European Journal of Oncology Nursing 23 (2016) 24e33

Contents lists available at ScienceDirect

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Causes of inadequate intake of nutrients during the treatment of

children with chemotherapy
Petra Klanjsek*, Majda Pajnkihar
University of Maribor, Faculty of Health Sciences, Zitnaulica 15, 2000 Maribor, Slovenia

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 12 February 2015
Received in revised form
13 February 2016
Accepted 6 March 2016

Purpose: The purpose of the research was to explore nurses' perceptions of different causes of inadequate food intake in children treated with chemotherapy and to determine how often nurses identify
these causes.
Method: Qualitative and quantitative approaches were used. Qualitative data were rst gathered using
semistructured interviews in a sample of six nurses and analysed by conventional content analysis. Based
on the results of qualitative data and literature analysis, a 28-item questionnaire was developed and
evaluated for its face validity in a sample of fteen nurses. Questionnaires were then administered to
twenty-seven nurses working at one pediatric oncology ward. Quantitative data were analysed using
descriptive statistic.
Results: The major themes that emerge from the content analysis, describing nurses' perceptions of
causes of inadequate food intake in children undergoing chemotherapy, were as follows: physiological
causes of eating problems, psychological causes of eating problems, change in food selection, hospital
food and individual counselling. 13 causes of inadequate food intake were identied from the questionnaire data. Pain due to mucositis was the most commonly identied cause of inadequate food intake
in children, followed by nausea and vomiting, altered taste, loss of appetite and an altered smell. Psychological causes of eating problems are rarely identied.
Conclusion: Nurses identify most of the physiological and psychological causes of inadequate food intake
in children treated with chemotherapy. The early identication and management by nurses of inadequate food intakes should be part of the curriculum for nurse education as well as part of treatment
planning in clinical environment.
2016 Elsevier Ltd. All rights reserved.

Keywords:
Children
Cancer
Chemotherapy
Inadequate food intake
Identication of causes
Nursing

1. Introduction
There are several food-related problems present in children
with cancer undergoing chemotherapy, for example mucositis,
nausea and loss of appetite (Skolin et al., 2006). Children treated
with intensive chemotherapy have signicantly reduced oral, energy and nutrient intake (Mosby et al., 2009; Owens et al., 2013).
Inadequate nourishment often leads to malnutrition (Sala et al.,
2012). It weakens the immune system and increases morbidity
and mortality due to infections (Schmitt et al., 2012; Gibson et al.,
2012). Malnutrition may also negatively affect drug action, increase toxicity of medicines and alter the response to treatment

* Corresponding author.
E-mail addresses: petra.klanjsek@um.si (P. Klanjsek), majda.pajnkihar@um.si
(M. Pajnkihar).
http://dx.doi.org/10.1016/j.ejon.2016.03.003
1462-3889/ 2016 Elsevier Ltd. All rights reserved.

(Brinksma et al., 2015). Selwood et al. (2010) emphasize that

appropriate management of eating problems during chemotherapy
has a signicant impact on the success of the treatment, quality of
life and health-care costs.
Ensuring adequate nutrient intakes in children treated with
chemotherapy is a challenging task because of the many physiological and psychological side effects of cytostatics. In their study

lu and Erdog

an (2014) found that in 76.7% of children
Mollaog
treated with chemotherapy, loss of appetite is a decisive reason for
a lower food intake. Chemotherapy causes damage to the mucosa of
the gastrointestinal tract, leading to abdominal pain, reduction of
the absorption of nutrients, and sometimes to serious enterocolitis
(Schiff and Ben-Arye, 2011). Pain affects 80e90% of all children
suffering with cancer (Collins et al., 2008). Oral mucositis occurs in
52e80% of children after receiving chemotherapy (Owens et al.,
2013). Clinical features combine erythema, oedema and sensitivity, followed by painful ulceration and mucosal bleeding (Elting

P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

et al., 2003), impeding oral feeding (Srinivasan et al., 2012). Nurses

state that nausea and consequent rejection of hospital food is the
primary reason for lower oral food intake in children with cancer
(Robinson et al., 2012). More than 50% of oncology children experience nausea and vomiting during chemotherapy treatment
(McCulloch et al., 2014). After repeated cycles of chemotherapy,
patients often experience anticipatory nausea and vomiting
(McCulloch et al., 2014; Kamen et al., 2014). The latter are associated with taste, odour, environmental and visual associations with
previously received chemotherapy (Roscoe et al., 2011). They
appear before receiving the chemotherapy, and the rate and
severity increases with each cycle of chemotherapy (Kamen et al.,
2014). The senses of taste and smell motivate food choice in children (Karaman et al., 2009). Mosby et al. (2009) stated that cancer
and chemotherapy treatment alter the taste perception, which
consequently leads to a reduction of food intake. Side effects of
chemotherapy can lead to long-lasting changes in odour perception. Cohen et al. (2014) found that in 23.5% of children a clear but
partly signicant degree of dysfunction in odour perception occurs.
Odour dysfunction in children gives rise to nausea and vomiting
(Roscoe et al., 2011). The occurrence of constipation during treatment is experienced by 50e60% of oncology children (Feudtner
et al., 2014). Researchers attribute the cause of constipation to the
use of antiemetics and narcotics, combined with cytostatics
(Vincristine) (Feudtner et al., 2014; Essa et al., 2014). Robinson et al.
(2012) found that children treated with chemotherapy suffer from
chronic fatigue. This affects the physical condition, quality of life
and daily activities of a child, and to a large extent, the process of
eating. In pediatric oncology, the perceptions of both the child and
parents regarding food intake and eating problems during
chemotherapy are important. Therefore, some researchers (Gibson
et al., 2012) have investigated the perceptions and experience of
children and their families relating to inadequate food intake.
However, very young patients have difculty in describing their
experiences or expressing their opinions. Even school-aged children or adolescents may have difculties in understanding and
articulating their experiences (Dupuis et al., 2010). As nurses often
act as the connection between child, parents and treatment, their
insight into the eating needs of the child is very important. Pediatric oncology nurses are specically trained to recognize and
manage the complications of childhood cancer and its treatment,
including malnutrition and associated symptoms (Ladas et al.,
2005). Qualied nurses know a great deal about children's nutritional problems during treatment with chemotherapy and may give
timely help to prevent nutrition becoming a problem for some
patients (Gibson et al., 2012). Skolin et al. (2006) state that nurses
play a vital role in the daily assessment of a child's nutritional status
and can, in close collaboration with parents, identify the causes of
child's inadequate food intake. We therefore, chose to explore
nurses' perceptions of causes of inadequate food intake in children
undergoing chemotherapy.

2. Purpose
The purpose of the research was to explore nurses' perceptions
of different causes of inadequate food intake in children treated
with chemotherapy and to determine how often nurses identify
these causes. The research questions were: (a) Which causes of
inadequate food intake in children treated with chemotherapy do
nurses perceive, and what is the frequency of these perceptions?
(b) How do groups of nurses (according to age, years of service in
nursing, years of service in pediatric oncology nursing) perceive the
causes of inadequate nutrient intake in children treated with
chemotherapy?

25

3. Methods
3.1. Study design
A qualitative and quantitative study design was used and undertaken in two phases. In the rst phase, qualitative data were
gathered using one-to-one semi-structured interviews. This technique was chosen as it is a sufciently exible technique to allow
the researcher to adapt questioning to the respondent's understanding of the topic under discussion. It offers a degree of latitude
to talk around central areas of discussion and to home-in on
chance remarks and probe further for additional views (Price,
2002). Interviews are usually appropriate when an existing theory or research literature about a phenomenon is limited
(Kondracki and Wellman, 2002). Burns (2000) stressed the need for
interviews to use open-ended questions to allow the interviewer to
become more of a respondent to gain insight into the opinions and
values of the interviewee. Coyne et al. (2014) state that an openended interviewing technique allows exibility with the questions, and follows the participant's own story. These types of
questions allow participants to bring up matters they judge to be
important. Therefore the interview questions in our study were of
an open-ended type to attain spontaneous information and to
encourage frank discussion with respondents to discuss the underpinning attitudes, opinions and values. This type of questions
was based on the theoretical discussion and instructions described
by Rose (1994). Using semistructured interviews with open-ended
questions therefore enabled participants to describe in detail their
experiences of causes of inadequate intake of nutrients during the
treatment of children with chemotherapy. According to Fielding's
(1994) suggestions, the questions were sequenced to allow the
researcher to probe and clarify responses in relation to the dimensions of the topic. Data gathered from interviews were analysed by conventional content analysis according to the instructions
by Hsieh and Shannon (2005).
In the second phase, a purpose-built questionnaire was
designed specically for this study to assess the frequency of
nurses' perceptions of different causes of inadequate food intake in
children treated with chemotherapy. According to researchers
Oppenheim (1992) and Sapsford (1999), a quantitative design using
questionnaires offers an objective means of collecting information
about participants' perceptions. The questionnaire was designed on
the basis of a literature and data analysis in phase one. The developed questionnaire was then evaluated for its face validity in the
pilot study. The majority of the closed-ended questions were in the
Likert scale form.
3.2. Participants
A qualitative study involving semistructured interviews with a
purposive sample of six nurses with at least one year of professional
experience, knowledge and professional reputation in pediatric
oncology nursing was conducted. These six nurses were not
included in the pilot and quantitative study. A convenience sample
of 15 nurses was chosen for the pilot study. These nurses were
predominantly involved in working in oncology wards, supervising
practice or educating nurses about oncology nursing. The 15 nurses
who took part in the pilot study were not included in interviewing
and completing the nal questionnaire. In this quantitative study, a
consecutive sample of 27 nurses working at the pediatric oncology
ward was chosen. Of the 27 eligible nurses, three refused or were
unable to participate and 24 nurses returned the questionnaire,
yielding a response rate of 88.75%. All participants were female. The
participants' age ranged from 23 to 58 years; mean age of 38.73.
Their mean years of service in nursing were 17.99 and their mean

26

P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

years of service in nursing in the pediatric oncology ward were

14.75. For more information and description of the participants, see
Table 1.
3.3. Data collection

purpose-build questionnaire in June 2014. Nurses were asked to

complete and return the questionnaires within three weeks to the
head nurse of the pediatric oncology ward. The questionnaires took
approximately 15e20 min to ll out.
3.4. Ethical consideration

The qualitative data were collected by audio-reordered individual interviews in April 2014. The interviews included openended questions. Interviews were carried out in the nurses' free
time. Each nurse choses the time and place of the interview,
thereby minimising any interference with nursing care. The interview questions were, for example: Do children have problems with
eating during treatment with chemotherapy? This question was
followed by If so, what kind of problems in particular?, and What
are the biggest problems with inadequate food intake in children
treated with chemotherapy? Follow-up questions were asked to
elucidate relevant aspects. All interviews lasted from 30 to 60 min
and were conducted in quiet, private areas.
Following the interviews, the purpose-built questionnaire was
constructed with 28 questions. The questionnaire consisted of four
sections: (1) demographics; (2) nurses' opinion on the frequency of
causes of inadequate nutrient and energy intakes in children
treated with chemotherapy; (3) statements/claims related to the
nutrition and eating habits of children treated with chemotherapy;
and (4) nutritional interventions to prevent inadequate food intake
in children undergoing chemotherapy implemented on the ward.
The questionnaire was closed-ended. The majority of the closedended questions required an ordinal response choice via a 5point Likert scale from 1 (never) to 5 (very often) in 1 (don't
agree) to 5 (completely agree). We added demographic questions
(gender, age, years of service in nursing, years of service in pediatric
oncology nursing, and level of education). The pilot study was
conducted in May 2014 in order to determine the relevance and
appropriate style of wording the questions, as well as general
appearance and acceptability of the overall questionnaire. Fifteen
pilot test questionnaires were distributed to nurses. Some changes
to the original questionnaire were made. We had to add some
auxiliary explanation for some specic terms (e.g. anticipatory
nausea). Descriptive, quantitative data were obtained by the

Ethical approval for conducting the research for this study on

the particular ward was obtained from the local clinical ethics
committee (30 April 2014) and from the head of nursing in the
participating organization. The participants were informed about
the nature of the study and given an information sheet about the
s, 2004). The covering letresearch process (Puotiniemi and Kynga
ter provided information about the purpose of the study, and gave
details about the voluntary and anonymous participation in the
study. The nurses who participated in interviews were asked for
permission to make a voice recording and they were informed of
their right to stop the interview. All participants were assured that
condentiality of collected information would be maintained at all
times.
3.5. Data analysis
Data from individual interviews were audio-recorded and notes
were taken. All interviews were performed by the same person. The
transcribed interviews were read several times to obtain an overall
sense of context. At the next step, the transcribed text was coded,
using individual terms or short expressions. As this process
continued, similar terms or expressions were organized into the
nal coded scheme. The codes were then sorted into categories
(main themes) based on how the different codes were related and
linked. These emergent categories were used to organize and group
codes into meaningful clusters (Coffey and Atkinson, 1996; Patton,
2002). For ease of understanding codes and categories were formed
through logical induction, using general terms in connection with
pediatric oncology care phenomena that might be familiar to the
general public. Also, terms used in the coding procedure were
extracted from a literature review process. Exemplars for each code
were identied from the data (Habjani
c and Pajnkihar, 2013).

Table 1
Characteristics of the participating nurses in interview and questionnaire.

Age
Work History (in Years)
In Hospital as a nurse
At study department

Minimum

Maximum

Mean

Median

Std. Deviation

23.00

58.00

38.73

36.00

8.863

2.5
1.0

37.8
35.0

17.993
14.750

16.500
13.500

9.7034
8.7757

Education
High school
University
Age
20e29
30e39
40e49
50e59
Years of service in nursing
0e9
10e19
20e29
30e39
Years of service in nursing at the pediatric oncology department
0e9
10e19
20e29
30e39

Frequency (n)

Percentage (%)

23
7

76.7
23.3

4
15
7
4

13.3
50.0
23.4
13.3

6
12
6
6

20.0
40.0
20.0
20.0

9
13
5
3

30.0
43.3
16.7
10.0

P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

Data collected by using the questionnaires were analysed with

SPSS software (version 21.0). Descriptive statistics, such as frequency distribution, were used to describe and summarise the
characteristic of the sample, variation in response and validation of
the questionnaires. Mann Whitney U test and Spearman correlation
was used to evaluate the impact of age and experience of pediatric
oncology nurses on their perception of the inuence of chemotherapy on the risk of malnutrition and vice versa. The KruskaleWallis test was applied to examine the differences in
perception of the causes of inadequate food intake in children
treated with chemotherapy among groups of nurses according to
their age, years of service in nursing and years of service in pediatric
oncology nursing. The full results of the questionnaire are presented in the results section.

3.6. Trustworthiness of the study

The trustworthiness was approached by consideration of its
credibility, conrmability, dependability and transferability
(Lincoln and Guba, 1985). Through participation of critical assessment in data analysis by both authors, credibility was sought. Both
authors agreed on the formation and content of the categories as
discussed by Padgett (1998). Dependability was addressed by
selecting a sample of nursing staff who had gained solid experience
through pediatric oncology nursing. By comparing the results with
earlier studies, conrmability was addressed. Transferability was
sought by representing the eld of pediatric oncology nursing
through general concepts, so as to guarantee a sufcient level of
abstraction for clinical pediatric oncology nursing.

4. Results
4.1. Results of interviews
Based on the interviews with the nurses, ve major themes of
causes of inadequate food intake in children treated with chemotherapy could be identied: (1) physiological causes of eating
problems, (2) psychological causes of eating problems, (3) a change
in food selection, (4) hospital food and (5) individual counselling.
For more information and description on coding, see Table 2.

4.1.1. Physiological causes of eating problems

According to nurses, pain due to mucositis, nausea and vomiting
are predominant causes for inadequate food intake. They stated
that pain due to inammation of oral mucosa (small sores or ulcers)
is the most frequent and important cause for food rejection in
children during treatment. In their opinion children often state that
they are afraid to eat because pain in the mouth will get worse.
Nurse 6 with 14 years nursing experience and eight years pediatric
oncology experience explained:
Swallowing food and drinks with difculties is often observed in
children. They will not eat because they feel pain due to mouth
ulcers. Smaller children, up to four-years old often cry during
feeding.
Nausea and vomiting were mentioned by all nurses as very
important and also frequent causes for lowered food intake. Nurses
believe that during a period of nausea and vomiting children do not
desire food and they eat far less than needed at their age. Nurse 5
with 10 years nursing experience and nine years pediatric oncology
experience stated:

27

Nausea and vomiting have the strongest impact on food intake.

Mostly they occur in the rst week after chemotherapy is given. At
that time children eat only half of what they should.
Very often altered taste in children is observed. Nurses stated
that food well liked before by children suddenly has no avour or
the avour is different. Often they do not like candy any more.
Nurse 2 with 12.5 years nursing experience and 11 years pediatric
oncology experience described:
A boy desired a specic food, which he previously liked. When I
brought him this food, he said that it has no avour and he does not
like it. He did not eat it.
Two nurses stated altered smell as a cause for rejecting food that
was observed many times in children. According to nurses, children
are more susceptible to the smell of food. The chemotherapy itself
also has a strong odour to them. These odours make children feel
nausea and consequently they vomit.
Loss of appetite in children caused by nausea and vomiting was
observed by nurses. Loss of appetite was also connected to altered
smell and altered taste during treatment. Children described a
metallic taste in the mouth. Nurse 3 with 12 years nursing experience and three years pediatric oncology experience stated:
Children often say they are not hungry or they do not have any
appetite because the food is avourless or they have a metallic taste
in the mouth.
As a cause for lower food intake, feeling ill is related to nurses
statements about fever due to infection as a result of neutropenia,
and constipation as a result of drugs (antiemetics). Nurse 5 with 10
years nursing experience and nine years pediatric oncology experience said:
When children have a fever or they feel discomfort and pain
because they are constipated, they often reject meals.

4.1.2. Psychological causes of eating problems

The nurses perceived that children develop learned food aversions after they felt nausea or vomited when eating familiar food.
The next time even the smell or sight of the same food can cause
secondary nausea and they were not able to eat it. Nurse 1 with 36
years nursing experience and 15 years pediatric oncology experience stated:
Children begin to refuse certain foods because they vomited once
when they ate it and now they think it will happen again.
Anticipatory nausea was mentioned by all nurses. It can be
induced by seeing a bottle or colour of chemotherapy, a nurse
entering the room, thinking of getting another cycle of treatment,
arrival at the ward etc. Nurse 4 with 37 years nursing experience
and 23 years pediatric oncology experience said:
I noticed that children complain about nausea even before they
arrive to the hospital. When they see a prescription with Daunorubicin, they can instantly feel sick.
According to nurses, the hospital environment has a negative
effect on children's eating. It is not usually recognized at the rst
hospitalisation, but at the second or third one. Children are trying
to protest the facts that they are affected by a disease and being

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P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

Table 2
Codes extracted and subcategorised formed (major themes).
Level 1 subcategory

Level 2 subcategory

Physiological causes of
eating problems

Nausea and vomiting

Psychological causes of
eating problems

A change in food
selection

Hospital food

Individual counselling

Codes (words, expressions)

Very important causes, very frequent causes, eat only half of what they should, very often, not desire food,
strongest impact on food intake.
Altered taste
Very often, different avour than they used to, no avour, avour is different, do not like candy any more.
Pain
The most noticeable causes, afraid to eat, very often, difculty swallowing food and beverages, crying,
predominant causes, mouth ulcers.
Loss of appetite
No appetite, food is avourless, metallic taste, nausea and vomiting, altered smell, altered taste.
Feeling ill
Fever, infection, pain, discomfort, antiemetics, constipation, neutropenia, reject meals.
Altered smell
Many times, more susceptible to the smell, food odours, strong odour of chemotherapy, nausea and vomiting.
Learned food aversions
Vomiting in the past, to refuse certain food, nausea and vomiting, smell, will happen again.
Anticipatory nausea
Seeing a bottle of chemotherapy, colour of chemotherapy, nurse entering a room, thought of treatment, arrival
at the ward, feel sick.
The negative impact of the
Protest, disease, control, refuse to eat and drink, blackmail, particular food requirements, stubborn, homehospital environment
made or purchased food, reject hospital food, often teenagers.
Changes of social environment Divorce of parents, depression, loneliness, low appetite.
Accepted food
Salty food, food atypical for that season, salty snacks, strong avoured food, carbonated beverages, fast food.
Food rejection
Sweets, sweet food, chocolate, desserts, pork, energy-rich oral nutritional supplements, bitter beverages,
familiar food had no taste, taste disgusting, taste like plastic, metallic taste, altered taste, altered smell.
Attractive manner of serving
Better looking food, decoration, plates and glasses painted with cartoon motives.
food and drinks
Meal serving times
Better appetite in the afternoon, early in the evening, calm down, presence of parents, often refuse to eat at the
set serving time, saving hospital meals.
Flexibility (customised) menus Food by choice, purvey food, beverages, baby porridge, toast daily on the ward, ice cream, food vending
machine.
Rejecting
Teenagers refuse more often, parents often buy food, protest against hospitalization, provide food from home.
Negative opinion
Teenagers often criticize (looks bad, smells awful), protest against hospitalization, home-made cooking tastes
better, sometimes parents criticize (unpleasant appearance and aroma), provide food from home, home-made
food looked better.
Positive opinion
Most of the parents have good opinion and commend hospital food, well prepared, with a lot of care, good
cooks, usually bring just salty/sweet snacks, commercial drinks.
Providing food by parents
Important, well-known food, favourite food, home environment, vomiting, rejection of hospital food,
adjustment of meals.
Informing
Side effects, instructions, counselling.
Advice
Improving appetite, instructions, alternative food, diets.
Health education
Positive effect, easier to cope, proper support, encouragement, understanding the importance of good
nutritional status.

hospitalized, by refusing to eat and drink. Parents are being

manipulated by children with particular food requirements. They
desire food made at home or purchased in a store. Nurse 3 with 12
years nursing experience and three years pediatric oncology
experience explained:
In the rst cycle of treatment children do not show that they are
dissatised with being hospitalised. I presume that is because
everything is new to them: a new environment, new faces, other
children. During the next cycles of treatments it is evident that
children want to go home as soon as possible. They become stubborn and sometimes they blackmail their parents by asking for
friends from home and for home-made or purchased food and
reject hospital food.
Another nurse mentioned that changes in the children's social
environment, like divorce, can greatly affect their appetite. Nurse 2
with 12.5 years nursing experience and 11 years pediatric oncology
experience explained:
I remember one little girl. At the time of chemotherapy she refused
to eat at all. We tried everything possible to get her to eat; she could
choose any food; the parents cooked for her. We tried counselling
by a dietician. She began to lose a lot of weight and we included a
children's psychologist in the treatment process. Finally it came to
light that the divorce of her parents had a great impact on the
child's appetite.
Other nurses mentioned that loneliness and depression also
contribute to lower appetite.

4.1.3. A change in food selection

All nurses stated that the selection of food by children had
changed after chemotherapy was given. The changed selection was
evident by refusing sweet foods (chocolate, desserts), pork and
bitter beverages (grapefruit juice). These changes were related to
the metallic taste in the mouth, altered taste, altered smell and to
the association with nausea that the children experienced at the
time the chemotherapy was given. They also refused energy-rich
oral nutritional supplements, as pointed out by nurse 3 (12 years
nursing experience and three years pediatric oncology experience):
We could improve the nutritional status of children with supplements during treatment, but children refuse to drink them. Children
say they taste disgusting, some even mention they taste like
plastic.
According to the nurses there are some types of food well
tolerated by children during treatment. Mostly children like salty
food rather than sweet food. Examples of preferred salty food by
children are: soup, pasta, French fries, chips, hamburgers, hot dogs
and salty snacks. The following was stated by nurse 2 with 12.5
years nursing experience and 11 years pediatric oncology
experience:
When you enter a child's hospital room and you look at the table
or nightstand, mostly you see different kinds of salty snacks or fast
food.
As one nurse mentioned, children also prefer strong avoured
food and carbonated drinks. They soothe the pain in the mouth that

P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

occurred due to mucositis. In the winter children often desired food

atypical for that season (strawberries, cherries and blueberries). All
nurses stated that children like foods and drinks made by wellknown brands (McDonalds, Coca Cola, Fanta and others).
Food and beverages are better accepted when served in an
attractive manner. Nurse 1 with 36 years nursing experience and 15
years pediatric oncology experience described:
It is evident that children prefer to eat food that is better looking or
decorated. Smaller children like it when parents serve them food on
plates and in glasses painted with cartoon motives. If we would
serve them the same food on hospital plates, they would reject it
more often.
Nurse 2 with 12.5 years nursing experience and 11 years pediatric oncology experience was of the opinion that more favourable
meal serving hours would be late in the afternoon or in the
evening:
I noticed many times that children have better appetite late in the
afternoon or early in the evening. Perhaps their appetite improves,
because they settle down. Usually also parents are present at this
time of day and this boosts their appetite. So we are very pleased to
see parents present at meal serving times.
Flexible (customised) menus and foods of choice are very
important ways of improving food intake in children during
treatment. Nurse 5 with 10 years nursing experience and nine years
pediatric oncology experience described her ambition to purvey
food that was acceptable to children during chemotherapy
treatment:
At the clinic, children can daily choose one of three lunch menus.
This proves to be a very effective method. I also encourage children
to choose one they prefer. When a child completely refuses food, we
also comply with them by ordering the food of their choice.
When children refuse prepared hospital meals, they can still be
provided with beverages, baby porridge and toast on the ward.
They can also order ice cream. There is also a food vending machine
placed near the ward so that children and parents can choose from
a number of different brand snacks and drinks. Nurses believed that
this range of food choice is very important during times of nausea
and vomiting. In that way a child gets at least something to eat.
Flexibility of meal serving times is very important and has a
positive effect on children's food intake. Two of the nurses
mentioned that children often refuse to eat meals at a certain time.
These meals are stored in the ward's kitchen. Nurse 3 with 12 years
nursing experience and three years pediatric oncology experience
stated:
We save meals on the ward for later, when a child may feel hungry
and has some appetite.

4.1.4. Hospital food

Teenagers have negative opinions about hospital food. Nurse 1
with 36 years nursing experience and 15 years pediatric oncology
experience explained:
Teenagers often criticize hospital food. They think it looks bad and
smells awful. They say that home-made cooking tastes better. Their
parents often buy food or cook for them. With criticizing and
refusing to eat hospital food, teenagers exercise their protest
against hospitalization.

29

Nurse 4 with 37 years nursing experience and 23 years pediatric

oncology experience mentioned:
I noticed that teenagers refuse hospital food more often than
younger children do.
Most of the parents have a good opinion of and commend
hospital food. This is also conrmed by nurse 6 (14 years nursing
experience, eight years pediatric oncology experience):
Food at our hospital is well prepared, with a lot of care. We have
our own kitchen and good cooks.
One of the nurses mentioned that sometimes parents criticize
hospital food. They complain about unpleasant appearance and
aroma. Most parents who complain also provide food from home,
but many parents bring their children just salty or sweet snacks and
commercial drinks. About providing food by parents, nurse 3 with
12 years nursing experience and three years pediatric oncology
experience said:
It is important that parents bring children well-known and
favourite food, which they enjoyed also at home. This is crucial for
children who often vomit and completely reject hospital food.
All the nurses appreciated when they learned from parents
about their child's preferred foods and drinks. In that way they
were able to adapt hospital meals.
4.1.5. Individual counselling
According to nurses, parents and children are acquainted with
the potential side effects of chemotherapy that impact children's
normal eating patterns. All nurses stressed that they give advice on
improving a child's appetite. Nurse 6 with 14 years nursing experience and eight years pediatric oncology experience explained:
At the beginning of treatment some parents do not follow our
instructions. They resort to various alternative and healthy diets for
their children (organic or fresh food). In time, children start to reject
this kind of food. After that happens, parents usually come for
counselling again and then they follow the instructions.
Nurses believe that health-education and, counselling parents
and children about eating during chemotherapy treatment has a
very positive effect on children's food intake. Parents can therefore
cope more easily with their child's eating problems and can give
good support and encouragement to their child. Nurse 1 with 36
years nursing experience and 15 years pediatric oncology experience noticed:
After individual counselling, older children begin to understand
the importance of a good nutritional status during their treatment
and they are trying to eat and drink as much as possible.

4.2. Results of the questionnaire

With the questionnaire, frequencies of 13 causes of inadequate
food intake in children treated with chemotherapy were obtained.
These causes were divided into two groups. Pain, nausea and
vomiting, altered taste, loss of appetite, altered smell and feeling ill
were classied in the group of physiological causes. Causes such as
gaining some control of the situation, learned food aversions,

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P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

anticipatory nausea, the ward environment, protesting against the

situation, changes of the social environment through depression or
loneliness, and meal serving times were included in the group of
psychological causes of inadequate food intake.
According to most nurses, pain due to mucositis, mouth ulcers,
throat pain, abdominal pain (83.4%) and nausea and vomiting
(83.3%) are predominant causes of inadequate food intake in children. Altered taste, loss of appetite and altered smell are stated as
frequent causes of inadequate food intake by most nurses.
The nurses think that altered taste (62.5%) and loss of appetite
(62.5%) are causing more eating problems than altered smell
(45.8%). Gaining some control of the situation was identied as a
frequent cause (37.5%) of inadequate food intake. One of the
interesting ndings is that after chemotherapy, 45.8% nurses
perceive increased desire for salty, spicy food and food with strong
avours. Two thirds of nurses (66.7%) agreed that changes in the
primary gustatory sense occur in children who receive chemotherapy, as well as changes in the perception of food. According to
70.8% of nurses some measures can be used during intensive
chemotherapy treatment in order to bring oral energy intake back
to recommended values, such as: exible (customised) menus,
exibility of meal times, food decoration and energy-rich snacks.
Just over half of nurses (54.2%) considered learned food aversions to
be a frequent cause of eating problems. Nurses identied anticipatory nausea in 58.3% as an occasional and in 20.8% as a rare cause
of inadequate food intake. Over 40% (41.7%) of nurses believe that
children's sight of equipment for application of chemotherapy can
induce anticipatory nausea. The majority of the nurses also identied feeling ill (83.4%), a negative impact of the ward environment
(75.6%) and protesting against the situation (79.2%) as occasional
causes of eating problems. Three quarters (75%) of nurses did not
agree that teenagers generally reject regular hospital food to
manifest their autonomy, but 70.8% of nurses agreed that teenagers
reject hospital food more often than younger children. In the
opinion of 41.6% nurses, changes of the social environment,
depression and loneliness can impact an inadequate nutrient
intake. Almost 80% of nurses believed that parents are not bringing
food from home, although 66% of nurses agreed that provision of
food by parents is important. One third of nurses (33.3%) believed
that parents have a poor opinion of the preparation of hospital
meals, menus and mealtimes. Two thirds of nurses (66.7%) believed
that food and drinks would be better accepted when served in an
attractive manner. In some nurses' opinion (45.8%) meal serving
times occasionally or rarely cause children's eating problems. An
important nding was that 62.5% of nurses were aware that a child
undergoing chemotherapy may be at risk of malnutrition; the
remaining 37.5% of nurses were unaware. The group of aware
nurses was on average more than ve years older (40.87 years
versus 35.67 years) and had on average more than seven years more
experiences in pediatric oncology (17.37 years versus 10.22 years).
However, the ManneWhitney U test indicated no signicant
differences between aware and unaware nurses regarding age
(U 44.50, p 0.174) and years of experience in pediatric oncology
(U 37.50, p 0.073). Awareness of nurses that a child undergoing
chemotherapy may be at risk of malnutrition is more inuenced by
years extent of experience in pediatric oncology than by age. A
similar percentage (66.6%) agreed that nutrient and energy intakes
in children with cancer are signicantly lower than the age-based
recommended values. Seventy-ve percent of nurses were aware
that malnutrition may alter pharmacokinetics, impair drug metabolism, increase toxicity and worsen response to treatment; the
remaining 25% of nurses were unaware. The group of aware nurses
was on average almost nine years older (41.11 years versus 32.33
years) and had on average almost seven years more experience in
pediatric oncology (16.42 years versus 9.50 years).

The ManneWhitney U test indicated signicant differences

between aware and unaware nurses regarding to age (U 22.50,
p 0.035) and no signicant differences regarding to experience in
pediatric oncology (U 30.00, p 0.108). Awareness of the nurses
that malnutrition may alter pharmacokinetics, impair drug metabolism, increase toxicity and worsen response to treatment is more
attributed to age than the extent of experience in pediatric
oncology. A majority of nurses (87.5%) agreed that individual dietrelated and nutritional counselling increases food intake, nutritional status and quality of life in children undergoing
chemotherapy.
Differences in opinions about the frequency of causes for inadequate food intake in children treated with chemotherapy among
groups of nurses (grouping by age, years of service in nursing, years
of service in pediatric oncology nursing) were not statistically signicant. This was the case in all statements included in the questionnaire for all groups. Nurses who participated in the survey had
common opinions on incidence of causes for inadequate food
intake in children during treatment with chemotherapy.
5. Discussion
As stated by the majority of nurses, pain due to mucositis,
nausea and vomiting are predominant causes for inadequate food
intake in children undergoing chemotherapy. Patients with severe
oral mucositis are unable to eat, speak or swallow due to pain
(Elting et al., 2003). Many strategies and drugs have been tested to
treat oral mucositis, but none is widely accepted and used
(McGuire, 2003; Clarkson et al., 2010). As oral mucositis takes time
to resolve, the risk of malnutrition increases. The likelihood of child
malnutrition due to reduced food intake during treatment is
greater when the periods of nausea and vomiting are long-term.
Because nausea has a signicant role in the development of
learned food aversions and anticipatory nausea, the prevention of
nausea in treating children with chemotherapy is very important
(Bernstein, 1978; Pelchat and Rozin, 1982). Yeh et al. (2012) have
shown that despite regular doses of 5-HT3 receptors during treatment, nausea and vomiting have not been completely eliminated.
According to ndings by Hong et al. (2009), chemotherapy destroys
receptors for smell and taste, followed by a change in taste and
smell, and consequently loss of appetite. Most nurses in our
research indicate a change of taste, loss of appetite and a change in
odour as frequent causes of children's insufcient food intake. The
nurses' opinion in our study was that a change in taste was an
important reason for altered food choice in children. Changes in the
perception of smell often lead to rejection of food, nausea and
vomiting. From experience nurses discovered that effects of taste
and odour dysfunction can be reduced by offering children cold
food. Most nurses believed that food intake in children can be
increased to the recommended values by using modern eating
routines (exible meal times, exible menus, food of choice, food
decoration). Psychological causes (negative impact of the hospital
environment, protest against the situation) are recognized as occasional causes for lower food intake by children. Food and eating
carry social and cultural meaning and have signicance for cultural
and individual identities (Fischer, 1988). Holm and Smidt (1997)
emphasize that this is a key factor in staying in hospital. Life in
hospital means that patients lose control: their autonomy is subordinated to hospital rules. Patients feel a loss of identity (not
wearing their own clothes), privacy (intimate care) and loss of
decision-making rights of when and what to eat. Rejection of
hospital food can be seen as an indication and proof of children's
attempt to preserve their control. To children, food provided by
parents may represent maintaining their identity and life outside
the hospital. That is why food provided by parents is better

P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

accepted than hospital food. Altered social conditions, depression

and loneliness can negatively affect the food intake in children
during hospital treatment. However, the presence of parents during
meal times stimulates the children's appetite. Woodruff and
Hanning (2013) considered that the children's eating is inuenced by their environment, including the physical environment
(home) and interpersonal relationships within the family. They
found that family lunches and dinners have a positive impact on
children's nutrition. Groben (2011) stated that nurses who work
with children during chemotherapy treatment have an extremely
supportive role in helping families to understand the different
therapies and in preventing or managing the expected side effects
of chemotherapy, which can lead to insufcient food intake. The
nurses' task is to observe the subsequent effects of chemotherapy,
which may affect food intake in children. The study ndings
conrm that the majority of nurses agreed that individual dietrelated and nutritional advice and counselling increases food
intake, nutritional status and quality of life in children undergoing
chemotherapy. An important nding of our study is that 37.5% of
nurses working on the pediatric ward are unaware of the fact that a
child undergoing chemotherapy may be at risk of malnutrition. An
awareness of nurses of this fact is more inuenced by the nurses'
years of experience in pediatric oncology than their age. The percentage of nurses on the ward (25.0%) who are not aware that
malnutrition may alter pharmacokinetics, impair drug metabolism,
increase toxicity and worsen the response to treatment was also
surprisingly high. Awareness of this is more inuenced by nurses'
age than the length of their experience. On the basis of clear early
identication of causes of inadequate nutrient intake and within a
multidisciplinary team a nurse can quickly and individually prepare
nutritional intervention. Such interventions are used to prevent or
treat malnutrition in children during intensive chemotherapy.
Numerous screening tools have been developed for the pediatric
population (White et al., 2016; Hulst et al., 2010; Gerasimidis et al.,
2010; McCarthy et al., 2012; Sermet-Gaudelus et al., 2000; Reilly
et al., 1995). All of these screening tools have been developed for
various goals, applications, and processes, but none of them meet
the specic requirements of children with cancer (Murphy et al.,
2016). For example, Mosby et al. (2009) propose the use of the
Subjective Global Assessment (SGA) tool for identifying children
with cancer who are at risk of malnutrition. However, this inexpensive screening tool has not been evaluated for its effectiveness
in children with cancer. For children with cancer, a screening tool
needs to consider the cancer type, treatment stages and nutritionrelated clinical symptoms that may occur throughout treatment as
an inpatient or outpatient. None of the currently available nutrition
screening tools address all the needs of a cancer specic tool
(Murphy et al., 2016). An ideal screening tool should include all
these factors and should reliably triage the nutritional status of
children with cancer, so as to identify children who are malnourished or at risk of malnutrition and need further assessment. According to these guidelines, only one validated screen tool has been
developed. The Nutrition Screening Tool for Childhood Cancer
(SCAN) allows early identication and treatment of malnutrition
and potentially improving clinical outcomes for children with
cancer (Murphy et al., 2016). At the institution where our research
was conducted, the screening is not routinely carried out to detect
and effectively manage the causes of inadequate food intakes in
children treated with chemotherapy due to the following reasons:
currently available screening tools are not specically developed
for children with cancer; nurses are not trained to work with such
tools; screening tools and instructions for use are not available in
the native language; the health care providers are not fully
acquainted with the newly developed SCAN tool. The SCAN
screening tool is still under examination.

31

In order that results could be generalized to a larger population

and compared with the results of studies in countries with a small
population, we believe that research should be carried out also in
other centres that treat children with chemotherapy. In future
research, it would be necessary to offer a questionnaire to children
and their parents. Only through a joint assessment of nurses, children and parents we could nd out which are the predominant and
primary causes of inadequate food intake. Such an assessment
would also help to establish proper guidelines to create a screening
tool. Only with appropriate screening tools and organized and
planned interventions can better nutritional care in this population
of patients be offered.
6. Limitations
It is necessary to emphasize that cancer in children is rare, the
number of pediatric oncology centres is small, and therefore the
number of nurses employed is lower than in other pediatric elds.
However, the sample size of this study is comparable to similar
studies in the eld of pediatric oncology. This may result in the
construction of general conclusions.
7. Conclusion
This research explored the nurses' perceptions of different
causes of inadequate food intake in children treated with chemotherapy. The results show that nurses identify most of the physiological and psychological causes of inadequate food intake in such
children. Pain due to mucositis is the most commonly identied
cause of inadequate food intake in children, followed by nausea and
vomiting, altered taste, loss of appetite and altered smell. Psychological causes of eating problems, such as gaining some control of
the situation, learned food aversions and anticipatory nausea are
rarely perceived. Only through close cooperation with the family
can nurses recognize the causes that hinder food intake in children,
give appropriate advice, and prepare and carry out appropriate
interventions in a timely manner. Future research should focus on
the opinion of the children and their parents to discover what they
consider to be predominant causes of a child's eating problems.
An important nding, which is of concern, is that 37.5% of nurses
are not aware that a child undergoing chemotherapy may be at risk
of malnutrition. Similarly, the percentage of nurses (25.0%), who are
not aware of the effects of malnutrition on treatment, was also
surprisingly high. These nurses are on average more than ve years
younger and have on average almost seven years less experience in
pediatric oncology than the group of aware nurses. Therefore, a
systematic training for every new nurse on the pediatric oncology
ward is suggested to ensure required knowledge about malnutrition in relation to chemotherapy. It is necessary that nurses are well
trained to identify and determine the nutritional status of children
daily and quickly. To do that nurses need to be equipped with
appropriate expertise, clinical experience, a well-dened body of
guidelines and evidence-based protocols. With the introduction of
evidence-based protocols for regular nutritional screenings, nutritional assessment checks and nutritional support interventions, the
nurses' tasks regarding children's nutritional status would be more
precisely dened and consequently more systematic in practice.
Conict of interest
No conict of interest has been declared by the authors.
Acknowledgements
We would like to express our gratitude to the nurses of the study

32

P. Klanjsek, M. Pajnkihar / European Journal of Oncology Nursing 23 (2016) 24e33

hospital that participated in this research for their kind assistance

during the collection of data.
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