Feeding and Appetite Changes in Childhood Cancer

"He won't eat" is a symptom, not a cause. NCI lists several reasons a person stops eating during cancer treatment: fatigue, pain, medicines, and feelings such as stress, fear, depression and anxiety. Side effects such as nausea, vomiting, constipation, or changes in how food tastes or smells can also get in the way. Treatments can cause mouth sores too.

So the first question at clinic is not "what should he eat." It is "why isn't he eating?" A mouth full of sores needs a different answer than a child who is frightened of vomiting again.

NCI advises gentle support rather than pushing someone to eat. Its booklet suggests 5 or 6 small meals or snacks each day instead of 3 large meals. It also says not to skip meals and snacks, even without hunger, because an empty stomach can make nausea worse.

A protein shake, smoothie or milkshake can help when eating is hard. Keep snacks nearby for when your child feels like eating.

Mouth sores. NCI says treatments can harm the lining of the mouth. It suggests soft, moist foods that are easy to swallow, cold or room-temperature food, and ice chips. Moisten food with sauce, gravy or broth. Avoid citrus, spicy, sour, salty and hard foods. NCI also suggests checking the mouth every day and rinsing 3 to 4 times a day. Its example rinse is 1/4 teaspoon of baking soda and 1/8 teaspoon of salt in 1 cup of warm water, followed by a rinse with plain water. Ask the care team what rinse they recommend. Tell them about any sores or white patches.

Taste changes. NCI suggests trying chicken or turkey if beef tastes or smells strange. It also suggests marinating meat, chicken or fish.

Nausea. NCI suggests bland, easy foods such as bananas, rice, applesauce and toast. Crackers or pretzels with morning medicines can help with morning nausea, unless the medicines must be taken on an empty stomach. Eat 5 or 6 small meals a day. If vomiting is severe or lasts more than 1 or 2 days, call the doctor. Tell them if your child cannot keep liquids down.

Dry mouth. NCI suggests plenty of fluids and moistening food with sauce or gravy. Ice chips, popsicles, frozen fruit, and sugar-free gum or hard candy help make saliva.

Constipation. NCI suggests warm or hot liquids and high-fiber foods such as whole grains, dried fruit, and cooked dried beans or peas. Tell the doctor or nurse if there has been no bowel movement in 2 to 3 days. Do not use a laxative, stool softener, fiber supplement or enema without asking first.

Diarrhea. NCI suggests plenty of fluids to prevent dehydration and 5 or 6 small meals a day. Talk with a dietitian about which foods to eat and avoid. NCI says dehydration from diarrhea can be life-threatening, so tell the doctor or nurse if your child has diarrhea.

When a child will only eat a small amount, add calories and protein. NCI suggests milkshakes and smoothies made with dry milk powder or protein powder. Ask for the dietitian by name. Pediatric oncology dietitians can work out what your child needs.

When treatment lowers white blood cells, ordinary foodborne germs become dangerous. The FDA's guidance for people with cancer names specific things to drop:

• Unpasteurized milk, and soft cheeses made from raw milk such as feta, brie, camembert, blue-veined cheeses, and queso fresco. Pasteurized milk and hard cheeses, cream cheese, and mozzarella are the safer swaps.
• Raw or undercooked eggs. Use pasteurized eggs in recipes that call for raw egg.
• Raw or undercooked meat and poultry.
• Raw fish and shellfish, sashimi, ceviche, and refrigerated smoked fish.
• Unwashed vegetables and raw sprouts.
• Cold deli meats and hot dogs, unless reheated to steaming hot, meaning 165 °F.

The FDA's safe cooking temperatures are worth taping inside a cabinet: ground beef 160 °F, all poultry 165 °F, egg dishes 160 °F, and fin fish 145 °F. Use a food thermometer rather than judging by color.

If nausea, vomiting, constipation or taste changes are stopping your child from eating, ask the oncology team what can help. Do not start a medicine, supplement or laxative on your own.

NCI says that sometimes a person cannot eat enough to stay strong, and a feeding tube may be a good option. Your child's doctor or dietitian will talk with you about it. A feeding tube is a tool, not a failure.

• Call 911 or go to the nearest emergency department if your child is confused or hard to wake, faints, has no urine at all, or has a rapid heartbeat or fast breathing. MedlinePlus says to get medical help right away for these signs of severe dehydration (MedlinePlus: confusion; MedlinePlus: dehydration). Do not drive yourself.
• Call the oncology team right away, day or night, if your child has signs of dehydration. In infants and young children, MedlinePlus lists no wet diaper for 3 hours or more, crying without tears, dry mouth and tongue, sunken eyes, unusual sleepiness, and irritability.
• Call the oncology team right away if your child is vomiting and cannot keep down fluids or medicines. NCI says the doctor needs to know if your child cannot keep liquids down. If your child is on chemotherapy, CDC lists vomiting as a sign of infection to report right away (CDC).
• Call the oncology team right away, day or night, if your child is on chemotherapy and has a temperature of 100.4 °F (38 °C) or higher. CDC says to call your doctor right away, and warns that an infection during chemotherapy can be life-threatening. If you cannot reach the team, go to the nearest emergency department and tell the staff your child is having chemotherapy. If your team gave you a different number, use theirs.
• Call the oncology team right away, day or night, if your child is on chemotherapy and has chills, a sore throat, mouth sores, burning when passing urine, or redness or swelling where a catheter enters the body. Do this even without a fever. A normal temperature is not a reason to wait.
• Call the oncology team the same day if your child is losing weight quickly, is newly weak, or has changes in mood or behavior.

For symptom-specific help, see Eating When You Have No Appetite, Eating When Food Tastes Different, and Eating with Mouth Sores. For tubes, see Feeding Tube Basics During Cancer Treatment. Also useful: Childhood Cancer Scans and Scanxiety and Fertility Questions for Childhood Cancer Survivors.

• Eating Hints: Before, During, and After Cancer Treatment, National Cancer Institute
• Food Safety for Older Adults and People with Cancer and Other Conditions, U.S. Food and Drug Administration
• Food Safety for People with Cancer (booklet PDF), U.S. Food and Drug Administration
• Dehydration, MedlinePlus, National Library of Medicine
• Watch Out for Fever, Centers for Disease Control and Prevention
• Infection and Neutropenia during Cancer Treatment, National Cancer Institute
• Diarrhea and Cancer Treatment, National Cancer Institute