During treatment

The immunity of your child may be reduced because of the cancer itself or because of treatment. There is little you can do to directly improve this. It is important, however, to make sure your child eats well and, if possible, stays physically active.

What is immunity?

When we talk about immunity, we usually mean how easily someone can get infections or illnesses. It describes how well the immune system works. This system protects the body from outside threats such as viruses and bacteria. It recognizes these germs and normally removes them.

Reduced immunity in cancer

Cancer and its treatment can lower your child’s immunity. Chemotherapy is the main reason for reduced immunity. Stress because of the illness, lack of sleep, less physical activity, and too little or unhealthy food can also weaken your child’s immunity.

Treatment can affect the production of white blood cells. These cells are very important for your child’s immune system.

When immunity is reduced, germs have more opportunity to grow in the body. This increases the chance of infections. It also increases the chance that your child may become more ill from an infection.

Children with cancer who are undernourished experience infections more often¹ ². It is still unclear how this works exactly. Nutrition cannot change the number of white blood cells, but good nutrition does seem important to help reduce the risk of infections.

What can I do to help support immunity?

You cannot change the low number of white blood cells, even though this plays a big role in your child’s immunity.

You do have influence on your child’s food intake and their level of physical activity. Unfortunately, these cannot completely prevent reduced immunity caused by the illness and treatment. Getting enough healthy nutrients does seem to help reduce the chance of infections.

Sources

1. Loeffen, E. A., Brinksma, A., Miedema, K. G., De Bock, G. H., & Tissing, W. J. (2015). Clinical implications of malnutrition in childhood cancer patients—infections and mortality. Supportive Care in Cancer, 23(1), 143–150.

2. Triarico, S., Rinninella, E., Cintoni, M., Capozza, M. A., Mastrangelo, S., Mele, M. C., & Ruggiero, A. (2019). Impact of malnutrition on survival and infections among pediatric patients with cancer: a retrospective study. Eur Rev Med Pharmacol Sci, 23(3), 1165–1175.

The basics of a healthy eating pattern for children with cancer are the same as for children without cancer. The nutrients your child needs are carbohydrates, proteins, fats, vitamins, minerals, and fluids. Together, these nutrients provide the energy your child needs.

Individual energy needs

Your child’s energy needs depend on growth and recovery after illness, as well as age, activity level, illness, fever or infection, and body composition. As with adults, one child may need more energy than another. A child who is ill usually needs more energy than a healthy child. It also depends on whether your child is physically active or stays in bed, and on how sick he or she is.

A dietitian can calculate your child’s individual energy needs. This is always an estimate based on height and weight, age, illness, treatment, and activity level.

A current study at the Princess Máxima Center is looking at the resting energy expenditure of children with cancer. This will give us better insight into how much energy these children need. In this study, energy needs are measured directly, which helps us understand the true requirement.

Carbohydrates

Carbohydrates are the body’s fuel and provide energy. This energy is needed for growth and for the body to function well. It keeps the digestive system, heart, lungs, and other organs working, and helps your child do things like walk, play, and learn.

Where are carbohydrates found?
In bread, crackers, pasta, rice, couscous, potatoes, vegetables, fruit, dairy, and foods with added sugars.

Proteins

Proteins are the building blocks of our cells. They are important for maintaining, repairing, and growing tissues and organs such as the heart, brain, liver, kidneys, and muscles. Eating enough protein helps maintain muscle mass. This is important for staying in good physical condition. The better the condition, the better your child can tolerate treatment.

Where are proteins found?
In fish, chicken, meat, meat alternatives, cheese, dairy products, eggs, legumes, and nuts.

Fats

Fats provide energy and are also building blocks for body cells. They help with the absorption of important vitamins such as vitamins A, D, E, and K.

Where are fats found?
In oil, butter, cheese, fish, meat, full-fat dairy products, avocado, and nuts.

Vitamins and minerals

Vitamins and minerals play different roles in the body. They are needed for growth and recovery during and after treatment. Most vitamins and minerals are not produced by the body, so your child needs to get them through food and drinks.

Where are vitamins and minerals found?
In many foods, including vegetables, fruit, whole grains, nuts, legumes, fish, and dairy products. It is important to vary food choices so your child gets all the necessary vitamins and minerals.

Fluids

Fluids are important for absorbing nutrients in the intestines, transporting nutrients and waste products, regulating body temperature, and keeping stools soft.

Where are fluids found?
In water, tea, coffee, milk, lemonade, and juice, but also in foods such as cucumber, tomatoes, apples, and strawberries.

Balance

As much as possible, it is important to pay attention to the right nutrients in your child’s diet. This also means the right balance of proteins, fats, and carbohydrates. A dietitian can explain what the right, balanced composition is for your child. Try to follow the dietitian’s advice. If this is difficult, let them know so you can look for alternatives together.

The following table shows how much a child needs per day.

Extra considerations for children with cancer

During treatment, children often find it more difficult to meet these recommended amounts. Illness can also change metabolism, which affects energy and protein needs. This means your child may need more or less of certain foods. Children with cancer may, for example, need more protein-rich foods. Getting too much protein is not good either. A dietitian can explain which amounts are right for your child.

Sources

Coss-Bu, J. A., Hamilton-Reeves, J., Patel, J. J., Morris, C. R., & Hurt, R. T. (2017). Protein Requirements of the Critically Ill Pediatric Patient. Nutr Clin Pract, 32(1_suppl), 128S–141S.

Voedingscentrum (2021). www.voedingscentrum.nl

During cancer and its treatment, your child’s body needs more energy and protein. Protein is essential for building cells, maintaining muscle mass, and supporting the immune system. That is why it is important that your child eats enough and chooses the right foods.

Our advice

Proteins are the building blocks of the body. They are important for maintenance, recovery, and growth of all parts of the body. We need protein every day to build and repair our body cells properly¹. Protein also helps your child stay strong and maintain muscle mass. In addition, protein supports a healthy immune system.

Animal and plant proteins

There are animal and plant proteins.
Animal proteins are mainly found in:

• meat

• fish

• dairy products, such as yogurt, milk, and cheese

• eggs

Plant proteins are mainly found in:

• nuts

• soy and vegetarian meat substitutes

• bread and grain products

• legumes such as brown beans, chickpeas, and lentils

The body can use animal proteins more easily than plant proteins. Therefore, people who do not eat animal products need 30% more plant protein than someone who eats animal products. It is also important to vary plant protein sources. Here you can read more about eating meat during cancer (Dutch).

What does research show?

Research findings about how much protein children with cancer eat and drink vary. One study shows that about 40% of children with cancer do not get enough protein and/or energy through food and drinks¹. Another study shows that children with cancer do eat less protein than healthy peers, but that their intake is still more than sufficient².

How much protein does my child need?

The amount of protein your child needs depends on age, muscle mass, illness, and physical activity. During cancer treatment, it is very important that your child gets enough protein^1,3,4.

During treatment, your child often needs more protein. Protein is necessary for the recovery of damaged tissue, which is a part of the body. Extra protein is also needed if your child loses protein, for example due to blood loss during surgery.

The table below shows how much protein sick children in different age groups need. The amounts are given in grams per kilogram of body weight per day.

These amounts are guidelines. The dietitian, together with the physician, can best determine how much protein your child needs. The dietitian will then advise you how your child can eat and drink to to reach this goal. On the bottom of this page you can read which foods are high in protein.

Sometimes additional high-protein medical products may be needed. The dietitian will advise you about this.

Protein and physical activity

Protein is needed, amongst other things, to maintain and build muscle⁶. When your child is physically active and eats protein-rich foods after exercise or physical therapy, it becomes easier to build muscle. The combination of enough protein and physical activity is important. Talk with the physician, nurse, or physical therapist about which activities are suitable for your child.

Sources

1. Marino, L., Meyer, R., Kruizenga, H. M., & Wierdsma, N. J. (2019). Dietetic Pocket Guide Paediatrics.

2. Brinksma, A., Roodbol, P. F., Sulkers, E., de Bont, E. S., Burgerhof, J. G., Tamminga, R. Y., ... & Tissing, W. J. (2015). Finding the right balance: an evaluation of the adequacy of energy and protein intake in childhood cancer patients. Clinical Nutrition, 34(2), 284–290.

3. Coss-Bu, J. A., Hamilton-Reeves, J., Patel, J. J., Morris, C. R., & Hurt, R. T. (2017). Protein requirements of the critically ill pediatric patient. Nutrition in Clinical Practice, 32, 128S–141S.

4. Mehta, N. M., Skillman, H. E., Irving, S. Y., Coss-Bu, J. A., Vermilyea, S., Farrington, E. A., ... & Braunschweig, C. (2017). Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient. Journal of Parenteral and Enteral Nutrition, 41(5), 706–742.

5. Carbone, J. W., McClung, J. P., & Pasiakos, S. M. (2012). Skeletal muscle responses to negative energy balance: effects of dietary protein. Advances in Nutrition, 3(2), 119–126.

Fiber is important for healthy digestion and regular bowel movements. Make sure your child eats enough fiber. The amount of fiber your child needs depends on age. Sometimes the physician or dietitian may advise eating fewer fibers for a period of time. Always follow the advice of the physician or dietitian in those situations.

What are fibers?

The cell walls of plants contain dietary fiber. When we eat plant-based foods, we take in fiber. In the body, fiber is mostly not digested or absorbed into the bloodstream but stays in the stool.

Fiber attracts water and holds it, like a sponge. Together with fluids, fiber helps keep stool from becoming too hard or too loose. Fiber also supports the movement of the intestines, helping stool pass more easily. Fiber is also important for the healthy bacteria in our gut.

How much fiber does my child need per day?

It is important that your child eats enough vegetables, fruit, and whole-grain products. This helps ensure your child gets enough fiber. If your child has constipation, ask the dietitian whether your child is getting enough fiber and fluids.

Which foods contain a lot of fiber?

Fiber is found only in plant-based foods. Foods high in fiber include whole-grain products such as whole-grain bread and whole-grain pasta, brown rice, breakfast cereals (such as muesli or oatmeal), cooked and raw vegetables, potatoes, fruit (fresh or dried), legumes, and nuts.

With this list you can see which foods contain a lot or a little fiber, making it easier to choose high-fiber foods.

Fiber and fluids

For fiber to work well, it is important to drink enough. Fluid helps keep stool soft so it can move through the intestines. If your child does not drink enough, stool can become hard and dry, leading to constipation. Choose mostly unsweetened drinks such as water, tea without sugar, milk and dairy drinks, soup, and broth.

Fiber and diarrhea

When your child’s stool is loose or your child has diarrhea, eating enough fiber is usually still helpful. Because fiber absorbs water, it can help thicken the stool.

Choose fine fibers, such as those in finely milled whole-grain bread, potatoes, and fruit. These fibers are less irritating for the intestines.

Coarse fibers can irritate the intestines more, which does not help with diarrhea. Coarse fibers are found in foods such as dark rye bread, coarse whole-grain bread, bread with seeds and kernels, muesli, and raw vegetables. Coarse fibers are also found in stringy fruits such as oranges, prunes, and pineapple.

Important: If your child has diarrhea caused by mucositis, do not give extra fiber. You can read more tips for diarrhea here.

Medicine as a cause of constipation or diarrhea

Constipation or diarrhea can also be caused by medicines such as chemotherapy or antibiotics. It is important then to take enough fiber, but extra large amounts will not help. Ask your physician or dietitian what may help your child. Macrogol (Forlax) is often prescribed to keep stool soft.

Our advice

Make sure your child gets enough fiber every day by eating foods such as whole-grain bread, whole-grain pasta, brown rice, breakfast cereals, vegetables, potatoes, fruit, legumes, and nuts. Also make sure your child drinks enough.

If your child has trouble eating enough fiber, for example because of low appetite or because he or she can only manage soft or liquid foods, ask a dietitian for advice. Together you can explore what is possible in this situation.

Sources

1. Gezondheidsraad (2006). Richtlijn voor de vezelconsumptie.

2. Maag Lever Darm Stichting (2021). www.mlds.nl

3. NEVO-online version 2019/6.0. https://nevo-online.rivm.nl

4. Vogel, S., Beijer, P., Delsink, N., Doornink, H., ten Have, R., & van Lieshout (2016). Handboek Voeding bij Kanker (2nd fully revised edition). Utrecht, De Tijdstroom.

5. Voedingscentrum (2021). https://www.voedingscentrum.nl/encyclopedie/vezels.aspx

6. World Cancer Research Fund/American Institute for Cancer Research (2018). Diet, Nutrition, Physical Activity and Cancer: A Global Perspective. Continuous Update Project Expert Report. Available at dietandcancerreport.org

It is important for every child to drink enough. For children who receive many medications, such as children with cancer, this is even more important. Cancer treatment affects how much fluid your child needs.

Fluids help regulate body temperature, transport nutrients and waste products, and support the absorption of nutrients in the intestines.

The amount of fluid a child needs is related to the amount of energy the child needs. Children have a faster metabolism than adults, and because they are growing, they need more energy and therefore more fluids.

Children also have a relatively large body surface area, which means they lose more fluid through sweat. Their faster breathing also causes more fluid loss compared to adults.

Drinking enough helps your child pass harmful waste products that develop in the body because of chemotherapy more quickly. Drinking enough also keeps the concentration of these substances in the urine low, which is important for protecting your child’s kidneys.

As a general guideline¹ ², unless the physician or dietitian advises otherwise:

Some children may need to drink less because of a fluid restriction. The physician or dietitian will explain how much your child may drink.

What should my child drink?

Offer mostly water, tea, milk, and occasionally fruit juice, lemonade, or drinking yogurt. Vegetables such as cucumber and tomatoes, and fruits such as apples and strawberries, also contain fluid.

Difficulty drinking enough

There are situations in which your child needs more fluids. For example, extra fluid is needed if your child has a drain, fistula, or ileostomy. Extra drinking is also important if your child has vomiting or diarrhea. If nausea, vomiting, diarrhea, or other significant fluid losses make it difficult for your child to drink enough, contact the physician. Fluids can be given through an IV, or Oral Rehydration Solution (ORS) may be recommended to prevent dehydration. ORS is a mixture of salt and sugar and comes in small packets that can be dissolved in water.

Sources

1. Gezondheidsraad (2015). Richtlijnen goede voeding 2015. Den Haag: Gezondheidsraad (publicatienr. 2015/24).

2. Marino, L., Meyer, R., Kruizenga, H. M., & Wierdsma, N. J. (2019). Dietetic Pocket Guide Paediatrics.

E-numbers are not harmful or dangerous for your child. They may only be used when they have been thoroughly tested and proven safe for health. There is no evidence that E-numbers affect cancer treatment.

What are E-numbers?

E-numbers are substances that can be added to food and drinks to improve quality, color, or shelf life¹ ². A substance receives an E-number when it has been approved by the European Food Safety Authority (EFSA).

For each E-number, a maximum safe amount has been established. An additional safety margin is used to account for individual differences in sensitivity. Laws describe which foods may contain the substance and how much may be added. If a product contains an E-number, the name of the substance or the E-number must be listed on the label.

Unprocessed foods, such as fresh vegetables and fruit, do not contain E-numbers.

Artificial and natural E-numbers

Some E-numbers do not occur naturally in food and are produced artificially. E102, for example, is an artificial yellow colorant. Other E-numbers are substances that occur naturally in foods. E300 stands for vitamin C, and E330 stands for citric acid.

Both artificial and natural E-numbers are approved by EFSA and are safe to use, including for children.

A full list of E-numbers⁴ with explanations can be found on the website of the Dutch Nutrition Center.

Aspartame is safe

One E-number that often receives attention is the sweetener aspartame (E951). EFSA research has shown that normal use of aspartame is safe³ ⁴.

Our advice

Your child can safely eat and drink products that contain E-numbers. This applies to children with cancer as well as to healthy children. The safety of these substances is strictly monitored, and there is no evidence that normal use affects cancer or its treatment.

Sources

1. Voedingscentrum (2021). E-nummers. https://www.voedingscentrum.nl/encyclopedie/e-nummers.aspx

2. Voedingscentrum (2021). E-nummers voor kinderen. https://www.voedingscentrum.nl/nl/service/vraag-en-antwoord/kinderen-en-jongeren/zijn-e-nummers-in-eten-en-drinken-slecht-voor-mijn-kind.aspx

3. EFSA ANS Panel (2013). Scientific Opinion on the re-evaluation of aspartame (E951) as a food additive. EFSA Journal, 11(12), 3496.

4. Mallikarjun, S., & Sieburth, R. M. (2015). Aspartame and risk of cancer: a meta-analytic review. Archives of Environmental & Occupational Health, 70(3), 133–141.

Children with cancer may eat sugar. There is no evidence that sugar makes cancer cells grow faster. For all children, too much sugar is not recommended because it can lead to weight gain. Eating a lot of sugar is also not good for dental health.

What is sugar?

Sugar belongs to the group of carbohydrates, along with starch and fiber. Carbohydrates provide the body with energy. Sugar naturally occurs in sugar cane and sugar beets, which are used to make table sugar, also called refined sugar. Sugar is also naturally present in milk and dairy products (milk sugar, or lactose), fruit and fruit juices (fruit sugar, or fructose), and honey (fructose and glucose).

Sugar is added to many foods, not only sweet foods such as cookies and candy, but also foods you might not expect, such as soup, sauces, mayonnaise, ketchup, and other ready-made products. Labels list whether sugar has been added and which types.

What does research show?

There is no research on sugar and cancer in children.

It is often claimed that sugar feeds cancer cells and makes them grow faster. However, few good studies have examined the effect of sugar on tumor growth.

Many studies were done in test tubes or in animal studies with mice. Their results cannot be directly translated to humans. The human body is more complex, and substances behave differently in the body than in isolated cells.

A few studies have been done in adults¹–⁶. Some showed that people who drank a lot of sugary drinks had a higher chance of dying from cancer or having cancer return. This was mostly seen in people with overweight. Because of this, researchers could not determine whether the effect was caused by sugar, by overweight, or by other factors such as low levels of physical activity.

Is eating sugar harmful during cancer treatment?

There is no reason to ban sugar after a cancer diagnosis. It is wise, however, to limit sugar and sugary products. This applies to both healthy and sick children. Eating or drinking a lot of sugar can contribute to weight gain.

There are situations in which high-energy foods may be helpful. If your child has been eating too little for a while, has unintentional weight loss, or has a poor appetite due to illness or treatment, high-energy foods may help maintain a healthy weight. These foods sometimes contain more sugar. Do not add sugar everywhere with the idea of increasing energy intake. Always discuss this with a dietitian.

Can my child do without sugar?

Your child can easily do without table sugar and foods high in added sugar, such as soft drinks, chocolate, candy, and pastries. These foods provide energy (calories) but few useful nutrients.

Foods that naturally contain milk or fruit sugars and also contain important nutrients such as protein, vitamins, and minerals are needed. Every cell in the body needs glucose to function and grow. If your child eats too few carbohydrates, the body will make glucose in another way. To do this, the body uses protein from food or from muscle tissue. Too little glucose can therefore lead to muscle breakdown, affecting strength and overall condition.

Carbohydrate-rich foods such as fruit, bread, grains, beans, and dairy products also contain many other important nutrients, including fiber, vitamins, and minerals.

Our advice

There is no reason to prohibit sugar completely after a cancer diagnosis. It is sensible to limit sugar and sugary foods. If you are unsure whether your child is getting too much or too little sugar, ask a dietitian for advice. The dietitian can assess how much energy your child needs and advise what is appropriate. A dietitian can also help if your child is gaining too much weight or is losing weight unintentionally.

Sources

1. Belle, F. N., et al. (2011). Cancer Epidemiology Biomarkers & Prevention, 20(5), 890–899.

2. Fuchs, M. A., et al. (2014). PLOS One, 9(6), e99816.

3. Goncalves, M. D., Hopkins, B. D., & Cantley, L. C. (2019). Annual Review of Cancer Biology, 3, 255–273.

4. Goodwin, J., et al. (2017). Nature Communications, 8, 15503.

5. Meyerhardt, J. A., et al. (2012). Journal of the National Cancer Institute, 104(22), 1702–1711.

6. Peeters, K., et al. (2017). Nature Communications, 8(1), 922.

Breast milk contains everything babies need for the first six months. After that, breast milk can be given as a supplement alongside other foods and drinks. There is no scientific evidence that breast milk can cure childhood cancer.

Be aware that breast milk is sometimes sold online. Drinking this milk can be dangerous because it is not checked for safety. Do not give your child with cancer any products sold as breast milk.

In this article, we refer to breast milk given by parents to older children (over one year old) with the idea of improving immunity or curing cancer.

Breastfeeding is healthy

Breast milk contains enough energy and all nutrients (except vitamins D and K) for the first six months of life. It also protects against infections and supports immunity.

Immunity

Our immune system protects us from illness. Breast milk helps protect against stomach and intestinal infections in children younger than two years. It also reduces the risk of ear infections in young children.

In the Netherlands, the advice is to give babies only breast milk for the first six months when possible. The World Health Organization advises continuing breastfeeding until a child is two years old, alongside other foods from six months onward.

There are good alternatives in the Netherlands if breast milk is not given. These are called infant formula.

What does research show?

There is no research on the benefits of breast milk specifically for children with cancer. A few laboratory studies have looked at certain components of breast milk that might influence cells, but there is not enough evidence.

Breast milk sold online

In some countries, breast milk is sold online. Drinking milk that has not been checked is dangerous. Breast milk sold online may be diluted with cow’s milk or contaminated with medicines, alcohol, drugs, bacteria, or viruses. This is dangerous for everyone, but especially for children with cancer. Do not give your child breast milk from someone else.

Selling breast milk online is forbidden in the Netherlands. The Dutch Human Milk Bank connects mothers who produce surplus milk with babies whose mothers cannot provide breastfeeding. This is an official organization that ensures the milk is safe to drink.

Our advice

Breast milk from the child’s own mother is suitable as full nutrition for babies up to six months and as supplemental nutrition for older children. Do not give your child with cancer breast milk with the goal of curing cancer. There is no evidence for this. Do not give your child breast milk bought from someone else, because it may contain harmful substances.

Discuss any questions you have about breast milk with your child’s physician and dietitian.

Sources

1. Buijssen, M., Jajou, R., van Kessel, F. G. B., MJM, V. N. S., Zeilmaker, M. J., Wijga, A. H., & van Rossum, C. T. M. (2015). Health effects of breastfeeding: an update.

2. Victora, C. G., et al. (2016). The Lancet, 387(10017), 475–490.

3. Goldman, A. S. (2019). The Journal of Pediatrics, 206, 274–279.

4. Fischer, W., et al. (2004). Cancer Research, 64(6), 2105–2112.

5. Mossberg, A. K., et al. (2010). The Journal of Urology, 183(4), 1590–1597.

6. Puthia, M., et al. (2014). Gut, 63(1), 131–142.

7. Reif, S., et al. (2019). Journal of Translational Medicine, 17, 1–10.

8. Keim, S. A., et al. (2014). Maternal and Child Health Journal, 18, 1471–1479.

9. Steele, S., et al. (2015). Journal of the Royal Society of Medicine, 108(6), 208–209.

10. Postma-Smeets, A., & Stafleu, A. (2020). Factsheet Borstvoeding. Voedingscentrum.

Children with cancer may eat meat. There is no evidence that eating meat during treatment is harmful. Meat is an important source of protein, iron, and vitamins B1 and B12.

What is red, white, and processed meat?

Red meat includes meat from cows, pigs, sheep, goats, and also venison and other game. It is called red meat because it is red when raw, and even after cooking it still belongs to this category.

Chicken, turkey, and other poultry are considered white meat. This meat is lighter in color when raw.

Processed meat is meat that has been smoked, salted, or preserved in another way to extend shelf life or improve flavor. Examples include all types of deli meats, ready-made hamburgers, pre-seasoned ground meat, smoked bacon, and sausage.

What does research show?

There is no research on how meat affects cancer treatment in children.

Research in adults with colorectal cancer¹ shows that people who continue to eat meat after diagnosis do not live longer or shorter than those who reduce or avoid meat.

How much meat per week?

Meat contains high-quality protein and important vitamins and minerals, such as iron. Meat can be part of a healthy eating pattern. For children aged 1–8 years, the recommendation is to eat no more than 250 grams of meat per week. For children 9 years and older, the recommendation is no more than 500 grams per week. Note: these amounts refer to the weight before cooking.

Eating less or no meat

If your child prefers to eat less or no meat because of animal welfare, the environment, health reasons, or a change in taste², that is fine. Make sure your child eats good alternatives and other foods that provide enough protein, iron, vitamin B1, and vitamin B12. Be careful with salt intake. The kidneys of children under four years cannot handle large amounts of salt. Many ready-made vegetarian meat alternatives contain a lot of salt.

Good alternatives to meat include fish, cheese, eggs, and vegetarian options such as tofu and tempeh. Milk and dairy products, whole-grain products, nuts, and legumes are good additions. You can read more here about a vegan eating pattern.

Eating more meat

Some children prefer to eat more meat during cancer treatment and may dislike other foods. In this situation, it is not a problem if your child eats more meat for a while. Be mindful of deli meats, as they contain a lot of salt.

It is important that your child eats enough to stay strong during treatment. A dietitian can help with this.

Extra attention to hygiene

If your child has reduced immunity due to treatment, pay careful attention to how you handle meat. Wash your hands before preparing food. Use clean kitchen tools made of plastic, glass, or metal. Keep raw and prepared foods separate. Do not eat raw meat. Defrost frozen meat in the refrigerator or microwave, and cook meat thoroughly.

Our advice

Your child may eat meat during cancer treatment. Meat can be part of a healthy diet. For children aged 1–8 years, the recommendation is no more than 250 grams of meat per week, and for children aged 9 years and older, no more than 500 grams per week. Note: this is the weight before cooking.

During cancer treatment, getting enough protein is important. Protein can come from meat, fish, milk, yogurt, cheese, and eggs, as well as bread, grains, legumes, and nuts. These foods contain less protein than meat, so your child may need more of them to meet daily needs.

It is not a problem if your child eats more meat for a short period. Eating enough is essential to stay strong during treatment. Ask the dietitian or physician for advice if you have questions.

Sources

1. Van Zutphen, M., Kampman, E., Giovannucci, E. L., & van Duijnhoven, F. J. B. (2017). Curr Colorectal Cancer Rep, 13(5), 370–401.

2. Vogel, J., Beijer, P., Delsink, N., Doornink, H., ten Have, R., & van Lieshout, R. (2016). Handboek Voeding bij Kanker. Utrecht, De Tijdstroom.

Yes, your child may eat (fatty) fish. If your child has reduced immunity, eating raw or partially raw fish is strongly discouraged.

Fish as part of a healthy eating pattern

Fish is part of a healthy diet. This applies to all children, with and without cancer. Give your child fish once a week¹. For a toddler this is about 50 grams, for children up to nine years 50–60 grams, and for older children 100 grams of fish per week¹. Eating more fish than this does not provide extra benefits for children with or without cancer.

Fatty fish contains omega-3 fats, which are important for brain development¹.

Choose mostly fatty fish such as mackerel, herring, salmon, bückling, and sardines. It does not matter whether you serve the fish as a warm meal, in a salad, or on bread.

Fish and chemotherapy

Several studies show that (fatty) fish likely does not affect how chemotherapy² works. These studies were done in adults with various types of cancer² ³ and looked at the influence of fish and fish oil on the effectiveness of chemotherapy.

Be aware that fish oil supplements² are discouraged from 24 hours before until 24 hours after treatment with irinotecan, carboplatin, cisplatin, and oxaliplatin. Fish oil supplements may contain large amounts of a specific fatty acid (PIFA), which may reduce the effectiveness of treatment.

Fish and reduced immunity

Cancer treatment can lower your child’s immunity, for example during chemotherapy or a stem cell transplant⁴. The physician will let you know if this applies to your child.

If immunity is reduced, your child should not eat raw fish. This also includes pre-packaged smoked fish kept in the refrigerator, such as smoked salmon, trout, mackerel, and eel. The type of packaging does not matter (vacuum-packed or other)⁴.

Avoid foods such as sushi with raw fish, new herring, or fish that is not fully cooked. Your child may eat fried or stewed fish, pickled herring (which is no longer raw), steamed fish, and canned fish.

Our advice

Give your child fish once a week, make sure it is not raw, and preferably choose a fatty fish variety.

Sources

1. Voedingscentrum (2021). Beschikbaar via: https://www.voedingscentrum.nl/nl.aspx

2. nl (2021) vis en visolie bij chemotherapie. Beschikbaar via: https://www.voedingenkankerinfo.nl/mag-ik-vis-eten-en-visolie-gebruiken-bij-chemotherapie/

3. Van der Meij, B. S., Teleni, L., Stanislaus, A. E., Murphy, R. A., Robinson, L., Damaraju, V. L., … & Mazurak, V. (2020). Plasma levels of platinum-induced fatty acid [16: 4n-3] do not affect response to platinum-based chemotherapy: A pilot study in non-small cell lung cancer patients. Clinical Nutrition ESPEN, 40, 263-268.

4. nl (2021) hygiënische voeding. Beschikbaar via: https://www.voedingenkankerinfo.nl/hygienische-voeding-bij-een-verminderde-afweer/

It is better not to let your child follow a vegan diet during cancer treatment. A vegan diet increases the risk of getting too little protein and other essential nutrients. Research in adults shows no evidence that a vegan diet slows down cancer.

What is a vegan diet?

A vegan diet excludes all foods that come from animals. This means no dairy products, eggs, or meat and fish products¹. A vegan diet consists of vegetables, fruit, legumes, grains, and nuts.

What does research show?

There is no research on the effects of a vegan diet in children with cancer. Research in adults with cancer shows no difference in the risk of dying from cancer between adults who eat a vegan diet and adults who do consume animal products².

There is also no research on how a vegan diet affects cancer treatment or its side effects. What we do know is that, during illness, getting enough protein, vitamins, and minerals is important for maintaining strength and overall condition. A good condition helps children cope better with illness and treatment.

Important: risk of nutrient deficiencies

Animal products contain important nutrients. On a vegan diet, it is more difficult to get enough protein and certain vitamins (such as vitamin B1 and B12) and minerals (such as iron). This increases the risk of deficiencies, especially during illness when eating is often challenging⁴:

• Protein is needed to build and repair body cells. A child on a vegan diet needs about 30% more protein than a child who also consumes animal products.

• Iron is needed to transport oxygen in the blood. Iron from plant-based foods is absorbed less efficiently than iron from meat. Vitamin C improves absorption.

• Vitamin B1 supports carbohydrate metabolism and the proper functioning of the heart and nervous system. B1 is found in grains, potatoes, and vegetables, but in lower amounts than in animal products.

• Vitamin B12 is needed for red blood cell production and for nerve function. It is found only in animal products.

Recent research shows that healthy children can follow a vegan diet only under strict conditions³ ⁴. They must eat more protein than children who consume animal products because the body uses plant proteins less efficiently.

Children who follow a vegan diet⁴ often get less energy and fewer essential nutrients than children who do eat animal products. It is not yet known how a vegan diet at a young age affects long-term health⁴.

Our advice

We advise against a vegan diet during cancer treatment. During treatment, it is especially important that your child gets enough energy and protein. This is harder to achieve with a vegan diet and increases the risk of deficiencies. This can lead to weight loss and a decline in physical condition.

Sources

1. Voedingscentrum (2021). https://www.voedingscentrum.nl/encyclopedie/vegetarisme-veganisme.aspx

2. Le, L. T., & Sabaté, J. (2014). Beyond meatless, the health effects of vegan diets: findings from the Adventist cohorts. Nutrients, 6(6), 2131-2147.

3. Craig, W. J., & Mangels, A. R. (2009). Position of the American Dietetic Association: vegetarian diets. Journal of the American dietetic association, 109(7), 1266-1282

4. Müller, P. (2020). Vegan Diet in Young Children. In Global Landscape of Nutrition Challenges in Infants and Children (Vol. 93, pp. 103-110). Karger Publishers.

5. Voedingscentrum (2021). https://www.voedingscentrum.nl/nl/service/vraag-en-antwoord/gezonde-voeding-en-voedingsstoffen/hoe-kan-ik-gezond-veganistisch-eten-.aspx

6. Nederlandse Vereniging voor Veganisme (2021) https://www.veganisme.org/voeding/gezondheid/kinderen/

No, there is no evidence that organic foods are better, including for children with cancer. Eating a healthy diet – especially whole-grain products, vegetables, fruit, and legumes – helps reduce the risk of developing cancer (again) and supports recovery after treatment. It does not matter whether these foods are organic or not.

What are organic products?

Organic products are produced with attention to the environment and animal welfare. For example, no artificial fertilizers or chemical pesticides are used, and animals have more space.

All organic products produced in Europe are required to carry the European organic label. They may also carry the EKO label. These labels show that the product meets European standards for organic farming.

What does research show?

There is no research on the effect of organic foods in children with cancer.

Research in adults with cancer also does not show that eating organic products leads to better recovery or fewer side effects. There is no evidence that eating organic foods reduces the risk of cancer recurrence more than non-organic foods.

Studies on the health effects of organic foods¹ show no clear difference between organic and non-organic products.

Safety and nutrient content

A large 2014 review² examined nutrient levels in organic foods. Organic fruit contained more antioxidants than non-organic fruit. No difference was seen in vegetables. Antioxidants can help protect cells from damage.

Two large studies from 2016³ ⁴ found that organic dairy and meat have a slightly different composition than non-organic products. Organic meat and milk contained higher levels of some beneficial nutrients. However, given the small amounts of meat and dairy we eat, the overall impact on health is minimal. Replacing solid cooking fats with olive oil or eating oily fish once a week provides far greater health benefits.

Organic products contain fewer pesticides and antibiotics than non-organic products⁵. However, this makes little difference to our health. All products, both organic and non-organic, are checked to ensure levels remain within safe limits.

Our advice

Make sure your child eats a healthy diet. This means plenty of plant-based foods such as whole-grain products, vegetables, fruit, and legumes. For recovery after cancer treatment and for lowering the risk of cancer returning, it does not matter whether these foods are organic.

If you want to consider the environment or animal welfare, choosing organic products is a good option.

Sources

1. Dangour, A. D., K. Lock, A. Hayter, A. Aikenhead, E. Allen en R. Uauy (2010). “Nutrition-related health effects of organic foods: a systematic review.” The American Journal of Clinical Nutrition 92(1): 203-210.

2. Baranski, M., D. S´rednicka-Tober, N. Volakakis, C. Seal, R. Sanderson, G. B. Stewart, C. Benbrook, B. Biavati, E. Markellou, C. Giotis, J. Gromadzka-Ostrowska, E. Rembiałkowska, K. S.-S. ta, R. Tahvonen, D. Janovska´, U. Niggli, P. Nicot and C. Leifert (2014). "Higher antioxidant and lower cadmium concentrations and lower incidence of pesticide residues in organically grown crops: a systematic literature review and meta-analyses." British Journal of Nutrition 26: 1-18.

3. Średnicka-Tober, D., Barański, M., Seal, C. J., Sanderson, R., Benbrook, C., Steinshamn, H., ... & Cozzi, G. (2016). Higher PUFA and n-3 PUFA, conjugated linoleic acid, α-tocopherol and iron, but lower iodine and selenium concentrations in organic milk: a systematic literature review and meta-and redundancy analyses. British Journal of Nutrition, 115(06), 1043-1060.

4. Średnicka-Tober, D., Barański, M., Seal, C., Sanderson, R., Benbrook, C., Steinshamn, H., ... & Cozzi, G. (2016). Composition differences between organic and conventional meat: a systematic literature review and meta-analysis. British Journal of Nutrition, 115(06), 994-1011.

5. Smith-Spangler, C., M.L. Brandeau, G.E. Hunter, J.C. Bavinger, M. Pearson, P.J. Eschbach, V. Sundaram, H. Liu, P. Schirmer, C. Stave, I. Olkin en D.M. Bravata (2012). “Are Organic Foods Safer or Healthier Than Conventional Alternatives? A Systematic Review.” Annals of Internal Medicine 157(5): 348-366.

If your child eats and drinks according to the Wheel of Five, he or she will get enough vitamins and minerals. A nutritional supplement is not needed in that case. Only give a supplement if the physician or dietitian recommends it.

If you are unsure whether your child is getting enough vitamins and minerals, ask the dietitian to assess your child’s diet. The dietitian can determine, together with the physician if needed, whether a supplement is necessary and which supplement is most suitable.

What are nutritional supplements?

Nutritional supplements are intended to complement the daily diet. They contain one or several vitamins and often minerals. Supplements come as pills, powders, drops, capsules, or drinks. Some supplements contain too many vitamins and minerals. Always read the label carefully, check whether the supplement is suitable for children, and make sure it does not contain more than 100% of the recommended daily allowance (RDA) for children.

What does research show?

Little research has been done on supplements in children with cancer. Research in adults shows that supplements can sometimes be harmful²–⁸. Supplements can interfere with cancer treatment. Large amounts of certain vitamins can reduce the effectiveness of chemotherapy and radiotherapy. Some studies showed that cancer treatment worked less well in people who used supplements unnecessarily. These people also had a lower chance of surviving cancer⁷ ⁸.

When does my child need extra vitamins or minerals?

Only give your child extra vitamins or minerals if the physician or dietitian indicates that this is necessary. A few groups of children always need extra vitamins:

• Breastfed infants: 150 micrograms of vitamin K drops for the first 12 weeks.

• Children under four years: 10 micrograms of vitamin D daily.

• Children with dark skin or children who spend less than 30 minutes per day outside due to illness or treatment: also 10 micrograms of vitamin D daily.

Vitamin D can be given as drops, tablets, or capsules. All forms work equally well.

If your child receives oral nutritional supplements or tube feeding, do not give an additional multivitamin. Oral and tube feeding are complete products and already contain enough vitamins and minerals.

Our advice

Make sure your child eats healthy and eats enough. If this is difficult or if you are unsure, discuss this with a dietitian. The dietitian can assess your child’s diet and, if needed, recommend a supplement in consultation with the physician. The dietitian can also advise which (multi-vitamin) supplement is best for your child.

Sources

1. Voedingscentrum (2020), http://www.voedingscentrum.nl

2. Fuchs-Tarlovsky, V. (2013). “Role of antioxidants in cancer therapy.” Nutrition 29(1): 15-21.

3. Ladas, E. J., J. S. Jacobson, D. D. Kennedy, K. Teel, A. Fleischauer and K. M. Kelly (2004). “Antioxidants and cancer therapy: a systematic review.” Journal of Clinical Oncology 22(3): 517-528.

4. Landelijke Werkgroep Diëtisten Oncologie (2010). Nut, noodzaak en risico’s van antioxidanten tijdens chemo- en radiotherapie.

5. Vogel, J., S. Beijer, P. Delsink, N. Doornink, H. ten Have en R. van Lieshout (2016). Handboek Voeding bij Kanker. Utrecht, De Tijdstroom

6. Bairati, I., F. Meyer, M. Gélinas, A. Fortin, A. Nabid, F. Brochet, J.-P. Mercier, B. Têtu, F. Harel and B. Mâsse (2005). “A randomized trial of antioxidant vitamins to prevent second primary cancers in head and neck cancer patients.” Journal of the National Cancer Institute 97(7): 481-488.

7. Vernieri, C., Nichetti, F., Raimondi, A., Pusceddu, S., Platania, M., Berrino, F., de Braud, F. (2018) Diet and supplements in cancer prevention and treatment: Clinical evidences and future perspectives. Crit Rev Oncol Hematol. 2018 Mar;123:57-73.

8. Yasueda, A., Urushima, H., & Ito, T. (2016). Efficacy and interaction of antioxidant supplements as adjuvant therapy in cancer treatment: A systematic review. Integrative cancer therapies, 15(1), 17-39.

There is not enough evidence that glutamine helps against mucositis. We also do not yet know whether glutamine is safe during chemotherapy. For this reason, the advice is not to give your child a glutamine supplement during cancer treatment.

Chemotherapy and radiation can damage the lining of the gastrointestinal tract. This damage can cause inflammation, called mucositis. Depending on where the inflammation occurs and how severe it is, children may have pain in the mouth, abdominal pain, difficulty swallowing, or diarrhea. You can read more here about what to do if your child has mucositis.

What is glutamine?

Glutamine is an amino acid, a building block of proteins. It is important for maintaining and repairing the gastrointestinal tract. Glutamine helps epithelial cells (the cells that line and protect mucous membranes) do their job.

Glutamine is also used in the body for cell division. Tumors are made up of cells that divide quickly. Because of this rapid division, glutamine can be used up faster, which means people with cancer may have lower glutamine levels.

What does research show?

Research in children with cancer

The studies that exist are small and use different methods to investigate the effect of glutamine on mucositis in children. Many questions remain unanswered. Because of this, it is not yet possible to give clear recommendations. More research is needed, including studies that examine safety.

Glutamine during chemotherapy

There is still too little known about how glutamine interacts with chemotherapy. For this reason, the use of glutamine supplements during chemotherapy is discouraged.

Our advice

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

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

Sources

1. Aquino VM, Harvey AR, Garvin JH, Godder KT, Nieder ML, Adams RH, Jackson GB, Sandler ES. 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. 2005 Oct;36(7):611-6.

2. 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.

3. 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 MG, 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

Do not give your child probiotics during cancer treatment. There is still little research on how probiotics affect children with cancer. We do know that probiotics are not always safe for adults with cancer who have reduced immunity during treatment. We also do not yet know what probiotics do to the long-term health of children with cancer.

What are probiotics?

Probiotics are bacteria. They are found in some dairy products or in dietary supplements. In the right amount and in healthy people, these bacteria can support gut health. Only a few types of bacteria continue to work in the intestines, such as certain lactic acid bacteria.

What does research show?

Very little research has been done on probiotics in children and adults undergoing cancer treatment. More research is needed to determine whether probiotics might help with side effects of treatment in childhood cancer. First, we need to know whether probiotics are safe in this situation and whether they do not interfere with treatment.

Risks when immunity is reduced

Research on probiotics in children with cancer is limited. One review study that combined results from several small studies suggested that probiotics might be safe for some children with cancer, but the groups studied were too small to draw firm conclusions.

In adults with reduced immunity, some people developed sepsis after taking probiotic supplements.

Another study looked at 600 adults with colorectal cancer who used probiotics around the time of surgery. They had fewer complications, such as infections and wound issues, compared with 600 adults who did not use probiotics. However, sepsis also occurred more often in the group using probiotics. Again, probiotics were not always safe for people with reduced immunity.

Several large studies have examined the effect of probiotic supplements in adults with cancer who had diarrhea. Some people had fewer and less severe symptoms, while others saw no benefit. An expert group indicates that probiotics may be useful for adults with stomach or intestinal cancer who are having surgery.

Caution is still needed because probiotic supplements do not help all adults with cancer, and more research is needed on safety.

Our advice

We advise against using probiotics during cancer treatment in children. Probiotics have not been studied enough in children with cancer, and research in adults shows that they are not always safe during treatment.

Sources

1. Markowiak, P., & Śliżewska, K. (2017). Effects of probiotics, prebiotics, and synbiotics on human health. Nutrients, 9(9), 1021.

2. Bai, J., Behera, M., & Bruner, D. W. (2018). The gut microbiome, symptoms, and targeted interventions in children with cancer: a systematic review. Supportive Care in Cancer, 26(2), 427-439.

3. Bossi, P., Antonuzzo, A., Cherny, N. I., Rosengarten, O., Pernot, S., Trippa, F., ... & Ripamonti, C. I. (2018). Diarrhoea in adult cancer patients: ESMO Clinical Practice Guidelines. Annals of Oncology.

4. Hassan, H., Rompola, M., Glaser, A. W., Kinsey, S. E., & Phillips, R. S. (2018). Systematic review and meta-analysis investigating the efficacy and safety of probiotics in people with cancer. Supportive Care in Cancer, 26(8), 2503-2509.

5. Wardill, H. R., Van Sebille, Y. Z., Ciorba, M. A., & Bowen, J. M. (2018). Prophylactic probiotics for cancer therapy-induced diarrhoea: a meta-analysis. Current opinion in supportive and palliative care, 12(2), 187-197.

6. Redman, M., E. Ward and R. Phillips (2014). "The efficacy and safety of probiotics in people with cancer: a systematic review." Annals of Oncology: mdu106.

7. Hendler, R., & Zhang, Y. (2018). Probiotics in the treatment of colorectal cancer. Medicines, 5(3), 101.

8. Lobo, D. N., Gianotti, L., Adiamah, A., Barazzoni, R., Deutz, N. E., Dhatariya, K., ... & Weimann, A. (2020). Perioperative nutrition: Recommendations from the ESPEN expert group. Clinical Nutrition.

We advise not giving creatine to your child during cancer treatment. Too little research has been done to know whether creatine works or whether it is safe for children with cancer.

What is creatine?

Creatine provides energy to the muscles. Many athletes use creatine when running or strength training to improve performance and speed up recovery. Creatine may help increase muscle mass and strength.

The body produces creatine on its own, and we also get creatine from food. Creatine is available as a supplement, usually in capsule or powder form. This is called creatine monohydrate.

Creatine in children with cancer

Very little research has been done on creatine in children with cancer. Some people think creatine may help children maintain muscle mass and strength. However, research has not yet shown whether this is true or whether creatine is safe for children with cancer. More research is needed.

What does research show?

Creatine in cancer

Cancer and its treatment can affect the muscles. Muscle mass and strength can decrease, causing fatigue and weakness. Physical activity and good nutrition help maintain muscle strength.

In healthy people, creatine can increase muscle mass and strength. But there is very little research on creatine in people with cancer, including children. It is not known whether creatine helps maintain or build muscle strength during cancer treatment.

Creatine during chemotherapy

One small study has examined creatine in children with acute lymphoblastic leukemia treated with chemotherapy and corticosteroids. Only nine children participated, which is far too few to draw conclusions.

Our advice

Do not give creatine supplements to your child during cancer treatment.

Always discuss the use of supplements with your child’s physician or dietitian.

Sources

1. Voedingscentrum (2023). Creatine. https://www.voedingscentrum.nl/encyclopedie/creatine.aspx

2. Allesoversport (2023). Factsheet Creatine. https://auteurs.allesoversport.nl/wp-content/uploads/2022/10/Topsport-Topics_Factsheet-Creatine.pdf

3. Fairman, C. M., Kendall, K. L., Hart, N. H., Taaffe, D. R., Galvão, D. A., & Newton, R. U. (2018). The potential therapeutic effects of creatine supplementation on body composition and muscle function in cancer. Critical Reviews in Oncology/Hematology. doi:10.1016/j.critrevonc.2018.

4. Jagim, A. R., & Kerksick, C. M. (2021). Creatine supplementation in children and adolescents.Nutrients, 13(2), 664.

5. Bourgeois, J. M., Nagel, K., Pearce, E., Wright, M., Barr, R. D., & Tarnopolsky, M. A. (2008). Creatine monohydrate attenuates body fat accumulation in children with acute lymphoblastic leukemia during maintenance chemotherapy.Pediatric blood & cancer, 51(2), 183-187.

6. Kreider, R.B.; Kalman, D.S.; Antonio, J.; Ziegenfuss, T.N.; Wildman, R.; Collins, R.; Candow, D.G.; Kleiner, S.M.; Almada, A.L.;Lopez, H.L. International Society of Sports Nutrition position stand: Safety and efficacy of creatine supplementation in exercise,sport, and medicine.J. Int. Soc. Sports Nutr.2017,14, 18.

7. Antonio, J., Candow, D. G., Forbes, S. C., Gualano, B., Jagim, A. R., Kreider, R. B., ... & Ziegenfuss, T. N. (2021). Common questions and misconceptions about creatine supplementation: what does the scientific evidence really show?.Journal of the International Society of Sports Nutrition, 18(1), 13.

8. FDA (2020). GRAS notice No. 931 https://www.fda.gov/media/143525/download

9. Zhang, L., & Bu, P. (2022). The two sides of creatine in cancer. Trends in Cell Biology, 32(5), 380-390

Tube feeding is liquid nutrition. It is given through a small tube that goes directly into the stomach or intestines. Tube feeding contains all the nutrients your child needs each day, including vitamins and minerals. It can partly or completely replace regular food.

You can read answers to frequently asked questions about tube feeding here.

Why tube feeding?

Sometimes a child cannot eat well because of the illness or its treatment. Your child may feel very sick or nauseous. Sometimes a child is temporarily not allowed to eat or drink, for example when swallowing is not safe.

If your child does not eat or drink enough, he or she may become tired. Because of this, treatment may be harder to tolerate. Growth and development can also be affected if your child gets too few nutrients. In these situations, tube feeding can help.

Having a child who needs tube feeding can be difficult. At the same time, it can also be a relief because it takes away the pressure to eat.

Some children receive a tube only for medication, not for feeding.

Different types of feeding tubes

• Nasogastric tube (NG tube):
  A thin tube goes through the nose, throat, and esophagus into the stomach. This tube is replaced every six weeks. It is usually used when tube feeding is needed for a shorter period.

• Nasojejunal tube (NJ tube):
  If feeding needs to go directly into the intestines, the tube passes through the nose, throat, esophagus, stomach, and into the intestines. This tube is also replaced every six weeks.

• PEG tube:
  A small tube is placed directly into the stomach through the abdominal wall during a minor procedure. This is useful when long-term tube feeding is needed.

Feeding schedules: portions or continuous

Tube feeding can be given in several ways:

• Portion feeding: several times a day using a syringe or a pump for a short period.

• Continuous feeding: feeding runs slowly throughout the day or night.

• A combination of both is also possible.

Types of tube feeding

There are many types of tube feeding. Some come ready-to-use, others are powders that need to be mixed. The dietitian will advise which type is best for your child, depending on age, weight, and nutritional needs.

Because tube feeding does not pass through the mouth, your child will not taste it. Tube feeding does not come in flavors.

Storing tube feeding

• Store unopened ready-to-use bottles or cartons in a cool, dark place.

• Once opened: refrigerate and use within 24 hours.

• Powder-based tube feeding is also safe for 24 hours in the refrigerator. Do not leave it out of the fridge for more than 8 hours.

• Always check the expiration date.

Caring for the tube

The tube can become blocked. Flush it 4–6 times per day to prevent this. Flush before and after giving tube feeding and medication.

• Use 3–5 ml of lukewarm water.

• Always use a 10 ml syringe.

• Replace the feeding set (the tube between the feeding pump and the feeding tube) every 24 hours.

Oral care during tube feeding

Good mouth care is extra important to prevent inflammation and dryness.

What to do:

• Brush teeth at least twice a day.

• Rinse the mouth with water three times a day, or give something to eat or drink three times a day.

• Your child’s nurse may give different instructions if needed.

• Sugar-free chewing gum can help stimulate saliva.

• Use lip balm or petroleum jelly to prevent cracked lips.

Tube feeding at home

Tube feeding almost always starts in the hospital, during an admission or outpatient visit. After discharge, your child can continue tube feeding at home.

The dietitian arranges home delivery through a specialized company. This company takes care of insurance approval and delivers the feeding and materials to your home.

Home care nurses can replace or reinsert the tube if needed.

You can also read answers to frequently asked questions about tube feeding.

Sources

1. ten Have, H. et al (2022). Handboek Voeding bij Kanker. (3eeditie) Utrecht, De Tijdstroom.

A blended diet is not recommended during cancer treatment in children, because their immunity is lower. Always discuss a blended diet with your child’s physician and dietitian before considering it.

What is a blended diet?

In a blended diet, regular food is pureed, thinned with liquid, and given through a feeding tube. This can partly or fully replace ready-to-use tube feeding.

A blended diet is only suitable for children over one year old, children who have finished cancer treatment, children with a tube that enters the stomach (with a diameter of at least 10 Charrière), and children who do not have a fever or infection. If your child has a tube that goes directly into the intestines (a duodenal tube), a blended diet should not be used.

Possible benefits of a blended diet

• Some stomach and intestinal symptoms such as vomiting, reflux, and constipation or diarrhea may improve.

• A blended diet may support the gut microbiome, the bacteria, fungi, and yeasts in the intestines. The microbiome helps protect against illness and helps digest fiber.

• Your child can have the same meals as the family and may help choose and prepare food. This can increase involvement at mealtimes.

Important considerations with a blended diet¹ ²

• It is harder to ensure your child gets enough nutrients. All food must be diluted with water, whole milk, juice, clear fruit juice, cream, or broth so it can pass through the tube. This increases the volume of each meal. Divide meals throughout the day to avoid giving large amounts at once.

• Unlike ready-to-use tube feeding, it is harder to know exactly how many nutrients your child receives. A dietitian must calculate your child’s needs and advise how to meet them. Ask for a dietitian experienced with blended diets.

• The feeding tube can become blocked if the food is not liquid enough.

• Give feeds at room temperature and do not administer them too quickly. This helps prevent stomach and intestinal discomfort.

• Prepare food hygienically to reduce infection risk. A blended diet is not suitable for children with reduced immunity.

• Preparing blended feeds takes more time than using ready-made tube feeding.

• Blended diets are not covered by insurance, while ready-to-use tube feeding is.

What does research show?

Little high-quality research has been done on blended diets, and most studies lack a comparison group³–⁶.

• In a small study⁴ with 15 children (not children with cancer), parents and children were satisfied. Children had fewer stomach complaints and felt better.

• In another small study⁵ of 17 chronically ill children who used a blended diet for six months instead of ready-to-use tube feeding, children vomited less often and needed fewer acid-reducing medicines. There was no effect on bowel movements.

It is still unclear whether risks such as nutrient deficiencies, tube blockages, and infections occur more often with a blended diet compared with ready-made tube feeding. More research is needed.

Our advice

There is not enough research on the benefits and risks of a blended diet compared with ready-to-use tube feeding in children with cancer. It is also unclear whether risks such as nutrient shortages, tube blockages, and infections occur more often with a blended diet.

Ready-to-use tube feeding is preferred because the nutrient content is known and because it carries a lower risk of infection. Infection risk is especially important for children with cancer.

Therefore, a blended diet is not recommended during cancer treatment. After treatment, it may be an option with careful support from a dietitian experienced in blended diets.

Always discuss a blended diet with your child’s physician and dietitian before using it. Dietitian supervision is essential to use a blended diet safely.

More information

You can read more about blended diets for children in this information leaflet from the Wilhelmina Children’s Hospital.

Sources

1. The British Dietetic Association (2019) Policy Statement The Use of Blended Diet with Enteral Feeding Tubes

2. Van Boxtel, J., Glas, B., Groenewold, M., Hofsteenge, A., De Jongh-Kampherbeek, L. et al. Standpunt blended diet bij kinderen. NtvD 2020;75(6) 34-37

3. Coad, J., Toft, A., Lapwood, S., Manning, J., Hunter, M. Jenkins, H. et al. Blended Foods for Tube-Fed Children: A Safe and Realistic Option? A Rapid Review of the Evidence'. Archdischild 2017 102 (3), 274-278

4. Philips, G. Patient and carer experience of blended diet via gastrostomy: a qualitative study’ JHumNutrDiet 2018. 32 (3) 391-399.

5. Gallagher, K., Flint, A., Mouzaki, M., Carpenter, A. Haliburton, B., Bannister,L.et al. Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds through a Gastric Tube in a Medically Complex Pediatric Population J Parenter Enteral Nutr. 2018 42 (6) 1046-1060

6. Armstrong, J., Buchanan, E., Duncan, H., Ross, K. and Gerasimidis K. Armstrong et al. Dietitians' Perceptions and Experience of Blenderised Feeds for Paediatric TubeFeeding'. Archdischild 2017 102 (2), 152-156

It depends on the situation. Weight gain can be caused by the treatment, changes in eating habits during treatment or less physical activity. Sometimes support from a dietitian and/or physical therapist is needed.

Our advice

From the start of treatment, pay attention to a healthy eating pattern and enough physical activity, as much as possible. This remains important after treatment as well. This can be difficult when your child is tired or does not feel well. A dietitian and/or physical therapist can help with this. Do you want to know what your child needs during treatment? In this article you can read more about what nutrition your child with cancer needs. Are you worried about your child’s weight? Discuss this with the physician.

Consequences of weight gain

Children who gain a lot of weight during treatment have a higher risk of becoming overweight. They often lose muscle mass as well. Research shows that gaining too much weight and becoming overweight during cancer treatment in childhood can lead to (significant) overweight in adulthood¹. This increases the risk of diabetes, cardiovascular disease and cancer in adulthood¹,².

What does research show?

There are several factors that may influence weight gain, such as:

• Eating and drinking during treatment (catch-up growth)

• Changes in eating behavior

• Less physical activity

• Side effects of treatment and medication³,⁴.

Eating and drinking during treatment (catch-up growth)

If your child has a poor nutritional status or malnutrition at the start of treatment, it may be necessary for your child to gain weight. Tube feeding may be given in these situations. Children with a poor nutritional status at diagnosis can gain weight quickly. This is also called catch-up growth. It is important to determine when tube feeding can be stopped so that the child does not gain more weight than needed⁵.

Changes in eating behavior

During treatment, children may develop unhealthy eating habits. They may, for example, become picky about what they eat and drink. Or they may use food to get attention or for distraction⁶. Children may eat enough, but choose foods high in fat and/or sugar. During treatment, children often eat fewer dairy products, vegetables and fruit and prefer savory snacks. Research shows that children with cancer often eat less varied foods and may therefore develop nutrient deficiencies, such as calcium⁶–⁸.

Less physical activity

Children may gain weight during treatment because they do not get enough physical activity⁵,⁶. Spending a lot of time in bed and having little energy can make it difficult to stay active.

Side effects of treatment and medication

Weight gain is especially seen during the treatment of hematologic tumors (blood and lymph node cancer) and brain tumors¹,⁵. In hematologic tumors, weight gain may be related to the medications used¹,⁵. Corticosteroids such as prednisolone and dexamethasone can change how fat and fluids are distributed in your child’s body². This can cause your child to temporarily have more fat in the face and around the abdomen.

Children who use corticosteroids may also have an increased appetite, which can contribute to weight gain. Sometimes changes in nutrition can help limit the increase in fat mass². Read more here about nutrition during corticosteroid use.

In brain tumors, weight gain (mainly fat mass) may be the result of less physical activity and hormonal changes¹,⁹. After radiation to the brain or damage from brain surgery, children with cancer may become less sensitive to the hormone that signals that they have eaten enough. This can cause children to eat more¹,⁹.

Sources

1. Brinksma, A., Sulkers, E., Kouwenberg, D., Lelieveld, O. T., Boot, A. M., Burgerhof, J. G., & Tissing, W. J. (2022). Changes in body size and body composition in survivors of childhood cancer: seven years follow-up of a prospective cohort study. Clinical Nutrition, 41(12), 2778-2785. https://doi.org/10.1016/j.clnu.2022.10.021

2. American Cancer Society (2023). Special Nutritional Issues For Children with Cancer. https://www.cancer.org/cancer/survivorship/children-with-cancer/nutrition/when-your-child-is-taking-steroids.html

3. Cohen J, Goddard E, Brierley M-E, Bramley L, Beck E. Poor Diet Quality in Children with Cancer During Treatment. Journal of Pediatric Oncology Nursing. 2021;38(5):313-321. doi:10.1177/10434542211011050

4. Sawicka-Żukowska, M., Łuczyński, W., Dobroch, J., & Krawczuk-Rybak, M. (2020). Factors affecting weight and body composition in childhood cancer survivors—cross-sectional study. ecancermedicalscience, 14.https://doi.org/10.3332%2Fecancer.2020.999

5. Brinksma, A., Roodbol, P. F., Sulkers, E., Kamps, W. A., de Bont, E. S., Boot, A. M., ... & Tissing, W. J. (2015). Changes in nutritional status in childhood cancer patients: a prospective cohort study.Clinical Nutrition, 34(1), 66-73. https://doi.org/10.1016/j.clnu.2014.01.013

6. Murphy-Alford, A. J., White, M., Lockwood, L., Hallahan, A., & Davies, P. S. W. (2019). Body composition, dietary intake and physical activity of young survivors of childhood cancer. Clinical nutrition (Edinburgh, Scotland), 38(2), 842–847. https://doi.org/10.1016/j.clnu.2018.02.020

7. Fleming, C. A. K., Murphy-Alford, A. J., Cohen, J., Fleming, M. R., Wakefield, C. E., & Naumann, F. (2022). Poor diet quality and adverse eating behaviors in young survivors of childhood cancer. Pediatric blood & cancer, 69(1), e29408. https://doi.org/10.1002/pbc.29408

8. Goddard, E., Cohen, J., Bramley, L., Wakefield, C. E., & Beck, E. J. (2019). Dietary intake and diet quality in children receiving treatment for cancer. Nutrition reviews, 77(5), 267–277. https://doi.org/10.1093/nutrit/nuy069

9. Van Schaik, J., van Roessel, I. M., Schouten-van Meeteren, N. A., van Iersel, L., Clement, S. C., Boot, A. M., ... & van Santen, H. M. (2021). High prevalence of weight gain in childhood brain tumor survivors and its association with hypothalamic-pituitary dysfunction. Journal of Clinical Oncology, 39(11), 1264-1273. https://doi.org/10.1200/jco.20.01765

Cancer and its treatment place a heavy burden on your child’s body. In addition, your child may sometimes have no appetite or may not be able to eat well for another reason. Your child may then eat too little, while the body actually needs a lot of energy and building blocks, such as protein. This is why it is important that your child eats enough and chooses the right products.

In this list you can see which products are most suitable for your child to eat in order to get enough protein and energy.

Everyone has their own eating habits, preferences and taste. Look at which products your child likes to eat or drink. Does your child follow a specific diet or avoid certain products because they cause discomfort? Of course, your child does not need to eat those products now.

Breakfast:

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

• Oatmeal or wheat cereal prepared with whole milk.

• Smoothie made with full-fat quark or yogurt, oatmeal and fruit.

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

• American-style (thick) pancakes made with whole milk.

• French toast made with egg and whole milk.

Lunch:

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

• Pancakes or small Dutch pancakes, preferably with bacon and/or cheese, nut spread or sugar/syrup.

• Quark and fruit.

• Meal soups such as split pea soup, meatball soup, bean soup or peanut soup.

• Grilled ham and cheese sandwich with a sauce such as ketchup or curry sauce.

Toppings:

• Energy-rich: Butter and margarine, jam, chocolate sprinkles, honey, sweet spreads.

• Energy- and protein-rich: Cheese (full-fat), cold cuts such as ham and sausage, cocktail sausages, oily fish such as salmon, mackerel and herring, fish salad such as tuna salad, avocado, (fried) egg, peanut butter or other nut spreads, herb cream cheese, store-bought 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 meat substitute with potatoes, rice, pasta or couscous and vegetables. Instead of meat, you can also choose eggs, legumes, tempeh or tofu.
  TIP: For extra energy, add mayonnaise or another sauce to the potatoes, a splash of olive oil through the pasta, rice or potatoes, or a melted slice of cheese over the vegetables.

• Meal soups such as split pea soup, meatball soup, bean soup or peanut soup.
  TIP: Add a splash of cream, crème fraîche or olive oil to the soup for extra energy.

Savory snacks:

• Cubes of cheese, slices of sausage, cold cuts, herring, small salad dishes, boiled egg, muesli roll (with margarine or butter and/or cheese), cheese-dippers, cheese roll, sausage roll, nuts, crackers with salad or cream cheese.

Sweet snacks:

• Full-fat quark, full-fat yogurt or Greek yogurt with a splash of diluted syrup.

• Custard.

• Smoothie made with fruit and full-fat quark/yogurt/ice cream.

• Cake, muffin, cookie, banana bread with peanut butter.

If it is difficult to eat enough, oral nutrition supplements may help your child get enough energy and nutrients.

Click here for more recipes.