Oral mucositis is a common condition associated with cancer treatment that does not have definitive guidelines for treatment in the pediatric population. It is an especially important issue, as it has been shown that children may be at higher risk for mucositis than adults.16
Poor control and prevention of mucositis in pediatric patients may have a detrimental outcome on growth and nutrition and may necessitate delays in chemotherapy treatment. While there are many published reports on the prevention and treatment of this condition, none have shown results that have designated them as the treatment of choice. Large, well-controlled studies in pediatric patients are lacking.
Prevention of mucositis should be a goal for all health care providers. Before initiating chemotherapy, all newly diagnosed children with cancer should receive an evaluation of their oral cavity, including the baseline condition of their teeth and gums. Ideally, a pediatric dental team should be included for oral examinations with the patient. These examinations should become routine, with the frequency determined by the toxicity of the treatment and the patient's baseline oral status.4
Because children with poor oral hygiene have been shown to be at increased risk of oral mucositis, brushing and flossing techniques should be evaluated and a complete dental history should be recorded.4
Children should be instructed to brush their teeth with fluoride toothpaste after each meal and at bedtime, along with flossing once a day. The tongue should be gently cleaned with a toothbrush or tongue scraper. For those on intensive chemotherapy, chlorhexidine gluconate mouthwash (0.12% or 0.2%) has been shown to decrease the severity and duration of oral mucositis. While there is variability in study findings of the significance of chlorhexidine mouthwash in the adult population, the lack of availability of product and pediatric literature on benzydamine in the United States makes chlorhexidine the more logical addition to an oral prevention protocol. Most trials have used chlorhexidine mouth rinse twice a day along with a 0.9% saline rinse in the morning, before going to bed, and after each meal. These studies are aimed at children 6 years of age and older who are able to swish, swallow, and spit. Younger children unable to perform these tasks should have these solutions applied to the oral mucosa with a soft cloth.
Not all mucositis can be prevented. Once mucositis has developed, therapy should focus on supportive care. Goals are to maintain hydration, provide appropriate caloric intake through enteral or parenteral nutrition support, and relieve pain and prevent infection. Mucositis severity should be graded using a validated scale, such as the WHO scale, prior to initiating supportive therapy, to establish a baseline. Patients with grade I and grade II mucositis should brush their teeth as described earlier with a soft toothbrush and fluoride toothpaste and rinse with a salt and bicarbonate solution. With grade III mucositis, children should be advised to clean the oral cavity 4 times a day as described earlier or with gauze dipped in a salt and bicarbonate solution. The salt and bicarbonate solutions should be used every 4 to 6 hours if possible. Grade IV mucositis requires the patient to cleanse the oral cavity 4 times a day with either a soft toothbrush or gauze and to use a salt and bicarbonate solution every 4 hours.5
When treating pain associated with oral mucositis, the health care provider should use a stepwise approach similar to the WHO analgesic ladder. Recently published practice guidelines recommend patient-controlled analgesia with morphine for treatment of the pain associated with oral mucositis in patients undergoing hematopoietic stem cell transplantation.32
This technique should be explored in children of an appropriate age and knowledge base.
When approaching analgesic therapy, clinicians should focus on providing adequate pain control to the patient. The amount of pain medication may not correlate with the grade of mucositis. The stepwise approach should begin with oral rinses (saline solution, sodium bicarbonate rinses, etc); topical anesthetics (lidocaine, benzocaine); combination mouthwashes (“magic mouth rinse” containing diphenhydramine, lidocaine, and combinations of aluminum hydroxide, magnesium hydroxide, and simethicone); and possibly mucosal surface protectants such as hydroxypropyl cellulose gels or sucralfate solutions.
When these medications do not provide adequate relief, a step-up approach to systemic analgesics is warranted.33
The use of opioids should parallel the WHO analgesic ladder, with those opioids used for mild to moderate pain being used first and then switching to the medications for moderate to severe pain, if needed ()34
. The route of administration, dosage, and treatment of side effects associated with opioids should be done on a patient-specific basis.
Adequate hydration and nutrition should be maintained in every pediatric patient. The oral route should be used whenever possible, although this becomes difficult with progressing mucositis. Because children have fewer caloric stores and a higher metabolic rate than adults, they are unable to tolerate inadequate nutrition for long. Practitioners should be aware of patients' nutritional status and may initiate total parenteral nutrition sooner than in those who are not experiencing mucositis. Guidelines published by the American Society for Parenteral and Enteral Nutrition35
state that parenteral nutrition should be considered in children who cannot maintain adequate nutritional intake orally or enterally for 5 to 7 days. However, the potential risks of parenteral nutrition, including increased risks of infection, electrolyte abnormalities, and cholestatic liver disease, must be taken into account.35
Prevention of secondary infections is a key issue in severe mucositis treatment with neutropenic pediatric patients. The oral cavity should be kept as clean as possible. When a bacterial infection is suspected, the patient should be treated empirically with broad-spectrum systemic antibiotic medication. In patients with a history of recurrent oral candidal lesions, nystatin suspension or fluconazole may be used prophylactically.4