In addition, cancer and cancer treatments can reduce the ability of a person's immune system to fight infection. When the immune system cannot protect the body from normal bacteria or outside germs, weakened or inflamed tissues in the mouth can become infected. The body's basic defenses are lowered temporarily. Therefore, an occasional side effect of cancer treatments is the presence of mouth sores or a very sore mouth, throat and esophagus.

Pain in the mouth or throat can cause children to avoid eating and drinking. If the child drinks little for 24 hours or more, he can become dehydrated. This is a serious problem, especially in young children. If sore mouth occurs repeatedly, your child may be unable to take in enough nutrients to fight infections and allow for normal growth and development.

Your goals are to:

• prevent mouth problems,
• call for help when it is needed,
• treat mouth sores, blisters, or infections, and
• maintain hydration and nutrition.

When To Get Professional Help

The first question you should ask is whether your child needs help from medical professionals. Then you'll need to find out how urgently he or she needs that help.  Report the signs and symptoms below to help the health care staff decide whether an infection is brewing in the mouth, tongue, throat, or esophagus (the tube leading to the stomach). Sometimes, these problems can become so severe that the child is hospitalized for antibiotic therapy or pain medication.

You should call the clinic, doctor or nurse immediately if any of the following are true:

• Temperature is over 101 degree F. (Refer to "How to Take Temperature" section.) Fever can indicate a mouth infection. If the temperature goes up suddenly, report it. However, a mouth infection can occur before the temperature goes up, so fever is not the only thing to watch for.
  
• So much difficulty swallowing that your child isn't taking medicine as often as it's been prescribed. When the throat is sore or swollen, swallowing becomes more difficult. Call if your child skips medicines because of this.
  
• So much difficulty swallowing that your child eats or drinks very little. (Refer to fluids chart, which your doctor or nurse will fill in for your child's situation.) The child may be eating or drinking less because of a sore or painful throat. Going without nutrition or fluid causes weakness and possibly dehydration. How soon to become concerned over this varies from infants through adolescents, so ask your doctor or nurse.

You should call the clinic, doctor, or nurse during office hours if any of the following are true:

• A light redness on tongue grows much redder. Redness comes before a mouth sore. You will need a light to tell if the mouth, gums, or tongue are redder than usual. If your child is taking little by mouth or complains of pain, use a small flashlight to look into the mouth and find any sores. Check the mouth twice a day, morning and night, until the sores have healed. Look at the roof of the mouth and all of the lining. Look under the tongue and gums.
  
• Redness on tongue turns to white patches, or white patches appear in mouth or on gums. White patches may indicate an infection. Usually, it's a thrush infection (Candida albicans). This infection happens when the mouth lining is unable to fight off normal organisms. Candida increases in number and becomes a problem.
  
• Sore or blister on the lips or in the mouth. If the normal skin lining the mouth is affected by chemotherapy, mouth soreness and sometimes mouth sores or blisters follow. If a cold sore or herpes blister appears, antiviral medication can be prescribed to hasten healing.
  
• Sore throat or painful throat.The lining of the throat is the same as the lining of the mouth. These areas are just as likely to get red and sore. Sores can also occur down to the stomach and result in heartburn.
  
• If your child needs stronger pain medications. A wide range of pain relief products is available. Maintaining comfort is a priority, so don't hesitate to ask about other options if your child's pain is not well controlled.

When you call the doctor or nurse, they may ask you the following questions:

1. When did the mouth problems start?
2. Is the mouth, tongue, or throat redder than usual? Have any white patches or blisters appear around or in the mouth?
3. What did your child eat or drink in the last 24 hours? For infants, have you found any changes in the daily patterns of wet diapers? For children or adolescents, has there been any change in the amount of urination?
4. How are the mouth and teeth cleaned? Are any rinses used?
5. How is your child's level of activity?
6. Is there a change in chewing or swallowing?
7. Has any medicine been ordered for the mouth or throat? How often is it taken?
8. Does your child have any problems, such as gagging or nausea, in taking medicines? Does this keep him or her from taking medicines as often as they're prescribed?
9. When was the last chemotherapy or radiation treatment?
10. Does your child have a fever?

Here is an example of what a parent might say when calling:
"I am Joan Smith, Billy Smith's mother. Billy is Dr. Neely's patient. He is being treated for lymphoma. The homecare plan says I should call if he's not able to drink well for 24 hours."

What You Can Do To Help

If you decided that the mouth problem is not an emergency, here are four things you can do to solve problems with mouth sores or a sore mouth.

• Soothe a sore mouth and ease swallowing
• Prevent dehydration
• Treat mouth sores, blisters, or infections
• Moisten a dry mouth
• Prevent mouth problems

Soothe a sore mouth and ease swallowing

• Encourage your child to rinse the mouth, after eating, with a solution of salt water or half-strength Peridex. Baking soda soothes the mouth and helps it heal. Rinsing after eating removes food particles that could irritate the gums, but does so more gently than commercial mouthwashes, many of which contain alcohol. Avoid these, because they dry out the mouth.
• Offer plenty of liquids and suck on ice chips or Popsicles.
• Moisten food with cream, milk, gravy, and sauces. Moist food is easy to swallow, especially when the mouth and throat are tender.
• Offer soft, moist, bland foods, such as soups, eggs, pastas, quiches, baby foods, cheese dishes, tuna fish, applesauce, custards, pudding, canned fruit, cooked cereals, bananas, gelatin, yogurt, ice cream, sherbet, frozen fruit bars, Popsicles, or shakes. Bland foods are those that are not spicy or salty. Examples are bread, pudding, Jello custard, rice, and tapioca. All are soft, moist, and easier to swallow than most food.

Prevent dehydration

Remember that the child's mouth may be too sensitive for extreme temperatures. In this case, cool (not cold) or tepid (not hot) liquids may be best tolerated. These may be offered carefully via a straw or syringe.

Treat mouth sores, blisters, or infections

Use the following list at the very hint of a sore or infection to reduce the seriousness of mouth and throat complications.

• Rinse after eating or drinking with warm tap water or a solution of 1/2 tsp salt to 2 cups of water. Mouth rinses remove food particles, which may build up and cause bacteria to grow. Rinses also soothe sore tissues, which helps them heal more rapidly. See that your child's mouth is rinsed at least 4 times a day and as often as every two hours while he or she is awake. If the salt rinse causes a burning sensation, use less salt.
• Ask about giving your child a numbing liquid or lozenge as a "throat coat" before eating and swallowing. Many people swallow mouth gels or "throat coats" (a thick, jelly-like liquid) before meals and at bedtime, when the mouth is very sore because of the effects of chemotherapy. Another choice is Maximum Strength Sucrets an over-the-counter anesthetic that a child can easily suck on. These products numb the tongue and throat enough to let liquid and soft foods pass without much trouble. Many hospital pharmacies will also make a mixture that may contain Maalox and liquid Benadryl which heal and soothe the soreness and decrease swelling and inflammation, especially in the throat and esophagus. Ask about these "mouth gels" or mouth medicines if they haven't been prescribed as part of the chemotherapy.
• Use acetaminophen according to label instructions (acetaminophen tablets or Tempra liquid, which is alcohol-free and may be easiest to tolerate. If you need further help, contact your nurse or doctor.
• Ask about other prescription medications. During chemotherapy and a few weeks after treatments, many people use a prescription mouth rinse (Peridex) to swish and spit at least two times per day. This prevents infection and sores.
• Finish antibiotics when they are prescribed to treat an infection. The doctor also may order an oral antibiotic. If so, be sure that your child takes all of it until the bottle is empty, or until a doctor or nurse instructs you to stop giving it. Antibiotics are intended to kill the infection in the mouth. If they are effective, your child's mouth should usually feel better, and eating and drinking should be easier.
• Ask about using other pain pills or liquids for pain relief. Pain pills or liquids could be taken about an hour before eating and drinking. This will help take the edge off biting, chewing, or swallowing when the mouth feels sore or when there are blisters.
• Avoid using hydrogen peroxide rinses. Peroxide kills bacteria, but it is very drying. Its use can lead to a mouth and throat infection known as thrush. It can also damage healing tissue.

Maintain nutrition and prevent dehydration by:

• Serving soft foods that are easier to swallow.
  
  MEATS AND PROTEINS-Include beef, pork, and chicken, fish, smooth peanut butter, eggs, cottage cheese, mild cheese, macaroni and cheese, yogurt, and bean casseroles. Always make sure that meat is well-cooked, tender, and easy to chew. Avoid sharp cheeses, crunchy peanut butter, and spicy foods.
  
  VEGETABLES-Include well-cooked vegetables that are easy to chew, and baked or mashed potatoes. Avoid vegetables with a lot of acid, such as tomatoes or potato skins, or crunchy or raw vegetables, fried potatoes or vegetables, and tomato soups and sauces.
  
  FRUITS-Include apple sauce, apple juice, grape juice, nectars, prune juice, soft cooked or fresh non-citrus fruit, and bananas. Avoid citrus fruits and juices, and fruit peels.
  
  MILK-Include milk, milk shakes, cream soups, eggnog, buttermilk, custards, and puddings.
  
  BREADS-Include all cooked or dry soft cereals, soft bread and rolls, and pasta with mild sauce. Avoid seeded breads, crusty breads, or granola bars.
  
• Softening breads and cereals with milk.
  
• Using a blender.
  
• Using gravy, butter, or cream sauces, which add liquid to food and make it easier to swallow.
  
• Eating foods at room temperature.
  
• Avoiding extremely hot or cold foods.
  
• Letting carbonation or fizz escape from sodas.
  
• Serving gelatin, pudding, and softened ice cream. These foods count as liquids. They are important to offer because the child with mouth sores needs many fluids to combat a dry, sore mouth and throat to prevent dehydration and electrolyte imbalances.
  
• Ask about high-calorie liquids, such as Ensure or Isocal or milk shake recipes.

Prevent mouth sores

If your child does not have mouth sores or blisters, follow this daily schedule to prevent such problems.

• Brush the teeth after meals and at bedtime. Brushing removes bacteria and food, and stimulates gums and the lining of the mouth.
• Use a soft toothbrush. However, if your child's gums are sensitive or bleeding, use a soft sponge applicator or a cotton-tipped applicator, until the problem resolves itself. Alternatively, a soft toothbrush can be further softened by soaking it in warm water before use. Because the mouth is easily irritated, give your child a soft-bristle toothbrush to use. Soft bristles prevent cutting or scraping, reducing the likelihood of infection.
• If your child has been given a prescription for Peridex an antimicrobial mouthwash, you should swab or rinse the mouth twice a day. Peridex is a special bacteria-fighting mouthwash that will prevent infected mouth sores. If your child objects to the taste, you can mix it with a little water to dilute it. You also can avoid having your child eat right after using Peridex because its residual taste tends to change the flavor of foods.
• Keep your child's lips moist with petroleum jelly, mild lip balm, or cocoa butter. If swallowing is difficult, then the mouth and lips become very dry. Lip balms prevent chapping and infection.
• Notify your nurse or doctor if your child is prone to cold sores. Cold sores are caused by a herpes virus and may flare up with each round of treatment. In some cases, it is necessary to prescribe an antiviral medicine to be used preventatively with each cycle of chemotherapy.
• If you have been given other mouth care medications, use them until your doctor or nurse instructs you to stop. Until then, ask for refills.
• Avoid cigarettes, chewing tobacco, and alcoholic beverages. Younger children are unlikely to be using these substances, but teenagers may be doing so. Discourage their use, as they irritate the mouth.
• Offer your child plenty of liquids (refer to the fluids chart, which your doctor or nurse will fill out for your child's situation). Taking frequent sips of water helps prevent dehydration. Many people carry large plastic cups with straws attached, and drink from these frequently to keep the mouth moist.
• Encourage your child to use dental floss at bedtime, but stop the flossing if it causes bleeding or pain, or if mouth sores are present. Flossing removes food particles. Flossing also can cause very small cuts in the gum tissue, but these heal during the night because no food is eaten.
• Avoid commercial mouthwashes. Many commercial mouthwashes contain alcohol, which is very drying. Ask your nurse what works best, and what mouthwashes the medical center recommends.
• Braces may need to be removed. Being made of metal, braces may rub the gums or lining of the mouth, and may need to be removed until soreness passes.

Possible Obstacles

Think about ideas and attitudes that could prevent you from carrying our your plan to solve your child's mouth sore problems.

Here are some obstacles that have sometimes stopped others.

1. "My daughter didn't want to brush her teeth or floss before diagnosis. How can I get her to do this now?"
   Response: It's important to stick with it and make it a routine. Food particles can build up and cause bacteria to grow. Don't wait until there's a problem to start your child on mouth care.
   
2. "My teenager doesn't want to quit smoking or drinking."
   Response: Both of these habits irritate the mouth. If the adolescent on chemotherapy doesn't quit either habit, then that's all the more reason to take other measures to care for the mouth.
   
3. "My child will eat only one food when she has mouth sores."
   Response: That's OK for a couple of days until the problem is resolved. It is most important that she is able to drink the recommended amount of fluid each day to prevent dehydration.

Carrying Out and Adjusting Your Plan

Your child will tell you if his or her mouth is sore. Keep track of how frequently these episodes take place, so the doctor or nurse can recommend specific treatments if they are needed.

Also, stay alert to whether mouth problems are interfering with your child's regular patterns of drinking and urinating, because dehydration and weight loss can lead to other problems. Are you doing everything you can to treat and prevent these sores?

If your plan doesn't work

If problems with mouth soreness or swallowing are getting worse, review "When To Get Professional Help." Ask yourself if you are doing everything you can to encourage good oral hygiene and to protect your child's mouth and throat against soreness and infection. Tell the doctor or nurse what you did to deal with any mouth problems and discuss what else should be done.

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