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Nutrition for children underdoing cancer treatment

Medical editor Susan Sødal
Clinical Nutritionist
Oslo University Hospital


Malnutrition and cachexia often occur in children with cancer. Both the illness and the treatment can reduce the child's appetite and tolerance for food.

Nutrition is very important when treating children with cancer. Good nutritional status facilitates tolerance for treatment. The immune system is improved, complications are reduced, and quality of life increases. Proper nutrition is also very important for normal growth.

It is also easier to prevent weight loss than to replace it afterwards. A small loss in weight may have great consequences for children since they have less energy storage than adults. 

Good nutritional status is crucial for optimal treatment. The child's nutritional status must be monitored closely during the entire treatment period and follow-up to ensure that proper measures are taken promptly, if needed.  

Calculation of energy and protein need for children with cancer

  • The energy need is calculated as 100% of the energy need of healthy children and is expressed in kcal/kg with the appropriate weight for the age. This must therefore be adjusted weekly and adjusted according to the increase of weight.
  • The protein need is calculated as 150% of protein need for healthy children. If the child eats a varied diet, the protein need will also be covered. Enteral feeding products also contain a sufficient amount of protein. Total protein intake should not surpass 4 g/kg body mass.

Treatment protocols and risk for malnutrition

Treatment protocols are developed for each cancer type. Treatment consists of chemotherapy, radiation, surgery, or a combination of these. Most chemotherapy causes side effects that can affect nutritional status, for example, nausea, vomiting, mucositis, diarrhea, constipation, and sensory changes.

The child will sometimes skip meals because of an increased need for sleep. It is possible, to a certain degree, to predict some of the nutritional problems associated with different treatment stages. It is therefore very important to know the patient's actual stage in the protocol to assess necessary measures to relieve side effects.

Indications for taking measures against malnutrition


  • If the child's nutritional needs are not met even if they are able to eat and drink themselves.

Enteral nutrition (tube feeding)

  • Lasting weight loss or lack of weight gain despite additional nutritional measures
  • The child uses > 4 hours per day to eat
  • Highly intensive treatment protocols with known nutritional problems
  • Unbalanced diet that does not meet the child's total nutritional needs


  • Severe gastrointestinal failure
  • Obstructive conditions in the pharynx and esophagus
  • Ileus
  • Intestinal perforation
  • Intra-abdominal sepsis
  • Acute pancreatitis
  • Lasting nausea
  • Stomach retention >300-500 ml
  • Untreated bleeding disturbances

Parenteral nutrion (intravenous feeding)

  • If the child's nutritional status is not met with regular food or tube feeding
  • When enteral peroral nutrition or tube feeding is not possible


  • Prevent weight loss
  • Ensure the child received adequate nutrition throughout the treatment and follow-up period



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If the child is able to eat and drink without assistance, but not enough to meet his/her nutritional needs, his/her diet should be supplemented with nutritional drinks and/or fortifying additives.

Enteral feeding (tube feeding)

Enteral feeding is used when the stomach and intestinal tract are functioning normally. Tube feeding is preferred over parenteral feeding (intravenous feeding) because it is more physiological and conserves the intestinal integrity. Even small amounts of enteral feeding are important to prevent intestinal atrophy. There is less risk for infection compared to parenteral feeding.

The need to start tube feeding is determined by an interdisciplinary team consisting of the treating doctor, clinical nutritionist, and nurse. If the child has oromotor problems, a physiotherapist/speech therapist should be contacted. When infants and small children are exclusively tube-fed, it is very important to stimulate oral motor skills to avoid eating problems problems later.

Feeding tube insertion


  • Standard localization
  • Most physiological for hormone/digestion response
  • Allows for higher osmolarity of the feeding solution than the small than small intestine 
  • Maintains antimicrobial function in the stomach


  • If there is gastric dysmotility
  • For retention
  • Persistant vomiting
  • Increased risk for aspiration

Percutaneous endoscopic gastrostomy (PEG)

  • Should be assessed as needed for tube feeding > 3 months
  • In youth that refuse a nasogastric tube
  • Surgery/radiation to the head/neck area
  • Contraindicated for ascites, abdominal tumor, and increased risk of bleeding 

Parenteral feeding

Parenteral feeding is utilized when the child's nutritional need cannot be met by another method. This type of feeding is prescribed by a doctor in collaboration with a pharmacist and clinical nutrtionist.

Intravenous feeding is associated with a higher risk for infections in children with cancer. Still, the child's nutritional needs have the highest priority, if there is a possible way. Intravenous feeding alone is unfavorable. Even small amounts of food and drink will prevent intestinal atrophy.   


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Assessment of nutritional status

The child's nutritional status should be assessed regularly during the entire treatment and follow-up period in order to start necessary nutritional measures at the right time. The child's nutritional status should be surveyed at each hospital admission and outpatient visit.  

Registering weight

The child's normal weight must be registered in the growth curve. This is done by using the child's growth chart from the public health clinic.

In order to assess growth increase and risk for malnutrition/obesity, the following measurements are performed: 


  • Frequency 
    • Weight < 10 kg: 2 x per week
    • Weight > 10 kg: 1 x per week
    • Children on nutritional therapy: 2 x per week


  • Frequency 
    • Age 1/2-1 years: 1 x per month
    • Age > 1 year: every 3rd month

Head circumference

  • Frequency 
    • 0-1/2 year: 1 x per month
    • 1/2-2 years: every 2 months 

These measurements should be performed until the child is 2 years of age.

Criteria for identifying malnutrition or obesity

If the child shows one or more of the following, nutritional therapy should be started:

  • Documented weightloss
    • ≥ 5 % in 1 month
    • 7,5 % in 3 months
    • 10 % in 6 months
  • Changes in the growth curve are equivalent to 1-2 percentile (underweight/overweight) 
  • Poor appetite without sign of improvement associated with expected long term illness and treatment period. Oral intrake of food in
    • children over 10 kg ® < 50 % of need x 5 days
    • children under 10 kg ® < 50 % of need x 3 days
  • Bone marrow transplantation
  • Expected intestinal dysfunction > 5 days for well nourished patients, for example
    • Graft Versus Host Disease (GVHD) from bone marrow transplant
    • operative procedure in the stomach/intestinal region
  • Patients with a high risk for malnourishment based on tumor type and treatment protocol
    • Wilms' tumor (stage III and IV)
    • Ewing sarcoma
    • Osteogenic sarkcoma
    • Hepatoblastoma
    • Rabdomyosarcoma (stage III and IV)
    • Cerebral tumor
    • Neuroblastoma (stage III and IV)
    • Acute myelogenous leukemia


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  • No added vitamins, minerals, or trace elements 
  • Usually only fat, carbohydrates or protein, possibly a combination of fat and carbohydrates.

Breast milk from the child's mother or bank milk (milk from a donor) can be used as the only form of nutrition until the child is 4-6 months. Thereafter the child should have a more enriched diet to support the greater need for energy. Unpasteurized bank milk or biologically active milk should not be used for children with cancer.  

Nutritional drinks

There is an assortment of ready-made nutritional drinks available on the market.  Some of these products are complete.  They contain carbohydrates, protein, fat, and all of the necessary vitamins, minerals, and trace elements are added. Fiber is also added in some. The energy content varies from 85-200 kcal /100 ml and certain products have a high protein content.

These products are age appropriate and dose is determined individually by a clinical nutritionist/doctor.

Most children prefer homemade nutritional drinks based on whole milk, cream, ice cream, fruit, and flavorings. These are free of additives and taste more fresh. The energy and protein content are close the commercial products and are much less expensive. Homemeade nutritional drinks are, however, not complete and should not be used as the only source of nutrition, but as a supplement to other nutrition.

Enteral feeding (tube feeding)

Choice of product

The choice of product is based on:

  • energy and protein need
  • age and condition of the illness
  • existing nutritional intolerance/allergy 
  • gastrointestinal function
  • the location of the tube
  • the characteristics of the product, for example, osmolality, nutritional content, protein type, user friendliness, and cost


Continual administration is recommended at the start of tube feeding to reduce the risk of diarrhea. When the child is established on full volume, he/she may change to bolus meals, and eventually intermittent administration. 

The tolerance for the volume of tube feeding and the different products varies from child to child. It may be necessary to change pruducts as well as assess the position of the tube. The tolerance for tube feeding during a course of chemotherapy is often reduced. The child's appetite is usually reduced for 1-5 days. Tube feeding must often be reduced or stopped for a few days and carefull resumed 2-3 days after ending a course with about 1/3 of the normal volume.

Food can be fed by tube feeding in three different ways:

  • Continual: Infusion with pump for 24 hours. The tube should be rinsed every 4-8 hours. It is recommended to take a break for 4 hours which will lower pH in the stomach. This has an antibacterial effect.
  • Bolus: Enteral formula given in small portions at the mealtimes the child normally eats. This is divided into 5-8 meals. Each meal is given over 15-60 minutes depending on the volume. Bolus can also be given after other food. The tube should be rinsed before and after each meal. 
  • Intermittent: The formula is given using a pump. For example, the child is given food continually through a tube at night and is able to eat normally during the day. The tube should be rinsed before and after each meal. 

Hygienic precautions during administration

  • The expiration date on the package should always be checked before use. 
  • The nutrition set should be changed after 24 hours.
  • Unopened packages of tube food should be stored at room temperature.
  • Opened packages that are not attached to the nutrion set should be stored in the refridgerator and used within 24 hours.
  • Enteral nutrition in a closed system may hang for 24 hours at room temperature, provided it is connected to the feeding set.
  • Enteral feeding solution in a glass may hang for 8 hours in room temperature.
  • Enteral feeding solution poured into a feeding bag may hang for 8 hours at room temperature.
  • Feeding solution mixed from powder may hang for 4 hours at room temperature.
  • The tube should always be sealed when disconnected.
  • The tube should be rinsed with water between meals. For immunosuppressed patients and babies, sterile water should be used.


For persisting diarrhea, enteral feeding should be stopped for 24 hours and oral rehydration fluid given. The enteral formula can then be gradually increased again.

The are multiple causes of diarrhea during treatment



Bacterial contamination

Use a closed system

Volume of feeding solution given as bolus is too large

Reduce the volume or rate

Feeding solution is given to quickly

Administer the formula continually

Feeding solution is too cold

Temperate the formula

Osmolarity of feeding solution is too high and is not well tolerated

Switch to an isotonic product

Intolerance for content in feeding solution

Use another product

Tube has reached the duodenum

Check the position of the probe

Parenteral nutrition


  • TPN mixtures last for 24 hours at room temperature. 
  • The infusion set is changed every day.
  • TPN bag is taken out of the refridgerator 2 hours before use.
  • The TPN infusjon should be stopped 3 hours before taking blood tests.  
  • The central venous catheter should be rinsed daily with 1 ml 45% ethanol to prevent accumulation in the catheter. The ethanol is aspirated after 1 minute. 
  • TPN should last as many hours as possible so the child is able to absorb as much of the nutrition as possible.  
  • A drug can be administered with TPN if it is documented that they will be mixabler. The documentation must apply to the relevant TPN formula.

Transfer from TPN to enteral feeding

It is important that TPN is not stopped too early. The transfer to enteral feeding should occur gradually. When the child is able to cover 25% of the calculated energy need required by enteral nutrition, a corresponding reduction of TPN can be made. TPN should not be stopped before the child has reached at least 75% of its nutritional need enterally.

Prednisolone treatment

Prednisolone treatment over a longer period of time leads to increased appetite and weight, both during and after concluded treatment. To prevent the child from becoming overweight, the amount of calories should be adjusted according to the consumption. If tube feeding is used, it is very important to reduce this to avoid to high calorie intake. Intake of calcium and vitamin D should be monitored during prednisolone treatment. Supplements should be given if the need is not met by diet or tube feeding.

Nutrition associated with bone marrow transplant (BMT)

Nutritional status for children who have bone marrow transplants must be assessed in advance before the transplantation. The nutritional condition must be optimized so the child is well nourished. Nutritional intake should be intensified. Some children may need tube feeding for a period before the transplantation.

The child should also have close follow-up of their nutritional status after the transplantation. Many children have a poor appetite for a long period after the transplantion and require tube feeding/supplementation. More children are bothered by sore mouth and nausea and require tube feeding due to this.

During the period right after the transplantation, the child will have neutropenia and be susceptible to gastrointestinal infections from foodborne pathogens.

According to the "Nordic guidelines for nutrition during BMT" the child should avoid the following foods while in isolation:

  • fresh fruit that cannot be peeled
  • raw berries and vegetables
  • cured or smoked salmon
  • candy in loose weight
  • McDonalds and other fast food
  • unpasteurized milk and milk products including unpasteurized bank milk

There is no consensus on whether Biola (probiotic milk) should be avoided by immunosuppressed patients.

Products with a high risk for high amount of listeria to be avoided:

  • fermented fish
  • cheese and sour cream of unpasteurized milk
  • soft cheesese, both pasteurized and unpasteurized
  • smoked fish
  • raw fish products
  • sprouts
  • raw meat
  • mildly preserved or long-lasting products 



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Follow-up care

Thorough registration of growth measurements should be performed at all hospital admissions and outpatient follow-ups.



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