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Some chemotherapy and transplants cause painful sores in the mouth and throat. Older children who can manage it suck ice during short infusions of certain drugs, and children having a stem cell transplant or radiotherapy to the head and neck have gentle red-light treatment inside the mouth. Good daily mouth care and a dental check before treatment help too.
The Pediatric Oncology Group of Ontario 2021 update (seven systematic reviews, 107 studies, GRADE), endorsed by the Children's Oncology Group, covers patients aged 0 to 18. Cryotherapy: use for older, cooperative children receiving short infusions of melphalan or 5-fluorouracil (strong, high), consider for short infusions of other mucotoxic chemotherapy (conditional, moderate); the panel thought it not feasible for infusions longer than 1 hour or in young children. Intraoral photobiomodulation in the red spectrum (620 to 750 nm): use for children having autologous or allogeneic transplant and for head and neck carcinoma radiotherapy (strong, high), consider for radiotherapy to other head and neck cancers such as rhabdomyosarcoma (conditional, moderate). Do not give palifermin routinely (strong, high), because its benefit was modest (risk ratio for severe mucositis 0.81) against short-term harms, possible long-term effects on cancer outcomes, cost and availability; do not give G-CSF to prevent mucositis (strong, high). The adult MASCC/ISOO 2020 guideline adds multiagent basic oral care protocols during chemotherapy, radiotherapy and transplant (level III), dental assessment before treatment (expert opinion), and differs on palifermin, which it recommends for autologous transplant with high-dose chemotherapy and total body irradiation.
Why: Bad teeth and gums can become a source of infection once the white count falls.
“the panel is of the opinion that dental evaluation and treatment as indicated before cancer therapy are desirable to reduce risk for local and systemic infections from odontogenic sources.”
MASCC and ISOO, Cancer 2020 · Expert opinion
Why: Combined mouth care routines lowered mucositis in trials of chemotherapy, radiotherapy and transplant, mostly in adults.
“The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during CT.”
MASCC and ISOO, Cancer 2020 · LoE III (suggestion)
Why: In trials it halved severe mucositis (risk ratio 0.49), with no documented harms and little cost; it suits infusions of 30 minutes or less.
“Cryotherapy should be used for older cooperative pediatric patients who will receive short infusions of melphalan or 5-fluorouracil.”
Pediatric Oncology Group of Ontario, European Journal of Cancer 2021 · Strong recommendation, High-quality evidence
Why: The benefit is likely to carry over to other drugs, but there is no direct evidence; cooling is not practical for infusions longer than an hour.
“Consider using cryotherapy for older, cooperative pediatric patients receiving treatment for cancer or undergoing HSCT who will receive short infusions of chemotherapy associated with mucositis other than melphalan or 5-fluorouracil.”
Children's Oncology Group 2022 · Conditional recommendation, Moderate-quality evidence
Why: It reduced severe mucositis by more than half in trials and was workable in children of all ages, though it needs trained staff, equipment and eye protection.
“Use intraoral photobiomodulation therapy in the red light spectrum (620–750 nm) for pediatric patients undergoing autologous or allogeneic HSCT and for pediatric patients who will receive radiotherapy for head and neck carcinoma.”
Children's Oncology Group 2022 · Strong recommendation, High-quality evidence
Why: The benefit is expected to be similar, but there are no direct data in these cancers.
“Consider using intraoral photobiomodulation therapy in the red light spectrum (620–750 nm) for pediatric patients who will receive radiotherapy for head and neck cancers other than carcinoma.”
Children's Oncology Group 2022 · Conditional recommendation, Moderate-quality evidence
Why: It reduced severe mucositis only modestly, has short-term side effects, may affect cancer outcomes in the long term, and is costly and hard to get.
“Do not administer palifermin routinely to pediatric patients with cancer receiving treatment for cancer or undergoing HSCT.”
Children's Oncology Group 2022 · Strong recommendation, High-quality evidence
Why: It did not prevent mucositis; children may still have it for other reasons, such as shortening neutropenia.
“Do not administer GCSFs to pediatric patients receiving treatment for cancer or undergoing HSCT for the purpose of mucositis prevention.”
Children's Oncology Group 2022 · Strong recommendation, High-quality evidence
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
For children, the POGO 2021 update endorsed by the Children's Oncology Group is the current guideline: cryotherapy for older, cooperative children on short melphalan or 5-fluorouracil infusions, red-light intraoral photobiomodulation for transplant and head and neck radiotherapy, and no routine palifermin or G-CSF. The adult MASCC/ISOO 2020 guideline agrees on cryotherapy (melphalan conditioning and bolus 5-fluorouracil, level II) and photobiomodulation (adult transplant, level I) and adds basic oral care protocols, but differs on palifermin: MASCC/ISOO recommends intravenous KGF-1 (palifermin) for haematological cancers having autologous transplant with high-dose chemotherapy and total body irradiation (level I), where the paediatric panel advises against routine use because of harms, possible long-term effects on cancer outcomes and cost.
Children's Oncology Group 2022 · Pediatric Oncology Group of Ontario, European Journal of Cancer 2021 · MASCC and ISOO, Cancer 2020
Where it differs: Gives intravenous palifermin to prevent mucositis in people with haematological cancers having autologous transplant with high-dose chemotherapy and total body irradiation.
Evidence: MASCC/ISOO level I recommendation in adults. The paediatric guideline makes a strong recommendation against routine use in children (risk ratio for severe mucositis 0.81).
MASCC and ISOO, Cancer 2020 · Children's Oncology Group 2022
Where it differs: Some units use chlorhexidine rinses as part of mouth care to prevent mucositis.
Evidence: MASCC/ISOO suggests chlorhexidine not be used to prevent mucositis during head and neck radiotherapy (level III); the paediatric guideline makes no recommendation on it.
Holding ice chips in the mouth for half an hour around a quick injection of fluorouracil, or high-dose melphalan before a stem cell transplant, cools the mouth while the drug level peaks. A review of 14 trials found it prevents mouth ulcers in about one in four people given fluorouracil, and a guideline recommends it. How often it is offered is not measured.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Cryotherapy for short melphalan or 5-fluorouracil infusions in older, cooperative children | Strong recommendation, High-quality evidence | Children's Oncology Group 2022 |
| Cryotherapy considered for other short mucotoxic infusions | Conditional recommendation, Moderate-quality evidence | Children's Oncology Group 2022 |
| Photobiomodulation for transplant and head and neck carcinoma radiotherapy | Strong recommendation, High-quality evidence | Children's Oncology Group 2022 |
| No routine palifermin in children | Strong recommendation, High-quality evidence | Children's Oncology Group 2022 |
| No G-CSF for mucositis prevention | Strong recommendation, High-quality evidence | Children's Oncology Group 2022 |
| Multiagent oral care protocols during chemotherapy (adults) | LoE III | MASCC and ISOO, Cancer 2020 |
| Palifermin for autologous transplant with high-dose chemotherapy and total body irradiation (adults) “The use of KGF‐1 intravenously is recommended for the prevention of OM in patients with hematologic cancer undergoing autologous HSCT with a conditioning regimen that includes high‐dose CT and TBI.” | LoE I | MASCC and ISOO, Cancer 2020 |
| Chlorhexidine not to be used to prevent mucositis during head and neck radiotherapy (adults) “The panel suggests that CHX not be used in the prevention of OM in patients undergoing H&N RT.” | LoE III | MASCC and ISOO, Cancer 2020 |
Shares Autologous stem cell transplant (high-dose therapy), Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Autologous stem cell transplant (high-dose therapy), Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Autologous stem cell transplant (high-dose therapy), Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.