• Good mouth care can enhance the quality of life for children in the palliative care setting
• Full examination should always include inspection of the mouth as oral problems are easily overlooked, but can usually be easily managed

Consider cause and treat as appropriate:

• Oral candidiasis
• Dry mouth: mouth breathing, oxygen
• Ulcers: traumatic, apthous, infectious
• Bleeding gums
• Dental caries
• Gum hyperplasia
• Medication e.g. morphine, antihistamines, anticholinergics; radiotherapy

Management

General measures

• Keep mouth clean and moist. Clear a coated tongue by gently brushing with a soft toothbrush, or by using effervescent vitamin C
• Regularly clean mouth and teeth with gauze dipped in water or mouthwash, particularly after eating/drinking
• Refer to dentist if appropriate
• Often a dry mouth can be a source of discomfort towards the end of life. This is well documented in the (more vocal) adult population and likely to a problem in children too. It often occurs in those who cannot eat or drink. General comfort can be increased by measures such as sucking ice or chips of ice lolly or sipping very cold water. Pleasure can still be had from placing tiny bits of chocolate in the mouth for example, but take care that you can retrieve less soluble substances if swallowing is an issue.

Medication

Oral candidiasis

May present as the classic white plaques or less commonly as atrophic candidiasis with a red glossy tongue. Remember that candidiasis may extend beyond your line of vision to the oesophagus.

Nystatin

Form

Oral solution: 100,000 units in 1mL

Dose (oral)

Neonate: 100,000 units 4 times a day,
Child 1 month–18 years: 100,000 units 4 times a day.

Treat for 7 days and continue 48h after clinical cure to prevent relapse. Licence: licensed for children.

Miconazole oral gel

Form

Oral gel: 24mg in 1mL

Dose

Neonate: 1 mL 2-4 times a day smeared around inside of mouth after feeds,
Child 1 month–2 years: 1.25mL 4 times daily smeared around inside of mouth after food,
Child 2–18 years: 2.5mL 4 times daily after meals; retain near lesions before swallowing (orthodontic appliances should be removed at night and brushed with gel).

Not licensed for use in children under 4 months or during the first 5-6 months of life of an infant born preterm. For infants, the gel should not be applied to the back of the throat due to possible choking.

Fluconazole

Form

Capsules: 50mg, 150mg, 200mg
Oral suspension: 50mg in 5mL; 200mg in 5mL

(Also available IV)

Dose (by mouth or intravenous infusion)

Neonate under 2 weeks: 3-6mg/kg on first day then 3mg/kg every 72 hours,
Neonate between 2-4weeks: 3-6mg/kg on first day then 3mg/kg every 48 hours,
Child 1 month–12 years: 3-6mg/kg on first day then 3mg/kg (maximum 100mg) daily,
Child 12–18 years: 50mg/day. Increase to 100mg/day in difficult infections.

Contraindications and warnings: reduce dose in renal impairment, monitor liver function. Co-administration of terfenadine contraindicated. Interacts with several drugs: see other texts. May cause haematological and biochemical abnormalities particularly in children with HIV or malignancies.

Licence: licensed for use in children.

Dry mouth

• If using oxygen, consider humidifying
• Some medication will cause a dry mouth as a side effect e.g. morphine, anti-spasmodics, tricyclic anti-depressants and anticholinergic medication: consider changing or reducing dose if possible
• Artificial saliva
  There are several preparations available in various forms including Glandosane spray
• KY jelly
  Is well tolerated and can be used around the inside of the mouth
• Pineapple chunks
  Sucking fresh pineapple may help with dryness and also help to prevent candidiasis
• Vaseline
  Applying Vaseline or a similar product regularly to lips will help prevent cracking

Ulcers/Mucositis

• Often related to high dose chemotherapy or total body irradiation with bone marrow transplantation
• Can be extremely painful
• Opioid analgesia is usually given via SC or IV continuous infusion ± PCA prophylactically

Apthous ulcers

Choline Salicylate (Bonjela®)

Form

Clear gel

Dose (topical directly to ulcers)

Child 16-18yrs: apply ½ inch of gel with massage not more than every 3 hours

Use in children under 16 years is not recommended due to theoretical risk of Reyes syndrome

Bleeding gums

See section on bleeding