Progressive Deterioration in Dietary Intake and Nutritional Risk During Oncological Treatment in Children with Solid Tumors: A Prospective Longitudinal Study

Progressive Deterioration in Dietary Intake and Nutritional Risk During Oncological Treatment in Children with Solid Tumors: A Prospective Longitudinal Study | 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 Progressive Deterioration in Dietary Intake and Nutritional Risk During Oncological Treatment in Children with Solid Tumors: A Prospective Longitudinal Study Ecem Mısırlıoğlu, Beril Köse, Derya Hopancı Bıçaklı, Mehmet Kantar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8991405/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose Children with solid tumors are highly vulnerable to treatment-related nutritional compromise. However, longitudinal data describing how dietary intake and nutritional risk evolve during therapy remain limited. This study aimed to examine longitudinal changes in dietary intake adequacy and nutritional risk across different phases of oncological treatment and to identify clinically vulnerable periods requiring intensified supportive care. Methods In this prospective longitudinal study, children aged 8–18 years with newly diagnosed solid tumors were assessed at three predefined treatment phases (early, mid- and late-treatment). Dietary intake was evaluated using 3-day food records at each time point. Energy and nutrient intakes were expressed as percentages of age- and sex-specific estimated requirements. Nutritional risk was assessed using the Screening Tool for Childhood Cancer Nutrition Risk (SCAN). Longitudinal changes were analyzed using non-parametric repeated-measures methods, and associations with gastrointestinal symptoms and taste alterations were explored. Results Sixty children completed all assessments. Energy adequacy declined significantly over time (p = 0.001), with most patients failing to meet recommended energy requirements throughout treatment. Significant reductions were observed in carbohydrate, fat, dietary fiber, and selected micronutrients, particularly iron and magnesium. More than 80% of patients were classified as being at nutritional risk at all time points. Higher nutritional risk scores were significantly associated with greater gastrointestinal symptom burden and taste alterations (all p < 0.05). The mid-treatment phase emerged as the period of greatest nutritional vulnerability. Conclusions Children with solid tumors experience progressive deterioration in dietary intake adequacy during oncological treatment, with mid-treatment representing a critical window for intensified nutritional monitoring and supportive intervention. Integrating repeated dietary assessment with structured nutritional risk screening may enhance early identification of vulnerable patients and improve supportive care delivery in pediatric oncology. pediatric oncology dietary intake nutritional risk supportive care solid tumors longitudinal study Introduction Children undergoing cancer treatment experience substantial nutritional challenges throughout the disease trajectory. This burden may be particularly pronounced in children with solid tumors, who are frequently exposed to intensive and prolonged multimodal therapies, including chemotherapy, surgery, and radiotherapy ( 1 , 2 ). Treatment-related toxicities such as nausea, mucositis, fatigue, and taste alterations, combined with increased metabolic demands and systemic inflammation, may significantly compromise oral intake and contribute to progressive nutritional vulnerability ( 1 , 3 , 4 ). Inadequate nutritional intake during therapy has been associated with impaired immune function, reduced treatment tolerance, delayed recovery, and adverse clinical outcomes ( 5 – 7 ), underscoring the importance of proactive supportive care strategies. In routine clinical practice, nutritional status in pediatric oncology is often evaluated using anthropometric measurements and screening tools. Although these approaches are valuable, they may not detect early or functional nutritional compromise ( 8 , 9 ). Alterations in dietary intake frequently precede measurable changes in body weight or body mass index ( 8 , 10 ). Consequently, direct assessment of dietary intake represents a critical component of comprehensive nutritional monitoring during active treatment. Beyond total energy intake, the adequacy of macronutrients and micronutrients warrants particular attention. Children undergoing oncological therapy may fail to meet requirements not only for energy and protein but also for essential micronutrients—including iron, calcium, zinc, and magnesium—that are fundamental for immune competence, hematopoiesis, tissue repair, and growth ( 10 – 12 ). Evaluating intake as a proportion of recommended dietary requirements allows more precise identification of clinically relevant nutrient gaps that may otherwise remain unrecognized. Despite increasing awareness of nutritional compromise in pediatric oncology, longitudinal data describing how dietary adequacy evolves across different phases of treatment remain limited ( 4 , 8 , 10 ). Many available studies are cross-sectional or focus primarily on total energy intake without examining phase-specific changes in macronutrient and micronutrient adequacy. Moreover, few investigations have integrated repeated dietary assessment with validated nutritional risk screening and symptom burden measures, limiting their applicability to supportive care practice. Understanding the temporal trajectory of dietary intake and nutritional risk during therapy may help identify critical windows of vulnerability and inform timely supportive interventions. Therefore, the present prospective study aimed to ( 1 ) evaluate longitudinal changes in energy, macronutrient, and micronutrient intake in children with solid tumors undergoing oncological treatment; ( 2 ) determine the proportion of recommended dietary requirements met at distinct treatment phases; and ( 3 ) examine the relationship between dietary adequacy, nutritional risk, and treatment-related symptoms. By integrating dietary monitoring with structured nutritional risk assessment, this study seeks to strengthen evidence-based supportive care strategies in pediatric oncology. Methods Study Design and Participants This prospective longitudinal cohort study was conducted in children aged 8–18 years newly diagnosed with solid tumors and receiving active oncological treatment at two tertiary pediatric oncology centers between August 2024 and September 2025. Eligible participants were scheduled to receive chemotherapy with or without radiotherapy and/or surgery. Exclusion criteria included severe gastrointestinal disease, metabolic disorders, or cognitive impairment affecting reliable dietary assessment. Written informed consent was obtained from parents or legal guardians, and assent was obtained from children when appropriate. The study was approved by the relevant institutional ethics committees. A total of 70 children with newly diagnosed solid tumors were initially enrolled. During follow-up, 10 patients were excluded due to treatment discontinuation, clinical instability, or incomplete dietary records. Sixty children completed dietary assessments at all three predefined time points and were included in the final longitudinal analysis. The sample size was determined based on previous literature using an a priori power analysis performed with G*Power software (version 3.1.9.2). The analysis assumed 80% statistical power, a two-sided significance level of 0.05, and a medium effect size (Cohen’s d = 0.5). Assessment Time Points Participants were evaluated at three predefined treatment phases: T1 (within the first month after diagnosis), T2 (approximately 2 months after treatment initiation), T3 (approximately 4 months after treatment initiation). Dietary Intake Assessment Dietary intake was assessed at all three follow-up time points using a 3-day food record. The records included two weekdays and one weekend day and were completed with parental assistance when necessary. Portion sizes were estimated using standard household measures and food photographs. Dietary data were collected through face-to-face interviews conducted by a trained dietitian to ensure completeness and accuracy. Reported food and beverage intake was analyzed using the Nutrition Information Systems software ( 14 ). Daily intakes of energy, macronutrients (carbohydrate, protein, and fat), and selected micronutrients (including iron, calcium, zinc, and vitamins) were calculated. To evaluate nutritional adequacy, individual intakes were compared with age- and sex-specific recommended dietary requirements according to the Turkish Dietary Guidelines ( 15 ). Results were expressed as the percentage of recommended intake met for each nutrient. This approach allowed identification of both overall insufficiency and specific nutrient gaps. Energy and nutrient intakes were calculated as the mean of the three recorded days. Days with no oral intake were retained in the calculation to reflect real-world intake during active oncological treatment. Basal metabolic rate (BMR) was estimated using the Schofield predictive equations according to age and sex. Estimated energy requirements were calculated as BMR multiplied by an activity factor of 1.3, reflecting the reduced habitual physical activity commonly observed during active oncological treatment. Nutritional Risk Assessment Nutritional risk was assessed at each time point using a validated pediatric nutritional risk screening tool (SCAN) ( 16 ). This tool incorporates clinical, dietary, and anthropometric parameters to identify children at risk of malnutrition. Symptom and Taste Assessment Gastrointestinal symptoms were assessed using the Gastrointestinal Symptom Rating Scale (GSRS), a validated 15-item instrument evaluating symptom severity across five domains including abdominal pain, reflux, indigestion, diarrhea, and constipation. Each item is rated on a 5-point Likert scale, with higher scores indicating greater symptom severity. Taste alterations were assessed using the Taste Alteration Scale for Children Receiving Chemotherapy (KAÇ-TADÖ), a validated self-report instrument developed for children aged 8–18 years undergoing chemotherapy. The scale consists of nine items rated on a 5-point Likert scale ranging from 0 (none) to 4 (very severe), with total scores ranging from 0 to 36. Higher scores indicate greater severity of taste alteration. The original validation study demonstrated good internal consistency (Cronbach’s α = 0.88). In the present study, internal reliability was confirmed with a Cronbach’s α coefficient of 0.81. Anthropometric Measurements Body weight and height were measured using standardized procedures. Body mass index (BMI) was calculated and expressed as age- and sex-specific z-scores according to World Health Organization reference standards ( 17 ). Anthropometric measurements were used to complement dietary intake data but were not considered sufficient alone to characterize early nutritional impairment. Statistical Analysis Statistical analyses were performed using SPSS (version 19) and R software (nparLD package). Continuous variables were assessed for normality using the Shapiro–Wilk test. Descriptive statistics were presented as mean ± standard deviation (SD) for normally distributed variables and median (minimum–maximum) for non-normally distributed variables. Longitudinal changes in energy and nutrient intake were analyzed using non-parametric repeated-measures methods (Brunner–Langer approach). Associations between dietary intake adequacy, nutritional risk (SCAN), gastrointestinal symptoms (GSRS), and taste alterations (KAÇ-TADÖ) were assessed using Spearman correlation analysis. A two-sided p-value < 0.05 was considered statistically significant. Results Participant Characteristics A total of 60 children with solid tumors were included in the final longitudinal analysis. The median age was 13 years (range: 8–18 years), and 56.7% were male. Central nervous system tumors (45.0%) and bone tumors (26.7%) represented the most common diagnostic categories. Most patients received multimodal therapy; 73.3% underwent chemotherapy in combination with surgery and/or radiotherapy. The mean baseline BMI Z-score was 0.16 ± 1.77, and the mean SCAN score was 4.73 ± 2.60, indicating a high prevalence of nutritional risk at treatment initiation (Table 1). Longitudinal Changes in Energy Intake Daily energy intake declined significantly throughout oncological treatment (p = 0.004). At baseline (T1), median energy intake met 22% (range: 5–133%) of estimated requirements. This decreased to 18% (0–88%) at mid-treatment (T2) and further to 17.5% (0–66%) at late treatment (T3) (p = 0.001). The proportion of children failing to meet ≥75% of their estimated energy requirements increased progressively over time, demonstrating a marked deterioration in energy adequacy during treatment. Macronutrient Intake and Adequacy Significant longitudinal changes were observed in macronutrient intake (Table 2). Absolute protein intake did not change significantly across time points (p = 0.890); however, the percentage of total energy derived from protein increased significantly (p = 0.003), likely reflecting reduced overall energy intake rather than improved protein adequacy. Absolute carbohydrate intake declined significantly over time (p = 0.003), whereas its proportional contribution to total energy intake remained stable. Fat intake also decreased significantly (p = 0.011), without significant changes in its relative energy contribution. Dietary fiber intake decreased substantially across the treatment period (p < 0.001), with the lowest median values observed at T2 and T3. Micronutrient Intake and Adequacy Micronutrient intake was consistently inadequate across all assessment points (Table 3). At baseline, median intakes of iron (27.7%), calcium (42.8%), potassium (40.9%), and zinc (22.9%) were substantially below recommended levels. During follow-up, significant declines were observed for magnesium (p = 0.012) and iron (p = 0.010), with the lowest adequacy levels typically occurring during mid-treatment. Inadequate calcium and iron intake persisted throughout treatment, while zinc and other micronutrients demonstrated considerable inter-individual variability. Dietary Intake and Nutritional Risk More than 80% of patients were classified as being at nutritional risk (SCAN ≥3) at all time points. Children at nutritional risk consistently exhibited lower energy and protein intake compared with those not at risk (p < 0.05). The percentage of recommended intake met for both macro- and micronutrients was significantly lower among children with elevated SCAN scores (Table 4). Correlation analyses revealed significant positive associations between SCAN scores and gastrointestinal symptom severity (GSRS), as well as taste alteration scores (KAÇ-TADÖ), at all time points (all p < 0.05). These findings indicate that increasing symptom burden and taste disturbances were associated with higher nutritional risk. Detailed correlation results are presented in Table 5. Identification of Critical Periods The mid-treatment phase (T2) emerged as the period of greatest nutritional vulnerability. This phase was characterized by: the lowest median energy intake, the poorest micronutrient adequacy, and the highest prevalence of nutritional risk. Collectively, these findings identify mid-treatment as a critical window during which intensified nutritional monitoring and proactive supportive interventions may be particularly warranted. DISCUSSION In this prospective longitudinal study, we demonstrated a sustained and clinically meaningful decline in dietary intake among children with solid tumors throughout oncological treatment. Energy and micronutrient adequacy were already suboptimal at treatment initiation and deteriorated further over time, with the most pronounced impairment observed during mid-treatment. These findings indicate that nutritional vulnerability begins early and progresses across the therapeutic trajectory, even under routine clinical surveillance ( 8 , 9 , 10 ). A central finding of our study was the persistently inadequate energy intake at all assessment points. Even at baseline, median energy intake represented only a small fraction of estimated requirements and declined significantly during treatment. By mid-treatment, the majority of children failed to meet ≥ 75% of their estimated energy needs. Similar reductions in energy intake during chemotherapy have been reported in pediatric oncology cohorts, particularly during intensive treatment phases ( 8 , 9 , 10 , 13 ). However, our longitudinal data suggest that inadequate intake is not limited to transient symptom peaks but may represent a sustained pattern throughout treatment. Most previous studies have relied on cross-sectional assessments or single treatment phases ( 13 , 18 ) whereas our findings demonstrate a sustained longitudinal decline across predefined stages of therapy.This persistent energy deficit may contribute to a progressive catabolic state, particularly in the context of treatment-related inflammation and increased metabolic demands ( 5 , 6 , 10 , 19 ). Energy adequacy values appear markedly low; however, these findings likely reflect the inclusion of days with minimal or no oral intake due to treatment-related toxicity, as well as the use of estimated requirements based on basal metabolic rate multiplied by an activity factor. While this calculation approach may have accentuated the relative deficit, it provides a clinically realistic representation of intake during active therapy. The absence of marked anthropometric decline despite low reported energy adequacy may reflect short-term metabolic adaptations, treatment-related fluid shifts, or the limited sensitivity of weight-based indicators during early phases of therapy ( 9 , 10 ). Although absolute protein intake remained statistically unchanged, the relative contribution of protein to total energy intake increased over time. This pattern likely reflects declining total caloric intake rather than true preservation of protein adequacy. In practical terms, children were not consuming sufficient protein to compensate for elevated metabolic demands; ( 5 , 10 ) instead, protein constituted a larger proportion of an overall reduced intake. The marked reduction in dietary fiber further supports the presence of a narrowing diet, potentially driven by avoidance of fibrous foods during episodes of gastrointestinal discomfort or mucosal toxicity ( 20 – 22 ). Micronutrient inadequacy was widespread and clinically relevant. Iron, calcium, magnesium, and zinc intake were already below recommended levels at baseline, suggesting that nutritional compromise may precede measurable anthropometric decline. Previous studies have also documented suboptimal micronutrient intake in children undergoing cancer treatment, although most investigations have focused primarily on energy and protein intake rather than detailed longitudinal micronutrient adequacy ( 1 , 9 , 10 ). During follow-up, intake adequacy declined further for magnesium and iron, while calcium inadequacy persisted across all time points. These findings are particularly concerning given the essential roles of these nutrients in immune competence, hematopoiesis, bone development, and tissue repair ( 5 , 10 ). In the absence of systematic biochemical monitoring, such deficits may remain clinically silent yet physiologically significant ( 10 ). Our results reinforce the importance of moving beyond weight-based assessment toward detailed dietary evaluation in pediatric oncology supportive care ( 1 , 10 ). Early identification of micronutrient inadequacy may allow targeted dietary counseling or supplementation strategies before overt clinical deficiency develops ( 6 , 10 ). Nutritional risk, as assessed by SCAN, remained high throughout treatment, affecting more than 80% of patients. Importantly, children classified as being at nutritional risk consistently exhibited lower energy and protein intake as well as poorer micronutrient adequacy. This supports the clinical validity of combining dietary intake assessment with structured nutritional risk screening tools ( 1 , 16 ). Anthropometric stability alone may underestimate early functional impairment, whereas intake-based measures appear more sensitive to dynamic treatment-related changes ( 1 , 10 ). Taste alterations emerged as a significant factor associated with nutritional vulnerability. Taste alteration scores increased over time and were positively correlated with both nutritional risk and gastrointestinal symptom severity. Chemosensory dysfunction has been increasingly recognized as a major driver of altered food behavior during cancer treatment ( 4 , 23 ). Our findings suggest that taste disturbances are not merely subjective complaints but are meaningfully linked to measurable declines in dietary adequacy and increased nutritional risk. Addressing taste-related symptoms may therefore represent an underutilized target for supportive nutritional interventions. Recent longitudinal evidence further supports the relationship between chemosensory function and nutritional outcomes in pediatric oncology. In a prospective cohort of 87 children with cancer, van den Brink et al. demonstrated that objectively measured taste function was positively associated with energy intake, while self-reported taste changes were linked to lower BMI and poorer health-related quality of life ( 24 ). Although energy intake increased over time in that cohort, children with reduced taste sensitivity consumed fewer calories, and subjective taste alterations were associated with greater nutritional vulnerability. These findings align with our observation that taste alterations were positively correlated with nutritional risk and gastrointestinal symptom burden. Together, these data reinforce the clinical importance of systematic assessment of taste disturbances during treatment, as chemosensory changes may meaningfully contribute to dietary inadequacy and subsequent nutritional risk. The distinction between objectively measured taste function and self-reported taste alterations may also be clinically meaningful, as subjective changes appear to better capture patient-perceived burden and broader functional impact ( 23 , 25 ). A key contribution of this study is the identification of mid-treatment as a critical window of nutritional vulnerability. This phase was characterized by the lowest energy intake, the poorest micronutrient adequacy, and the highest prevalence of nutritional risk. Cumulative treatment toxicity, systemic inflammation, and persistent symptom burden likely converge during this period, amplifying the risk of nutritional deterioration. These observations have direct clinical implications: nutritional monitoring strategies should be intensified during mid-treatment rather than restricted to diagnosis or end-of-therapy evaluations. The strengths of this study include its prospective design, repeated dietary assessments at predefined treatment stages, and detailed evaluation of both macro- and micronutrient adequacy using age- and sex-specific reference values. Nevertheless, several limitations should be acknowledged. Dietary intake was assessed using self-reported food records, which are inherently subject to reporting bias. The heterogeneous tumor spectrum may limit disease-specific generalizability. Furthermore, biochemical markers of micronutrient status were not systematically evaluated. Future studies integrating dietary, biochemical, inflammatory, and functional outcomes would provide a more comprehensive understanding of treatment-related nutritional compromise. In conclusion, children with solid tumors experience progressive and clinically significant declines in dietary intake throughout oncological treatment, with mid-treatment representing a particularly vulnerable phase. Repeated intake-based assessment, combined with structured nutritional risk screening and symptom evaluation, appears essential for early identification of at-risk patients. Embedding such strategies within routine supportive care pathways may help prevent cumulative nutritional deterioration and may ultimately contribute to improved resilience during treatment and enhanced survivorship outcomes. Conclusion Children with solid tumors experience progressive deterioration in dietary intake during oncological treatment, with mid-treatment emerging as a critical period of nutritional vulnerability. Energy and micronutrient inadequacy were closely associated with nutritional risk and treatment-related symptom burden. These findings highlight the limitations of relying solely on anthropometric measures and support the integration of repeated dietary assessment and structured nutritional risk screening into routine pediatric oncology supportive care. Declarations Acknowledgments The authors thank the participating children and their families, as well as the clinical and dietetic teams at the participating pediatric oncology centers for their valuable contributions to data collection and patient care. Author Contributions Ecem Mısırlıoğlu: Conceptualization, methodology, data curation, formal analysis, investigation, visualization, writing – original draft, writing – review and editing. Beril Köse: Methodology, supervision,writing, review and editing. Derya Hopancı Bıçaklı: Methodology, supervision, writing – review and editing. Mehmet Kantar: Methodology, Conceptualization, supervision, project administration, writing – review and editing. (All authors approved the final manuscript.) Funding This study received no external funding. Conflict of Interest The authors declare that they have no conflict of interest. Ethical Approval and Consent to Participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the relevant institutional ethics committees.Written informed consent was obtained from the patients or legal guardians of all participants, and assent was obtained from children when appropriate. Clinical trial number: Not applicable. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. References Brinksma A, Huizinga G, Sulkers E, Kamps WA, Roodbol PF, Tissing WJE. Malnutrition in childhood cancer patients: a review on its prevalence and possible causes. Crit Rev Oncol Hematol. 2012;83(2):249–275. Muratore E, Lerdini D, Baccelli F, Fabozzi F. Nutritional support in pediatric cancer: novel insights and future perspectives. Front Nutr. 2024;11:1397439. https://doi.org/10.3389/fnut.2024.1397439 Hutton JL, Baracos VE, Wismer WV. Chemosensory dysfunction is a primary factor in the evolution of declining nutritional status and quality of life in patients with advanced cancer. J Pain Symptom Manage. 2007;33(2):156–165. Nolden AA, Hwang LD, Boltong A, Reed DR. Chemosensory changes from cancer treatment and their effects on patients' food behavior: a scoping review. Nutrients. 2019;11(10):2285. Bauer J, Jürgens H, Frühwald MC. Important aspects of nutrition in children with cancer. Adv Nutr. 2011;2(2):67–77. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11–48. Sala A, Rossi E, Antillon F, Molina AL, de Maselli T, Bonilla M, et al. Nutritional status at diagnosis is related to clinical outcomes in children and adolescents with cancer: a perspective from Central America. Eur J Cancer. 2012;48(2):243–252. Brinksma A, Sulkers E, IJpma I, Burgerhof JGM, Tissing WJE. Eating and feeding problems in children with cancer: prevalence, related factors, and consequences. Clin Nutr. 2020;39(10):3072–3079. Brinksma A, Roodbol PF, Sulkers E, Kamps WA, de Bont ES, Boot AM, et al. Changes in nutritional status in childhood cancer patients: a prospective cohort study. Clin Nutr. 2015;34(1):66–73. Joffe L, Ladas EJ. Nutrition during childhood cancer treatment: current understanding and a path for future research. Lancet Child Adolesc Health. 2020;4(6):465–475. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): National Academies Press; 2005. Institute of Medicine. Dietary Reference Intakes for Vitamins and Minerals. Washington (DC): National Academies Press; 2006. Skolin I, Wahlin YB, Broman DA, Koivisto Hursti UK, Vikström Larsson M, Hernell O. Altered food intake and taste perception in children with cancer after start of chemotherapy: perspectives of children, parents and nurses. Support Care Cancer. 2006;14(4):369–378. Erhardt DJ. Nutrition Information System (BEBIS), version 7.1. Stuttgart: University of Hohenheim; 2010. Republic of Türkiye Ministry of Health, General Directorate of Public Health. Turkey Dietary Guidelines (TÜBER 2022). Ankara: Ministry of Health; 2022. Murphy AJ, White M, Viani K, Mosby TT. Evaluation of the nutrition screening tool for childhood cancer (SCAN). Clin Nutr. 2016;35(1):219–224. World Health Organization. Global database on body mass index. Geneva: WHO. Available from: https://www.who.int. Accessed 17 Feb 2026. Skolin I, Hursti U.K, Wahlin Y.B. Parents' perception of their child's food intake after the start of chemotherapy J Pediatr Oncol Nurs. 2001; 18(3):124-136 Loeffen EAH, Knops RRG, Boerhof J, Feijen EAM, Merks JHM, Reedijk AMJ, et al. Treatment-related mortality in children with cancer: prevalence and risk factors. Eur J Cancer. 2019;121:113–122. Johnston DL, Hyslop S, Tomlinson D, Baggott C, Gibson P, Orsey A, et al. Describing symptoms using the Symptom Screening in Pediatrics Tool in hospitalized children with cancer and hematopoietic stem cell transplant recipients. Cancer Med. 2018;7(5):1750–1755. Baggott C, Dodd M, Kennedy C, Marina N, Miaskowski C. Multiple symptoms in pediatric oncology patients: a systematic review. J Pediatr Oncol Nurs. 2009;26(6):325–339. van den Brink M, Been R, Grootenhuis MA, et al. Nausea and nausea-related symptoms in children with cancer: presence, severity, risk factors and impact on quality of life during the first year of treatment. EJC Paediatr Oncol. 2023;2(4):100128. Spotten LE, Corish CA, Lorton CM, Ui Dhuibhir PM, O’Donoghue NC, O’Connor B, et al. Subjective and objective taste and smell changes in cancer. Ann Oncol. 2017;28(5):969–984. van den Brink M, Tissing WJE, Grootenhuis MA, Fiocco M, Havermans RC. Taste and smell are associated with dietary intake, eating behavior, nutritional status, and health-related quality of life in children with cancer. Support Care Cancer. 2024;43(12):140–145. Özkan İ, Taylan S, Eroğlu N. The relationship between malnutrition and subjective taste change experienced by patients with cancer receiving outpatient chemotherapy treatment. Nutr Cancer. 2022;74(5):1670–1679. Tables Tables 1 to 5 are available in the supplementary files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 07 Apr, 2026 Editor assigned by journal 07 Apr, 2026 Submission checks completed at journal 06 Mar, 2026 First submitted to journal 27 Feb, 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8991405","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619186768,"identity":"e9de94a6-7b8d-4b0e-b8ef-9cb431874722","order_by":0,"name":"Ecem Mısırlıoğlu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYNACAwYeBnbGBgaGAgY5EP/AA6K0MIO0GDAYg7UkEGUTM0RvYgOIxqeFn/3w0U03CupkzJuZGx9+MTicPj/s8EOgLXZyug3YtUj2pKXdzjE4zCNzmLHZWMbgcO7G22kGQC3JxmYHcPjiBo8ZUMsBHglmxjZpCZCW2QkgLQcSt+HQYn+D/xtQSx1cS7rh7PQPeLUYSPCwAbUwg7VIfjA4nCAvnYPfFokzaWZgvwC1NBszGKQbbpDOKTiQYIDbL/zth5/dzvlTZy/B3v7w4Y8Ka3n52embP3yosJPDpQUFMPOAnApWaUCEchBg/AEk5BuIVD0KRsEoGAUjBgAAjrxcIfUhFmIAAAAASUVORK5CYII=","orcid":"","institution":"Avrasya University","correspondingAuthor":true,"prefix":"","firstName":"Ecem","middleName":"","lastName":"Mısırlıoğlu","suffix":""},{"id":619186769,"identity":"747cbae7-c3ca-4479-ba88-090514e7f2dc","order_by":1,"name":"Beril Köse","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Beril","middleName":"","lastName":"Köse","suffix":""},{"id":619186770,"identity":"c0d40d8b-e341-4ba1-b348-932326f0c81f","order_by":2,"name":"Derya Hopancı Bıçaklı","email":"","orcid":"","institution":"Muğla University","correspondingAuthor":false,"prefix":"","firstName":"Derya","middleName":"Hopancı","lastName":"Bıçaklı","suffix":""},{"id":619186771,"identity":"b9b9dd3f-3ac5-435a-9f57-b27d2c5e3a02","order_by":3,"name":"Mehmet Kantar","email":"","orcid":"","institution":"Ege Üniversitesi Tıp Fakültesi Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Kantar","suffix":""}],"badges":[],"createdAt":"2026-02-27 20:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8991405/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8991405/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106950104,"identity":"52e0be3b-b23b-4aff-8468-5f9d2686b486","added_by":"auto","created_at":"2026-04-15 07:18:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":778141,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8991405/v1/6f025e5c-fb71-43a3-967c-ae14dedcf58f.pdf"},{"id":106950103,"identity":"ffab29ab-258a-41c3-a810-9defb008b8f4","added_by":"auto","created_at":"2026-04-15 07:18:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20633,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8991405/v1/7a70d6145b164668b3c6389e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Progressive Deterioration in Dietary Intake and Nutritional Risk During Oncological Treatment in Children with Solid Tumors: A Prospective Longitudinal Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildren undergoing cancer treatment experience substantial nutritional challenges throughout the disease trajectory. This burden may be particularly pronounced in children with solid tumors, who are frequently exposed to intensive and prolonged multimodal therapies, including chemotherapy, surgery, and radiotherapy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Treatment-related toxicities such as nausea, mucositis, fatigue, and taste alterations, combined with increased metabolic demands and systemic inflammation, may significantly compromise oral intake and contribute to progressive nutritional vulnerability (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Inadequate nutritional intake during therapy has been associated with impaired immune function, reduced treatment tolerance, delayed recovery, and adverse clinical outcomes (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), underscoring the importance of proactive supportive care strategies.\u003c/p\u003e \u003cp\u003eIn routine clinical practice, nutritional status in pediatric oncology is often evaluated using anthropometric measurements and screening tools. Although these approaches are valuable, they may not detect early or functional nutritional compromise (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Alterations in dietary intake frequently precede measurable changes in body weight or body mass index (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Consequently, direct assessment of dietary intake represents a critical component of comprehensive nutritional monitoring during active treatment.\u003c/p\u003e \u003cp\u003eBeyond total energy intake, the adequacy of macronutrients and micronutrients warrants particular attention. Children undergoing oncological therapy may fail to meet requirements not only for energy and protein but also for essential micronutrients\u0026mdash;including iron, calcium, zinc, and magnesium\u0026mdash;that are fundamental for immune competence, hematopoiesis, tissue repair, and growth (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Evaluating intake as a proportion of recommended dietary requirements allows more precise identification of clinically relevant nutrient gaps that may otherwise remain unrecognized.\u003c/p\u003e \u003cp\u003eDespite increasing awareness of nutritional compromise in pediatric oncology, longitudinal data describing how dietary adequacy evolves across different phases of treatment remain limited (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Many available studies are cross-sectional or focus primarily on total energy intake without examining phase-specific changes in macronutrient and micronutrient adequacy. Moreover, few investigations have integrated repeated dietary assessment with validated nutritional risk screening and symptom burden measures, limiting their applicability to supportive care practice.\u003c/p\u003e \u003cp\u003eUnderstanding the temporal trajectory of dietary intake and nutritional risk during therapy may help identify critical windows of vulnerability and inform timely supportive interventions. Therefore, the present prospective study aimed to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) evaluate longitudinal changes in energy, macronutrient, and micronutrient intake in children with solid tumors undergoing oncological treatment; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) determine the proportion of recommended dietary requirements met at distinct treatment phases; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) examine the relationship between dietary adequacy, nutritional risk, and treatment-related symptoms. By integrating dietary monitoring with structured nutritional risk assessment, this study seeks to strengthen evidence-based supportive care strategies in pediatric oncology.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis prospective longitudinal cohort study was conducted in children aged 8\u0026ndash;18 years newly diagnosed with solid tumors and receiving active oncological treatment at two tertiary pediatric oncology centers between August 2024 and September 2025. Eligible participants were scheduled to receive chemotherapy with or without radiotherapy and/or surgery.\u003c/p\u003e \u003cp\u003eExclusion criteria included severe gastrointestinal disease, metabolic disorders, or cognitive impairment affecting reliable dietary assessment. Written informed consent was obtained from parents or legal guardians, and assent was obtained from children when appropriate. The study was approved by the relevant institutional ethics committees.\u003c/p\u003e \u003cp\u003eA total of 70 children with newly diagnosed solid tumors were initially enrolled. During follow-up, 10 patients were excluded due to treatment discontinuation, clinical instability, or incomplete dietary records. Sixty children completed dietary assessments at all three predefined time points and were included in the final longitudinal analysis. The sample size was determined based on previous literature using an a priori power analysis performed with G*Power software (version 3.1.9.2). The analysis assumed 80% statistical power, a two-sided significance level of 0.05, and a medium effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.5).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAssessment Time Points\u003c/h3\u003e\n\u003cp\u003eParticipants were evaluated at three predefined treatment phases:\u003c/p\u003e \u003cp\u003eT1 (within the first month after diagnosis),\u003c/p\u003e \u003cp\u003eT2 (approximately 2 months after treatment initiation),\u003c/p\u003e \u003cp\u003eT3 (approximately 4 months after treatment initiation).\u003c/p\u003e\n\u003ch3\u003eDietary Intake Assessment\u003c/h3\u003e\n\u003cp\u003eDietary intake was assessed at all three follow-up time points using a 3-day food record. The records included two weekdays and one weekend day and were completed with parental assistance when necessary. Portion sizes were estimated using standard household measures and food photographs. Dietary data were collected through face-to-face interviews conducted by a trained dietitian to ensure completeness and accuracy.\u003c/p\u003e \u003cp\u003eReported food and beverage intake was analyzed using the Nutrition Information Systems software (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Daily intakes of energy, macronutrients (carbohydrate, protein, and fat), and selected micronutrients (including iron, calcium, zinc, and vitamins) were calculated. To evaluate nutritional adequacy, individual intakes were compared with age- and sex-specific recommended dietary requirements according to the Turkish Dietary Guidelines (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Results were expressed as the percentage of recommended intake met for each nutrient. This approach allowed identification of both overall insufficiency and specific nutrient gaps. Energy and nutrient intakes were calculated as the mean of the three recorded days. Days with no oral intake were retained in the calculation to reflect real-world intake during active oncological treatment.\u003c/p\u003e \u003cp\u003eBasal metabolic rate (BMR) was estimated using the Schofield predictive equations according to age and sex. Estimated energy requirements were calculated as BMR multiplied by an activity factor of 1.3, reflecting the reduced habitual physical activity commonly observed during active oncological treatment.\u003c/p\u003e\n\u003ch3\u003eNutritional Risk Assessment\u003c/h3\u003e\n\u003cp\u003eNutritional risk was assessed at each time point using a validated pediatric nutritional risk screening tool (SCAN) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This tool incorporates clinical, dietary, and anthropometric parameters to identify children at risk of malnutrition.\u003c/p\u003e\n\u003ch3\u003eSymptom and Taste Assessment\u003c/h3\u003e\n\u003cp\u003eGastrointestinal symptoms were assessed using the Gastrointestinal Symptom Rating Scale (GSRS), a validated 15-item instrument evaluating symptom severity across five domains including abdominal pain, reflux, indigestion, diarrhea, and constipation. Each item is rated on a 5-point Likert scale, with higher scores indicating greater symptom severity.\u003c/p\u003e \u003cp\u003eTaste alterations were assessed using the Taste Alteration Scale for Children Receiving Chemotherapy (KA\u0026Ccedil;-TAD\u0026Ouml;), a validated self-report instrument developed for children aged 8\u0026ndash;18 years undergoing chemotherapy. The scale consists of nine items rated on a 5-point Likert scale ranging from 0 (none) to 4 (very severe), with total scores ranging from 0 to 36. Higher scores indicate greater severity of taste alteration. The original validation study demonstrated good internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.88). In the present study, internal reliability was confirmed with a Cronbach\u0026rsquo;s α coefficient of 0.81.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnthropometric Measurements\u003c/h2\u003e \u003cp\u003eBody weight and height were measured using standardized procedures. Body mass index (BMI) was calculated and expressed as age- and sex-specific z-scores according to World Health Organization reference standards (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Anthropometric measurements were used to complement dietary intake data but were not considered sufficient alone to characterize early nutritional impairment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS (version 19) and R software (nparLD package). Continuous variables were assessed for normality using the Shapiro\u0026ndash;Wilk test.\u003c/p\u003e \u003cp\u003eDescriptive statistics were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for normally distributed variables and median (minimum\u0026ndash;maximum) for non-normally distributed variables.\u003c/p\u003e \u003cp\u003eLongitudinal changes in energy and nutrient intake were analyzed using non-parametric repeated-measures methods (Brunner\u0026ndash;Langer approach). Associations between dietary intake adequacy, nutritional risk (SCAN), gastrointestinal symptoms (GSRS), and taste alterations (KA\u0026Ccedil;-TAD\u0026Ouml;) were assessed using Spearman correlation analysis.\u003c/p\u003e \u003cp\u003eA two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 60 children with solid tumors were included in the final longitudinal analysis. The median age was 13 years (range: 8\u0026ndash;18 years), and 56.7% were male. Central nervous system tumors (45.0%) and bone tumors (26.7%) represented the most common diagnostic categories.\u003c/p\u003e\n\u003cp\u003eMost patients received multimodal therapy; 73.3% underwent chemotherapy in combination with surgery and/or radiotherapy. The mean baseline BMI Z-score was 0.16 \u0026plusmn; 1.77, and the mean SCAN score was 4.73 \u0026plusmn; 2.60, indicating a high prevalence of nutritional risk at treatment initiation (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLongitudinal Changes in Energy Intake\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDaily energy intake declined significantly throughout oncological treatment (p = 0.004). At baseline (T1), median energy intake met 22% (range: 5\u0026ndash;133%) of estimated requirements. This decreased to 18% (0\u0026ndash;88%) at mid-treatment (T2) and further to 17.5% (0\u0026ndash;66%) at late treatment (T3) (p = 0.001).\u003c/p\u003e\n\u003cp\u003eThe proportion of children failing to meet \u0026ge;75% of their estimated energy requirements increased progressively over time, demonstrating a marked deterioration in energy adequacy during treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMacronutrient Intake and Adequacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant longitudinal changes were observed in macronutrient intake (Table 2). Absolute protein intake did not change significantly across time points (p = 0.890); however, the percentage of total energy derived from protein increased significantly (p = 0.003), likely reflecting reduced overall energy intake rather than improved protein adequacy.\u003c/p\u003e\n\u003cp\u003eAbsolute carbohydrate intake declined significantly over time (p = 0.003), whereas its proportional contribution to total energy intake remained stable. Fat intake also decreased significantly (p = 0.011), without significant changes in its relative energy contribution.\u003c/p\u003e\n\u003cp\u003eDietary fiber intake decreased substantially across the treatment period (p \u0026lt; 0.001), with the lowest median values observed at T2 and T3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMicronutrient Intake and Adequacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMicronutrient intake was consistently inadequate across all assessment points (Table 3). At baseline, median intakes of iron (27.7%), calcium (42.8%), potassium (40.9%), and zinc (22.9%) were substantially below recommended levels.\u003c/p\u003e\n\u003cp\u003eDuring follow-up, significant declines were observed for magnesium (p = 0.012) and iron (p = 0.010), with the lowest adequacy levels typically occurring during mid-treatment. Inadequate calcium and iron intake persisted throughout treatment, while zinc and other micronutrients demonstrated considerable inter-individual variability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDietary Intake and Nutritional Risk\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than 80% of patients were classified as being at nutritional risk (SCAN \u0026ge;3) at all time points. Children at nutritional risk consistently exhibited lower energy and protein intake compared with those not at risk (p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe percentage of recommended intake met for both macro- and micronutrients was significantly lower among children with elevated SCAN scores (Table 4).\u003c/p\u003e\n\u003cp\u003eCorrelation analyses revealed significant positive associations between SCAN scores and gastrointestinal symptom severity (GSRS), as well as taste alteration scores (KA\u0026Ccedil;-TAD\u0026Ouml;), at all time points (all p \u0026lt; 0.05). These findings indicate that increasing symptom burden and taste disturbances were associated with higher nutritional risk.\u0026nbsp;Detailed correlation results are presented in Table 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentification of Critical Periods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mid-treatment phase (T2) emerged as the period of greatest nutritional vulnerability. This phase was characterized by:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ethe lowest median energy intake,\u003c/li\u003e\n \u003cli\u003ethe poorest micronutrient adequacy,\u003c/li\u003e\n \u003cli\u003eand the highest prevalence of nutritional risk.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eCollectively, these findings identify mid-treatment as a critical window during which intensified nutritional monitoring and proactive supportive interventions may be particularly warranted.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this prospective longitudinal study, we demonstrated a sustained and clinically meaningful decline in dietary intake among children with solid tumors throughout oncological treatment. Energy and micronutrient adequacy were already suboptimal at treatment initiation and deteriorated further over time, with the most pronounced impairment observed during mid-treatment. These findings indicate that nutritional vulnerability begins early and progresses across the therapeutic trajectory, even under routine clinical surveillance (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA central finding of our study was the persistently inadequate energy intake at all assessment points. Even at baseline, median energy intake represented only a small fraction of estimated requirements and declined significantly during treatment. By mid-treatment, the majority of children failed to meet\u0026thinsp;\u0026ge;\u0026thinsp;75% of their estimated energy needs. Similar reductions in energy intake during chemotherapy have been reported in pediatric oncology cohorts, particularly during intensive treatment phases (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, our longitudinal data suggest that inadequate intake is not limited to transient symptom peaks but may represent a sustained pattern throughout treatment. Most previous studies have relied on cross-sectional assessments or single treatment phases (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) whereas our findings demonstrate a sustained longitudinal decline across predefined stages of therapy.This persistent energy deficit may contribute to a progressive catabolic state, particularly in the context of treatment-related inflammation and increased metabolic demands (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Energy adequacy values appear markedly low; however, these findings likely reflect the inclusion of days with minimal or no oral intake due to treatment-related toxicity, as well as the use of estimated requirements based on basal metabolic rate multiplied by an activity factor. While this calculation approach may have accentuated the relative deficit, it provides a clinically realistic representation of intake during active therapy. The absence of marked anthropometric decline despite low reported energy adequacy may reflect short-term metabolic adaptations, treatment-related fluid shifts, or the limited sensitivity of weight-based indicators during early phases of therapy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough absolute protein intake remained statistically unchanged, the relative contribution of protein to total energy intake increased over time. This pattern likely reflects declining total caloric intake rather than true preservation of protein adequacy. In practical terms, children were not consuming sufficient protein to compensate for elevated metabolic demands; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) instead, protein constituted a larger proportion of an overall reduced intake. The marked reduction in dietary fiber further supports the presence of a narrowing diet, potentially driven by avoidance of fibrous foods during episodes of gastrointestinal discomfort or mucosal toxicity (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMicronutrient inadequacy was widespread and clinically relevant. Iron, calcium, magnesium, and zinc intake were already below recommended levels at baseline, suggesting that nutritional compromise may precede measurable anthropometric decline. Previous studies have also documented suboptimal micronutrient intake in children undergoing cancer treatment, although most investigations have focused primarily on energy and protein intake rather than detailed longitudinal micronutrient adequacy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). During follow-up, intake adequacy declined further for magnesium and iron, while calcium inadequacy persisted across all time points. These findings are particularly concerning given the essential roles of these nutrients in immune competence, hematopoiesis, bone development, and tissue repair (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In the absence of systematic biochemical monitoring, such deficits may remain clinically silent yet physiologically significant (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Our results reinforce the importance of moving beyond weight-based assessment toward detailed dietary evaluation in pediatric oncology supportive care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Early identification of micronutrient inadequacy may allow targeted dietary counseling or supplementation strategies before overt clinical deficiency develops (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Nutritional risk, as assessed by SCAN, remained high throughout treatment, affecting more than 80% of patients. Importantly, children classified as being at nutritional risk consistently exhibited lower energy and protein intake as well as poorer micronutrient adequacy. This supports the clinical validity of combining dietary intake assessment with structured nutritional risk screening tools (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Anthropometric stability alone may underestimate early functional impairment, whereas intake-based measures appear more sensitive to dynamic treatment-related changes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTaste alterations emerged as a significant factor associated with nutritional vulnerability. Taste alteration scores increased over time and were positively correlated with both nutritional risk and gastrointestinal symptom severity. Chemosensory dysfunction has been increasingly recognized as a major driver of altered food behavior during cancer treatment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Our findings suggest that taste disturbances are not merely subjective complaints but are meaningfully linked to measurable declines in dietary adequacy and increased nutritional risk. Addressing taste-related symptoms may therefore represent an underutilized target for supportive nutritional interventions. Recent longitudinal evidence further supports the relationship between chemosensory function and nutritional outcomes in pediatric oncology. In a prospective cohort of 87 children with cancer, van den Brink et al. demonstrated that objectively measured taste function was positively associated with energy intake, while self-reported taste changes were linked to lower BMI and poorer health-related quality of life (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Although energy intake increased over time in that cohort, children with reduced taste sensitivity consumed fewer calories, and subjective taste alterations were associated with greater nutritional vulnerability. These findings align with our observation that taste alterations were positively correlated with nutritional risk and gastrointestinal symptom burden. Together, these data reinforce the clinical importance of systematic assessment of taste disturbances during treatment, as chemosensory changes may meaningfully contribute to dietary inadequacy and subsequent nutritional risk. The distinction between objectively measured taste function and self-reported taste alterations may also be clinically meaningful, as subjective changes appear to better capture patient-perceived burden and broader functional impact (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA key contribution of this study is the identification of mid-treatment as a critical window of nutritional vulnerability. This phase was characterized by the lowest energy intake, the poorest micronutrient adequacy, and the highest prevalence of nutritional risk. Cumulative treatment toxicity, systemic inflammation, and persistent symptom burden likely converge during this period, amplifying the risk of nutritional deterioration. These observations have direct clinical implications: nutritional monitoring strategies should be intensified during mid-treatment rather than restricted to diagnosis or end-of-therapy evaluations.\u003c/p\u003e \u003cp\u003eThe strengths of this study include its prospective design, repeated dietary assessments at predefined treatment stages, and detailed evaluation of both macro- and micronutrient adequacy using age- and sex-specific reference values. Nevertheless, several limitations should be acknowledged. Dietary intake was assessed using self-reported food records, which are inherently subject to reporting bias. The heterogeneous tumor spectrum may limit disease-specific generalizability. Furthermore, biochemical markers of micronutrient status were not systematically evaluated. Future studies integrating dietary, biochemical, inflammatory, and functional outcomes would provide a more comprehensive understanding of treatment-related nutritional compromise.\u003c/p\u003e \u003cp\u003eIn conclusion, children with solid tumors experience progressive and clinically significant declines in dietary intake throughout oncological treatment, with mid-treatment representing a particularly vulnerable phase. Repeated intake-based assessment, combined with structured nutritional risk screening and symptom evaluation, appears essential for early identification of at-risk patients. Embedding such strategies within routine supportive care pathways may help prevent cumulative nutritional deterioration and may ultimately contribute to improved resilience during treatment and enhanced survivorship outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eChildren with solid tumors experience progressive deterioration in dietary intake during oncological treatment, with mid-treatment emerging as a critical period of nutritional vulnerability. Energy and micronutrient inadequacy were closely associated with nutritional risk and treatment-related symptom burden. These findings highlight the limitations of relying solely on anthropometric measures and support the integration of repeated dietary assessment and structured nutritional risk screening into routine pediatric oncology supportive care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the participating children and their families, as well as the clinical and dietetic teams at the participating pediatric oncology centers for their valuable contributions to data collection and patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEcem Mısırlıoğlu:\u003c/strong\u003e Conceptualization, methodology, data curation, formal analysis, investigation, visualization, writing \u0026ndash; original draft, writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeril K\u0026ouml;se:\u003c/strong\u003e Methodology, supervision,writing, review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDerya Hopancı Bı\u0026ccedil;aklı:\u003c/strong\u003e Methodology, supervision, writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMehmet Kantar:\u0026nbsp;\u003c/strong\u003eMethodology, \u0026nbsp;Conceptualization, supervision, project administration, writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e(All authors approved the final manuscript.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical 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 was approved by the relevant institutional ethics committees.Written informed consent was obtained from the patients or legal guardians of all participants, and assent was obtained from children when appropriate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBrinksma A, Huizinga G, Sulkers E, Kamps WA, Roodbol PF, Tissing WJE. Malnutrition in childhood cancer patients: a review on its prevalence and possible causes. \u003cstrong\u003eCrit Rev Oncol Hematol.\u003c/strong\u003e 2012;83(2):249\u0026ndash;275.\u003c/li\u003e\n \u003cli\u003eMuratore E, Lerdini D, Baccelli F, Fabozzi F. Nutritional support in pediatric cancer: novel insights and future perspectives. \u003cstrong\u003eFront Nutr.\u003c/strong\u003e 2024;11:1397439. https://doi.org/10.3389/fnut.2024.1397439\u003c/li\u003e\n \u003cli\u003eHutton JL, Baracos VE, Wismer WV. Chemosensory dysfunction is a primary factor in the evolution of declining nutritional status and quality of life in patients with advanced cancer. \u003cstrong\u003eJ Pain Symptom Manage.\u003c/strong\u003e 2007;33(2):156\u0026ndash;165.\u003c/li\u003e\n \u003cli\u003eNolden AA, Hwang LD, Boltong A, Reed DR. Chemosensory changes from cancer treatment and their effects on patients\u0026apos; food behavior: a scoping review. \u003cstrong\u003eNutrients.\u003c/strong\u003e 2019;11(10):2285.\u003c/li\u003e\n \u003cli\u003eBauer J, J\u0026uuml;rgens H, Fr\u0026uuml;hwald MC. Important aspects of nutrition in children with cancer. \u003cstrong\u003eAdv Nutr.\u003c/strong\u003e 2011;2(2):67\u0026ndash;77.\u003c/li\u003e\n \u003cli\u003eArends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. \u003cstrong\u003eClin Nutr.\u003c/strong\u003e 2017;36(1):11\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eSala A, Rossi E, Antillon F, Molina AL, de Maselli T, Bonilla M, et al. Nutritional status at diagnosis is related to clinical outcomes in children and adolescents with cancer: a perspective from Central America. \u003cstrong\u003eEur J Cancer.\u003c/strong\u003e 2012;48(2):243\u0026ndash;252.\u003c/li\u003e\n \u003cli\u003eBrinksma A, Sulkers E, IJpma I, Burgerhof JGM, Tissing WJE. Eating and feeding problems in children with cancer: prevalence, related factors, and consequences. \u003cstrong\u003eClin Nutr.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e2020;39(10):3072\u0026ndash;3079.\u003c/li\u003e\n \u003cli\u003eBrinksma A, Roodbol PF, Sulkers E, Kamps WA, de Bont ES, Boot AM, et al. Changes in nutritional status in childhood cancer patients: a prospective cohort study. \u003cstrong\u003eClin Nutr.\u003c/strong\u003e 2015;34(1):66\u0026ndash;73.\u003c/li\u003e\n \u003cli\u003eJoffe L, Ladas EJ. Nutrition during childhood cancer treatment: current understanding and a path for future research. \u003cstrong\u003eLancet Child Adolesc Health.\u003c/strong\u003e 2020;4(6):465\u0026ndash;475.\u003c/li\u003e\n \u003cli\u003eInstitute of Medicine. \u003cstrong\u003eDietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.\u003c/strong\u003e Washington (DC): National Academies Press; 2005.\u003c/li\u003e\n \u003cli\u003eInstitute of Medicine. \u003cstrong\u003eDietary Reference Intakes for Vitamins and Minerals.\u003c/strong\u003e Washington (DC): National Academies Press; 2006.\u003c/li\u003e\n \u003cli\u003eSkolin I, Wahlin YB, Broman DA, Koivisto Hursti UK, Vikstr\u0026ouml;m Larsson M, Hernell O. Altered food intake and taste perception in children with cancer after start of chemotherapy: perspectives of children, parents and nurses. \u003cstrong\u003eSupport Care Cancer.\u003c/strong\u003e 2006;14(4):369\u0026ndash;378.\u003c/li\u003e\n \u003cli\u003eErhardt DJ. \u003cstrong\u003eNutrition Information System (BEBIS), version 7.1.\u003c/strong\u003e Stuttgart: University of Hohenheim; 2010.\u003c/li\u003e\n \u003cli\u003eRepublic of T\u0026uuml;rkiye Ministry of Health, General Directorate of Public Health. \u003cstrong\u003eTurkey Dietary Guidelines (T\u0026Uuml;BER 2022).\u003c/strong\u003e Ankara: Ministry of Health; 2022.\u003c/li\u003e\n \u003cli\u003eMurphy AJ, White M, Viani K, Mosby TT. Evaluation of the nutrition screening tool for childhood cancer (SCAN). \u003cstrong\u003eClin Nutr.\u003c/strong\u003e 2016;35(1):219\u0026ndash;224.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Global database on body mass index. Geneva: WHO. Available from: https://www.who.int. Accessed 17 Feb 2026.\u003c/li\u003e\n \u003cli\u003eSkolin I, Hursti U.K, Wahlin Y.B. Parents\u0026apos; perception of their child\u0026apos;s food intake after the start of chemotherapy J Pediatr Oncol Nurs. 2001; 18(3):124-136\u003c/li\u003e\n \u003cli\u003eLoeffen EAH, Knops RRG, Boerhof J, Feijen EAM, Merks JHM, Reedijk AMJ, et al. Treatment-related mortality in children with cancer: prevalence and risk factors. \u003cem\u003eEur J Cancer.\u003c/em\u003e 2019;121:113\u0026ndash;122.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Johnston DL, Hyslop S, Tomlinson D, Baggott C, Gibson P, Orsey A, et al. Describing symptoms using the Symptom Screening in Pediatrics Tool in hospitalized children with cancer and hematopoietic stem cell transplant recipients. \u003cem\u003eCancer Med.\u003c/em\u003e 2018;7(5):1750\u0026ndash;1755.\u003c/li\u003e\n \u003cli\u003eBaggott C, Dodd M, Kennedy C, Marina N, Miaskowski C. Multiple symptoms in pediatric oncology patients: a systematic review. \u003cem\u003eJ Pediatr Oncol Nurs.\u003c/em\u003e 2009;26(6):325\u0026ndash;339.\u003c/li\u003e\n \u003cli\u003evan den Brink M, Been R, Grootenhuis MA, et al. Nausea and nausea-related symptoms in children with cancer: presence, severity, risk factors and impact on quality of life during the first year of treatment. \u003cem\u003eEJC Paediatr Oncol.\u003c/em\u003e 2023;2(4):100128.\u003c/li\u003e\n \u003cli\u003eSpotten LE, Corish CA, Lorton CM, Ui Dhuibhir PM, O\u0026rsquo;Donoghue NC, O\u0026rsquo;Connor B, et al. Subjective and objective taste and smell changes in cancer. \u003cem\u003eAnn Oncol.\u003c/em\u003e 2017;28(5):969\u0026ndash;984.\u003c/li\u003e\n \u003cli\u003evan den Brink M, Tissing WJE, Grootenhuis MA, Fiocco M, Havermans RC. Taste and smell are associated with dietary intake, eating behavior, nutritional status, and health-related quality of life in children with cancer. \u003cem\u003eSupport Care Cancer.\u003c/em\u003e 2024;43(12):140\u0026ndash;145.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zkan İ, Taylan S, Eroğlu N. The relationship between malnutrition and subjective taste change experienced by patients with cancer receiving outpatient chemotherapy treatment. \u003cem\u003eNutr Cancer.\u003c/em\u003e 2022;74(5):1670\u0026ndash;1679.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the supplementary files section\u003c/p\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":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"pediatric oncology, dietary intake, nutritional risk, supportive care, solid tumors, longitudinal study","lastPublishedDoi":"10.21203/rs.3.rs-8991405/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8991405/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003ePurpose\u003c/b\u003e \u003c/p\u003e \u003cp\u003eChildren with solid tumors are highly vulnerable to treatment-related nutritional compromise. However, longitudinal data describing how dietary intake and nutritional risk evolve during therapy remain limited. This study aimed to examine longitudinal changes in dietary intake adequacy and nutritional risk across different phases of oncological treatment and to identify clinically vulnerable periods requiring intensified supportive care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn this prospective longitudinal study, children aged 8\u0026ndash;18 years with newly diagnosed solid tumors were assessed at three predefined treatment phases (early, mid- and late-treatment). Dietary intake was evaluated using 3-day food records at each time point. Energy and nutrient intakes were expressed as percentages of age- and sex-specific estimated requirements. Nutritional risk was assessed using the Screening Tool for Childhood Cancer Nutrition Risk (SCAN). Longitudinal changes were analyzed using non-parametric repeated-measures methods, and associations with gastrointestinal symptoms and taste alterations were explored.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSixty children completed all assessments. Energy adequacy declined significantly over time (p\u0026thinsp;=\u0026thinsp;0.001), with most patients failing to meet recommended energy requirements throughout treatment. Significant reductions were observed in carbohydrate, fat, dietary fiber, and selected micronutrients, particularly iron and magnesium. More than 80% of patients were classified as being at nutritional risk at all time points. Higher nutritional risk scores were significantly associated with greater gastrointestinal symptom burden and taste alterations (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The mid-treatment phase emerged as the period of greatest nutritional vulnerability.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eChildren with solid tumors experience progressive deterioration in dietary intake adequacy during oncological treatment, with mid-treatment representing a critical window for intensified nutritional monitoring and supportive intervention. Integrating repeated dietary assessment with structured nutritional risk screening may enhance early identification of vulnerable patients and improve supportive care delivery in pediatric oncology.\u003c/p\u003e","manuscriptTitle":"Progressive Deterioration in Dietary Intake and Nutritional Risk During Oncological Treatment in Children with Solid Tumors: A Prospective Longitudinal Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-15 07:18:28","doi":"10.21203/rs.3.rs-8991405/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"142254722034618445298464317344374845242","date":"2026-04-28T14:49:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199855725056509405948952219643666528217","date":"2026-04-28T06:50:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T20:18:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-07T20:17:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T05:56:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-02-27T20:14:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"58cca867-706e-4586-828f-79bbc3ec51f6","owner":[],"postedDate":"April 15th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T07:18:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-15 07:18:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8991405","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8991405","identity":"rs-8991405","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}