Symptoms

Cancer treatment can cause inflammation in your child’s mouth and throat. The mucous membranes may become damaged, making the mouth and throat sore and sensitive. This can make eating and drinking difficult for your child. Although certain foods won’t make the pain go away, there are several adjustments that can make eating and drinking less painful.

Ask your doctor about medication for mouth pain.

Depending on your child’s symptoms, the doctor can determine which medication is most suitable.

Try ice chips or ice water
These can help relieve pain, unless cold foods or drinks cause extra discomfort.

Avoid foods that cause pain

Let your child try what works and what doesn’t. Avoid foods that cause discomfort or replace them with alternatives. Rinsing the mouth with water may also help reduce pain.

If sour dairy products (such as buttermilk, yogurt, cream yogurt, yogurt drinks, quark, or whey drinks) are painful, try neutral or sweet dairy options instead—like milk, chocolate milk, vanilla pudding, chocolate pudding, whipped cream, sweet milk products, or coffee or tea with plenty of milk.

Fruit and fruit juices like apple juice, grape juice, orange juice, or grapefruit juice can sting because of their natural acids. Adding cream or dairy to acidic foods can make them milder—for example, pudding with fruit. Fruits with a softer taste include banana, strawberry, cherry, apricot, plum, peach, and nectarine.

Avoid spicy or salty foods

Skip very salty foods such as smoked meats or fish, broth, salted snacks, chips, peanuts, and salty licorice. Highly seasoned dishes can also make mouth pain worse. Mild herbs like parsley, oregano, dill, chervil, thyme, and watercress are usually well tolerated.

Avoid hard foods

Hard foods like nuts, hard fruit, crackers, raw vegetables, crusts, and crispy dishes can be painful. You can soften foods such as crackers or bread crusts by dipping them in tea, milk, broth, or soup.

Avoid very hot foods and drinks

Let your child experiment with different temperatures to find what feels most comfortable. Warm dishes are often more painful, while room-temperature foods are usually easier to tolerate. Some children prefer cold foods or drinks, but not always.

Use a short straw

A short, wide straw can help reduce contact between food or drink and sore spots in the mouth. Cut the straw shorter so that your child doesn’t have to suck as hard.

Take good care of your child’s mouth

For children without teeth:
Clean the mouth twice a day using water and a cotton swab or gauze.

For children with teeth:
Brush twice a day with fluoride toothpaste.

Use fluoride toothpaste for toddlers up to age 5.

Children aged 5 and older can use regular fluoride toothpaste.
If your child uses fluoride toothpaste, extra fluoride tablets are not needed.

Brush gently in the morning and before bedtime with a soft toothbrush, especially along the gum line. Even if the gums bleed, continue brushing. Rinse the toothbrush well after use, store it upright to dry, and replace it when the bristles start to spread.

Sugar-free chewing gum can help stimulate saliva production, especially for children who are already used to chewing gum.

If brushing is too painful, have your child rinse their mouth with water or mouthwash. After vomiting, rinse the mouth with tap water.

Care for your child’s lips

Apply lip balm regularly to prevent dry lips. The lip balm should be used by your child only.

Try soft, smooth, or liquid foods

Soft or blended foods can be more comfortable for a sore mouth, but try not to switch too quickly. Chewing has benefits—it stimulates saliva production, which can help with a dry mouth, and improves the sense of taste.

Let your child chew sugar-free gum or pieces of cucumber, or suck on a popsicle, candy, or mint to help produce more saliva.

If your child does better with soft, blended, or liquid foods, check out these articles:

Nutrition tips for soft foods

Nutrition tips for blended foods

Nutrition tips for liquid foods

Use medical nutrition if needed

Sometimes, medical nutrition with extra protein and calories is needed if your child can’t eat enough because of mouth pain. These products include powders, drinks, soups, and desserts. The dietitian will advise which products are best for your child and arrange the order and insurance coverage.

If your child’s mouth or throat is too inflamed to eat or drink normally, it may be necessary to start tube feeding or TPN (total parenteral nutrition), which provides nutrients directly into the bloodstream through an IV. Tube feeding can supplement or completely replace regular food. This will be discussed with your child’s doctor or dietitian.

Damaged and inflamed mucous membranes are also called mucositis. This condition can occur in different parts of your child’s body. Mucositis often affects the mouth and throat, but it can also appear in the gastrointestinal tract.

What causes damaged mucous membranes?

Chemotherapy not only targets cancer cells, but also healthy cells in the body. It particularly affects cells that divide quickly, such as those in the mucous membranes of the mouth, esophagus, and intestines. This can lead to inflammation of the mucous membranes.

Radiation therapy can also damage these cells, which may cause inflammation in the mouth, throat, or gastrointestinal tract. Mucositis is a common side effect. When chemotherapy and radiation are given together, inflammation may last longer than when either treatment is given alone.

Pain caused by inflamed mucous membranes

Damaged mucous membranes are painful, which can make eating and drinking difficult for your child. The pain may become so severe that your child refuses to eat. Talk to your doctor and dietitian—they can help manage the symptoms and provide pain relief or nutrition support.

Abdominal symptoms caused by mucositis in the gastrointestinal tract

Chemotherapy and radiation can damage the mucous membranes in the gastrointestinal tract. This can cause uncomfortable symptoms such as nausea, bloating, stomach pain, constipation, or diarrhea. Discuss these symptoms with your doctor and dietitian. They can help, for example by prescribing medication or adjusting your child’s diet.

What can I do to help my child?

Try these resources and practical tips, you find them below on this page:

• Advice for a sore mouth

• Advice for nausea

• Advice for diarrhea

Sources

• Vogel, J., Beijer, S., Delsink, P., Doornink, N., ten Have, H., & van Lieshout, R. (2016). Handbook of Nutrition in Cancer Care. Second revised edition. Utrecht: De Tijdstroom.

• Havermans, R., & Hendriks, A. (2018). Why children with cancer eat too little. Ned Tijdschr voor Voeding & Diëtetiek, 73(4), 42–44.

There is not enough evidence that glutamine helps prevent or reduce mucositis (inflammation of the mucous membranes) during cancer treatment. In addition, we do not yet know whether glutamine is safe to use during chemotherapy. Therefore, the advice is not to give your child any glutamine supplements during cancer treatment.

Chemotherapy and radiation can damage the lining of the gastrointestinal tract. These damaged areas can become inflamed, a condition called mucositis. Depending on the location and severity of the inflammation, this can cause mouth pain, stomach pain, swallowing problems, and diarrhea.

What is glutamine?

Glutamine is an amino acid, which is one of the building blocks of proteins. It plays an important role in maintaining and repairing the gastrointestinal tract. For example, glutamine helps the epithelial cells (the cells that form the mucous membranes) perform their protective functions. Glutamine is also used by the body for cell division. Because cancer cells divide quickly, glutamine is used up more rapidly, which means people with cancer can develop a glutamine deficiency.

What does research show?

Studies in children with cancer
Several small studies have looked at the effects of glutamine in children with inflamed mucous membranes, but they were all conducted in different ways. Much remains unclear, and it is not yet possible to make clear recommendations. More research is needed, especially to determine whether glutamine is safe for children.

Glutamine during chemotherapy
There is still not enough known about the effects of glutamine during chemotherapy. For this reason, the use of glutamine during chemotherapy is not recommended.

Our advice

There is not enough research evidence to show that glutamine helps treat mucositis in children with cancer. We also do not yet know whether glutamine supplements are safe to use during chemotherapy. Do not give your child glutamine supplements during cancer treatment.

If you have any doubts or questions, always discuss them with your child’s treating physician.

Sources

• Aquino, V. M., Harvey, A. R., Garvin, J. H., Godder, K. T., Nieder, M. L., Adams, R. H., Jackson, G. B., & Sandler, E. S. (2005). A double-blind randomized placebo-controlled study of oral glutamine in the prevention of mucositis in children undergoing hematopoietic stem cell transplantation: a pediatric blood and marrow transplant consortium study. Bone Marrow Transplant, 36(7), 611–616.

• Caselin-García, M. R., Stein, K., Kumazawa-Ichikawa, M. R., González-Ramella, O., Vásquez-Garibay, E. M., Gallegos-Castorena, S., ... & Sánchez-Zubieta, F. (2013). Glutamine: Beneficial to prevent oral mucositis in Mexican children with acute lymphoblastic leukemia? Journal of Hematological Malignancies, 3(1), 49.

• Uderzo, C., Rebora, P., Marrocco, E., Varotto, S., Cichello, F., Bonetti, M., Maximova, N., Zanon, D., Fagioli, F., Nesi, F., Masetti, R., Rovelli, A., Rondelli, R., Valsecchi, M. G., & Cesaro, S. (2011). Glutamine-enriched nutrition does not reduce mucosal morbidity or complications after stem-cell transplantation for childhood malignancies: a prospective randomized study. Transplantation, 91, 1321–1325.

Nausea can have several causes. It may be a side effect of the illness itself or of treatment, such as chemotherapy or radiation. Certain medicines, such as painkillers, can also cause nausea.

Food is usually not the cause of nausea. However, nausea can make your child eat less. To help your child still get enough to eat and drink, you can try the following tips:

• Let your child eat and drink at times when they feel less nauseous. If the nausea is severe, take a short break from eating.

• Offer small, light meals or snacks more often instead of large meals.

• Choose cold dishes or let food cool down first. Cold food is often better tolerated than warm food.

• Make sure your child always has something in their stomach. An empty stomach can make nausea worse. In the morning, it can help to eat something light such as toast, crackers, or a breadstick.

• Let your child suck on an ice cube, chewing gum, popsicle, or soft fruit pieces. Sucking stimulates saliva production, which helps prevent a dry mouth and unpleasant taste.

• Try ginger tea or peppermint to help calm your child’s stomach and reduce the feeling of nausea. Ginger and peppermint cannot prevent or completely stop nausea, but they may help ease it.

• Ensure your child drinks enough fluids. Dehydration can make nausea worse. You can check hydration by the color of your child’s urine—dark urine means not enough fluids.

• See whether carbonated drinks help. The bubbles can help your child burp and relieve pressure in the stomach, which may reduce nausea. Make sure drinks aren’t too cold, as this can cause stomach discomfort.

• Avoid foods that may make nausea worse, such as fatty foods, snacks, and strongly spiced or aromatic dishes.

• Make sure the room has plenty of fresh air and try to keep your child away from strong food smells.

• Remove leftover food and drinks from your child’s sight to prevent nausea from getting worse.

• Have your child sit upright during and for about half an hour after meals. This helps food settle better.

• Create a calm eating environment. Anxiety or excitement can increase nausea, while relaxation and distraction can help reduce it.

• Don’t force your child to eat.

• Talk to your doctor to see if anti-nausea medication might help your child.

Diarrhea can be caused by chemotherapy or radiation. These treatments can irritate the lining of the intestines, leading to diarrhea. In most cases, food is not the cause. However, diarrhea can prevent your child’s intestines from properly absorbing nutrients. It’s important to keep eating as well as possible, even if that means smaller portions.

There are no foods that can stop diarrhea. For a long time, it was thought that foods such as banana, white bread, toast, white rice, grated apple, or cinnamon could help stop diarrhea, but this has not been proven.

Good nutrition can, however, help prevent the diarrhea from getting worse.

If the diarrhea lasts for a longer period, talk to your child’s doctor to see if medication might help.

Tips

Maintain a normal eating pattern
Try to help your child eat as normally as possible. It doesn’t help to eat less or to fast. Because food moves more quickly through the intestines during diarrhea, your child has less time to absorb nutrients. If possible, it’s actually good for your child to eat a bit more than usual.

Make sure your child drinks enough
Keep your child well hydrated to prevent dehydration. All fluids count. Drinking may be difficult at first because your child may not feel thirsty, so encourage small sips throughout the day.

Avoid sweeteners
Do not give your child products containing sorbitol, as this can worsen diarrhea. Sorbitol is often found in chewing gum, throat lozenges, candies, diet sodas, cakes, and cookies. Always check the packaging to see if a product contains sorbitol.

Limit fruit juice
Undiluted fruit juices like apple, pear, or grape juice contain a lot of fructose (fruit sugar), which can have a laxative effect. You can offer diluted juice instead—for example, mix one glass of juice with plenty of water and divide it into several portions throughout the day.

Limit sweet milk products
Give your child milk, pudding, or porridge no more than two or three times a day. These foods contain lactose (milk sugar), which can be harder to digest during diarrhea.

Sour milk products, such as buttermilk and yogurt, are easier to digest because they contain less lactose. These are therefore a better choice.

If your child is receiving medical or tube feeding, this usually isn’t a problem, as those feeds contain little lactose. Sometimes the tube feeding needs to be temporarily adjusted—for example, to a formula like Peptisorb. The proteins in this formula are already partially digested, making it easier to absorb. In that case, the feeding may also be given continuously (slowly throughout the day) instead of in portions.

Avoid irritating foods
Foods like legumes, onions, and spicy herbs can irritate the intestines. Carbonated drinks may also have a stimulating effect on the gut.

Replace salt losses
During diarrhea, the stool contains extra salt (sodium), which means your child loses more salt. Replace this by offering soups or broths, savory spreads such as cold cuts and cheese, or snacks like crackers and chips.

Include fiber
Make sure your child gets enough fiber. Dietary fiber absorbs water in the intestines and helps create softer, more regular stools. Choose gentle fibers such as those in fine whole-grain bread, potatoes, and fruit. These fibers don’t irritate the intestines.

Offer small portions
Serve small meals more frequently rather than large ones. Smaller portions are easier to digest and less likely to stimulate the intestines.

Avoid probiotics during cancer treatment
When diarrhea is caused by antibiotics, probiotics (drinks or capsules containing live bacteria that may support gut health) are sometimes recommended. However, during cancer treatment, this is not advised. There is no research yet on the effects of probiotics in children with cancer, and in adults with reduced immunity, probiotics are not always safe.

Constipation is a common problem in children with cancer. It is also called obstipation or difficulty passing stool. Constipation means that it’s hard for your child to have a bowel movement. This usually happens because the stool becomes dry and hard, or because it moves too slowly through the intestines.

Constipation can have several causes. It may occur when your child:

• takes medicines that affect bowel movements

• is less active

• eats or drinks less

• eats too little fiber

• doesn’t drink enough fluids

• has a narrowing in the intestine, for example due to a tumor or surgery

Constipation can also cause stomach pain and a reduced appetite. If your child is constipated, the doctor may prescribe a laxative. During chemotherapy, a laxative is often prescribed as a preventive measure. The following nutrition tips can help relieve or prevent constipation.

Note: If constipation is caused by a tumor that partly blocks the stomach or intestines, the advice below does not apply. In that case, always ask your doctor or dietitian for personalized advice.

Nutrition tips

Make sure your child drinks enough
Drinking plenty of fluids helps keep stool soft and easy to pass. Fluids don’t only come from water, but also from other drinks such as tea, milk, or coffee (for older children). Foods like soup, pudding, and yogurt also count.
The combination of fiber and fluids is especially important. [See also: article on fluids]

Make sure your child eats enough fiber
Fiber, together with enough fluids, helps keep stool soft and supports regular bowel movements. Fiber also stimulates the intestines to stay active.
Foods that contain fiber include whole-grain bread, vegetables, (dried) fruit, nuts, seeds, and kernels. [See also: article on fiber]

Make sure your child eats breakfast every day
The intestines are less active at night. Eating breakfast helps “wake them up” and get things moving again.
A good breakfast might include a bowl of yogurt or quark with fruit and muesli, or one to two slices of whole-grain bread with toppings, along with a drink such as milk, water, or tea.

Encourage your child to be active
Physical activity - like walking, cycling, or playing outside - helps the intestines move. This makes it easier for stool to pass through, which can help relieve constipation.

Create a calm environment
Make sure your child has a calm, private environment where they can relax and take their time to go to the toilet. Reading a book or listening to music can help your child feel more at ease.

Ask for help
If constipation does not improve, ask your doctor for advice.

Many children notice that their sense of taste changes during treatment, and some also find that smells seem different. This can be unpleasant and make it harder to eat well.

How taste and smell change differs from child to child. Some children no longer taste much, others find flavors much stronger, and some say food tastes different from before treatment. Many children develop a preference for savory or salty foods and dislike sweet foods. Children who notice a change in smell usually don’t lose their sense of smell, but become more sensitive to odors.

Causes

Changes in taste and smell can be caused by the illness or by treatment. Chemotherapy can damage taste and smell cells and may also cause sores in the mouth. Infections, a dry mouth, and certain medicines can also change taste.

Most changes in taste and smell go away after treatment, though it can take time. How long it lasts varies for each child.

What can you do?

For children, it can be confusing when food suddenly tastes different, and for parents, it can take time to find out how to best support their child. These tips may help.

Taste and smell can even vary from day to day, so keep trying different foods and offer plenty of variety.

If your child tastes less

• Add flavor to porridge, yogurt, or oatmeal with cinnamon or gingerbread spices.

• Try savory spreads or toppings such as pesto, mustard, piccalilli, or sambal, or make a grilled cheese sandwich.

• Add fresh herbs or strong spices like basil, cinnamon, ginger, chili, garlic, or mint.

• Use sauces or dressings with a fresh or strong flavor, such as lemon or lime juice, balsamic vinegar, mustard, ketchup, mayonnaise, chili sauce, sambal, piccalilli, or yogurt.

• Add something crunchy or fresh to dishes, such as raw onion, crispy fried onions, croutons, cucumber strips, capers, pickles, or pearl onions.

• Offer vegetables with a strong flavor, such as fennel, celery, celeriac, onion, bell pepper, or tomato.

• Serve vegetables, raw vegetables, or bread with a dip such as salad dressing, hummus, tzatziki, guacamole, or cocktail sauce.

If your child tastes flavors more strongly

• Offer foods with a mild flavor, such as:

  • Bread, toast, or crackers (like crispbread or cream crackers)

  • Yogurt, milk, mild cheese, or cream cheese

  • Boiled potatoes, mashed potatoes, rice, or pasta

  • Mild vegetables such as cucumber, carrot, cauliflower, or peas

  • Chicken or egg instead of red meat

• Avoid adding salt, pepper, or spicy herbs.

• Cook meat, fish, chicken, or meat substitutes in neutral oils, such as mild olive oil or sunflower oil.

• Avoid foods with strong smells.

• Serve food cold or at room temperature—it will have a milder taste and smell.

If your child says food tastes very different

• Reintroduce foods your child used to dislike after some time—tastes can change, and they may enjoy them again later.

• Try new foods or recipes.

• Combine flavors—for example, use herb butter instead of regular butter on bread with cheese.

• Fresh vegetables and fruit often taste better than canned or frozen varieties.

• Keep a food list together with your child to track what tastes good and what doesn’t.

If your child has a bad taste in their mouth

• Take good care of oral hygiene.

• Sipping water or lemonade throughout the day can help.

• Let your child suck on a mint, candy, or lollipop, especially after flushing a line or VIT.

If your child is sensitive to food smells

• Avoid cooking near your child.

• Serve food cold or at room temperature—it will smell less intense.

• Try meals like salads, cold soups, or smoothies made from frozen fruit.

• Drinks smell and taste less strong when served with a covered cup and a straw.

If your child prefers savory foods

• Offer savory snacks such as rice crackers, pretzel sticks, nuts, peanuts, corn puffs, salted popcorn, or rice cakes (limit fatty chips).

• Alternate bread with something crunchy like crackers, toast, or rice cakes.

• Add flavor with smoked ham, crisped salami, smoked chicken, bacon, anchovies, or (Parmesan) cheese to dishes like mashed potatoes, pasta, soups, or salads.

• Use a splash of low-salt soy sauce or ketjap, or herbs such as parsley or chives instead of salt.

• Try dishes with an umami flavor (savory and rich in protein) such as fried rice, noodles, or miso soup.

Because of cancer and its treatment, your child’s metabolism changes. As a result, your child may have less appetite and feel full quickly after eating. A reduced appetite can also be caused by tension, anxiety, or fatigue. Other symptoms such as nausea or changes in taste can also make your child less interested in food.

Tips for a reduced appetite

• Offer several small meals throughout the day.
  Try giving 6–7 small meals instead of three large ones. Sometimes, just the thought of finishing a full plate can already feel stressful.

• Choose foods rich in energy and protein.
  If your child can only eat small amounts, make sure each bite counts. Good options include whole dairy products, cheese, cold cuts, richly topped bread or crackers, and adding a bit of (olive) oil, butter, or crème fraîche to warm meals.

• Focus on what your child enjoys.
  Talk with your child about which foods they like and which are nutritious too. Keep those foods in the house so your child can decide what to eat when they feel up to it.

• Try smoothies.
  Drinking may sometimes be easier than eating. You can make a smoothie with quark or yogurt, fruit, and a bit of oatmeal or peanut butter for extra energy and protein.

• Avoid sweets and sugary drinks before meals.
  Candy, juice, chocolate milk, or lemonade can make your child feel full and reduce appetite during meals.

• Avoid drinking during meals.
  Drinking while eating can cause a feeling of fullness. Encourage your child to drink enough between meals instead.

• Create a calm and pleasant mealtime atmosphere.
  Help your child relax before meals—some children benefit from rest, while others prefer to get some fresh air or move around first.
  For some, eating in a quiet space helps, while others eat better with some distraction, such as listening to music, watching TV, or talking with family or friends.

• Avoid mealtime struggles.
  Arguing about food can make eating even harder and create a negative association with meals.

• Make food visually appealing.
  Use a fun plate, colorful food, or a cute straw. For older children, set the table nicely and present the food attractively—using different colors of vegetables can make the meal more inviting.

• Involve your child in cooking.
  Some children are more eager to eat when they’ve helped prepare the meal.

• Pay attention to posture.
  Sitting upright while eating helps food move down more easily and reduces the feeling of fullness.

If these tips don’t help, or if you’re worried that your child isn’t eating enough or is losing too much weight, ask a dietitian for personal advice.

Source

Vogel, J., Beijer, S., Delsink, P., Doornink, N., ten Have, H., & van Lieshout, R. (2016). Handbook of Nutrition in Cancer Care. Second revised edition. Utrecht: De Tijdstroom.

Cancer and its treatment place a high demand on your child’s body. Your child may have little appetite or may not be able to eat well for other reasons. This can lead to eating too little, even though the body needs extra energy and nutrients such as protein. That’s why it’s important for your child to eat enough and choose the right foods.

This list shows foods that can help your child get enough protein and energy.

Every child has their own eating habits, preferences, and tastes. Choose foods your child enjoys. If your child follows a special diet or certain foods cause discomfort, those foods can be avoided.

Breakfast

• full-fat quark, full-fat yogurt, or Greek yogurt (10% fat) with muesli or granola

• oatmeal or hot cereal made with whole milk

• smoothie made with quark or yogurt, oatmeal, and fruit

• bread, crispbread, or crackers generously spread with butter or margarine and topped thickly or twice

• American-style pancakes made with whole milk

• French toast made with egg and whole milk

Lunch

• bread or crackers generously spread with butter or margarine and topped thickly or twice

• pancakes or small Dutch pancakes with bacon and/or cheese, nut butter, or syrup

• quark with fruit

• hearty soups such as pea soup, soup with meatballs, bean soup, or peanut soup

• grilled ham-and-cheese sandwich with ketchup or curry sauce

Toppings and spreads

• High in energy: butter, margarine, jam, sprinkles, honey, chocolate spread

• High in energy and protein: full-fat cheese, cold cuts such as ham and sausage, small sausages, oily fish (salmon, mackerel, herring), fish salad, avocado, cooked egg, peanut butter or other nut spreads, cream cheese with herbs, ready-made salads such as egg salad or chicken curry salad

Drinks

• whole milk

• chocolate milk

• full-fat drinking yogurt

• fruit juice

Hot meal

• Meat, oily fish, or a vegetarian substitute with potatoes, rice, pasta, or couscous and vegetables other options: eggs, legumes, tempeh, or tofu.

  Tip: add extra energy with mayonnaise or another sauce on potatoes, a drizzle of olive oil over pasta, rice, or potatoes, or melted cheese on vegetables.

• Hearty soups: pea soup, soup with meatballs, bean soup, or peanut soup
  Tip: add a splash of cream, crème fraîche, or olive oil for extra energy.

Savory snacks

• cubes of cheese, pieces of sausage, cold cuts, herring, or salad spread

• boiled egg, muesli roll (with butter, margarine, or cheese), cheese dippers, cheese roll, sausage roll

• nuts, crackers with salad spread or cream cheese

Sweet snacks

• full-fat quark, full-fat yogurt, or Greek yogurt with a splash of lemonade syrup

• custard

• smoothie with fruit, quark, yogurt, or ice cream

• cake, muffin, cookie, or banana bread with peanut butter

If your child is unable to eat enough, medical nutrition drinks can help provide the necessary energy and nutrients.

Click here for more recipes.