Understanding the Problem

Children with cancer lose their appetite for many reasons. Cancer treatments and other medicines can decrease the desire for food, as can emotional distress.

Losing weight can upset the person with cancer, especially when he or she sees it as a sign that the illness is getting worse. Rapid weight loss, however, can often be slowed down by treating its cause, such as stopping diarrhea and giving high-calorie foods.

Children need to stay well-nourished for normal growth and development, and so they have an additional need for calories. Depending on what is causing the loss of appetite, you can set several goals to solve this problem.

Your goals are to:

• call for professional help when it is needed
• encourage ways to increase the appetite
• cover up tastes and smells that are bothersome
• prevent an early feeling of fullness
• add more proteins and calories to what is eaten

When To Get Professional Help

The first question you should ask is whether professional help is needed. Show this homecare plan to your doctor or nurse and ask them to fill in the blanks.

Call during office hours if any of the following are true:

If your child has had very little to eat in * days. Ask the doctor or nurse when you should report a poor appetite. If nausea causes the loss of appetite, read the homecare plan section on nausea for steps you can take to relieve that symptom. When nausea lasts more than a few days and your child eats very little, it's important to understand how to control and prevent it.

If your child loses * pounds in one week. Ask the doctor or nurse when to call about weight loss. If the number of pounds lost is more than they say is reasonable to lose, then talk about this on a clinic visit or with the home health nurses if they are visiting the home.

If your child notices pain with chewing or swallowing. Painful chewing or swallowing interferes with normal eating and drinking. Pain can be caused by a mouth sore or an infection on the tongue, gums, or throat. If the appetite suddenly changes, ask your child if he or she is having trouble eating, chewing, or swallowing. Check your child's mouth for sores and if you find any, refer to the homecare plan section on mouth sores for steps you can take to ease the situation. * Ask the doctor or nurse for the numbers that fit your child.

Call immediately if the following is true:

If your child has had very little to drink. (Refer to fluid chart.) It's important for children to avoid dehydration. Refer to the fluid chart, which your doctor or nurse fills out for your child, to determine whether he or she is drinking too little. When you call, the doctor or nurse may ask you the following questions:

• When did the poor appetite problem start?
• If this problem happened before, what brought the appetite back or helped it improve?
• Does food taste different, such as bitter or metallic? If so, does this make eating less desirable?
• Which foods taste better and which taste worse?
• Is your child's mouth dry or sore, and is swallowing difficult?
• Do you have medication to help with mouth problems?
• Does your child feel full or bloated soon after starting to eat?
• Is he or she experiencing nausea, vomiting, or problems with bowels, such as constipation or diarrhea?
• When the appetite changed, was there a change in where or how he or she ate the food?
• Does your child have a better or worse appetite at certain meals or certain times of day?
• How much weight has your child lost?

Here is an example of what someone might say when calling for help:

"I am David Sondheim, Christopher Sondheim's father. My son is Dr. Greenberg's patient. He is being treated for medulloblastoma. The homecare plan for appetite says that we should call if he eats or drinks very little. He's taken only a few sips of liquids all day today."

What You Can Do To Help

You can use four approaches to solve child or adolescent problems with appetite.

Increase the appetite

Sometimes children with cancer lose their appetite because of treatments or emotional distress. You can take several actions to help stimulate appetite.

Encourage light exercise or walking before meals, in fresh air if possible. Any increase in activity just before eating also increases the appetite. Try going for a walk with your child five to 15 minutes or up to half an hour before meals. Fresh air always stimulates the appetite.

Have your child eat meals with family members or others whenever possible. Don't let your child eat alone. Eating with someone else distracts a child's attention from food and can increase the amount he or she eats. Sometimes meal habits change after a cancer diagnosis, because the person doesn't feel like eating, or the family schedule is disrupted by trips to clinics for checkups and treatments. Returning to normal meal times or planning to have the family eat together will help increase the appetite.

Serve meals nicely in a pleasant, relaxed atmosphere. Use small plates and serve smaller portions, or experiment with a combination of a small portion on a large plate. A small portion on a small plate can be arranged attractively and looks like something that can be finished. For some younger children, serving a small portion on a large plate may make it seem to be more manageable.

Serve lemonade or orange juice if the mouth is not sore. Juices contain acids that can stimulate appetites. A few ounces before a meal may enhance the appetite.

Cover up tastes and smells that are bothersome

Cancer treatments sometimes can change how foods taste to your child. You can do several things to make food appealing again.

Use plastic utensils. Plastic forks and spoons and knives take away a bitter or metal taste, which is a common complaint among people receiving chemotherapy.

Try new spices, such as basil, curry, coriander, mint, oregano, or rosemary. Spices make our mouths water and change the tastes of food. You may find a new spice that makes your child hungry again. Try old spices in new ways, because the chemotherapy sometimes changes the way food tastes. Avoid trying new flavors or foods on chemotherapy days, because that may condition your child to associate that food with a difficult experience, thus causing him or her to dislike that food in the future.

Add new flavors, such as lemon, pickles, salad dressings, vinegar, mayonnaise, relishes, or fruit juices.

Marinate meats in liquids, such as fruit juices, salad dressings, sweet and sour sauce, soy sauce, or barbecue sauce. Sauces and marinades change flavors of foods and make them more appealing.

Sprinkle more sugar and salt in food if these are not restricted. These decrease the metallic and bitter tastes that people with cancer sometimes complain about. Some people receiving chemotherapy cannot tolerate a sweet taste, so they use small amounts of sugar to taste.

Eat food cold. A cold temperature downplays the smell and taste of food. Aromas are blocked or linger for shorter times, and cold foods are not as flavorful so odd tastes are covered up. Also, the coolness numbs the tongue to some unpleasant tastes.

Suck on hard, sugar-free, sour, or mint candy, or, for younger children, lollipops. Candies like these can mask strange tastes any time of the day and even before a meal. These should be offered only to children older than four years of age, to avoid the possibility of choking.

Drink ginger ale or mint tea. Ginger ale and mint tea cover up metallic tastes and help with swallowing food.

Eat chicken and fish, and avoid red meat. Changes in taste buds may make red meat distasteful. People receiving chemotherapy often prefer chicken or fish, which retain their flavors.

Prevent an early feeling of fullness

Poor appetite can be caused by an early feeling of being full. Sometimes, medicines cause gas and the child feels bloated after eating very little. Following are six tactics you can take to deal with this.

Exercise between meals. Any exercise gets the intestinal tract moving and shakes up pockets of gas. Even stretching and bending the waist by getting out of chairs or off couches helps relieve gas and move stomach contents.

Walk around or sit up for awhile after meals, but avoid strenuous exercise immediately after eating. Any exercise stimulates the bowel muscles to move downward. This action helps to empty the stomach and break up any gas that adds to a sense of fullness.

Drink beverages between meals instead of with meals. Liquids at mealtime can make the stomach feel full. Drinking less while eating allows more room for food.

Eat small amounts 6 to 8 times a day. Small, frequent meals or snacks prevent early fullness.

Eat slowly and chew food well.  Avoid certain vegetables and carbonation. Cut back on fatty foods and gas-producing foods such as beans, cucumbers, green peppers, onions, broccoli, brussels sprouts, corn, cauliflower, sauerkraut, turnips, cabbage, chewing gum, milk, rutabagas, or carbonated beverages. Some vegetables naturally create stomach and intestinal gas and can keep your child feeling full as the food is slowly digested. Avoid these, as well as carbonated sodas or waters. Relieve the carbonation by opening cans and bottles early and letting the fizz evaporate while the sodas turn flat.

Use over-the-counter medicines to help break up gas. Many of these contain herbs or drugs that break up gas. One particular ingredient, simethicone, is very helpful with attacking gas and breaking up air trapped in the intestines. Check with the doctor and nurse before buying these over-the-counter medicines because they shouldn't be used with some other medicines.

Add more proteins and calories to food

Rapid weight loss often can be slowed down by increasing the nutritional value of food that is eaten, especially with calories and proteins. The next two pages contain 16 suggestions for how you can make the food count more.

Offer small, frequent snacks (six per day) even if your child is not hungry, and encourage eating as much as wanted. Smaller meals and snacks may add up to higher protein and calorie intake.

Choose nutritious carbohydrates and high-protein options, such as fish, chicken, turkey, eggs, cheeses, milk, ice cream, tofu, nuts, peanut butter, yogurt, beans, and peas. Try to get as much protein and carbohydrates as possible from each food item served. This is called `power-packing' foods.

Add butter or margarine to vegetables, soups, pasta, cooked cereal, and rice. These add fat and calories.  Add sugar, syrup, honey, and jelly to vegetables, meats, cereals, waffles, and rolls. Sweet sauces add calories.  Use sour cream or cream cheese on baked potatoes, vegetables, or crackers. Creams are fattening and nutritious and easy to swallow.

Add whipped cream to hot chocolate, ice cream, pies, puddings, gelatin, and other desserts. Add sugar to whipped cream, boosting calories and fat. Add powdered coffee creamers or powdered milk to gravy, sauces, soups, and hot cereals. These are good sources of calcium. Use milk instead of water to dilute condensed soups or cooked cereals. If a recipe calls for water, use whole milk instead.

For children who take bottles, feed high-calorie formulas. Ask your nurse or dietitian about these products, which are available in stores or pharmacies.

Use mayonnaise instead of salad dressing and light cream for all or part of milk in recipes. Mayonnaise contains more fat than salad dressing and is high in calories. Light cream has more fat and calories than milk.
Add ice cream to milk drinks. Ice cream increases the fat and calorie content to milk.

Add nonfat dry milk (1 cup) to one quart of whole milk for drinking and use in recipes. You can more than double the protein and calorie content of regular (4%) milk if you add powdered dry milk.  Use half-and-half or evaporated milk instead of water in recipes. Half cream and half milk or evaporated milk are much higher in fat, protein, and calories than water, and they provide vital minerals and nutrients. Also, many people with cancer drink "Instant Breakfast" mixes for their extra calories. These are sold in grocery stores.

Use peanut butter on crackers, bread, waffles, apple wedges, or celery sticks. Peanut butter is an excellent source of protein and calories.
Offer crushed granola, nuts, seeds, or wheat germ in shakes or on desserts. Use nutritional supplements in between meals or with snacks, such as Isocal Ensure, Sustacal, Resource, or Citrotein. These powders or liquids are loaded with nutrients and can be purchased in most drug stores. Ask the nurse or pharmacist for information about buying them and ask for recipes. Also, in some states, the American Cancer Society will help with purchasing these supplements. Avoid diets designed to "purge the system" or restrict certain foods or food groups. Certain diets are designed to purge the intestinal tract. Unfortunately, they also promote looser stools and remove important vitamins and minerals and fluids from the body. The child with cancer needs these nutrients, so such diets should be avoided. Ask your child's nurse or doctor about using vitamin supplements. Vitamins replace some of those that are lost because of a smaller appetite and lower intake of food. A daily multivitamin and iron can be important supplements to the diet. However, some vitamins counteract certain chemotherapy medicines, so you should check with the doctor or nurse first before taking vitamins. For example, B vitamins counteract methotrexate, which is often taken by children undergoing treatments for leukemia. A health-care professional such as a doctor, nurse, or dietitian can recommend brands of vitamins that would be acceptable.

Possible Obstacles

Think about what will stop you from carrying out your plan and how you will deal with it.

Here is an obstacle that other people have faced. 

"He says he's just not interested in food. He's not hungry at all."

Response: Lack of interest in food cannot be easily changed. Try to offer small snacks or meals in the company of people he or she enjoys. Try the other tips in this homecare plan but don't focus on eating so much that it's the only topic you ask about or talk about.

Carrying Out and Adjusting Your Plan

Keep track of the amount of food your child is eating and his or her weight. If you see a problem, check When To Get Professional Help to see if you need professional help. Try to determine whether your child's eating is being hindered by bothersome tastes and smells, dry or sore mouth, or an early feeling of fullness.

If your plan doesn't work

If you are dissatisfied with progress towards meeting these goals and easing the problem with loss of appetite, review the list of appetite problems in this homecare plan and select those that stand in the way of solving this problem. Then review the suggestions underneath that heading and ask yourself what steps you can add to your plan. Another helpful booklet is "Eating Hints," available free from the National Cancer Institute. Ask your nurse or dietitian for a copy.

If you or your child are discouraged with progress, voice your concern to your doctor or nurse. They may refer you to a dietitian, who may be able to give you new ideas and who can analyze whether the diet is adequate. The doctor may also make other suggestions to help you deal with this problem.

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