Nutritional management of oral mucositis in pediatric cancer patients: a narrative review
DOI:
https://doi.org/10.18203/2349-3291.ijcp20261156Keywords:
Oral mucositis, Pediatric oncology, Nutritional support, Cancer-related complications, Supportive careAbstract
Oral mucositis is a frequent and debilitating chemotherapy complication that significantly impairs oral intake and worsens nutritional status, particularly in children undergoing cancer treatment who are already nutritionally vulnerable. While numerous studies in the literature focus on the therapeutic management and prevention of mucositis, nutritional management remains an overlooked area, especially in pediatric oncology. This review aims to address this gap by examining current evidence on nutritional strategies for the management of oral mucositis in pediatric oncology, including dietary modifications tailored to disease severity and the potential role of functional foods and nutrient-based supplements. A structured literature search was conducted for studies published between January 2000 and October 2025 using suitable search terminologies and phrases. Eligible studies included randomized and non-randomized clinical trials, reviews, and primary research published in English. A two-stage screening process identified 41 studies eligible for inclusion in the final analysis. The analysis indicated that glutamine demonstrated consistent benefits in reducing the incidence and severity of oral mucositis in children receiving chemotherapy, while honey was associated with shorter duration and reduced severity of mucositis episodes. Evidence for other interventions, including vitamins, zinc, olive oil, aloe vera, and probiotics, was more heterogeneous and limited. Given the lack of clear guidance on nutritional management across mucositis severity, this review also proposes a practical severity-based dietary modification framework to support clinical care. Collectively, the findings suggest that integrating functional foods and targeted nutritional strategies may help alleviate symptoms, support oral intake, and improve supportive care in pediatric oncology patients.
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References
Ethier MC, Regier DA, Tomlinson D, Judd P, Doyle J, Gassas A, et al. Perspectives toward oral mucositis prevention from parents and health care professionals in pediatric cancer. Support Care Cancer. 2012;20(8):1771-7. DOI: https://doi.org/10.1007/s00520-011-1274-x
Attinà G, Romano A, Maurizi P, Mastrangelo S, Zecca M, Cefalo MG, et al. Management of oral mucositis in children with malignant solid tumors. Front Oncol. 2021;11:591211. DOI: https://doi.org/10.3389/fonc.2021.599243
Gandhi K, Datta G, Ahuja S, Saxena T, G Datta A. Prevalence of oral complications occurring in a population of pediatric cancer patients receiving chemotherapy. Int J Clin Pediatr Dent. 2017;10(2):166-71. DOI: https://doi.org/10.5005/jp-journals-10005-1428
Miller MM, Donald DV, Hagemann TM. Prevention and treatment of oral mucositis in children with cancer. J Pediatr Pharmacol Ther. 2012;17(4):340-50. DOI: https://doi.org/10.5863/1551-6776-17.4.340
Cheng KK. Oral mucositis, dysfunction, and distress in patients undergoing cancer therapy. J Clin Nurs. 2007;16(11):2114-21. DOI: https://doi.org/10.1111/j.1365-2702.2006.01618.x
Sonis ST. Oral mucositis in cancer therapy. J Support Oncol. 2004;2(6):3-8. DOI: https://doi.org/10.1038/ncponc0104
Cheng KK, Molassiotis A, Chang AM, Wai WC, Cheung SS. Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in paediatric cancer patients. Eur J Cancer. 2001;37(16):2056-63. DOI: https://doi.org/10.1016/S0959-8049(01)00098-3
Sung L, Robinson P, Treister N, Baggott C, Gibson F, Tissing W, et al. Guideline for the prevention of oral and oropharyngeal mucositis in children receiving treatment for cancer or undergoing haematopoietic stem cell transplantation. BMJ Support Palliat Care. 2017;7(1):7-16. DOI: https://doi.org/10.1136/bmjspcare-2014-000804
Patel P, Robinson PD, Baggott C, Gibson F, Phillips R, Dupuis LL, et al. Clinical practice guideline for the prevention of oral and oropharyngeal mucositis in pediatric cancer and hematopoietic stem cell transplant patients: 2021 update. Eur J Cancer. 2021;154:92-101. DOI: https://doi.org/10.1016/j.ejca.2021.05.013
Yarom N, Hovan A, Bossi P, Bensadoun RJ, Chuprov I, Elad S, et al. Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines—part 1: vitamins, minerals, and nutritional supplements. Support Care Cancer. 2021;29(7):4170-4. DOI: https://doi.org/10.1007/s00520-021-06141-9
Clinical practice guideline for the prevention of oral and oro-pharyngeal mucositis in pediatric cancer and hematopoietic stem cell transplant patient. Toronto (ON): Pediatric Oncology Group of Ontario (POGO). 2021. Available at https://www.pogo.ca/healthcare/clinical-practice-guidelines/mucositis/. Accessed on 18 February 2026.
Damascena LCL, De Lucena NNN, Ribeiro ILA, De Araújo TL, De Lima KC, De Oliveira AKM, et al. Factors contributing to the duration of chemotherapy-induced severe oral mucositis in oncopediatric patients. Int J Environ Res Public Health. 2018;15(6):1153. DOI: https://doi.org/10.3390/ijerph15061153
Bell A, Kasi A. Oral mucositis. In: StatPearls. Treasure Island (FL): StatPearls Publishing. 2025.
Zheng Z, Zhao X, Zhao Q, Wang Y, Liu Y, Zhang L, et al. The effects of early nutritional intervention on oral mucositis and nutritional status of patients with head and neck cancer treated with radiotherapy. Front Oncol. 2021;10:595632. DOI: https://doi.org/10.3389/fonc.2020.595632
Pumphrey T, Frasier K, Rahni S, Sobotka MH, Goldstein LB, Javaid S. Updates on nutritional recommendations for patients with severe oral mucositis secondary to chemotherapy and radiation. Clin Res Rep. 2024;2(1):e100. DOI: https://doi.org/10.59657/2995-6064.brs.24.011
Jacobs S, Baggott C, Agarwal R, Gibson F, Phillips R, Dupuis LL, et al. Validation of the Children's International Mucositis Evaluation Scale (ChIMES) in paediatric cancer and SCT. Br J Cancer. 2013;109(10):2515-22. DOI: https://doi.org/10.1038/bjc.2013.618
Abdalla-Aslan R, Bonomo P, Keefe DMK, Gibson RJ, Elad S, Bowen J, et al. Guidance on mucositis assessment from the MASCC Mucositis Study Group and ISOO: an international Delphi study. EClinicalMedicine. 2024;73:102675. DOI: https://doi.org/10.1016/j.eclinm.2024.102675
Maria OM, Eliopoulos N, Muanza T. Radiation-induced oral mucositis. Front Oncol. 2017;7:89. DOI: https://doi.org/10.3389/fonc.2017.00089
Widjaja NA, Pratama A, Prihaningtyas R, Irawan R, Ugrasena I. Efficacy oral glutamine to prevent oral mucositis and reduce hospital costs during chemotherapy in children with acute lymphoblastic leukemia. Asian Pac J Cancer Prev. 2020;21(7):2117-21. DOI: https://doi.org/10.31557/APJCP.2020.21.7.2117
Chang YH, Yu MS, Wu KH, Huang SY, Lin MT, Chen JS, et al. Effectiveness of parenteral glutamine on methotrexate-induced oral mucositis in children with acute lymphoblastic leukemia. Nutr Cancer. 2017;69(5):746-51. DOI: https://doi.org/10.1080/01635581.2017.1324995
Sankaran SS, Dewan P, Malhotra RK Sankaran SS, Dewan P, Malhotra RK, et al. Glutamine mouthwash for preventing methotrexate-induced mucositis in children with acute lymphoblastic leukemia: a randomized cross-over trial. Indian Pediatr. 2025;62(4):269-75. DOI: https://doi.org/10.1007/s13312-025-00042-4
Oosterom N, Dirks NF, Heil SG, De Rijke YB, Pieters R, Van den Heuvel-Eibrink MM, et al. A decrease in vitamin D levels is associated with methotrexate-induced oral mucositis in children with acute lymphoblastic leukemia. Support Care Cancer. 2019;27(1):183-90. DOI: https://doi.org/10.1007/s00520-018-4312-0
El-Housseiny AA, Saleh SM, El-Masry AA, Allam AA. The effectiveness of vitamin E in the treatment of oral mucositis in children receiving chemotherapy. J Clin Pediatr Dent. 2007;31(3):167-70. DOI: https://doi.org/10.17796/jcpd.31.3.r8371x45m42l10j7
Thornley I, Lehmann LE, Sung L, Holmes C, Spear JM, Brennan L, et al. A multiagent strategy to decrease regimen-related toxicity in children undergoing allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2004;10(9):635-44. DOI: https://doi.org/10.1016/j.bbmt.2004.06.004
Pattanakitsakul P, Chongviriyaphan N, Pakakasama S, Poomthavorn P, Anurathapan U, Hongeng S, et al. Effect of vitamin A on intestinal mucosal injury in pediatric patients receiving hematopoietic stem cell transplantation and chemotherapy: a quasi-randomized trial. BMC Res Notes. 2020;13:464. DOI: https://doi.org/10.1186/s13104-020-05307-8
Shah D, Gupta A, Meena JP, Singh P, Yadav S, Sharma RK, et al. Efficacy and safety of zinc in the prevention of oral mucositis in children with cancer receiving intensified chemotherapy: a randomized double-blind placebo-controlled trial. Pediatr Blood Cancer. 2023;70(7):e30309. DOI: https://doi.org/10.1002/pbc.30309
Gutiérrez-Vargas R, Villasis-Keever MÁ, Portilla-Robertson J, Ascencio-Montiel ID, Zapata-Tarrés M. Effect of zinc on oropharyngeal mucositis in children with acute leukemia undergoing chemotherapy. Med Oral Patol Oral Cir Bucal. 2020;25(6):e791-8. DOI: https://doi.org/10.4317/medoral.23798
Alkhouli M, Laflouf M, Comisi JC. Assessing the topical application efficiency of two biological agents in managing chemotherapy-induced oral mucositis in children: a randomized clinical trial. J Oral Biol Craniofac Res. 2021;11(3):373-8. DOI: https://doi.org/10.1016/j.jobcr.2021.04.001
Soares ADS, Wanzeler AMV, Cavalcante GHS, Barros MDS, Carneiro RC, Tuji EFM. Therapeutic effects of andiroba oil compared to low power laser on oral mucositis in children undergoing chemotherapy: a clinical study. J Ethnopharmacol. 2020;113365. DOI: https://doi.org/10.1016/j.jep.2020.113365
Coconut oil to prevent mouth sores in pediatric patients receiving high dose chemotherapy. Bethesda (MD): National Library of Medicine (US). 2022.
Al Jaouni SK, Al Muhayawi MS, Hussein A, Elfiki I, Al-Raddadi R, Al Muhayawi SM, et al. Effects of honey on oral mucositis among pediatric cancer patients undergoing chemo/radiotherapy treatment. Evid Based Complement Alternat Med. 2017;2017:5861024. DOI: https://doi.org/10.1155/2017/5861024
Kobya Bulut H, Güdücü Tüfekci F. Honey prevents oral mucositis in children undergoing chemotherapy: a quasi-experimental study with a control group. Complement Ther Med. 2016;29:132-40. DOI: https://doi.org/10.1016/j.ctim.2016.09.018
Singh R, Sharma S, Kaur S, Medhi B, Trehan A, Bijarania SK. Effectiveness of topical application of honey on oral mucosa of children for the management of oral mucositis associated with chemotherapy. Indian J Pediatr. 2019;86(3):224-8. DOI: https://doi.org/10.1007/s12098-018-2733-x
Abdulrhman M, Elbarbary NS, Ahmed Amin D, Saeid Ebrahim R. Honey and a mixture of honey, beeswax, and olive oil–propolis extract in treatment of chemotherapy-induced oral mucositis: a randomized controlled pilot study. Pediatr Hematol Oncol. 2012;29(3):285-92. DOI: https://doi.org/10.3109/08880018.2012.669026
Mishra L, Nayak G. Effect of flavored honey and tulsi ice chips on reduction of oral mucositis among children receiving chemotherapy. Int J Pharm Sci Rev Res. 2017;43(1):25-8.
Alkhouli M, Laflouf M, Alhaddad M. Evaluation of the effectiveness of olive oil to prevent chemotherapy-induced oral mucositis: a randomized controlled clinical trial. Pediatr Dent J. 2.019;29(3):123-31. DOI: https://doi.org/10.1016/j.pdj.2019.08.001
Badr LK, El Asmar R, Hakim S, Saad R, Merhi R, Zahreddine A, et al. The efficacy of honey or olive oil on the severity of oral mucositis and pain compared to placebo in children with leukemia receiving intensive chemotherapy. J Pediatr Nurs. 2023;70:e48-53. DOI: https://doi.org/10.1016/j.pedn.2022.12.003
Christian H, Suharsini M, Fauziah E. Effects of probiotics on clinical appearance of oral mucositis in children with leukemia during chemotherapy. Int J Dent Oral Sci. 2020;7(11):931-39.
Sharma A, Tilak T, Bakhshi S, Gupta R, Kumar L, Seth R, et al. Lactobacillus brevis CD2 lozenges prevent oral mucositis in patients undergoing high dose chemotherapy followed by haematopoietic stem cell transplantation. ESMO Open. 2017;1(6):e000138. DOI: https://doi.org/10.1136/esmoopen-2016-000138
Otmani N, Hattad S. Clinical outcome in children with chemotherapy-induced mucositis. Semin Oncol Nurs. 2021;37(3):151160. DOI: https://doi.org/10.1016/j.soncn.2021.151160
Huang W, Choi W, Chen Y, Gibson JD, Walker D, Rezenom YH, et al. A proposed role for glutamine in cancer cell growth through acid resistance. Cell Res. 2013;23(5):724-7. DOI: https://doi.org/10.1038/cr.2013.15
Rubio IT, Cao Y, Hutchins LF, Westbrook KC, Klimberg VS. Effect of glutamine on methotrexate efficacy and toxicity. Ann Surg. 1998;227(5):772-80. DOI: https://doi.org/10.1097/00000658-199805000-00018
homsen M, Vitetta L. Adjunctive treatments for the prevention of chemotherapy- and radiotherapy-induced mucositis. Integr Cancer Ther. 2018;17(4):1027-47. DOI: https://doi.org/10.1177/1534735418794885
Zasadzińska M, Borowski G, Matuszewska K, Bystroń A. Zinc sulphate for oral mucositis: an updated narrative review of existing and recent evidence. Palliat Med Pract. 2025. DOI: https://doi.org/10.5603/pmp.104407
Hao S, Ji L, Wang Y. Effect of honey on pediatric radio/chemotherapy-induced oral mucositis: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2022;2022:6906439. DOI: https://doi.org/10.1155/2022/6906439
Elad S, Cheng KKF, Lalla RV, Yarom N, Hong CHL, Logan RM, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-31. DOI: https://doi.org/10.1002/cncr.33100
Miranda-Silva W, Gomes-Silva W, Zadik Y, Gibson F, Bensadoun RJ, Bowen J, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis in pediatric cancer patients. Support Care Cancer. 2021;29(7):3539-62. DOI: https://doi.org/10.1007/s00520-020-05803-4
Šimiaková M, Bielik V. The pros and cons of probiotic use in pediatric oncology patients following treatment for acute lymphoblastic leukemia. Front Pediatr. 2024;12:1427185. DOI: https://doi.org/10.3389/fped.2024.1427185
Horhat RM, Alexandru A, Ivan C-S, Varga N-I, Suba M-I, Ciurariu E, et al. Nutritional and supplemental interventions for prevention and treatment of oral mucositis in pediatric oncology. Nutrients. 2025;17:3521. DOI: https://doi.org/10.3390/nu17223521
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