Helping Children Cope With Chemotherapy

This article offers practical hints for coping with treatment side effects that may affect your child's appetite.

These suggestions have helped other parents manage eating problems that can be frustrating to handle. Try all the ideas to find what works best for your child.

Loss of Appetite

Loss of appetite or poor appetite is one of the most common problems that occur with cancer and its treatment. Many things affect appetite, including feeling sick (nausea, vomiting) and being upset or depressed about having cancer. A child who has these problems, whether physical or emotional, may not be interested in eating. You may find the following advice helpful in making mealtimes more relaxed so that your child will feel more like eating.

• Make mealtimes calm and relaxed. Don't hurry meals.
• Encourage normal activities, but don't force them.
• Try changing the time, place, and surroundings of meals, once in a while. A picnic, even if it is in the house, can make mealtime more fun. Watching a favorite TV show or inviting a special friend to join your child at meal or snack time also can enhance willingness to eat.
• Let your child eat whenever hungry. A child does not need to eat just three main meals a day. Several smaller meals throughout the day may be even better. Sometimes having a regular schedule can help the body adjust to a new eating pattern. See what works best for your child.
• Praise good eating. Try using small rewards such as a favorite dessert or new toy, to encourage good eating.
• Avoid arguing, nagging, or punishing. Forcing a child to eat may make the situation worse.
• Offer food often during the day, even at bedtime. Have healthy snacks handy. Taking just a few bites of the right foods or sips of the right liquids every hour or so can help increase protein and calories.
• Ask your child's doctor about medicines that can improve appetite if the problem becomes serious.

Sore Mouth or Throat

Mouth sores, tender gums, and a sore throat may result from radiation therapy to the brain, head, or neck; chemotherapy; and/or infection. If your child has a sore mouth or gums, see the doctor to be sure the soreness is a treatment side effect and not an unrelated dental problem. The doctor may be able to give you medicine that will control your child's mouth and throat pain. A dentist also can give you tips for proper mouth care. (See "Tooth Decay" below for more suggestions.)

Certain foods will irritate an already tender mouth and make chewing and swallowing difficult. By carefully choosing foods and by taking good care of your child's mouth, you usually can make eating easier. Here are some suggestions that may help:

• Try soft foods that are easy to chew and swallow such as: ice cream, milkshakes, bananas, applesauce, and other soft fruits, peach, pear, and apricot nectars, watermelon, cottage cheese, mashed potatoes or macaroni and cheese, custards, puddings, and gelatin, scrambled eggs, oatmeal or other cooked cereals, pureed or mashed vegetables such as peas and carrot, pureed meats, liquids.
• Avoid serving your child foods that can irritate the mouth: citrus fruit or juices such as orange, grapefruit, or tangerine; spicy or salty foods such as potato chips; rough, coarse, or dry foods such as raw vegetables, crackers, or toast.
• Cook foods until they are soft and tender.
• Cut foods into small pieces.
• Mix food with butter, thin gravies, and sauces to make it easier to swallow.
• Use a blender or food processor to puree food.
• Give your child a straw for drinking liquids.
• Try serving foods cold or at room temperature. Hot and warm foods can irritate a tender mouth and throat.
• To make swallowing easier, have your child try tilting his or her head back or moving it forward.
• If teeth and gums are sore, the dentist may be able to recommend a special product for teeth cleaning.
• Have your child rinse his or her mouth often with water to help remove food and bacteria and to promote healing.
• Ask the doctor about anesthetic lozenges and sprays that can numb your child's mouth and throat during meals.

Changed Sense of Taste

Your child's sense of taste may change. Chemotherapy, radiation therapy, or the cancer itself may cause this problem, which sometimes is called mouth blindness. Some children complain of a bitter, metallic taste, especially when eating meat or other protein foods. They also may find that many foods have less taste. This is usually a short-term problem. Each person's taste may be affected differently. If there is a problem, take your child to the dentist to check for dental conditions that may affect food's taste. Ask the dentist about special mouthwashes and good mouth care.

You will need to learn which foods, if any, taste different to your child. Depending on how taste has been affected, some of the following ideas for improving flavor may work better than others.

• Choose and prepare foods that look and smell good.
• If red meat such as beef tastes unpleasant, replace with chicken, turkey, eggs, dairy products, or fish without a strong odor.
• Help the flavor of meat, chicken, or fish by marinating it in sweet fruit juices, Italian dressing, or sweet-and-sour sauce.
• Try using small amounts of flavorful seasonings such as basil, oregano, or rosemary.
• Try tart foods such as oranges or lemonade that may have more taste. A tart lemon custard might taste good and also will provide needed protein and calories. Do not try this if your child also has a sore mouth, throat, or gums.
• Try using bacon, ham, or onion to add flavor to vegetables.
• Stop serving problem foods.
• Try serving foods at different temperatures (cold, unheated, warm or hot) to see which preparation your child likes best. Warm or hot foods may have more flavor and taste than cold foods. However, do not serve warm or hot foods if your child has a sore throat, mouth, or gums; feels nauseated; or is vomiting.

Talk to your child 's doctor or registered dietitian if a sore throat, mouth, or gums makes eating difficult for your child. They can suggest ways to improve the taste of food without hurting the sore area.

Dry Mouth

Radiation therapy to the head or neck area, which can reduce the flow of saliva, often causes dry mouth. When this happens, foods are harder to chew and swallow. Dry mouth also can change the way foods taste. The suggestions that follow may be helpful in dealing with dry mouth. (Also, try some of the ideas for dealing with a sore mouth or throat)

• Try very sweet or tart foods and beverages such as lemonade; these foods may help the mouth produce more saliva. Do not try this if your child also has a tender mouth or sore throat.
• Have your child suck on sugar-free hard candy or popsicles or chew sugar-free gum, which also can help produce more saliva. Because some cancer treatments such as radiation therapy can increase the chance of tooth decay, sugar-free candies and gum usually are better than those with sugar.
• Fix soft and pureed foods, which may be easier to swallow.
• Keep your child's lips moist with lip salves.
• Serve foods with sauces, gravies, and salad dressings to make them moist and easier to swallow.
• Offer a sip of water every few minutes to help make it easier to swallow and talk.
• To lessen dry mouth, have your child try to breathe through his or her nose rather than through the mouth. If this is too difficult ask the doctor, nurse, or dentist for suggestions.
• If the dry mouth problem is severe, ask your doctor or dentist about products that coat and protect the mouth and throat.

Nausea

Nausea, with or without vomiting, is a common side effect of cancer treatment. The disease itself, or other conditions unrelated to cancer or treatment, may also cause nausea.

Whatever the cause, nausea can keep your child from getting enough food and needed nutrients. Here are some ideas that may be helpful:

• Ask your doctor about medicine to help control nausea. Medicines used to control nausea and vomiting are called antiemetics.
• Try foods such as: toast and crackers, yogurt, sherbet, pretzels, angel food cake, oatmeal, skinned chicken (baked or broiled, not fried), fruits and vegetables that are soft or bland such as canned peaches, clear liquids sipped slowly, sugar-free hard candies, popsicles, or ice chips.
• Avoid foods such as: fatty, greasy, or fried foods, very sweet foods, spicy, hot foods, foods with strong odors.
• Have your child eat small amounts of food frequently and slowly.
• Avoid serving meals in a room that is stuffy, too warm, or has cooking odors or scents that might be disagreeable.
• Offer liquids throughout the day, except at meal times. Liquids are filling and may reduce the appetite for solid foods. Some good choices include cooled, liquid, fruit-flavored gelatin and flat soda. Stir the soda until the fizz is gone before serving the drink to your child. Give your child a straw to make drinking easier.
• Serve beverages cool or chilled. Try freezing favorite beverages in ice cube trays.
• Serve foods at room temperature or cooler; hot foods may add to nausea.
• Don't force favorite foods during nausea attacks. It may cause a permanent dislike of those foods.
• Let your child rest after meals because activity may slow digestion. It's best to rest sitting up for about an hour after meals.
• If nausea is a problem in the morning, try serving dry toast or crackers while the child remains in bed.
• Make loose-fitting clothes available; they are more comfortable.
• Avoid giving food for 1 or 2 hours before treatment if nausea occurs during radiation therapy or chemotherapy.
• Try to keep track of the time when the nausea occurs and the causes of it (specific foods, events, surroundings). If possible, make appropriate changes in your menus or schedule. Share the information with your doctor or nurse.

Vomiting

Vomiting may follow nausea and may be brought on by treatment, food odors, gas in the stomach or bowel, or motion. In some children, certain surroundings such as the hospital may cause vomiting.

If vomiting is severe or lasts for more than a few days, contact your doctor.

Very often, if you can control nausea, you can prevent vomiting. At times though, you may not be able to prevent either nausea or vomiting. If vomiting occurs, try these hints to prevent further episodes:

• Ask your doctor about medicine to control nausea.
• Do not give your child anything to drink or eat until the vomiting is under control.
• Once you have controlled vomiting, offer small amounts of clear liquids (e.g., water, broth, milk-free ices and gelatin desserts, fruit drinks). Begin with 1 teaspoonful every 10 minutes; gradually increase the amount to 1 tablespoonful every 20 minutes; and finally, try 2 tablespoonfuls every 30 minutes.

Your child's doctor or nurse may suggest oral rehydration therapy to replace the water and important electrolytes lost as a result of vomiting. Solutions that contain sodium, potassium, chloride, and sugars may be used.

When your child is able to keep down clear liquids, try a full-liquid diet (e.g., strained cereal, pudding, yogurt, milkshakes, cream soups). Continue offering small amounts as often as your child can keep them down. If your child feels okay on a full-liquid diet, gradually work up to a regular diet.

Diarrhea

Diarrhea may have several causes, including chemotherapy, radiation therapy to the abdomen, infection, food sensitivity, and emotional upset.

Long-term or severe diarrhea may cause other problems. When diarrhea occurs, food passes quickly through the bowel before the body gets enough vitamins, minerals, and water. This may cause dehydration and increase the risk of infection. Contact your doctor if the diarrhea is severe. Here are some ideas for coping with diarrhea:

• Try foods that are high in protein and calories, but low in fiber: plain or vanilla yogurt without fruits; rice with broth; noodles; Farina or cream of wheat; eggs (cooked until the whites are solid; not fried); ripe bananas; canned or cooked fruit without skins; cottage cheese, cream cheese; chicken or turkey, skinned; tender or ground beef; or fish that is baked or broiled, not fried.
• Eliminate foods such as: greasy, fatty, or fried foods; raw vegetables and fruits; high-fiber vegetables, such as broccoli, corn, beans, cabbage, peas, and cauliflower; strong spices such as hot pepper, curry, and Cajun spice mix; high-sugar foods such as fruit-flavored gelatin desserts; caffeine-containing beverages such as coffee or cocoa; carbonated beverages.
• Offer small amounts of food and liquids throughout the day instead of three large meals.
• Serve plenty of liquids during the day, except at mealtimes because liquids are filling and may reduce the appetite for solid foods. Drinking fluids is important. The body needs water and fluids, and your child may lose a lot of fluids from diarrhea.
• Offer liquids at room temperature. Avoid serving very hot or very cold foods.
• Serve plenty of foods and liquids that contain sodium (salt) and potassium. These minerals often are lost during diarrhea. Good liquid choices include bouillon or fat-free broth. Foods high in potassium that don't cause diarrhea include bananas, peach and apricot nectar, and boiled or mashed potatoes.
• Do not give your child any antidiarrheal medicines without the doctor's okay-some of these products can actually make the diarrhea last longer.
• After sudden, short-term attacks of diarrhea (acute diarrhea), a clear-liquid diet may be helpful for the first 12 to 14 hours. This lets the bowel rest while replacing the important body fluids lost during diarrhea. Rehydrating solutions may be given to replace the water and important minerals lost as a result of diarrhea, especially if the diarrhea is severe or lasts for a few days or more. Ask your child's doctor or registered dietitian for guidelines.
• Be careful when using milk and milk products. Diarrhea may be caused by lactose intolerance. Ask the doctor or dietitian for advice if you think your child has this problem.

Constipation

Some anticancer drugs and other drugs such as pain medicines may cause constipation. This problem also may occur if the diet lacks enough fluid or bulk or if the child has been bedridden. Keep track of changes in your child's bowel movements; if there are no bowel movements for 48 hours, talk with the doctor or nurse.

Here are some suggestions to prevent and treat constipation:

• Serve plenty of liquids, except at mealtime. (Liquids are filling and may reduce the appetite for solid foods.) This will help to keep stools soft.
• Constipation may be more easily avoided or relieved if your child has a usual time for a bowel movement. The morning and the hour after meals are best. Offering a hot drink about 30 minutes before these times may help.
• Serve high-fiber foods such as whole-grain breads and cereals; brown rice; dried fruits such as raisins and prunes; and raw fresh vegetables and fruits such as cauliflower, potatoes with skin, peas, apples, pears, oranges, and berries.
• Keeping the skins on vegetables and fruits, whether raw or cooked, also will increase the amount of fiber in the diet.
• Add wheat bran to foods such as casseroles and homemade breads.
• When possible, encourage exercise. Talk to the doctor or a physical therapist about the amount and type of exercise that is right for your child.

If none of these suggestions work for your child, ask your doctor about medicine to ease constipation. Be sure to check with your doctor before giving your child any laxatives or stool softeners.

Weight Gain

Sometimes children gain excess weight during treatment without eating extra calories. For example, certain anticancer drugs such as prednisone, can cause the body to hold fluid and, thus, to gain weight. This buildup of excess fluids is called edema. The weight is in the form of water buildup and does not mean the child is eating too much.

It is important not to put your child on a diet if you notice weight gain. Instead, tell your doctor, so you can find out what may be causing this change. If anticancer drugs cause weight gain, the doctor may recommend limiting salt because salt causes the body to hold on to water. The doctor also may prescribe drugs called diuretics to get rid of extra fluid.

Tooth Decay

Cancer and cancer treatment can cause tooth decay and other problems such as infection for teeth and gums. Changes in eating habits also may add to the problem. When children eat often, or eat a lot of sweets, they may need to brush their teeth more often. Brushing after each meal or snack is a good idea. Regular check ups by the dentist should include a dental exam before cancer treatment begins, visits during the treatments, and followup visits afterward.

Here are some ideas to help prevent dental problems:

• Be sure to take your child to the dentist regularly. Patients who are receiving treatment that affects the mouth (e.g., radiation to the head and neck) may need to see the dentist more often than usual.
• Use a soft toothbrush or ask your doctor, nurse, or dentist to suggest a special kind of toothbrush and/or toothpaste. If your child's gums are very sensitive, clean the teeth with cotton swabs or mouthswabs made especially for teeth cleaning.
• Encourage rinsing the mouth with warm water when gums and mouth are sore.
• Avoid serving foods that stick to the teeth such as caramels or chewy candy bars.
• Encourage your child to eat sugar-free candy, gum, and desserts because they lower the chance of tooth and gum decay.

Lactose Intolerance

Lactose intolerance means that the body cannot digest or absorb the milk sugar called lactose. Milk, other dairy products, and foods to which milk has been added contain lactose.

Cells in the intestine normally produce an enzyme that breaks down the lactose in dairy products. However, most types of cancer treatment affect the cells in the intestine and the rest of the digestive tract. As a result, many people who had no problem digesting milk and dairy products before being treated for cancer, find it difficult to eat or drink these foods during, and sometimes after, their treatment.

If your child has this problem, your doctor may suggest that you offer a diet that contains lactose-free or low-lactose foods. You can buy lactose-free milk, or you can have your child take liquid drops or caplets that will help break down the lactose in milk and other dairy products. Ask your child's doctor, nurse, or dietitian about these products.

If milk had been a main source of protein in your child's diet, it will be important to substitute other sources of protein. Soybean formulas and aged cheeses are good protein sources. The registered dietitian at the hospital can help you plan meals that provide enough protein.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.