Nutrition for Children with Cancer

Receiving adequate nutrition is important for all children to help them grow and stay healthy. However, consuming sufficient calories and protein is more important for children with cancer since the disease typically increases their nutritional needs. But since every child is unique and tolerates treatment differently, the child's healthcare team will individualize the nutrition plan. A dietitian can determine your child’s specific calorie and protein needs.
Children with cancer need proper nutrition to:

• Continue to grow and heal.
• Better tolerate chemotherapy or radiation and experience fewer side effects.
• Maximize quality of life.
• Gain, maintain, or lose only a minimal amount of weight.

Following a high-protein and high-calorie diet

The treatment of cancer can be difficult for individuals of any age. It is important that children with cancer receive supportive care from the entire healthcare team, such as physicians, dietitians, and child life therapists, to make the nutritional aspects of treatment less difficult. Suggestions such as creating a child-centered environment, making tasty high-calorie snacks, and offering alternatives to oral nutrition are all part of supportive care. If your child is having trouble eating enough calories and protein, your child’s physician or dietitian may suggest serving a high-calorie and high-protein diet. This will ensure that each bite has the highest nutritional value possible.

Foods high in protein include:

• meats - such as beef, chicken, fish, turkey, and lamb
• milk, cheese, eggs - including cottage cheese, yogurt, and cream cheese
• peanut butter

Puddings and yogurts packed for children typically contain high amounts of protein and are often appealing to your child. Dried beans and peas are also high in protein, but because they cause gas they may not be the best food choice for your child.

Listed below are foods to use to add calories and protein to your child’s meals and snacks:

• Add powdered milk (adds 33 calories and 3 grams protein per tablespoon):
  • to foods and beverages.
  • to puddings, potatoes, cream soups, ground meats, vegetables, cooked cereal, milkshakes, yogurt, and pancake batter.
• Add eggs or egg substitute (adds 80 calories and 6 grams protein per egg):
  • to casseroles, meat loaf, mashed potatoes, cooked cereal, macaroni and cheese, and chicken or tuna salads.
  • to French toast and pancake batter. Add more eggs than you normally would.

Egg Beaters® add 25 calories and 5 grams protein per 1/4 cup. Do not use raw eggs or egg substitutes in uncooked items.

• Add butter or margarine (45 calories and 0 grams protein per teaspoon) to puddings, casseroles, sandwiches, vegetables, cooked cereals, breads, and pasta.
• Use cheese (100 calories and 7 grams protein per ounce) as tolerated:
  • as snacks, or on sandwiches. String cheese can be fun for kids to eat.
  • in casseroles, potatoes, vegetables, and soups.
• Add wheat germ (25 calories and 2 grams protein per tablespoon):
  • to hot cereals.
  • to meat dishes, cookie batter, and casseroles.

Wheat germ is fiber. It is okay as long as the child’s gastrointestinal condition does not preclude its use. It should only be taken orally - not in a tube feeding. To determine the amount of fiber your child needs per day, consider their “age plus 5.” For example, if child is10 years old the recommendation would be 15 grams of fiber per day. Fiber should be encouraged especially if cancer drugs are constipating or the child is not very active.

• Add mayonnaise or salad dressing (45 calories and 0 grams protein per teaspoon) liberally to sandwiches, salads, and as a dip for raw vegetables, or add a ranch, Italian or oil/vinaigrette dressing as a sauce on cooked vegetables.
• Add whole milk (150 calories and 8 grams protein per cup) to desserts, baked goods, meat dishes, and cooked cereal.
• Add sour cream (26 calories and 0 grams protein per tablespoon) to:
  • potatoes, casseroles, and dips.
  • sauces and baked goods.
• Add sweetened condensed milk (60 calories and 1 gram protein per tablespoon) to:
  • pies, puddings, and milkshakes.
  • 1-2 tablespoons of peanut butter and spread on toast.
• Use peanut butter (95 calories and 4 gram protein per tablespoon) on toast, bagels, crackers, bananas, apples, and celery. Put it on pretzel rods for peanut butter to go, or even spread it on a tortilla for a new twist to the traditional peanut butter and jelly sandwich.
• Add Carnation Instant Breakfast™ (130 calories and 7 grams protein per packet) to milkshakes or milk. Buy the vanilla flavor and add a variety of flavors from Strawberry Quick to almond extract so that your child does not become bored with the taste. You can mix it in milk as directed, and use it to cook hot cereal for a new taste treat.
• Add gravies (40 calories and 0 grams protein per tablespoon) liberally on mashed potatoes, rice, noodles, and meats. Thickened pureed meats – canned infant/baby food meat – may be a better alternative than just gravy itself.

Calcium for children with lactose intolerance

If your child’s physician indicates your child has lactose intolerance, you will want to be sure your child’s calcium needs are met from products besides milk. Some other ways to include calcium in your child’s diet include:

• Use calcium fortified orange juice that can be frozen into treats.
• Yogurt is often well tolerated because it contains less lactose than milk.
• Adding spinach to your child's diet.
• A multivitamin supplement with calcium or even the use of Tums® antacids could also be used, but you should check with your child’s physician first before using either.

Your child's cancer treatment (chemotherapy, radiation, medications, and surgery) may cause side effects such as nausea, vomiting, or diarrhea. This can contribute to poor nutrition and poor growth. Other factors that may influence how well children eat or maintain their weight include:

• the hospital environment
• depression
• changes in the cells of the mouth which may alter the way food tastes
• inadequate absorption of calories due to vomiting and diarrhea
• food odors (that can be avoided by using cold plates or serving food cool or at room temperature

If a child with cancer maintains adequate nutrition, then he/she may be more likely to:

• better tolerate chemotherapy or radiation and with fewer side effects
• heal
• grow and develop
• maximize quality of life

Nutritional side effects of cancer treatment and suggestions

As each child's individual medical profile and diagnosis is different, so is his/her reaction to treatment. Side effects may be severe, mild, or absent. Be sure to discuss with your child's cancer care team any/all possible side effects of treatment before the treatment begins.

• decreased appetite
  
  • Try smaller, more frequent meals and snacks.
  • Try changing the time, place, and surrounding of meals.
  • Let your child help with shopping and preparing meals.
  • Offer high-calorie, high-protein meals and snacks.
  • Avoid forcing your child to eat - this may make your child's appetite worse.
  • Make mealtime a happy time.
  • Have mini meals or snacks ready so that a fleeting appetite can be addressed immediately.
• mouth sores
  • Use soft foods that are easy to chew.
  • Avoid foods that may cause irritation to the mouth, including the following:
    • citrus fruits or juices (i.e., orange, tangerine, or grapefruit)
    • spicy or salty foods
    • rough, course, or dry foods (i.e., raw vegetables, crackers, or toast)
  • Use pear, peach, and apricot nectars and pudding pops.
  • Cut foods into small pieces.
  • Serve foods cold or at room temperature - hot foods may irritate the mouth and throat.
  • Use a blender to make foods softer and easier to chew.
  • Add sauces or gravies to food to make them easier to swallow.
• taste alterations
  Sweet foods are often the first to lose their appeal. Many commercial supplements are especially sweet, so your child may not want them. Continue to try alternatives until you find something your child will accept.
  • Offer salty or seasoned foods.
  • Use flavorful seasoning on foods.
  • Marinate meats in fruit juice, teriyaki sauce, or Italian dressing.
  • Try serving foods at different temperatures.
  • Give your child plastic utensils.
  • Offer foods that look and smell good.
  • Keep your child's mouth clean by rinsing and brushing.
• dry mouth
  • Try sweet or sour foods, and drinks such as lemonade.
  • Offer hard candy, frozen treat, or chewing gum.
  • Offer softer foods that may be easier to swallow.
  • Keep your child's lips moist with lip balm.
  • Offer small, frequent sips of water.
  • Offer foods that have more liquid in them.
  
  Chewing gum can stimulate gastric secretions and help to increase appetite but it can also cause physical fatigue in a child with cancer and therefore be a possible choking risk.
• nausea and vomiting
  • Try easy-to-digest food such as clear liquids, gelatin, toast, rice, dry cereals, or crackers.
  • Avoid foods that are fried, greasy, very sweet, spicy, hot, or strong-flavored.
  • Offer small, frequent meals.
  • Offer sips of water, juices, sports drinks, or other beverages throughout the day.
• diarrhea
  Try to avoid high-fiber foods including the following:
  • nuts and seeds
  • whole grains
  • dried beans and peas
  • raw fruits and vegetables
  
  Try to limit greasy (i.e., beans, cauliflower, broccoli, cabbage, onions), fatty, or fried foods. Offer small, frequent meals and drink liquids throughout the day. If lactose intolerance is a problem, limit milk and milk products.
• constipation
  Include high-fiber foods, including the following:
  • whole grain breads and cereals
  • raw fruits and vegetables
  • raisins and prunes
  
  Drink plenty of fluids; hot drinks are sometimes helpful. Keep the skin on vegetables when cooking them. Add bran or wheat germ to foods such as casseroles, cereals, or homemade breads.
• tooth decay
  • Use a soft toothbrush and take your child to the dentist regularly.
  • Encourage rinsing the mouth with warm water when gums and mouth are sore.
  • Encourage brushing teeth after eating meals and sweets.
  • Limit foods that stick to the teeth such as caramels, taffy, gummy candy, or chewy candy bars.

In some cases, tube or intravenous feeding becomes necessary to deliver the nutrients a child requires. Specially balanced nutrients are delivered directly into the stomach, intestines or bloodstream. The oncology team can explain why enteral or parenteral nutrition is recommended, and advise about how long such support may be necessary.

What is enteral and parenteral nutritional support?

Sometimes, even when high-calorie and high-protein foods are offered, children with cancer have trouble eating enough to meet their nutritional needs. Tube feedings may be needed to supplement your child’s diet or to serve as the sole source of nutrition to prevent malnutrition. This can involve placing a small tube through the nose, down the esophagus and leaving it either in the stomach (nasogastric or NG tube) or duodenum (nasoduodenal or the first part of the small intestine). The gastrointestinal tract or “gut” must be functioning properly before a tube feeding can be placed. Sometimes, a PEG (percutaneous endoscopic gastrostomy) tube is used instead. This is a tube inserted through the abdominal wall that rests in the stomach and is used to give nutrients to patients who cannot swallow. These alternatives to oral feedings may be only temporary.

Sometimes, children undergoing treatment for cancer need total parenteral nutrition (TPN) to help meet their nutritional needs. TPN is a special mixture of glucose, protein, fat, vitamins, and minerals that are given intravenously (IV). Many people call this "intravenous feedings." TPN provides the nutrients your child needs when he/she is not tolerating food by mouth, not absorbing nutrients in their gut, or needing bowel rest. The TPN solution is usually infused continuously over several hours of the day.