provide ONS when intensified counseling improves but does not meet nutritional requirements [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23. ONS selection: Standard whole-protein formula for most cases; elemental formula for severe intestinal dysfunction; diabetes-specific for diabetes/glucose intolerance; specialized for chronic kidney disease with electrolyte abnormalities; high-energy-density for fluid restriction; immunomodulating may benefit major surgery. Routine enrichment with ω-3 fatty acids, β-hydroxy-β-methylbutyrate, arginine, glutamine, branched-chain amino acids, or probiotics is not recommended [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24. Whey protein-fortified ONS may improve albumin, immunoglobulins, and nutritional status scores [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25. Initiate artificial nutrition support when oral intake is impossible or ONS insufficient [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26. EN indications: Oral intake\u0026thinsp;\u0026lt;\u0026thinsp;50% of standard for 5 consecutive days; severe wasting/malnutrition (BMI or MUAC \u0026lt;5th percentile or z-score \u0026lt;-1); weight loss\u0026thinsp;\u0026gt;\u0026thinsp;5% or MUAC reduction\u0026thinsp;\u0026gt;\u0026thinsp;10% from diagnosis [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27. EN includes oral and tube feeding; use tube feeding when oral intake is inadequate [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28. Tube selection: Nasogastric for short-term (\u0026lt;\u0026thinsp;4 weeks); nasojejunal for intolerance, reflux/aspiration risk, post-abdominal surgery, high gastric residual volume, or inability to tolerate full-volume feeds; PEG/PEJ for long-term (\u0026gt;\u0026thinsp;4 weeks) when feasible [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29. Initiate EN at low dose and concentration, with gradual progression [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30. EN administration: Maintain formula at 37\u0026ndash;40\u0026deg;C; osmolality\u0026thinsp;\u0026lt;\u0026thinsp;330 mmol/L to reduce diarrhea; continuous pump infusion; head of bed elevated 30\u0026ndash;45\u0026deg;; maintain semi-recumbent position for 30 minutes post-infusion [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31. EN monitoring: Gastrointestinal symptoms (measure gastric residual volume if vomiting/distension); fluid input/output; nutritional adequacy (daily intake percentage); laboratory indicators (complete blood count and biochemistry every 1\u0026ndash;2 days initially, then every 1\u0026ndash;2 weeks) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32. EN is preferred for hematologic malignancies. Use PN for critically ill or high-dose chemotherapy patients when oral/enteral intake is insufficient, and discontinue upon gastrointestinal recovery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33. PN indications: EN contraindicated or fails to meet\u0026thinsp;\u0026le;\u0026thinsp;60% of target energy for 3\u0026ndash;5 days, per ESPEN guidelines and five-step ladder [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34. Monitor PN complications: Mechanical/device-related issues, infections, metabolic complications, electrolyte/acid-base imbalances, drug-nutrient interactions, intestinal failure-associated liver disease, and refeeding syndrome [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35. Initiate nutritional therapy at low doses and gradually increase to target levels [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation and Follow-up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36. Provide individualized nutrition education [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37. Encourage physical activity to maintain and improve appetite, adjusting intensity according to health status and function [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38. Conduct regular monitoring and follow-up during and after treatment to implement and evaluate interventions [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative interview\u003c/h3\u003e\n\u003cp\u003eThematic analysis of the interviews with 10 pediatric cancer patients, 12 family caregivers, and 12 healthcare professionals (5 physicians and 7 nurses) yielded five central themes that capture their experiences, needs, and perceptions of nutritional support during chemotherapy. Demographic and clinical data of patients, caregivers and healthcare professionals were collected in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric Patients with Cancer\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily caregivers\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealthcare Professionals\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (41.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (58.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (91.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school / technical secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior college\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (58.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecivil servant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eteacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esalesman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efamer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (25.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (25.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional title, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (66.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSub-senior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of working experience, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (58.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIllness leading to hospitalization (medical specialty), n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (30.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (25.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuroblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedulloblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRhabdomyosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatoblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilms' tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisease duration, months, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.90\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.83\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDegree of kinship, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (41.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (58.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eData are presented as mean \u0026plusmn; standard deviation for continuous variables and as number (percentage) for categorical variables. \u0026ldquo;\u0026mdash;\u0026rdquo; indicates that the variable was not applicable to the respective participant group.\u003c/p\u003e\n \u003cp\u003eInterviews were transcribed verbatim within 48 hours, yielding 127,600 Chinese characters of transcribed text from a total interview duration of 896 minutes. The themes and sub-themes derived from the analysis of the interview data are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnalyze the gaps between clinical practice and the best evidence. Based on the theory of nutritional ecology, specific supplements were made to the initial draft of the plan. The specific strategies are collected in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegration of evidence\u0026ndash;practice gaps and protocol development strategies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGap Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence-Based Recommendation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCurrent Clinical Practice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEcological Disconnection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProtocol Development Response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScreening gap\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStandardized nutritional risk screening using validated tools (e.g., STRONGkids), with regular reassessment throughout treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScreening performed only at admission; no systematic follow-up. High-risk children faced\u0026thinsp;\u0026gt;\u0026thinsp;24-hour delays awaiting formal assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFragmented approach failed to capture dynamic changes in the child\u0026rsquo;s internal environment (e.g., deteriorating nutritional status due to treatment toxicity), delaying early intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNutritional Risk Screening\u0026nbsp;dimension restructured to ensure systematic monitoring throughout treatment trajectory. Established clear escalation pathways with specified reassessment and response timelines, enabling standardized dynamic surveillance of the child\u0026rsquo;s internal environment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntervention gap\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreventive nutritional interventions for anticipated chemotherapy-induced toxicities (e.g., mucositis, nausea, vomiting, diarrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReactive management: interventions initiated only after symptoms became clinically significant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTemporal misalignment between internal system changes (emergence of gastrointestinal toxicity) and external system responses (nutritional support), reflecting lack of ecological synergy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNutritional Management of Chemotherapy-Related Adverse Effects\u0026nbsp;module developed to shift from reactive to proactive paradigm. Integrated fragmented guidance into timeline-based framework, including defined eating windows relative to chemotherapy (e.g., 3 hours before, 4 hours after) and stepwise escalation for oral mucositis initiated before symptom onset\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation gap\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonalized, actionable health education tailored to caregivers\u0026rsquo; needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverly generic educational content delivered in standardized formats; no consideration of health literacy, cultural background, or specific concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInadequate allocation of educational resources within the external system (hospital) to address families\u0026rsquo; complex, individualized nutritional challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth Education\u0026nbsp;dimension reconfigured into modular packages aligned with treatment phases (diagnosis, active chemotherapy, myelosuppression, maintenance). Assigned clear accountability: Primary nurses for delivery; dietitians for quality control, ensuring tailored information transfer throughout treatment journey\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoordination gap\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe multidisciplinary nutrition support team is composed of hematologists/oncologists, clinical nutritionists/nutritionists, nurses/pharmacists, etc., and is a multi-disciplinary team that jointly participates.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoorly defined role boundaries among physicians, nurses, and dietitians; no clear mechanism for collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSystemic fragmentation reflected absence of effective communication channels and collaboration mechanisms among subsystems, preventing an integrated support system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandardized Training\u0026nbsp;added to define standardized operating procedures for screening, education delivery, and escalation protocols. Specified distinct responsibilities of physicians, nurses, and dietitians to optimize information flow and create a cohesive external support system\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eDelphi expert consensus\u003c/h3\u003e\n\u003cp\u003eA total of 20 experts consented to participate in this study, and all of them completed both rounds of the Delphi survey. All participating experts were female and engaged in clinical practice. The characteristics of the experts are presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of the experts that participated in the Delphi-study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRound 1\u0026ndash;2 (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMEAN (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of professional experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince of experts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJilin Province\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShanghai Municipality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHubei Province\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHunan Province\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eField of expertise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric oncology clinical experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric oncology nursing experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNutritional nursing experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult oncology nursing experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational background\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctorate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional title\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate senior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the Delphi survey, two rounds of expert consultation were conducted. In each round, 20 questionnaires were distributed, and all 20 were returned valid, resulting in a 100% effective response rate. The expert authority coefficients were 0.903 in the first round and 0.895 in the second round. In the first round, the coefficients of variation (CV) for individual items ranged from 0 to 0.312, the full-score rate was 82.94%, and Kendall\u0026rsquo;s coefficient of concordance (Kendall\u0026rsquo;s W) was 0.229 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the second round, the CVs ranged from 0 to 0.183, the full-score rate was 96.76%, and Kendall\u0026rsquo;s W was 0.227 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003cp\u003e18 experts provided 20 substantive modification suggestions. Based on the predefined retention criteria and team discussion, the following revisions were made:\u003c/p\u003e \u003cp\u003eItem Additions: (1 second-level items) \u0026ldquo;Nutritional strategies for chemotherapy-related adverse effects\u0026rdquo; ; (4 third-level items): \u0026ldquo;Medical social workers are responsible for providing medical play therapy and social support to children and their caregivers\u0026rdquo; \u0026ldquo;Nutritional strategies for nausea and vomiting after chemotherapy\u0026rdquo; \u0026ldquo;Nutritional strategies for chemotherapy-induced oral mucositis\u0026rdquo; \u0026ldquo;Nutritional strategies for Chemotherapy-induced diarrhea\u0026rdquo;.\u003c/p\u003e \u003cp\u003eItem Deletions: (2 third-level items) \u0026ldquo;Assess nutritional status using the Nutritional Risk Index (NRI)\u0026rdquo;\u0026mdash;experts noted limited validation of this tool in pediatric oncology populations; \u0026ldquo;Consider supplementing with soy protein to improve nutritional status\u0026rdquo;\u0026mdash;concerns were raised regarding potential interactions with chemotherapy and lack of pediatric-specific safety data.\u003c/p\u003e \u003cp\u003eItem Modifications: Three second-level items and 13 third-level items were revised. Key modifications included: Relocating \u0026ldquo;Nutritional Requirements\u0026rdquo; to the \u0026ldquo;Standardized Screening and Assessment\u0026rdquo; dimension to improve logical flow; merging original items \u0026ldquo;Health Education Formats\u0026rdquo; and \u0026ldquo;Health Education Channels\u0026rdquo; into a single item \u0026ldquo;Health Education Methods\u0026rdquo; to reduce redundancy; (3) Renaming original \u0026ldquo;Transitional Care Formats\u0026rdquo; to \u0026ldquo;Transitional Care Methods\u0026rdquo; for terminological consistency; (4) Expanding \u0026ldquo;Use telephone or WeChat follow-up\u0026rdquo; to \u0026ldquo;Use diversified follow-up modes selected based on patient circumstances: video consultations, telephone follow-up, home visits, etc.,\u0026rdquo; reflecting experts' emphasis on individualized transitional care.\u003c/p\u003e \u003cp\u003eAfter incorporating the expert feedback, the second-round questionnaire was finalized. The complete questionnaire is presented in Supplementary File 2.\u003c/p\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003cp\u003eAfter this round of consultation, none of the experts proposed any modification opinions to the intervention program. The statistical analysis of the second round of consultation revealed that all the items had a mean of 4.50 or more. The nutrition support protocol was designed and finalized accordingly (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e7\u003c/span\u003e) since the experts\u0026rsquo; opinions tended to be consistent, and the consultation ended.\u003c/p\u003e\n\u003ctable float=\"Yes\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNutrition support protocol for pediatric cancer patients during chemotherapy (Final version).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eRound 1 (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eRound 2 (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Organization and management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.1 Establish a multidisciplinary nutrition management team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.1.1 Team members include pediatric oncology specialists and nurses, dietitians, rehabilitation physicians, psychotherapists, and medical social workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2 Define roles and responsibilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2.1 Pediatric oncology clinician: Responsible for disease assessment, formulation and implementation of treatment plans, and health education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2.2 Dietitian: Responsible for nutritional screening, assessment, and diagnosis; formulation and adjustment of individualized nutrition plans; nutritional monitoring; and health education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2.3 Primary nurse: Performs initial screening, supervises daily nutritional support, provides guidance and consultation, observes and reports adverse reactions, coordinates team communication, and establishes and manages nutrition records for patients at high nutritional risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2.4 Psychotherapist: Provides psychological counseling for patients and their family caregivers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2.5 Rehabilitation physician: Develops individualized exercise plans for patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.2.6 Medical social worker: Provides medical play guidance and social support for patients and their family caregivers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.3 Conduct standardized training and assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1.3.1 Organize periodic professional nutrition training and assessments, with different training focuses for each team member to ensure standardization of core content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e17 (85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Standardized screening and assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.1 Nutritional requirements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.1.1 Individualized assessment of target energy and protein requirements: For children in a stable disease phase, reference the recommended intake of energy, protein, and micronutrients for healthy children of the same age as outlined in the \u003cem\u003eChinese Dietary Reference Intakes\u003c/em\u003e published by the Chinese Nutrition Society, with dynamic adjustments based on treatment response, metabolic status, and weight trends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.2 Nutritional risk screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.2.1 Use the STRONGkids tool to screen for nutritional risk in children diagnosed with cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.2.2 Timing of screening: Routine screening at admission and discharge; no nutritional intervention required for a score of 0, with weekly rescreening; for scores of 1\u0026ndash;3, nutritional intervention is required, with weight monitored twice weekly and rescreening performed weekly; for scores of 4\u0026ndash;5, children are identified as being at high nutritional risk, requiring initial nutritional assessment within 24 hours and comprehensive assessment within 72 hours to confirm the diagnosis. Reassessment is performed weekly thereafter, with frequency adjusted based on changes in clinical status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3 Nutritional status assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3.1 Use the \u0026ldquo;ABCDEF\u0026rdquo; approach for nutritional assessment, which includes: Anthropometry (A), biochemistry (B), clinical assessment (C), diet assessment (D), and environment/family information (E/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3.2 A (Anthropometry): Weight, height, body mass index (BMI), mid-upper arm circumference, and triceps skinfold thickness (referencing WHO standards)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3.3 B (Biochemistry): ALB, PA, anemia status, inflammatory markers, and specific minerals and vitamins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3.4 C (Clinical assessment): Dietary intake, muscle wasting, subcutaneous fat, skin and mucous membranes, edema, and hair condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3.5 D (Diet assessment): Documentation of dietary intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.3.6 E/F (Environment/Family): Assessment of family support and environmental factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Nutritional intervention strategies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.1 Timing and methods of intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.1.1 Timing: Screening and assessment indicate high nutritional risk and/or malnutrition; growth trajectory shows a decline crossing two major percentile curves in a short period; recent weight loss exceeding 5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.1.2 Methods: Follow the five-step treatment ladder for malnourished patients (oral diet and nutrition education \u0026rarr; diet plus oral nutritional supplements \u0026rarr; enteral nutrition \u0026rarr; partial enteral nutrition plus partial parenteral nutrition \u0026rarr; total parenteral nutrition). Advance to the next step when the current step fails to meet 60% of target energy requirements for 3\u0026ndash;5 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.1.3 Nutritional interventions should be individualized based on the child\u0026apos;s specific needs, clinical condition, and gastrointestinal function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.2 Oral nutritional supplements (ONS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.2.1 ONS is preferred when gastrointestinal function is present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.2.2 ONS is indicated when oral intake does not improve sufficiently with nutrition education to meet nutritional needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.2.3 ONS formulations should be selected based on the medical condition (e.g., whole protein, elemental, diabetes-specific, renal-specific, high-energy-density, or immune-enhancing formulas). Whey protein-fortified formulas are recommended to improve nitrogen balance (assess renal function and allergy status first). In the absence of contraindications, supplementation with vitamins C, D, E, and selenium is recommended to improve nutritional status and alleviate treatment-related side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.3 Enteral nutrition (EN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.3.1 Timing of initiation: When oral intake is not possible or ONS is insufficient, or in cases of absorption disorders, metabolic abnormalities, food allergies, pancreatitis, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.3.2 Tube feeding route selection: For short-term (\u0026lt;\u0026thinsp;4 weeks), nasogastric tube is preferred; for intolerance or high reflux risk, nasojejunal tube is used; for long-term (\u0026gt;\u0026thinsp;4 weeks), percutaneous endoscopic gastrostomy/jejunostomy is recommended when conditions permit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.3.3 Administration method: Choose bolus or intermittent feeding based on tolerance; formula temperature at 37\u0026ndash;40\u0026deg;C, osmolality\u0026thinsp;\u0026lt;\u0026thinsp;330 mmol/L; use an infusion pump; elevate the head of the bed to 30\u0026ndash;45\u0026deg;; maintain a semi-recumbent position for 30 min after infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.3.4 Monitoring and complication management: Monitor gastrointestinal symptoms, intake and output, achievement rate of nutritional targets, and laboratory parameters; promptly manage complications such as diarrhea, nausea, vomiting, and constipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.4 Parenteral nutrition (PN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.4.1 Timing of PN: PN is indicated when EN is contraindicated, when EN fails to meet\u0026thinsp;\u0026ge;\u0026thinsp;60% of target energy requirements for 3\u0026ndash;5 days, or when critically ill children or those receiving high-dose chemotherapy cannot meet nutritional needs via oral and enteral routes. Transition to EN as soon as gastrointestinal function recovers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.4.2 Monitor PN-related complications: Mechanical or equipment-related complications, infections, metabolic complications, electrolyte and acid-base imbalances, drug interactions, intestinal failure-associated liver disease, and refeeding syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.5 Exercise intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.5.1 Exercise type: Under the guidance of a rehabilitation physician, choose individualized resistance and/or aerobic exercises (e.g., radio calisthenics, aerobic exercises)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.5.2 Exercise intensity: Under caregiver supervision, low-to-moderate intensity training is recommended, with adjustments based on health status and physical function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.5.3 Exercise frequency: Individualized approach is recommended, with sessions 3 times per week, 10\u0026ndash;30 minutes each session, starting with low intensity and short duration, and progressing gradually\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.6 Psychological care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.6.1 Continuously monitor the emotional status of children and their caregivers, especially in the early post-diagnosis period; provide psychological support, counseling, and lectures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.6.2 Medical social workers regularly organize medical play activities and relaxing activities such as flower arranging, crafts, and picture book reading\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e16 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.7 Nutritional strategies for chemotherapy-related adverse effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.7.1 Chemotherapy-induced nausea and vomiting: It is recommended to have breakfast 3 hours before chemotherapy, consisting of high-protein, high-energy, low-fat, vitamin-rich, light, and easily digestible foods, with intake limited to approximately two-thirds of usual volume; start eating 4 hours after chemotherapy, with a light diet and small, frequent meals. In cases of severe vomiting, fasting for 4\u0026ndash;8 hours (may be extended to 24 hours if necessary), with gradual resumption of intake after symptom relief\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.7.2 Oral mucositis: During chemotherapy, avoid foods that are excessively hot, rough, hard, spicy, or irritating. Choose high-protein, high-energy, soft, and easily digestible foods such as high-protein and high-energy milkshakes, pureed foods, or liquid diets. Small, frequent meals are recommended to reduce mucosal irritation. For children with severe symptoms who cannot eat orally, EN or PN should be administered as prescribed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3.7.3 Chemotherapy-induced diarrhea: Choose light, easily digestible foods; avoid spicy, irritating, and hyperosmolar dietary supplements. Limit lactose intake in cases of lactose intolerance. Appropriately restrict raw vegetables and fresh fruits rich in dietary fiber based on gastrointestinal tolerance. In severe cases with insufficient energy intake, EN or PN should be administered as prescribed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Health education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.1 Timing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.1.1 Design modular education packages for different treatment phases (diagnosis, chemotherapy, myelosuppression, and maintenance phases) and implement targeted health education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.2 Content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.2.1 Provide detailed guidance covering the entire nutrition management process, focusing on both daily diet and therapeutic diet. When EN and PN are administered, inform patients and family caregivers about monitoring and handling of complications such as diarrhea, constipation, nausea, vomiting, infection, and metabolic issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.3 Methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.3.1 Establish an online (internet) and offline (inpatient ward/outpatient clinic) dual-track information service platform; regularly share professional lectures; conduct daily evening Q\u0026amp;A sessions via WeChat groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e4.3.2 Conduct various health education activities, including patient-caregiver meetings, parent education classes, peer education, and distribution of nutrition education videos and illustrated materials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Transitional care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5.1 Timing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5.1.1 Initiate the day after discharge; consultation with caregivers regarding the frequency of transitional care based on the child\u0026apos;s nutritional status and treatment plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5.2 Content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5.2.1 Monitor dietary intake and weight changes during home stay; assess current caregiving status and needs; address questions and concerns regarding nutritional care. For children receiving home EN, closely monitor gastrointestinal symptoms (vomiting, abdominal pain, bloating, diarrhea), fluid intake and output, nutritional target achievement, and laboratory parameters; instruct caregivers to seek timely follow-up in case of abnormalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5.3 Methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5.3.1 Employ diverse follow-up models, selecting video consultations, telephone follow-up, or home visits based on the child\u0026rsquo;s condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQuasi-experimental study\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eCharacteristics of the participants\u003c/h2\u003e \u003cp\u003eA total of 148 children were initially enrolled, with 74 allocated to each group. During the intervention period, one child in the experimental group was transferred to the intensive care unit due to sudden clinical deterioration, and three caregivers voluntarily withdrew. In the control group, two children were lost to follow-up due to transfer to other hospitals. The final analysis included 70 children in the experimental group and 72 children in the control group, yielding a completion rate of 94.6% and 97.3%, respectively. The age of children in the control group was (7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11) years, while that in the experimental group was (7.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.13) years. No statistically significant differences were observed between the two groups in terms of demographic and clinical characteristics, including age, sex, disease diagnosis, STRONGkids scores, BMI-Z scores, serum ALB, and PA (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of baseline characteristics between the two groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperimental group (n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u0026sup2; /\u0026nbsp;t\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.487\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeukemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHepatoblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRhabdomyosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeuroblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGerm cell tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWilms tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOsteosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedulloblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStrongkids score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI-Z score\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(\u0026lt;-2/\u0026gt;-2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6/66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(6/64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePA (g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALB(g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.49\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRisk of malnutrition and nutritional status\u003c/h2\u003e \u003cp\u003eAfter the 12-week intervention period, the experimental group showed significant improvements in multiple nutritional indicators compared to the control group:\u003c/p\u003e \u003cp\u003eNutritional risk: STRONGkids scores in the experimental group were significantly higher than those in the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating reduced nutritional risk.\u003c/p\u003e \u003cp\u003eLaboratory Indicators: Both serum PA and ALB levels were significantly elevated in the experimental group compared to controls (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eAn thropometric indicator: The incidence of emaciation (defined as BMI-Z score\u0026lt;-2) was significantly lower in the experimental group (2.9%, 2/70) than in the control group (12.5%, 9/72) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThese findings demonstrate that implementation of the nutrition support protocol effectively improved nutritional outcomes for pediatric cancer patients undergoing chemotherapy (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of risk indicators and nutritional status of malnutrition between the two groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;/t\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSTRONGkids score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI z-score (\u0026lt;-2 / \u0026ge;-2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(9/63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2/68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePA (g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALB (g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.89\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.68\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e Data are presented as mean \u0026plusmn; standard deviation or n (%). The t-test was used for continuous variables, and the chi-square (\u0026chi;\u0026sup2;) test was used for categorical variables.\u003c/p\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eProtocol implementation feasibility\u003c/h2\u003e \u003cp\u003eThe protocol demonstrated high implementation feasibility, with consistently high execution and accuracy rates across all core components. Efficiency metrics showed seamless integration into routine workflows, and stakeholder feedback indicated strong clarity and acceptance. The specific data is presented in Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of feasibility indicators for the nutrition support protocol.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResult / Data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExecution Rates\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission nutritional risk screening execution rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100% (74/74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll children in the experimental group completed initial screening within 24 hours of admission\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive nutritional assessment execution rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.7% (42/43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne incomplete assessment due to sudden clinical deterioration and transfer to the ICU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNutritional follow-up completion rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.9% (70/73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThree missed follow-ups due to voluntary withdrawal from the study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorrect Execution Rates\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening documentation completeness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompleted by primary nurses using the standardized STRONGkids tool\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening scoring accuracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStandardization rate for anthropometric data collection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComprehensive nutritional assessments led by nutritionists\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdverse event rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo adverse events related to nutritional support documented during the intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExecution Efficiency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission screening time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 min/patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompleted by primary nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBedside reassessment time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 min/patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubsequent nutritional re-examination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth education time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 min/patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsing standardized patient education materials\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkflow integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo substantial increase in task duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCombined with routine post-chemotherapy assessments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStakeholder Feedback\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse clarity rating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;90% (14/15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRated the protocol as \u0026ldquo;clear\u0026rdquo; or \u0026ldquo;very clear\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily comprehension rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.7% (60/70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReported nutritional guidance as \u0026ldquo;easy to understand\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse qualitative feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStructured protocol provided a \u0026ldquo;clear sense of purpose\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced confidence and role clarity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Data are presented as n (%)\u003cem\u003e\u0026nbsp;\u003c/em\u003eor mean \u0026plusmn; standard deviation. ICU, intensive care unit.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, a theory-driven, multilevel nutrition support protocol for pediatric cancer patients undergoing chemotherapy was developed based on the theory of nutritional ecology and validated in a quasi-experimental trial. The final protocol comprised 5 first-level, 19 second-level, and 44 third-level items. Implementation of the protocol significantly improved nutritional outcomes, as evidenced by higher BMI‑Z scores, lower STRONGkids risk scores, and elevated serum albumin and prealbumin concentrations in the experimental group compared with the control group (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). To our knowledge, this is the first study to operationalize the nutritional ecology framework into a clinical nutrition support protocol for this vulnerable population, bridging best evidence, multi‑stakeholder perspectives, and real‑world feasibility.\u003c/p\u003e \u003cp\u003eIn this study, the best available evidence was identified through a systematic literature search, and a draft nutrition support protocol was developed based on this evidence. This draft is generally consistent with current guidelines and expert consensuses, such as the \u0026ldquo;ABCDEF\u0026rdquo; method for nutritional assessment [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], the \u0026ldquo;five‑step approach\u0026rdquo; for nutritional support [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and the gradual increase of nutritional treatment from a low dose to the target value [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, the present study also incorporates the theory of nutritional ecology as a guiding framework, which may offer a somewhat different analytical perspective on nutritional problems. Nutritional ecology views humans as complex biological systems interacting with internal and external environments and suggests that nutritional status is shaped by interactions across multiple levels [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. To our knowledge, this study represents one of the initial attempts to apply this theoretical framework to nutritional support for pediatric cancer patients, moving beyond a sole focus on individual nutrient intake and symptom management. Through qualitative interviews, we incorporated the perspectives of multiple stakeholders, including patients, family caregivers, and healthcare professionals, on the current status of clinical nutritional support. Based on these insights, we integrated three ecological levels into a unified analytical and interventional framework. The individual level encompasses chemotherapy‑induced taste alterations, nausea, vomiting, diarrhea, and other direct symptoms that impair nutritional intake. The interpersonal level addresses caregivers\u0026rsquo; feeding anxiety, knowledge, and practical skills. The organizational or system level involves standardized hospital workflows, multidisciplinary collaboration models, and transitional care after discharge. This theoretical shift may enable the protocol to identify and address certain ecological factors that, although less emphasized in existing guidelines, may still exert an important influence on nutritional outcomes.\u003c/p\u003e \u003cp\u003eIn the present study, implementation of the nutrition support protocol was associated with a significantly reduced risk of malnutrition, as evidenced by lower STRONGkids scores in the experimental group than in the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The STRONGkids tool is validated for identifying malnutrition risk in hospitalized children, and up to 62% of children undergoing chemotherapy are classified as high-risk by this instrument [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. From a nutritional ecology perspective, the observed improvement in STRONGkids scores may reflect coordinated interventions acting across multiple levels of influence. At the individual level, the protocol included strategies to manage chemotherapy-induced taste alterations, nausea, vomiting, oral mucositis, and diarrhea. These items were added during the Delphi process based on expert input. Such symptoms are known to be major barriers to adequate oral intake during chemotherapy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. By addressing them directly, the protocol may have enabled children to maintain higher nutrient intake compared with routine care, where symptom management is often reactive. At the interpersonal level, the protocol incorporated health education components that targeted caregivers\u0026rsquo; feeding anxiety and practical skills, which were identified as barriers in our qualitative interviews. Empowering caregivers in this way might have helped sustain nutritional intake beyond the hospital setting. At the organizational level, standardized screening workflows and diversified follow-up modes, including video consultations, telephone follow-up, and home visits, may have facilitated early identification of at-risk children and timely intervention, factors considered important for successful malnutrition prevention [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Therefore, the multi-level nature of the protocol, which addressed individual symptoms, interpersonal support, and organizational workflows, may have produced synergistic effects that surpass the more fragmented approaches typical of routine care. This interpretation is consistent with nutritional ecology theory, which suggests that nutritional status results from interactions across multiple ecological layers rather than from individual factors alone [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond individual and interpersonal factors, the protocol introduced several organizational‑level changes that may have shifted nutritional management from a fragmented, reactive model toward a more systematic and structured approach. This shift aligns with nutritional ecology theory, which proposes that optimizing external systems can enhance the responsiveness of internal biological processes to nutritional support. One such change was embedding nutritional screening into the admission workflow. Early identification of at‑risk children through standardized screening is a prerequisite for timely intervention. This is highly consistent with the international concept of \u0026ldquo;early identification and full management of nutritional issues in pediatric cancer patients\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. By systematizing the timing and criteria for screening, the protocol may have enabled the care team to initiate support before significant nutritional deterioration occurred. Another key change involved clarifying the division of responsibilities among multidisciplinary team members. Effective clinical nutrition management necessitates the establishment of a multidisciplinary nutritional support team [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Explicit role definitions for clinicians, dietitians, nurses, psychotherapists, rehabilitation physicians, and social workers may have reduced communication gaps and helped prevent fragmented care. When each professional understands their specific tasks, the overall care system becomes more coordinated and responsive [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In addition, the protocol established a closed‑loop management pathway that integrated assessment, intervention, and re‑evaluation. This pathway ensured continuous monitoring of nutritional status rather than one‑time assessment at admission. A systematic, cyclical approach has been shown to improve early recognition of malnutrition and facilitate timely adjustments to interventions [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Taken together, these organizational changes may have optimized the responsiveness of the external care system to the child\u0026rsquo;s internal nutritional needs. When screening is systematic, roles are clearly defined, and a closed loop connects assessment to intervention and re‑evaluation, the care environment becomes more predictable and responsive. In turn, this improved external system responsiveness may support the child\u0026rsquo;s internal metabolic and nutritional regulation, creating conditions in which individual‑level dietary strategies and interpersonal caregiver support can be more effective. Consequently, the improved nutritional outcomes observed in the experimental group may reflect not only the content of the protocol but also the system within which it was delivered. This interpretation is consistent with the nutritional ecology premise that external environmental factors shape internal biological outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe protocol demonstrated satisfactory clinical applicability. First, it provides a structured, evidence‑based, and stakeholder‑endorsed roadmap for nutritional care in pediatric oncology wards. Its feasibility for implementation was validated in a real‑world tertiary hospital setting in China, where core components consistently achieved high rates of execution and accuracy. Efficiency metrics indicated seamless integration into routine workflows, and stakeholder feedback reflected strong clarity and acceptability (Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e). These observations suggest that the protocol is not only effective but also practical for routine clinical use. Second, because the protocol was developed using a rigorous mixed‑methods approach that included summary of the best evidence, qualitative inquiry, and a Delphi consensus process, it may offer greater content validity and contextual relevance than locally developed ad‑hoc practices. Furthermore, the protocol was informed by the perspectives of multiple stakeholders, including children, family caregivers, and healthcare professionals. This multi‑stakeholder foundation may enhance its acceptability among patients, families, and providers, thereby supporting implementation fidelity.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eSeveral limitations should be acknowledged. Firstly, the quasi‑experimental (non‑randomized) design was conducted at a single tertiary hospital, which limits the ability to infer causality. Although baseline characteristics were comparable between groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all demographic and clinical variables, Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e), the possibility of selection bias and unmeasured confounding cannot be completely ruled out. Secondly, the final analysis included a relatively small sample (70 children in the experimental group and 72 in the control group) drawn from a single geographic region, which restricts the generalizability of the findings to other populations or healthcare systems. Thirdly, outcome measures were collected only at the end of the 12‑week intervention period; consequently, long‑term effects on treatment completion rates, infection episodes, event‑free survival, and late malnutrition sequelae remain unknown, and extended follow‑up would be needed to assess whether the observed short‑term improvements are sustained over time. Fourthly, given the behavioral nature of the nutritional intervention, blinding of participants and healthcare providers was not feasible. This lack of blinding may have introduced performance and detection bias, although outcome assessors could in principle have been blinded. Readers should therefore interpret the findings with caution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice\u003c/h2\u003e \u003cp\u003eThe protocol provides a structured, evidence‑based, and stakeholder‑endorsed framework for nutritional support in pediatric oncology wards. Establishing a closed‑loop assessment‑intervention‑re‑evaluation pathwayrkflows and clarifying multidisciplinary team roles, and can help reduce fragmented care and improve the responsiveness of the care system to children\u0026rsquo;s nutritional needs. The protocol\u0026rsquo;s development incorporated perspectives from multiple stakeholders, including children, family caregivers, and healthcare professionals. This multi‑stakeholder foundation may enhance acceptability and adherence among users, thereby supporting implementation fidelity.\u003c/p\u003e \u003cp\u003eTo further strengthen clinical application, future multicenter, cluster‑randomized controlled trials are needed to confirm the effectiveness of the protocol in diverse settings. Extended follow‑up should be implemented in routine practice to monitor long‑term clinical outcomes, including treatment completion rates, febrile neutropenia episodes, and overall survival. In addition, the protocol may be adapted for use in other treatment contexts, such as radiotherapy or stem cell transplantation, as well as across different pediatric age groups, which could broaden its clinical utility.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study, grounded in nutritional ecology theory, systematically developed and evaluated a nutrition management protocol for pediatric cancer patients undergoing chemotherapy. The protocol was formulated through a rigorous multi-method approach encompassing evidence synthesis, qualitative stakeholder interviews, and Delphi expert consensus. Preliminary clinical application demonstrated that the protocol effectively reduced nutritional risk and improved nutritional status during chemotherapy, with favorable clinical applicability and safety profiles. By translating nutritional ecology theory into a structured, implementable protocol, this study not only advances clinical practice by providing an evidence-based framework for systematic nutritional management but also extends the theoretical application of nutritional ecology in pediatric oncology care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ealbumin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprealbumin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erandomized controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethe coefficients of variation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKendall\u0026rsquo;s W\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKendall\u0026rsquo;s coefficient of concordance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNutritional Risk Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the First Hospital of Jilin University under No.25K350-001. All participants signed the Informed Consent Form, for child participants, assent was obtained in addition to parental consent, ensuring the principles of autonomy, confidentiality and voluntary participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Nursing Research Fund of the First Hospital of Jilin University in 2024 (Project No.: HLKY20240107).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXY: Writing \u0026ndash;review\u0026amp; editing, Methodology, Investigation, Resources, Conceptualization.\u003c/p\u003e\n\u003cp\u003eYZ: Writing \u0026ndash; original draft, Methodology, Data curation, Formal analysis, Conceptualization, Project administration.\u003c/p\u003e\n\u003cp\u003eSG: Methodology, Investigation, Data curation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the children with tumors, their family caregivers, and the medical workers who participated in this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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JCO Global Oncol. 2023;37384860(9).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pediatric oncology, Chemotherapy, Nutritional ecology, Nutrition support, Best evidence, Qualitative research, Delphi","lastPublishedDoi":"10.21203/rs.3.rs-9491500/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9491500/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Malignant neoplasms are the leading cause of disease‑related mortality in children. Although chemotherapy remains the primary treatment for pediatric malignancies, it frequently causes highly prevalent and challenging nutritional problems. Given that nutritional issues during chemotherapy represent a complex systemic challenge, this study aimed to develop a nutritional support protocol based on nutritional ecology theory for children undergoing chemotherapy and to evaluate its clinical application effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A mixed-methods design was employed, comprising four phases: Phase 1 involved a systematic literature search and quality evaluation to synthesize evidence on nutritional support for children with cancer undergoing chemotherapy. Phase 2 comprised semi-structured interviews with pediatric cancer patients, family caregivers, and healthcare providers to explore multi‑stakeholder perspectives on internal and external systemic factors influencing nutritional status. Based on the findings of Phases 1 and 2, an initial nutrition support protocol was developed, which was then refined and finalized through a Delphi expert consultation in Phase 3, incorporating multiple ecological determinants. In Phase 4, a quasi‑experimental study was performed from January to October 2025 at a tertiary grade A hospital, enrolling 148 pediatric cancer patients. The experimental group received the nutritional support protocol, while the control group received routine care. Following a 12‑week intervention period, the two groups were compared regarding body mass index (BMI) z‑scores, STRONGkids scores, serum albumin (ALB), and prealbumin (PA) levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The protocol comprised 5 first‑level, 19 second‑level, and 44 third‑level items. After implementation, the experimental group showed significantly higher BMI‑Z scores, STRONGkids scores, serum ALB, and PA than the control group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This scientifically rational, safe, and feasible nutritional support protocol reduces malnutrition risk and improves nutritional status in pediatric cancer patients, and can serve as a reference for clinical nursing practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Development and evaluation of a nutritional support protocol for pediatric cancer patients during chemotherapy: A mixed-method study based on nutritional ecology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 10:53:28","doi":"10.21203/rs.3.rs-9491500/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-02T00:59:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261129941007241894366840178752127703055","date":"2026-05-01T22:54:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-01T08:19:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-01T08:15:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-29T06:31:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-29T05:08:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-04-29T05:03:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"23a25aed-cc92-445a-ac6a-b8b320c335d8","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-02T00:59:07+00:00","index":33,"fulltext":""},{"type":"reviewerAgreed","content":"261129941007241894366840178752127703055","date":"2026-05-01T22:54:27+00:00","index":32,"fulltext":""},{"type":"reviewersInvited","content":"7","date":"2026-05-01T08:19:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-01T08:15:25+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T10:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 10:53:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9491500","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9491500","identity":"rs-9491500","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}