Prevalence, diagnostic methods, and clinical outcomes of wasting among paediatric cancer patients in Africa: A systematic review and meta-analysis

Figures
Abstract
Background
Malnutrition is a prevalent and modifiable co-morbidity in paediatric oncology, yet no comprehensive pan-African synthesis of its burden has been conducted. This systematic review and meta-analysis estimated the pooled prevalence of wasting and acute malnutrition among paediatric cancer patients in Africa, evaluated the impact of diagnostic assessment methods on reported prevalence, and characterised associations with adverse clinical outcomes.
Methods
We searched PubMed/MEDLINE, EMBASE and Web of Science for observational studies published from January 2000 to December 2025 reporting wasting or acute malnutrition among children and adolescents (0–19 years) with confirmed malignancies in African healthcare settings. Two independent reviewers screened studies, extracted data, and appraised quality using the Joanna Briggs Institute Critical Appraisal Checklist. Pooled prevalence was calculated using a random-effects model with Freeman-Tukey double arcsine transformation. Heterogeneity was assessed using the I² statistic and Cochran’s Q test. Publication bias was evaluated with Egger’s regression test. Certainty of evidence was assessed using the GRADE framework.
Results
Sixteen independent cohorts comprising 2,419 paediatric cancer patients across eight African countries were included. The pooled prevalence of wasting or acute malnutrition was 39.7% (95% CI: 30.7%–49.1%), with individual study estimates ranging from 11.7% to 67.6%. Between-study heterogeneity was substantial (I² = 95.3%; 95% CI: 92.7%–96.1%, p < 0.001). Studies using mid-upper arm circumference (MUAC) consistently detected substantially higher rates of malnutrition than those relying on weight-for-height or body mass index criteria from the same patient populations. No significant publication bias was detected (Egger’s test p = 0.503). GRADE certainty of evidence was very low, primarily due to heterogeneity. Wasting was independently associated with higher chemotherapy toxicity, treatment-related neutropenia, sepsis, and reduced overall survival across two of the included cohorts.
Conclusions
Wasting and malnutrition affects about two in five children with cancer in the African countries studied. The diagnostic tool employed is the single most consequential determinant of detected prevalence, and weight-based metrics alone are inadequate in populations with large solid tumours. Universal adoption of MUAC-based screening, structured algorithm-guided nutritional intervention, and integration of socioeconomic vulnerability assessment into routine oncological care are evidence-based priorities for improving treatment tolerability and survival in this population.
Citation: Pitua I, Wannyana D, Abila DB, Bongomin F (2026) Prevalence, diagnostic methods, and clinical outcomes of wasting among paediatric cancer patients in Africa: A systematic review and meta-analysis. PLoS One 21(7): e0353569. https://doi.org/10.1371/journal.pone.0353569
Editor: Nicolas Padilla-Raygoza, Institute of Public Health from Guanajuato State, MEXICO
Received: April 16, 2026; Accepted: June 25, 2026; Published: July 9, 2026
Copyright: © 2026 Pitua et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data from this study are available within the manuscript.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Childhood cancer represents one of the most pressing yet under-recognized public health challenges in Africa, where survival rates remain markedly lower than those achieved in high-income countries [1,2]. While children diagnosed with cancer in North America and Western Europe now achieve five-year survival rates exceeding 80% [2], comparable figures in sub-Saharan Africa rarely surpass 30% [2–4]. This disparity reflects not only limited access to curative therapies but also a constellation of structural barriers that undermine treatment delivery, including inadequate supportive care infrastructure, delayed diagnosis, and the pervasive burden of malnutrition [5,6].
The World Health Organization Global Initiative for Childhood Cancer, launched in 2018, set an ambitious target to achieve at least 60% survival for children with cancer globally by 2030 [7]. Central to this goal is the recognition that survival cannot be improved through chemotherapy alone. The physiological capacity to tolerate intensive multimodal treatment is fundamentally compromised by malnutrition, yet this modifiable risk factor continues to receive insufficient attention in oncological care pathways across low- and middle-income countries [8,9].
Wasting, defined as low weight-for-height or low mid-upper arm circumference (MUAC), is an acute manifestation of malnutrition that signals immediate mortality risk [10]. In the context of pediatric oncology, wasting arises from a dual etiology. First, many African children present to oncology units already malnourished, reflecting widespread food insecurity and pre-existing growth faltering in resource-limited settings [11,12]. Second, the hypermetabolic and inflammatory state induced by cancer itself, compounded by the catabolic effects of chemotherapy, precipitates rapid somatic wasting even in children who were adequately nourished at diagnosis [13,14]. This phenomenon, known as cancer cachexia, is mediated by pro-inflammatory cytokines that drive skeletal muscle proteolysis and lipolysis, creating a syndrome distinct from simple starvation [15,16].
The biological consequences of wasting in pediatric cancer patients extend beyond energy depletion. Malnutrition impairs immune function, increasing susceptibility to severe infections, febrile neutropenia, and sepsis [17,18]. Furthermore, acute malnutrition alters drug pharmacokinetics, particularly for chemotherapeutic agents dosed by body weight or surface area, potentially leading to both under-dosing and heightened toxicity [8]. Malnutrition also disrupts gut mucosal integrity, exacerbating chemotherapy-induced mucositis and increasing translocation of enteric pathogens [19]. The cumulative effect is a cascade of treatment-related morbidity, prolonged hospitalization, treatment delays, and ultimately, reduced survival [20,21].
Despite these well-documented associations, the true magnitude of wasting among African children with cancer remains unclear. Existing prevalence estimates vary widely, ranging from below 10% to over 80% within different cohorts [22]. Many African oncology centers rely on weight-based metrics such as body mass index or weight-for-height Z-scores, which are unreliable in the presence of large solid tumors, organomegaly, or ascites [23,24]. Conversely, clinical assessment based on visible wasting alone has been shown to have a sensitivity of less than 45% compared to anthropometric measurement, meaning that more than half of wasted children are overlooked by visual inspection [23].
MUAC provides a direct measure of lean tissue mass in the upper arm and is less susceptible to confounding by tumor burden [25]. However, MUAC is not routinely incorporated into pediatric cancer assessment protocols across Africa, and national malnutrition screening programs often exclude children over five years of age, leaving adolescents with cancer particularly vulnerable to under-detection [21,26].
Beyond diagnostic inconsistency, a second major knowledge gap concerns the clinical outcomes associated with wasting in African pediatric cancer cohorts. While small single-center studies have reported associations between malnutrition and increased mortality [12,27], these findings have not been systematically synthesized.
By synthesizing data from multiple cohorts spanning diverse African settings, we aimed to provide the most comprehensive epidemiological picture to date of the malnutrition burden in pediatric oncology populations across the continent.
Methods
Protocol and registration
This systematic review and meta-analysis was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [28]. Full checklist can be accessed in additional files (S1 File). The protocol was prospectively registered in the PROSPERO International Prospective Register of Systematic Reviews (Registration Number: CRD420251237859) and published in PLOS ONE [29], with the review being conducted in accordance with the registered protocol.
Information sources and search strategy
A comprehensive search strategy was developed using Medical Subject Headings (MeSH) and free-text keywords. The search was conducted in PubMed, EMBASE and Web of Science from January 1, 2000 to December 31, 2025. The core search combined terms for the population (paediatric, child, adolescent), condition (cancer, malignancy, neoplasm, leukaemia, lymphoma), exposure (wasting, cachexia, malnutrition, MUAC, BMI, weight-for-height), and setting (Africa, sub-Saharan Africa, and individual African country names). Reference lists of all included studies and relevant systematic reviews were manually screened to identify additional eligible studies. The full search string is provided in additional files (S2 File).
Eligibility criteria
We included observational studies (cross-sectional, prospective cohort, retrospective cohort, and case-control designs) that reported the prevalence of wasting, cachexia, or acute malnutrition among children and adolescents aged 0–19 years with a confirmed diagnosis of any malignancy (haematological or solid tumour), receiving care at healthcare facilities located within Africa. Studies were eligible if they defined wasting or acute malnutrition using any recognised standard, including anthropometric Z-scores (weight-for-height/length, BMI-for-age, or MUAC-for-age below −2 SD), MUAC absolute thresholds, triceps skinfold thickness below the 5th percentile, clinician-assigned nutritional categories (poor/fair/good), or Subjective Global Assessment.
We excluded case reports and case series with fewer than ten patients, conference abstracts without sufficient quantitative data, qualitative studies, narrative reviews, editorials, and animal studies. Studies conducted outside Africa and those enrolling exclusively adult populations (aged ≥20 years) were also excluded.
Study selection
Search results were imported into Covidence systematic review software for deduplication and screening. Two independent reviewers (IP and DBA) screened all titles and abstracts for relevance. Full-text articles of potentially eligible studies were retrieved and assessed against the inclusion criteria. Disagreements at either stage were resolved by consensus. The study selection process is documented in a PRISMA flow diagram (Fig 1).
Data extraction
Data were extracted independently by two reviewers using a standardised form piloted on five randomly selected studies. Extracted variables included: study citation and country; study design and data collection period; sample size; participant age (mean, median, or age strata); cancer types and proportions; method and tool of nutritional assessment; wasting definition and cut-off employed; number and proportion of patients classified as wasted or acutely malnourished; and, where reported, outcome data including mortality, neutropenia, sepsis, and overall survival. Where studies reported multiple nutritional metrics, all available wasting-specific data were extracted.
Risk of bias assessment
The methodological quality of each included study was independently assessed by two reviewers using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Prevalence Studies [30]. This nine-item instrument assesses the adequacy of the sampling frame, sample size justification, representativeness of subjects, use of standardised and validated measurement conditions, appropriateness of statistical methods, and management of missing data. Studies scoring 8–9 out of 9 were classified as low risk, 6–7 as moderate risk, and ≤5 as high risk of bias. Disagreements between the two reviewers (IP and DBA) were resolved by discussion; where consensus could not be reached, a third reviewer (FB) would adjudicate.
Statistical analysis
A meta-analysis was performed using R Statistical Software (version 4.5.2) with the meta and metafor packages. The pooled prevalence of wasting was calculated using the Freeman-Tukey double arcsine transformation to stabilise variances, which is the recommended approach for pooling proportions that approach the boundaries of 0 or 1. A random-effects model was applied using the DerSimonian-Laird method, given the anticipated heterogeneity of healthcare settings, diagnostic methods, and patient populations across the African continent.
Between-study heterogeneity was quantified using the I² statistic, with values of 25%, 50%, and 75% representing low, moderate, and substantial heterogeneity respectively, and by Cochran’s Q test (with significance at p < 0.10). Publication bias was assessed by visual inspection of a contour-enhanced funnel plot and by Egger’s linear regression test (with significance at p < 0.05). Certainty of the body of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) [31] framework, assessing five domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias. No formal subgroup analyses were pre-specified as primary analyses; exploratory interpretation of heterogeneity by diagnostic tool type and cancer category was conducted narratively based on the extracted study data.
Results
Study selection
The initial comprehensive database search across PubMed/MEDLINE, Web of Science and EMBASE yielded 759 records after deduplication. Following title and abstract screening, 41 studies were retrieved for full-text assessment. After full-text evaluation and the exclusion of overlapping clinical reports to prevent double-counting of patient populations, 16 independent studies (cohorts) were included in the final synthesis. The complete screening process is documented in the PRISMA flow diagram (Fig 1).
Characteristics of included studies
The 16 included cohorts encompassed 2,419 paediatric cancer patients across eight African countries: South Africa (n = 5 cohorts), Malawi (n = 3), Uganda (n = 2), Ethiopia (n = 2), Kenya (n = 1), Ghana (n = 1), Tanzania (n = 1), and Morocco (n = 1). Sample sizes ranged from 40 to 463 patients per study. The majority of cohorts evaluated mixed paediatric oncology populations, while three focused exclusively on Wilms tumour and one on Hodgkin lymphoma. Study designs included prospective cohorts (n = 6), retrospective cohorts (n = 5), cross-sectional studies (n = 3), and observational studies (n = 2). Detailed characteristics of all included studies are presented in Table 1.
Risk of bias
The overall methodological quality of included studies was moderate to high. JBI scores ranged from 6/9–9/9. Six studies were rated low risk of bias (score 8–9/9. The remaining ten were rated moderate risk of bias (score 6–7/9). Common methodological limitations in moderate-risk studies included the absence of sample size justification, reliance on retrospective data with incomplete records, and variability in the documentation of nutritional assessment procedures. No study was rated high risk of bias. Full risk of bias scores are presented in Table 2.
Certainty of evidence
The certainty of the body of evidence was evaluated using the GRADE framework. Because all included studies were observational, the baseline certainty began at “Low.” The evidence was downgraded by one additional level due to serious inconsistency, driven by the high and unexplained statistical heterogeneity (I² = 95.3%). No downgrades were applied for risk of bias, indirectness, imprecision (the total sample of 2,419 provided narrow confidence intervals), or publication bias. The final GRADE certainty rating was Very Low (Table 3).
Pooled prevalence and publication bias
The prevalence of wasting and acute malnutrition at diagnosis or hospital admission varied substantially across included studies, ranging from a low of 11.7% to a high of 67.6%. Data from the 16 independent cohorts (N = 2,419) were pooled using a random-effects model with logit transformation. The overall pooled prevalence of wasting among paediatric cancer patients in Africa was 39.7% (95% CI: 30.7%–49.1%; Fig 2).
A high degree of between-study heterogeneity was observed (I² = 95.3% [95% CI: 92.7%–96.1%]; Cochran’s Q p < 0.0001), consistent with the diverse geographic regions, differential healthcare infrastructure, and varying diagnostic criteria employed across the included studies. Visual inspection of the contour-enhanced funnel plot revealed a symmetrical distribution of included studies, suggesting the absence of meaningful small-study effects (Fig 3). This was statistically confirmed by Egger’s linear regression test (bias coefficient = −2.13; SE = 3.09; t = −0.69; df = 14; p = 0.503), indicating no significant publication bias.
Discussion
This study provides the first comprehensive pan-African synthesis of the burden of wasting and acute malnutrition among children with cancer, revealing that approximately two in five children diagnosed with cancer in Africa are acutely malnourished at presentation or during treatment. The pooled prevalence of 39.7% substantially exceeds estimates from high-income settings, where wasting prevalence in pediatric oncology populations typically ranges between 6% and 15% [21,32,42–44]. This disparity shows the unique convergence of pre-existing food insecurity, delayed cancer diagnosis, and limited supportive care resources that characterizes pediatric oncology care across much of sub-Saharan Africa [5,22].
A key finding of this review is that the diagnostic tool employed is the single most consequential determinant of detected wasting prevalence. Studies using mid-upper arm circumference systematically identified substantially higher rates of malnutrition compared to those relying on weight-for-height Z-scores, visual or body mass index criteria within the same patient populations. For example, in a Ugandan cohort, visible wasting had low sensitivities in detecting wasting generally (43.9%) and moderate wasting (19.4%) compared to the anthropometric measures, specifically, with false negative rates of 56.1% and 80.6%, respectively [23]. These findings are consistent with mechanistic understanding of how tumor mass can artificially inflate body weight. It is important to note, however, that these assessment methods are not interchangeable: MUAC, BMI-based indices, weight-for-height, triceps skinfold thickness (TSFT), and clinician-assigned categories each capture a distinct dimension of nutritional status, ranging from lean tissue mass to overall body proportionality, and this methodological heterogeneity likely contributes substantially to the variability in pooled prevalence estimates observed in this review. TSFT, used in two included cohorts [41,45] as a component of the wasting/malnutrition definition, was not evaluated as an independent predictor of clinical outcomes in any included study; given its potential to detect fat mass depletion distinct from the lean mass captured by MUAC, this represents a specific gap for future research.
Weight-based metrics alone are inadequate for nutritional screening in populations with high prevalence of solid tumors and thus the integration of MUAC into routine oncological triage protocols is a fundamental requirement for case detection. MUAC measurement is rapid, requires minimal training, and can be performed reliably by nurses or community health workers using inexpensive, reusable tapes [25]. However, MUAC-based screening also carries an important limitation: WHO reference cut-offs for MUAC are validated only for children aged 6–59 months, and although several MUAC-for-age growth references have since been developed for older children and adolescents, these have not been harmonized into a single internationally accepted standard [46]. This lack of a unified reference for children and adolescents older than five years, the very age group shown in this review to carry a disproportionate wasting burden, remains an unresolved barrier to consistent case detection across the continent. The failure to adopt MUAC-based screening in African pediatric oncology units likely results in the systematic under-identification of malnourished children, depriving them of timely nutritional intervention and exposing them to heightened risk of chemotherapy toxicity and mortality [18,23].
The substantial heterogeneity observed in pooled prevalence estimates (I² = 95.3%) reflects not only methodological variation but also genuine differences in the populations served by different oncology centers. Prevalence estimates ranged from 11.7% in a Kenyan cohort [35] to 67.6% in a Ethiopian cohort [39]. Some of this variation is geographic, reflecting differential burdens of baseline food insecurity across regions. South Africa, Malawi, and Ethiopia reported some of the highest wasting prevalence rates, consistent with known high burdens of child undernutrition in these settings [21,39,40,47,48]. It is also important to note that the evidence base underlying this synthesis, while pan-African in framing, is drawn from only eight of Africa’s 54 countries, with South Africa alone contributing five of the sixteen included cohorts. The findings presented here should therefore be interpreted as the best currently available evidence on paediatric oncology wasting in Africa rather than as fully representative of the continent’s diverse healthcare systems, nutritional contexts, and cancer care pathways. However, patient-level factors also contribute to heterogeneity. Older children and adolescents exhibited higher wasting prevalence than younger children in multiple cohorts [24,32], likely reflecting both the exclusion of this age group from national malnutrition screening programs and the increased metabolic demands of adolescence in the context of active malignancy. Cancer type also influences wasting risk. Gastrointestinal tumors, hematological malignancies, and advanced-stage disease were consistently associated with higher wasting prevalence, reflecting tumor-specific metabolic effects and disease severity [24,26].
Our findings regarding clinical outcomes corroborate and extend prior evidence linking malnutrition to adverse events in pediatric cancer. Across two included cohorts, wasting at diagnosis was independently associated with higher rates of chemotherapy-induced neutropenia, febrile neutropenia, sepsis, and reduced overall survival [18,23]. Poverty and household food insecurity, assessed using validated screening tools, were strong independent predictors of wasting in the South African cohort [32], reinforcing that malnutrition in the pediatric cancer population is not only a medical issue but a socioeconomic determinant of nutritional status. The same cohort additionally reported that household hunger was associated with elevated odds of treatment abandonment and mortality, suggesting that food insecurity may influence cancer outcomes through pathways beyond wasting alone. Interventions that address food insecurity at the household level, including cash transfers, food vouchers, or provision of ready-to-use therapeutic foods, may be as essential to improving survival as chemotherapy dose optimization [9,26,49,50].
The observed associations between wasting and chemotherapy toxicity merit specific attention. The Ghanaian study reported that wasted children, defined by MUAC criteria, were significantly more likely to develop severe mucositis and anemia requiring transfusion during the first 12 weeks of chemotherapy [18]. Paradoxically, the same study found that wasted children had lower rates of prolonged neutropenia than well-nourished children, possibly reflecting dose reductions or treatment delays implemented by clinicians in visibly malnourished patients. This finding shows a critical tension in resource-limited setting: the absence of standardized nutritional intervention pathways forces clinicians to make ad hoc decisions about dose modification, potentially compromising both treatment intensity and cure rates. Evidence-based guidelines for nutritional support, integrated into chemotherapy protocols, are urgently needed [6,25].
The recently published consensus recommendations for nutritional management of children with cancer in limited-resource settings, developed by the International Initiative for Pediatrics and Nutrition, provide a practical framework for implementation [9]. These adapted protocols emphasize serial MUAC measurement, structured nutritional risk stratification, and algorithm-guided interventions including oral nutritional supplements and ready-to-use therapeutic foods. Field testing in hospitals across South Africa demonstrated feasibility and acceptability, with significant improvements in nutritional status over six months of implementation [51]. However, scaling these interventions across Africa will require sustained investment, training of clinical staff, and integration of nutritional services into routine oncological care pathways. The World Health Organization has not yet recognized childhood cancer as a high-risk category warranting prioritized nutritional intervention in global malnutrition guidelines [22]. Our findings provide the epidemiological foundation to advocate for this policy change.
Strengths and limitations
This systematic review provides the first comprehensive synthesis of wasting prevalence in African children with cancer, analyzing 16 cohorts (2,419 patients) from eight countries. Strengths include rigorous methodology using PRISMA guidelines, robust statistical pooling, and GRADE assessments, offering actionable clinical insights. However, key limitations exist. The geographic distribution of included studies was uneven, with South Africa, Malawi, and Uganda contributing the majority of cohorts and several major African regions, including North and Central Africa and most of West Africa, unrepresented; the pooled estimate should accordingly be interpreted as the best available evidence rather than a figure representative of the continent as a whole. Evidence certainty is very low due to high heterogeneity, which precluded formal subgroup meta-analyses; this heterogeneity is likely driven in part by the use of non-interchangeable nutritional assessment tools (MUAC, BMI-based indices, weight-for-height, triceps skinfold thickness, and clinical judgement) across included studies, each of which captures a distinct dimension of nutritional status. The absence of a harmonized MUAC reference standard for children older than five years further limits comparability of wasting estimates in this age group across studies. Findings rely heavily on single-center, retrospective observational studies, limiting causal inferences due to potential confounding. Furthermore, inconsistent outcome reporting prevented quantitative meta-analysis of clinical impacts.
Implications for public health, policy, and research
Routine MUAC-based nutritional screening should become standard across all African pediatric oncology units. This cost-effective measure enables crucial early intervention and national malnutrition programs should expand eligibility beyond children under five to include all pediatric cancer patients, closing a policy gap that drives preventable mortality. From a policy perspective, global health authorities like the WHO should formally designate childhood cancer as a high-risk condition, guaranteeing automatic inclusion in therapeutic feeding programs. National treatment protocols should mandate regular nutritional assessments and establish clear clinical thresholds for interventions. We urgently need prospective randomized trials to quantify the survival benefits of structured nutritional support versus standard care. Additionally, pharmacokinetic studies are required to determine if malnutrition alters chemotherapy exposure, which could guide safer dosing strategies. Future research must also employ implementation science to sustainably integrate nutritional care into local health systems.
Conclusions
Wasting and malnutrition affects about two in five children with cancer in the African countries studied. Wasting was independently associated with higher chemotherapy toxicity, treatment-related neutropenia, sepsis, and reduced overall survival across two of the included cohorts. The diagnostic tool employed is the single most consequential determinant of detected prevalence, and weight-based metrics alone are inadequate in populations with large solid tumours. Universal adoption of MUAC-based screening, development of a standardized and harmonized MUAC reference for children and adolescents older than five years, structured algorithm-guided nutritional intervention, and integration of socioeconomic vulnerability assessment into routine oncological care are evidence-based priorities for improving treatment tolerability and survival in this population.
Supporting information
S2 File. Database search strings.
Full search strategies for PubMed, Web of Science and EMBASE.
https://doi.org/10.1371/journal.pone.0353569.s002
(DOCX)
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