Table 1.

Summary of recommendations.

Questions	Recommendations
Why would nutritional screening be part of supportive care in children with cancer?	The main objective of nutritional treatments is not only to avoid malnutrition, but also to support growth in line with genetic target.
When should nutritional assessment be done in children with cancer?	Assessment of nutritional status should be performed on all patients at diagnosis and repeated periodically during treatment and follow-up.
How should nutritional screening be done in children with cancer?	A-B-C-D methods could be considered a useful method for nutritional screening in children with cancer.
What are the anthropometric measures that should be assessed?	Weight, height, body mass index (BMI), and mid-upper arm circumference (MUAC) plotted on WHO growth charts could be considered part of a minimal nutritional screening.
What are the biochemistry exams that should be performed?	Biochemical exam should include protein status, organ function, bone health, anemia, evidence of inflammation, and specific mineral and vitamin deficiencies.
What should be investigated during the clinical evaluation?	Clinical evaluation should detect signs of malnutrition and consider conditions that may affect oral food intake.
What is the role of the dietitian and clinical nutritionist?	Collaboration between dietitians, clinical nutritionists, and oncologist is pivotal.
Can the use of screening tools be useful?	Screening Tool for Risk of Nutritional Status and Growth (Strong Kids) seem to be balanced and takes into account several aspects.
Which risk factors for malnutrition are related to disease and treatment?	Some specific tumors and some specific therapies are more at risk of both overnourishment and undernourishment.
What kind of diet should be suggested?	A diet corresponding to those of children of the same age and sex should be proposed. Counselling on grocery shopping, food hygiene, food storage, cooking, preparation, and serving according to the FDA-approved food safety guidelines should be carried out to families.
What is the role of “alternative” therapies and diets?	There are no high-quality studies demonstrating the effectiveness of natural health products or special diets in pediatric cancer cures.
What is the management for initial starting nutritional support like in children with cancer?	Nutritional support, starting with oral supplements, is indicated when the patient has no high-risk features or when they are unable to meet the 50% of the daily requirements orally. If a patient is adequately nourished, does not lose weight, and is consuming at least 50% of the recommended nutritional intake, nutritional counselling by an expert dietician is considered sufficient. Nutritional counselling is mandatory also for overweight and obese patients at diagnosis or during treatment, with special attention to children taking long course of steroids, who are at risk of sarcopenic obesity (ALL patients).
When can enteral nutrition (EN) be considered in children with cancer?	-When the child is unable to take his or her nutritional needs orally (less than 50%) for more than 5 consecutive days. -For severely wasted or malnourished patients (BMI for age <5th percentile or z score less than –1) or MUAC (<5th percentile or z score less than –1). -When the patients have over 5% weight loss since diagnosis; a decrease of >10% in MUAC.
Which type of enteral access (nasogastric tube or periendoscopic gastrostomy) is used in children with cancer?	-Nasogastric tube is the first access that should be used. -Gastrostomy can be proposed when prolonged support is required (>4–6 weeks) or the nasopharynx needs to be bypassed. -Jejunal enteral access could be considered when intragastric feeding is contraindicated.
Which modalities of EN should be used (bolus/continuous) in children with cancer?	We suggest starting with continuous feeding and, if well tolerated (no vomiting or abdominal distension), switching to bolus feeding.
How should an enteral formula be chosen in children with cancer?	-Standard polymeric formulas are suitable for a functioning gastrointestinal tract. -Formulas containing amino acids and medium-chain triglycerides may be indicated in conditions of malabsorption. -Concentrated formulas can be used in case of fluid restriction or reduced gastric capacity.
When should a parenteral nutrition (PN) be considered in children with cancer?	PN should be considered when enteral nutrition is not feasible or inadequate.
How personalized should PN be in children with cancer?	PN formulations should be prescribed, taking into account age requirements, nutritional status, fluid requirement, and type of venous access.
What are the risks related to PN?	The possible complications related to the use of PN are mechanical or equipment-related complications, infections and metabolic complications, acid-base or electrolyte imbalance, drug interaction, intestinal failure associated liver disease, and refeeding syndrome.
When should nutritional assessment be done in cancer survivors?	Nutritional assessment in cancer survivors should be done during the first year of follow-up: Monthly for undernourished patients; Quarterly for obese children and well-nourished patients with nutritional risk factors; Six months for children without risk factors