BACKGROUND:The impact of social determinants of health (SDoH) on survival outcomes is unclear in the universal Canadian health care system. We investigated the impact of distance to treatment center and income quintile on survival outcomes in pediatric extracranial solid tumors in Canada. METHODS:Children < 15 years old diagnosed with 7 common solid extracranial tumors from 2001 to 2020 were included using the Cancer in Young People in Canada (CYP-C) data tool. We used logistic regression to examine the association of income quintile and distance on cancer outcomes. We used Cox proportional hazard models to examine associations with time-to-event outcomes (OS) and Fine-Gray competing risk regression (recurrence) adjusting for metastasis, age, region, and tumor location. RESULTS:The cohort included 3969 patients. Median age was 3.6 years (IQR: 1.3-8.9); 48.7% were female. Tumor diagnosis: 34% neuroblastoma, 21% Wilms tumor, 13% rhabdomyosarcoma, 11% osteosarcoma, 8% Ewing sarcoma, 7% hepatoblastoma, and 6% germ cell tumors. On multivariable analysis, income quintile and distance did not significantly or consistently impact survival across all tumors. In rhabdomyosarcoma, the second lowest income quintile had inferior survival compared to the highest income quintile (p = 0.0264, HR 1.91, 95% CI 1.08, 3.37). In neuroblastoma, the lowest income quintile had inferior survival compared to the highest (p = 0.0052, HR 1.82, 95% CI 1.20, 2.77). Patients diagnosed with hepatoblastoma living > 500 km from a pediatric treatment facility had inferior OS compared to those within 50 km (p = 0.0065, HR 3.29, 95% CI 1.40, 7.79). CONCLUSION:Overall, distance and income did not show a consistent significant impact on survival outcomes for children with extracranial solid tumors.

Ongoing refinements of multidrug regimens, and particularly the addition of L-asparaginase, resulted in an immediate gain in survival for pediatric acute lymphoblastic leukemia patients. Yet L-asparaginase has substantial side effects which may require dose reductions or delays in subsequent doses. There are at least 3 possible sources of L-asparagine to consider when balancing blood levels with asparaginase dosing, diet, cell synthesis and bacterial synthesis. To date, there is one precedent, in mice, in which blood L-asparagine levels are reduced as a consequence of reducing consumed levels. We build on that approach in experiments aimed at testing whether long-term dietary restriction of L-asparagine and possibly gut bacteria can impact blood levels. In our experiment, 2 groups of mice received food pellets with either 4% or 0% L-asparagine. Blood and fecal metabolites and fecal bacteria were sampled over 72 days. After this accommodation period, all mice continued their diet and received a single injection of pegylated E. coli recombinant L-asparaginase. Samples for bacteria and metabolites were collected 4 and 5 days later, respectively. Neither diet had adverse effects on the general health of the mice nor did diet alone change blood L-asparagine levels. Both diets led to changes in gut bacteria. L-asparaginase depleted blood L-asparagine in mice consuming either diet. Bacteria identified in fecal pellets revealed that the microbiomes of mice in the 2 cages were different (cage effect) and remained different although metagenomic analyses of day 72 feces indicated there were no diet-dependent differences in bacterial asparaginase or asparagine synthetase. These outcomes indicate that mice recover from any short-term down regulation of blood L-asparagine due to diet and consequently the metabolic controls become complex, and the gut microbes seem to not be a great influence. Further research should include approaches to determine the source of L-asparagine in the blood while ingesting diets with no/low or high amounts of L-asparagine.

Background: The incidence of pediatric venous thromboembolism (VTE) is increasing, and research is needed to determine safe and effective thromboprophylaxis strategies. Objectives: To identify and prioritize key research gaps in pediatric VTE. Methods: The VTE Risk Factors and Thromboprophylaxis Working Party of the Pediatric and Neonatal Thrombosis and Hemostasis Subcommittee of the International Society on Thrombosis and Haemostasis (ISTH) Scientific and Standardization Committee conducted a crowdsourcing initiative during the 2023 and 2024 ISTH Congresses and via email listservs through the Children's Healthcare Advancements in Thrombosis Consortium and the Venous thromboEmbolism Network U.S. (VENUS) pediatric subgroup. Respondents identified priority research questions, which were then thematically grouped, ranked, and reviewed against current and ongoing research to define future research needs. Results: Research questions were categorized into 4 themes: 1) risk factor identification and stratification, 2) advancements in risk assessment models and biomarkers, 3) optimal thromboprophylaxis approaches, and 4) implementation and practice integration. While risk assessment models and select randomized trials have informed prophylaxis for specific pediatric subgroups, evidence gaps remain, particularly for populations excluded from prior studies. Critical unanswered questions include the role of immobility, the value of mechanical prophylaxis, optimal anticoagulant selection, dosing and duration, and strategies for integrating risk-based prophylaxis across diverse care settings. Conclusion: This initiative defines consensus-driven research priorities for pediatric VTE prevention that, when addressed, will support the development of evidence-based clinical practice guidelines.

10024 Background: Adolescents and young adults (AYA) with cancer, commonly defined as patients aged 15–39 years at diagnosis, experience higher morbidity and mortality compared with other age groups. In this study, we compared outcomes of adolescents with newly diagnosed cancer treated at Canadian pediatric oncology centers with those of younger children. Methods: We conducted a retrospective cohort study using the population-based CYP-C database, including children aged 1–18 years with newly diagnosed cancer across Canada (2015–2020). Event-free survival (EFS) and overall survival (OS) were compared between adolescents (15–18 years) and younger children (1 to <15 years) across cancer subtypes using Kaplan–Meier analyses and univariable and multivariable Cox proportional hazards models. Results: Of the 6,794 patients, adolescents aged 15–18 years comprised 16% (n=1,075) of the cohort. Median age at diagnosis was 16 years (IQR: 15.7–17.2), and among those with solid tumors, 26% (n=150) had metastatic disease at diagnosis. The most frequent adolescent cancers were Hodgkin lymphoma (20%), gliomas and other glioneuronal tumors (12%), acute lymphoblastic leukemia (11%), osteosarcoma (6%), thyroid carcinoma (6%), malignant extracranial germ cell tumors (5%), and Ewing sarcoma (4%). Adolescents with leukemia had comparable 5-year EFS (71% vs. 79%; p=0.06) and OS (83% vs. 89%; p=0.07) to younger children, as did those with non-central nervous system (CNS) solid tumors for EFS (65% vs. 65%; p=0.55) and OS (74% vs. 75%; p=0.23). Among patients with sarcomas, adolescents had similar 5-year EFS (50.7% vs. 52.0%, p=0.55) and OS (55.6 vs. 59.7%, p=0.14) to younger children. Adolescents with CNS tumors had superior EFS (83% vs. 66%; p=0.005) and OS (89% vs. 73%; p=0.006), primarily driven by ependymoma and choroid plexus tumors, and other gliomas/glioneuronal tumors excluding pilocytic astrocytoma. Conclusions: Although AYA with cancer are often reported to have poorer outcomes, adolescents aged 15–18 years treated exclusively in Canadian pediatric oncology centers did not have inferior outcomes to younger children, underscoring the effectiveness of pediatric treatment approaches. 5-year EFS and 5-year OS of adolescents (≥15 years-old) vs. younger children (1 to < 15 years old) across major cancer categories. - Adolescents 5-year EFS (%) [95% CI] Younger children 5-year EFS (%) [95% CI] p-value Adolescents 5-year OS (%) [95% CI] Younger children 5-year OS (%) [95% CI] p-value All cancers 76.4 [72.8-79.9] 72.6 [70.8-74.3] 0.12 84.7 [81.4-87.4] 81.1 [79.6-82.7] 0.13 Leukemias 71.2 [58.7-80.5] 79.0 [75.8-81.9] 0.06 83.2 [73.3-89.7] 88.6 [86.2-90.6] 0.07 Lymphomas 88.5 [82.6-92.5] 87.3 [82.6-90.7] 0.63 96.2 [91.9-98.3] 95.5 [92.7-97.3] 0.50 Non-CNS solid tumors 65.4 [58.6-71.3] 65.2 [61.8-68.3] 0.55 73.5 [66.7-79.0] 74.8 [71.5-77.9] 0.23 CNS tumors 83.1 [74.2-89.1] 66.3 [62.5-69.8] 0.005 89.1 [82.0-93.5] 72.5 [68.8-75.9] 0.006

PURPOSE:Infants with cancer are rare and face unique challenges. Our study aims to describe the incidence of infantile cancers in Canada and to compare treatment-related mortality (TRM) and their outcomes with those of older children. METHODS:We conducted a retrospective cohort study using the Cancer in Young People in Canada database, including all infants (0 to <1 year old) with newly diagnosed cancer from 2001 to 2020. Population-based data were used to estimate annual cancer incidence. Cox proportional hazards models were used to compare TRM, event-free survival (EFS) and overall survival (OS) between (1) neonates (<30 days old) and older infants (≥30 days to <1 year old, (2) younger (<6 months) and older infants (≥ 6 months), and (3) all infants with older children (≥1 to ≤10 years old). RESULTS:A total of 2256 infants were included. The incidence was 30.8 per 100,000 infant-years, and this incidence increased with an annual percent change of 1.6%, p < 0.001. Neonates had significantly higher TRM (6.1 vs. 3.6%, HR 2.76, p < 0.001) as well as infants younger than 6 months (5.2 vs. 2.7%, HR 2.05, p < 0.001). Compared with older children, infants experienced higher risk of TRM (4.1 vs. 2.1%, HR 2.45, p < 0.001) and had inferior 5-year EFS (66.2 vs. 68.6%, HR 1.27, p < 0.001) and OS (77.5 vs. 78.6%, HR 1.22, p < 0.001). CONCLUSION:The annual incidence of infantile cancers in Canada has increased and their outcomes are significantly worse than those of older children, as they face a higher risk of TRM, particularly in younger infants. PRÉCIS: The incidence of cancer in infants has increased significantly in Canada between 2001 and 2020 and their outcomes are significantly lower than those of older children, being at greater risk of TRM.

Introduction Infectious complications are a leading cause of morbidity and mortality in pediatric leukemia, particularly during intensive chemotherapy. Febrile neutropenia (FN), bacteremia, and fungemia are common and potentially life-threatening. This study evaluated the effectiveness of antimicrobial prophylaxis in preventing infectious complications in pediatric patients with leukemia. Methods A retrospective, matched chart review was conducted involving 182 pediatric patients (aged 1–18 years) diagnosed with leukemia. Patients were stratified based on receipt of antimicrobial prophylaxis, Levofloxacin, Caspofungin, Fluconazole, or a combination (n = 40), versus no prophylaxis (n = 64). Primary outcomes included the number of FN episodes, bacteremia, and fungemia. Results Patients who received antimicrobial prophylaxis experienced significantly fewer FN episodes and bacteremia events compared to those who did not receive prophylaxis. No cases of increased antimicrobial resistance were observed in the prophylaxis group. Rates of fungemia were low in both groups. Conclusions Antimicrobial prophylaxis during high-risk phases of chemotherapy is associated with reduced FN and bacteremia in pediatric leukemia patients. These findings support its implementation as a preventative strategy in HR patients to reduce infectious complications without increasing antimicrobial resistance.

Childhood obesity can result in adverse health outcomes. Objectives were to describe the prevalence of obesity and determine the association between obesity at cancer diagnosis and event-free survival (EFS) and overall survival (OS) in children diagnosed with cancer in Canada. We conducted a retrospective cohort study using the Cancer in Young People in Canada database, a population-based surveillance program collecting data from all paediatric cancer patients. This study included all children with newly diagnosed cancer aged 2 to 18 years across Canada from 2001 to 2020. Obesity was defined as age and sex-adjusted body mass index ≥ 95th percentile. EFS was defined as the time from diagnosis to first event (relapse, progression, secondary malignancies, or death). Univariate and multivariable Cox proportional hazards models compared EFS and OS between patients with and without obesity. A total of 11,291 patients were included (37.1% leukemias, 14.5% lymphomas, 21.8% central nervous system (CNS) tumors, 26.6% non-CNS solid tumors). At diagnosis, 10.5% were obese and the prevalence of obesity was significantly higher at 1 year (15.7%, p<0.001) and 2 years (20.1%, p<0.001) after diagnosis. The prevalence of obesity was higher in the leukemia and lymphoma cohort compared to other cancer categories (11.4% vs. 9.5%, p=0.001). In multivariable models controlling for age at diagnosis, sex, ethnicity, neighborhood income quintile, treatment era and cancer categories, obesity at diagnosis remained significantly associated with inferior EFS [adjusted HR (aHR) 1.16, 95% CI 1.02–1.32] and OS [aHR 1.29, 95% CI 1.11–1.49]. In children with acute lymphoblastic leukemia (ALL) (n=3458, 82.5% of all leukemias), after adjusting for high-risk features such as age, white blood cell count and CNS status, obesity at diagnosis remained significantly associated with inferior EFS [aHR 1.55, 95% CI 1.17–2.04] and OS [aHR 1.75, 95% CI 1.23–2.49]. In patients with CNS tumors, obesity at diagnosis was also independently associated with inferior EFS [aHR 1.38, 95% CI 1.09–1.76] and OS [aHR 1.47, 95% CI 1.13–1.91]. In this population-based study of children with cancer, the prevalence of obesity was 11% at diagnosis and continued to increase in the following 2 years. Obesity at cancer diagnosis was independently associated with inferior survival across the entire cohort, especially in children with ALL and CNS tumors. Prevention of childhood obesity should be emphasized as it can lead to several adverse health outcomes in children with cancer.

Background: Thromboembolism (TE) is a known complication in pediatric oncology patients. While its adverse prognostic impact on survival has been shown in hematologic malignancies, limited data exist for children with solid tumors. Objectives: Among children diagnosed with extracranial solid tumors, a) To describe risk factors for TE and b) to evaluate the association between TE and overall survival (OS) and event-free survival (EFS). Methods: We conducted a retrospective cohort study using data from the Cancer in Young People – Canada (CYP-C) population-based registry. The cohort included patients aged 0–<18 years diagnosed with extracranial solid tumors (International Classification of Childhood Cancers-3 diagnostic groups II, IV–XI) between January 1, 2001, and December 31, 2021, at 12 pediatric oncology centers across Canada outside of Ontario. Patients were followed for up to 5 years following cancer diagnosis. The main exposure was the occurrence of grade ≥3 TE as per Common Terminology Criteria for Adverse Event (i.e. requiring medical treatment, life-threatening, or fatal), as abstracted by trained data managers from medical records. Outcomes were 5-year OS and EFS, with EFS defined as time between diagnosis and death from any cause, relapse, or second malignancy (whichever came first). Demographic, clinical, and treatment-related variables for children with and without TE were presented descriptively and were compared using univariate and multivariable logistic regression. We used Kaplan-Meier estimators with log-rank test and multivariable Cox proportional hazards models to evaluate the association between TE and survival. Only TEs that occurred before relapse or second malignancy were considered. Patients without the outcome of interest were censored at last medical follow-up in CYP-C. Multivariable models were adjusted for age, sex, cancer type, treatment intensity (using the Intensity-Treatment Rating version 3.0 scale), and metastatic status. Results are presented using hazard ratios (HR) and 95% confidence intervals (CI). P-values <0.05 were considered statistically significant. Results: We included 5,153 patients, 200 of whom had a thromboembolic event. The median age was 6.7 years (IQR: 2.0-12.8), 52.7% were male, 62.7% self-reported as White. The most common cancer diagnoses were “Lymphomas and reticuloendothelial neoplasms” (25.5%), “Neuroblastoma and peripheral nervous cell tumors” (18.0%), and “Soft tissue and extraosseous sarcomas” (12.2%). Metastatic involvement was present in 38.2% of cases. The 5-year cumulative incidence of TE reached 4.9% (95% CI: 3.5-4.7%). Of note, 35 patients (0.7%) experienced TE within 7 days of cancer diagnosis. The following characteristics were independently associated with TE: primary cancer diagnoses of lymphoma or hepatic tumors, metastatic disease at diagnosis, and exposure to chemotherapy. Sex, race, income quintile, and surgery were not associated with TE. Five-year OS was 73.0% and 85.5% in pediatric cancer patients with and without TE, respectively (absolute difference: 12.5%, log rank test, p<0.0001). TE was independently associated with decreased OS (unadjusted HR=1.90, 95% CI: 1.44-2.50, p<0.001; adjusted HR = 1.55, 95% adjusted CI: 1.17–2.04, p=0.0021). Additionally, in this model, male sex and metastatic status were associated with worse OS. Five-year EFS was 76.8% and 86.1% in pediatric cancer patients with and without TE (absolute difference: 9.3%, log-rank test: p=0.0018). TE was also independently associated with worse EFS (Unadjusted HR= 1,67, 95% CI: 1.21-2.30; p=0.002; Adjusted HR = 1.46; 95% adjusted CI: 1.05-2.02, p=0.023). Conclusion: In this large, population-based cohort of children with extracranial solid tumors, TE was associated with metastatic disease. After adjustment for other known adverse prognostic factors, such as age and metastatic status, TE was independently associated with worse OS and EFS, suggesting that TE may serve as a marker of poor prognosis. Further work is needed to determine whether thromboprophylaxis may reduce TE and its impact on survival in children.

Importance:Pediatric patients with cancer experience severely bothersome symptoms during treatment. It was hypothesized that symptom screening and provision of symptom reports to the health care team would reduce symptom burden in pediatric patients with cancer. Objective:To determine if daily symptom screening and provision of symptom reports to the health care team was associated with lower total symptom burden as measured by the Symptom Screening in Pediatrics Tool (SSPedi) compared to usual care among pediatric patients with cancer admitted to a hospital or seen in a clinic daily for at least 5 days. Design, Setting, and Participants:This randomized clinical trial enrolled participants from July 2018 to September 2023 from 8 Canadian tertiary care centers that diagnose and treat pediatric patients with cancer. Patients aged 8 to 18 years with cancer expected to be in a hospital or clinic daily for at least 5 consecutive days were eligible for inclusion. Participants were randomized to intervention (n = 176) vs control (n = 169) groups. Data were analyzed from November 2023 to December 2023. Intervention:Intervention participants completed the SSPedi once daily for 5 days. Printed symptom reports were provided daily to the health care team, and email alerts were distributed for severely bothersome symptoms. Control participants received usual care. Main Outcomes and Measures:The primary outcome was self-reported total SSPedi score on day 5. Secondary outcomes were individual SSPedi symptoms, pain, quality of life, symptom documentation, and intervention provision. The primary analysis compared the day 5 total SSPedi scores between randomized groups using a multiple linear regression model. For the secondary analysis comparing individual SSPedi symptom scores, the odds ratio for the intervention was estimated using a proportional odds model. Pain and quality of life were analyzed using the same approach as the primary outcome. Fisher exact test was used to compare symptom documentation, any intervention, and symptom-specific intervention between groups. Results:A total of 345 participants were enrolled; median (range) participant age was 13.8 (8.0-18.8) years, and 150 participants (43.5%) were female. Day 5 SSPedi score was significantly better with symptom screening compared to usual care (adjusted mean difference, -2.5; 95% CI, -3.8 to -1.2). Symptom screening reduced the odds of higher individual symptom scores; 8 of 15 symptom reductions were statistically significant. There were no significant differences in pain or quality of life scores between groups. Five symptoms were documented or treated significantly more often with symptom screening than usual care. Conclusions and Relevance:In this randomized clinical trial, among pediatric patients with cancer admitted to a hospital or seen in a clinic daily for at least 5 days, symptom screening with SSPedi improved total symptom scores compared to usual care. Trial Registration:ClinicalTrials.gov Identifier: NCT03593525.

BackgroundChildhood obesity can result in adverse health outcomes. The objectives of this study were to describe the prevalence of obesity and determine the association between obesity at cancer diagnosis and event-free survival (EFS) and overall survival (OS) in children diagnosed with cancer in Canada.MethodsThe authors conducted a retrospective cohort study using the Cancer in Young People in Canada database, including all children with newly diagnosed cancer aged 2-18 years across Canada from 2001 to 2020. Obesity was defined as age-adjusted and sex-adjusted body mass index greater than or equal to the 95th percentile. Univariate and multivariable Cox proportional hazards models compared EFS and OS between patients with and without obesity at diagnosis.ResultsIn total, 11,291 patients were included, of whom 10.5% were obese at diagnosis. In multivariable models controlling for age, sex, ethnicity, neighborhood income quintile, treatment era, and cancer categories, obesity at diagnosis was independently associated with inferior EFS (adjusted hazard ratio [aHR], 1.16; 95% confidence interval [CI], 1.02-1.32; p = .02) and OS (aHR, 1.29; 95% CI, 1.11-1.49; p = .001). The adverse prognostic impact of obesity was particularly notable for acute lymphoblastic leukemia (ALL) and central nervous system (CNS) tumors. In children with ALL (n = 3458), obesity remained associated with inferior EFS (aHR, 1.55; p = .002) and OS (aHR, 1.75; p = .002) in multivariable analysis. In patients with CNS tumors (n = 2458), obesity was also associated with inferior EFS (aHR, 1.38; p = .008) and OS (aHR, 1.47; p = .004).ConclusionsIn this population-based study, obesity at cancer diagnosis was independently associated with inferior survival across the entire cohort, and prominently in children with ALL and CNS tumors.

A 10-month-old male infant presented to the emergency department with acute abdominal pain. Diagnostic images showed bowel intussusception. A laparotomy with a reduction of ileocolic intussusception and a small bowel resection was done. Initial complete blood count (CBC) showed significant abnormalities of blasts and pancytopenia. Flow cytometry, surgical pathology, and molecular testing confirmed the diagnosis of myeloid sarcoma (MS)/acute myeloid leukemia (AML). The patient was treated as per the Children's Oncology Group (COG) study AAML 1831, low-risk stratification Arm B (LR2), and was treated with five cycles of chemotherapy. Currently, the patient is in remission one year post-therapy. A literature review of pediatric MS patients with presentation of intussusception is included.

Background: Ferric carboxymaltose (FCM) is a third-generation intravenous dextran-free, intravenous iron formulation that can be given in a single dose over a small duration. The study assessed hematological parameters before and after FCM administration in pregnant women for whole population and according to gestational age, severity of anemia and gravida status. Methods: This was a single centre, prospective, observational, open label, clinical study at real life scenario with 4 weeks follow up. Thirty pregnant women with IDA and visiting to the Pushpam Maternity Hospital, Ahmedabad for antenatal care were enrolled for the study. I.V. FCM was administered as a single dose of 1000 mg. Change in the haemoglobin (Hb), ferritin, other hematological parameters at baseline and after 4 weeks of completion of parenteral iron therapy was noted. Results: A significant increase in the haemoglobin (Hb) of 2.08 gm/dl and ferritin of 92.89 ng/ml was recorded at 4 weeks. There was also a significant rise in Hb, ferritin, MCV, MCH, RBC count, MCHC as compared to the baseline in patients with moderate anemia. There was significant increase in Hb, hematocrit, ferritin and MCV as compared to baseline in primi and multigravida women and also in gestational age ≤ and >28 weeks. No adverse effects were observed throughout the duration of the study. Conclusions: FCM infusion prior to delivery significantly increased hemoglobin levels and improved ferritin levels and other haematological parameters at 4 weeks in whole population and also in moderate anemia, primi and multigravida, gestational age ≤ and >28 weeks.

Abstract Background Iron deficiency (ID) in childhood is linked to adverse neurodevelopmental outcomes in the long-term. Extremely premature infants (EPI; born < 28 weeks gestation) are more susceptible to ID due to a multitude of factors including lower iron reserves at birth, rapid growth, immature erythropoiesis, and multiple phlebotomy tests during hospital stay. Therefore, professional societies advise prophylactic iron therapy for these infants from 2-6 weeks age until 6-12 months. However, there is paucity of data on the iron status in EPI receiving this prophylactic iron supplementation. Objectives To investigate the prevalence and risk factors associated with ID in EPI. Design/Methods A retrospective cohort study analyzed a Provincial database of EPIs born between 2005-2018. Infants with congenital malformations, chromosomal anomalies and blood disorders were excluded. All included infants received prophylactic iron supplementation from 2-4 weeks of chronological age that was recommended to continue at discharge until 9-12 months corrected age (CA). At 4-6 months CA, these infants underwent blood testing. ID was defined as serum ferritin < 20mcg/L at 4 months CA or SF < 12mcg/L at 6 months CA. Through a univariate analysis using single-variable logistic regression, factors linked to ID were identified. Those with a p-value < 0.20 progressed to a multivariable model, retaining variables with a p-value < 0.05. Results Of 146 infants, 45.9% had ID. ID group had lower mean ferritin (16.4 µg/L vs 50.0 µg/L, p < .001) and reticulocyte hemoglobin equivalent (28.4pg vs 31.6pg, p < .001) compared to the non-ID group. ID prevalence reduced from 59.7% in 2005-2011 to 40.3% in 2012-2018 cohort. Exclusive or partial breastfeeding at 4-6 months CA was protective against ID (Odds: 0.2, p = 0.003). Iron therapy at 4-6 months CA was not protective in the final model. Notably, 27.4% stopped iron therapy before 4-6 months CA, and exclusive formula-fed infants had notably lower iron intake than breastfed infants (66.1% vs 99.1%, p = 0.006). Conclusion Nearly half of the EPI exhibited ID at 4-6 months CA despite prophylactic iron supplementation. About a quarter discontinued therapy before reaching this age. Breastfeeding at this age was protective against ID. This high prevalence of ID in EPI underscores the need of future studies to discern strategies to mitigate ID in this vulnerable population.

ImportancePediatric patients with cancer experience severely bothersome symptoms during treatment. It was hypothesized that symptom screening and provision of symptom reports to the health care team would reduce symptom burden in pediatric patients with cancer.ObjectiveTo determine if daily symptom screening and provision of symptom reports to the health care team was associated with lower total symptom burden as measured by the Symptom Screening in Pediatrics Tool (SSPedi) compared to usual care among pediatric patients with cancer admitted to a hospital or seen in a clinic daily for at least 5 days.Design, Setting, and ParticipantsThis randomized clinical trial enrolled participants from July 2018 to September 2023 from 8 Canadian tertiary care centers that diagnose and treat pediatric patients with cancer. Patients aged 8 to 18 years with cancer expected to be in a hospital or clinic daily for at least 5 consecutive days were eligible for inclusion. Participants were randomized to intervention (n = 176) vs control (n = 169) groups. Data were analyzed from November 2023 to December 2023.InterventionIntervention participants completed the SSPedi once daily for 5 days. Printed symptom reports were provided daily to the health care team, and email alerts were distributed for severely bothersome symptoms. Control participants received usual care.Main Outcomes and MeasuresThe primary outcome was self-reported total SSPedi score on day 5. Secondary outcomes were individual SSPedi symptoms, pain, quality of life, symptom documentation, and intervention provision. The primary analysis compared the day 5 total SSPedi scores between randomized groups using a multiple linear regression model. For the secondary analysis comparing individual SSPedi symptom scores, the odds ratio for the intervention was estimated using a proportional odds model. Pain and quality of life were analyzed using the same approach as the primary outcome. Fisher exact test was used to compare symptom documentation, any intervention, and symptom-specific intervention between groups.ResultsA total of 345 participants were enrolled; median (range) participant age was 13.8 (8.0-18.8) years, and 150 participants (43.5%) were female. Day 5 SSPedi score was significantly better with symptom screening compared to usual care (adjusted mean difference, −2.5; 95% CI, −3.8 to −1.2). Symptom screening reduced the odds of higher individual symptom scores; 8 of 15 symptom reductions were statistically significant. There were no significant differences in pain or quality of life scores between groups. Five symptoms were documented or treated significantly more often with symptom screening than usual care.Conclusions and RelevanceIn this randomized clinical trial, among pediatric patients with cancer admitted to a hospital or seen in a clinic daily for at least 5 days, symptom screening with SSPedi improved total symptom scores compared to usual care.Trial RegistrationClinicalTrials.gov Identifier: NCT03593525