Nutrition is a critical component of cancer treatment and a foundation of IM treatment. Poor nutrition decreases survival rates, response to treatment, and quality of life and increases time in the hospital (Bauer et al. 2011; Brinksma et al. 2012). The primary goals of an integrative nutrition plan are maintenance of existing body stores of healthy tissue, minimization of wasting due to illness and treatment side effects, support of age-appropriate growth, reduction of inflammation, and maintenance of good QOL (Bauer et al. 2011). Challenging confounding factors include presence of a hypermetabolic and pro-inflammatory state due to tumor metabolism, anorexia and cachexia, hormonal or other metabolic disruptions, stage of illness, infection, treatment regimen, and individual susceptibility to malnutrition. Unfortunately, the hypermetabolic state is often not reversible, even with adequate caloric supplementation. In addition, different malignancies have been associated with specific nutritional states. For example, children with solid tumors are at higher risk of undernourishment compared to children receiving high-dose steroids or cranial radiation, who are at high risk for fat accumulation, insulin resistance, and possible metabolic syndrome. Multimodal treatment regimens add to the complexity of nutrition management as each treatment may result in different or overlapping toxicities (Bauer et al. 2011).

The Mediterranean diet is a mainstay of IM and consists of a primarily plant-based diet with ample vegetables and fruits, whole grains, lean proteins with an emphasis on fish, low-fat dairy, and beverages and spices with potent anti-inflammatory and antioxidant properties. One study in 117 adult survivors of childhood leukemia showed that adherence to a Mediterranean diet pattern was associated with lower adiposity, waist circumference, body mass index, and odds of developing metabolic syndrome (Tonorezos et al. 2013). Few studies exist on the benefit of this diet pattern in patients undergoing treatment.

A concern about the use of the Mediterranean diet during cancer treatment is the potential of naturally antioxidant-rich foods to interfere with certain types of treatment especially anthracyclines, platinum-containing agents, alkylating agents, and radiation therapy, which act against cancer cells by generating free radicals. While no data exist to support outright interference with therapy, some sources, such as the American Cancer Society, recommend not exceeding 100 % of the RDA for antioxidant-type vitamins such as vitamins C and E during treatment (Doyle et al. 2006).

NCI guidelines regarding food safety are consistent in recommending no raw foods that have not been packaged and then thoroughly washed; no foods from salad bars, buffets, sidewalk vendors, potlucks, delis, or bulk food bins; no fish, oysters, shellfish, or eggs that have not been thoroughly cooked (no sushi or cookie dough); no sprouts; no whole pieces of poultry not cooked to 180° or ground poultry cooked to 165°; and no beef, pork, lamb, or venison not cooked to 160°. All milk, yogurt, cheese, other dairy products, fruit juices, and honey should be pasteurized (National Cancer Institute 2014c).

For these vegetarian parents who are eager to help boost their child’s immune system, the best approach is to provide a varied diet that contains adequate protein from cooked tofu, beans, and nuts; mono- and polyunsaturated fats; whole grains and fiber; vitamins and minerals from well-washed fruits and vegetables; and good hydration with water as well as pasteurized fruit juices. Small snacks of energy-dense foods (that might not typically be considered “healthy”) may be needed to provide extra calories. Also, their son should avoid snacks that may make treatment-related side effects worse. If diarrhea is a problem, for example, avoid popcorn and raw fruits and vegetables. If mucositis is a problem, their son should avoid dry, coarse, or acidic foods. He should increase the amount of fiber he eats if constipation is an issue. In addition, taste can change with treatment. Some things that were formerly considered delicious may not appeal and vice versa. Getting enough protein may be a problem with a strict vegetarian diet. The parents may be willing to modify their child’s eating practices to allow more variety during treatment and the early days of recovery (American Cancer Society 2014).

Probiotics are a heterogeneous group of live nonpathogenic strains of microorganisms that can be taken as foods (sea kelp, algae, yogurt) or supplements to modify gut microbial ecology, leading to beneficial structural and functional changes. Of all the gut microbiota, Lactobacilli and Bifidobacteria are considered the most important to maintaining good health. Because chemotherapy and radiation therapy target rapidly dividing neoplastic cells, they also affect rapidly dividing cell populations throughout the body. As a result, the epithelia of the GI tract are particularly susceptible, leading to the development of mucositis. It appears that intestinal damage is due both to increased apoptosis and to the activity of pro-inflammatory cytokines (Wardill et al. 2012). Most probiotic preparations available over-the-counter are heterogeneous. However, achieving the potentially beneficial effects of probiotic treatment appears to require a high degree of species and strain specificity (Prisciandaro et al. 2011).

Probiotics are classified as “generally regarded as safe” with most safety concerns related to risk of infection caused by the probiotic bacteria and transfer of antibiotic resistance. However, the antibiotic resistance is intrinsic and so nontransmissible. This resistance may benefit patients if their intestinal flora has become unbalanced due to the administration of multiple antimicrobial agents. On the negative side, some strains carry potentially transmissible plasmid-encoded antibiotic resistance genes that could be transferred to endogenous flora producing a new antibiotic-resistant pathogen. This risk is increased in immunocompromised hosts. Overall, despite a substantial number of publications, findings from the current literature are inconclusive about the use of probiotic interventions during treatment (Mego et al. 2013). Lastly, virtually all studies have been conducted in adults, and although the patient presented here might possibly fall into that physiological category, his risk is not fully represented by the data available.

There are three primary concerns about the use of dietary supplements in pediatric cancer patients: (1) the paucity of evidence-based data to help guide safe use, (2) low rates of disclosure creating risk of unwanted drug–herb interactions; and (3) selected supplements high in antioxidant activity interfering with commonly used chemotherapies that act against cancer cells by generating free radicals.

Many patients have questions about coenzyme Q10, which is synthesized in the body and present in most tissues (e.g., heart, liver, kidneys, and pancreas). It has an active role as a carrier of electrons and protons in mitochondrial ATP synthesis and in its reduced form (ubiquinol), acts as an antioxidant, protecting cells from damage due to free radicals (Ernster and Forsmark-Andree 1993).

Coenzyme Q10 deficiency was correlated with certain cancers in the early 1960s, and interest remains high in its potential use in treatment due to its role in energy production, positive effect on the immune system (Folkers et al. 1982, 1991), and antioxidant properties that stabilize cell membranes and protect against free radical damage to tissue (National Cancer Institute 2014b). However, other studies raised concern that the free radical scavenging action of coenzyme Q10 may interfere with the efficacy of some cancer treatments, such as radiation therapy (Lund et al. 1998).

Studies of coenzyme Q10 as either primary or adjuvant therapy in humans are limited, with mixed results. Other common antioxidants, such as vitamin C, vitamin E, and lycopene, have similarly limited evidence for use in cancer prevention or treatment, especially in pediatrics (van Dalen et al. 2008; Greenwald et al. 2007; Fortmann et al. 2013).

A comprehensive review of antioxidant supplementation by Ladas and Kelly (2010) concludes that insufficient evidence exists to broadly recommend antioxidant therapies. Current NCI recommendations urge caution in the use of any antioxidant supplement during cancer treatment. However, ingestion of normal amounts of antioxidants in foods is not contraindicated (National Cancer Institute 2014a).

Black elderberry extract has an excellent safety profile and has been shown to have strong antiviral properties, especially against some strains of influenza. Small studies have also investigated its potential to activate a healthy immune system by increasing cytokine production. One study in 12 healthy adult volunteers using black elderberry extract demonstrated increased production of inflammatory cytokines, especially TNF-alpha, compared to controls (Barak et al. 2001). However, similar studies on the immunostimulating properties of elderberry, or other natural immune stimulants, are lacking in immunocompromised children making it difficult to recommend using the supplement. Simple supportive measures (e.g., adequate sleep/good nutrition) are low risk and may provide benefit.

Ginger has been shown to be safe and effective in clinical trials for motion sickness and postoperative vomiting and in pregnancy. Although some studies have shown promise and low risk for the use of ginger in anticipatory nausea and vomiting in cancer treatment, results have been limited by variable study design and quality issues. Randomized, double-blind, placebo-controlled trials are underway in adults; similar studies are needed in children (Marx et al. 2014). Interest in the use of other approaches, for example, antinausea lollipops, is high; however, there are currently no evidence-based recommendations for the use of other dietary supplements in pediatric anticipatory nausea and vomiting. Research is ongoing in this area (Gottschling et al. 2014).

Milk thistle (Silybum marianum) has historically been used to treat hepatic and biliary disorders and in detoxification of hepatic toxins (Greenlee et al. 2007; Tamayo and Diamond 2007). A double-blind study of 50 children with ALL and hepatic toxicity given a 28-day course of milk thistle showed a significantly lower AST level and a trend toward a lower ALT level in the treatment group at day 56. No evidence of interference with treatment was observed (Ladas et al. 2010a, b).

These brief vignettes demonstrate the complexity of dietary supplement use in pediatric oncology and reinforce the importance of having an organized approach to researching the dietary supplement in question. A systematic review of articles examining the prevalence of CT use in pediatric cancer patients identified 28 studies (n = 3526 patients with varied cancer diagnoses). Herbal remedies were the most commonly used modality and occurred in up to 48 % of patients. Only 50 % of patients disclosed use of the dietary supplement or botanical to their doctor (Ndao et al. 2013).

A five-step approach to dietary supplement use in pediatric oncology:

Mind–body medicine is the deliberate harnessing of positive interactions between thought, emotion, and physiology for the specific purpose of enhancing health. In a 2007 US population study, mind–body therapies were identified as the second most common CT used by people <18 years old (Birdee et al. 2010). Mind–body therapies are also used to address caretaker stress and distress (Kanitz et al. 2013; Elkins et al. 2010). The need for more effective interventions to reduce pain and stress has increased with better understanding of the detrimental physiologic effects of chronic pain and stress in children (Garner et al. 2012; Zempsky 2008; Kennedy et al. 2008).

Some of the best studied mind–body modalities in pediatrics include:

Yoga can be a gentle, safe approach to stress management and physical fitness. A study of 286 young-adult cancer survivors showed 32.8 % had practiced yoga from their initial diagnosis to promote relaxation and maintain flexibility. Average length of practice was 25 months, with a mean of 7 hours of practice/month. Positive benefit was noted, and no adverse outcomes were reported (Park et al. 2013). Studies have shown improvement in gross motor function and QOL (Geyer et al. 2011) and significant improvement in flexibility and fitness (Wurz et al. 2014).

Special considerations in oncology patients participating in any movement therapy such as yoga, tai chi, or Qigong include physician approval, verifying teacher credentialing, avoiding any pose that causes pain or discomfort, and attention to wounds or indwelling catheters.