The Six Aspect Meal Model as a Conceptual Framework in Nursing Research - Childhood cancer/stem cell transplantation and the mealtime situation with a gastrostomy tube

Background: Children with cancer usually undergo an intensive and demanding course of treatment, which can consist of chemotherapy, radiation, surgery or stem cell transplantation, separately or in different combinations. The cancer treatment may induce side effects, which negatively affect the child’s appetite and ability to eat and drink, thus causing eating problems. Because of this, a gastrostomy tube may be required in order to maintain and optimise the child’s nutritional needs. There is limited knowledge and experience of the environment and the mealtime situation for children who have undergone a stem cell transplantation and require a gastrostomy tube. Methods: Interviews were developed from semi-structured questions and were performed with the aim of investigating the experience of living with a gastrostomy tube, focusing on the mealtime situation. The Six Aspect Meal Model (SAMM) was used as a base in the interview guide. The transcripts were analysed using the qualitative directed content analysis approach outlined by Hsieh and Shannon. Results: It emerged that all the different aspects were represented in the interviews, but there were also many experiences related to the gastrostomy tube that did not fit under any of the six predetermined categories. Experiences that were associated with psychosocial dimensions emerged as an important factor with regard to the gastrostomy tube and the mealtime situation. As a result, the Six Aspect Meal Model (SAMM) needs to be supplemented with one more aspect. Conclusions: The psychosocial aspect seems to affect the mealtime situation, and it is important to include this in nursing practice. According to the result, the Six Aspect Meal Model (SAMM) have to be added with one more aspect in order to meet the children´s needs in an optimal way. It seems to be a model which can be transferred and used in clinical nursing practice in order to chart and improve the mealtime situation for those involved in the study design, and UM in the data collection. and SN analysed the data, wrote the first draft and subsequently coordinated the writing of the drafts and the final version of the paper. UM, MJN, KM, HW and SN contributed to the review of all subsequent drafts of the paper. All the authors read and approved the final version of the paper.

children with cancer who are required to use a gastrostomy tube.

Background
This article discusses a new approach to meeting childhood cancer and nutrition needs, with a focus on the mealtime situation when the child with cancer is living with a gastrostomy tube. In the article, we argue for a conceptual move and we discuss the opportunity to apply the Five Aspect Meal Model (FAMM) to clinical nursing practice. The objective is to develop and adapt FAMM into a model called the Six Aspect Meal Model (SAMM) in order to accommodate children with cancer who require a gastrostomy tube.
The goal of SAMM is to explore the relationship between he mealtime situation and the use of a gastrostomy tube and to create a functional model to use in clinical nursing practice.
A nurse researcher expects to base their research work on a theory or a conceptual model.
Risjord [1] writes that a conceptual model provides a framework for the specific nursing study and Polit and Beck [2] emphasise the importance of the researcher actually declaring and arguing for the connection between different aspects of a specific phenomenon as a basis for the constitution of a conceptual model. According to Risjord [1], a conceptual model is interpreted as an instrument that helps the researcher to orient and guide himself/herself in the research or makes the specific phenomenon salient to the current research. In addition, Risjord [1] accentuates the importance of highlighting the specific nursing values and goals in the conceptual model, since these, according to Risjord [1], point out to the researcher what is important to investigate further. Risjord [1] indicates that an important area of research is to ascertain that the planned interventions connect, with the aim of supporting patients in order to meet and improve their state of health. According to this, Risjord [1] emphasises that a conceptual model can play a crucial role in making clear the relationship between the specific model and the nursing standpoint.
In Sweden, around 300 children are afflicted by cancer every year, with leukaemia and brain tumours together constituting about half of all the tumour diseases in this group [3].
Children with cancer usually undergo an intensive and demanding course of treatment, which can consist of chemotherapy, radiation, surgery or stem cell transplantation, separately or in different combinations, depending on the kind of tumour, its stage and its position [3]. The cancer treatment may induce side effects in the form of nausea [4][5][6], vomiting [4][5][6][7], mucositis [3,[5][6], altered taste and smell experience [5] and lack of appetite [5]. These side effects negatively affect the child's appetite and ability to eat and drink and thus cause eating problems [5]. An effect and consequence of the complications can be that the children risk developing malnutrition [5][6][7], with an impaired treatment and an increased risk for morbidity and mortality as a result [6][7][8][9][10]. Nutritional status [6][7], nutritional assessment [6,11] and nutritional support [6,11] in children with cancer [6][7]11] are therefore of the greatest importance [6][7]11]. A complex problem requires a number of different combinations of strategies, measures and solutions in terms of nutrition and feeding, as well as in terms of nursing, in order to prevent malnutrition [5].
It is important to maintain a good nutritional status [6][7]10] in order to provide the opportunity for children with cancer to complete an optimal course of treatment that ensures their survival [6][7].
Application of the Five Aspect Meal Model (FAMM) to children with cancer and their mealtime situation when they have received a gastrostomy tube: The steps in the article are adapted from The Engel's model, Renjith et al. 2016 [14].
Step I: Identification of an appropriate conceptual model Step II: Overview of the selected conceptual model Step III: Link the conceptual model concepts with study variables Step IV: Analyse the relationship between study variables on the basis of the conceptual model Step V: Applicability of the conceptual model

Methods
Step I: Identification of an appropriate conceptual model According to Gustafsson [15], a mealtime situation deals with many more factors and aspects than just the food. A model called the Five Aspect Meal Model (FAMM) is described [15][16][17], which in the beginning was designed and produced with the aim of developing and improving restaurant visits [15]. The fundamental idea and the establishment of the model (FAMM) are based on the Michelin Guide [15][16][17] and thereby have the restaurant visit as a starting point [16][17]. The model consists of five different aspects [15][16][17], which are seen as a whole [15][16][17], and together they establish and form the model called the FAMM [15][16][17]. In a structured way, the model describes exactly what is necessary for and represents a complete meal experience by using five different aspects, that is, the room, the meeting, the product, the management control system and the atmosphere [15][16][17]. An essential and important vision of the model is that the food needs to be prepared, planned and served on the basis of several phases in order to be appreciated [17]. The authors emphasise the importance of the context of the mealtime situation, which actually affects how the food is accepted and consumed [17].
Step II: Overview of the selected conceptual model The room: The authors [16][17] describe this aspect as an important part of the mealtime situation, because all meals are consumed in some kind of room. According to the model (FAMM), the environment in the room is of importance, no matter where it is, though factors such as, for example style, textiles, design and art, as well as lights, sounds and colours, affect and have an impact on the mealtime situation [16][17]. These factors can have such an effect that the same mealtime situation can be perceived as a completely different experience depending on where it is consumed [16][17]. Because of these factors, according to the model, it is important that someone who has knowledge about the mealtime situation is also the person serving the meal, in order to meet every person's individual requirements and wishes [16][17].

The meeting:
The meeting aspect in the model is defined as the interaction and the interpersonal relationship between all of the individuals who are in some way involved in the mealtime situation [15][16][17]. Research has state that it requires knowledge and competence in, for example, social psychology, with the aim of meeting and managing different kinds of people and their needs as well as possible [16][17].

The product:
In the model, the food and the drink are declared as the most important factors [16][17].
The visual effect [16][17] as well as the taste experience [17] are highlighted and pointed out as key factors, according to the experience of the mealtime situation [16][17]. Because of this, knowledge about the food is of the greatest importance for a good experience around the mealtime situation [15][16][17].

The management control system:
The FAMM includes the management control system and administrative factors [15][16][17], which can be described as the work and the process that cannot actually be seen outwardly, but in fact affect all of the other aspects in the model [16][17].

The atmosphere:
The atmosphere has been described as an experience when an individual feels "comfortable and at ease" [15 p.12, 17 p. 89]. The atmosphere is described as a situation that is in fact formed and shaped by the participants themselves [15], and where the importance of verbal communication in particular is pointed out [15,17]. The atmosphere creates the mealtime situation as a whole [16], and is influenced by all the other aspects of the model [17].
Step III: Link the conceptual model concepts with study variables The Six Aspect Meal Model (SAMM) is based on the Five Aspect Meal Model (FAMM), and has been adapted for children with cancer who have received a gastrostomy tube. As a result of this, the five aspects (the room, the meeting, the product, the management control system and the atmosphere) were not sufficient to describe the mealtime situation for children with cancer, so the FAMM has been modified and supplemented with the sixth dimension of inflammation/infection. The reason for this is the issue of common complications due to gastrostomy surgery, such as skin irritation [12,18], granuloma [12,[18][19][20], leakage [12,[18][19][20] and infection [12,[19][20]. One assumption is that the lack of an inflammatory/infectious gastrostomy is probably crucial in creating a good mealtime situation for the child.

The Six Aspect Meal Model (SAMM):
The Five Aspect Meal Model (FAMM) is designed for the restaurant visit [15], and the original form is probably not when they have a gastrostomy tube. Because of this, the FAMM [15][16][17] was modified and adapted; a sixth aspect was added to the model. The new direction is to focus on the children's needs according to the illness. The SAMM highlights the aspect of inflammation/infection, which concerns, for example, medical and physical complications caused by the gastrostomy tube, such as inflammation and infection, discomfort and pain, as well as the experience of the diversion of the gastrostomy tube [ Figure 1].
Step IV: Analyse the relationship between study variables on the basis of the conceptual model Case description A child required a gastrostomy tube because she underwent a stem cell transplantation at the Childhood Cancer Centre in western Sweden. The child, as well as both the parents, were interviewed. The interviews, which proceeded from semi-structured questions, were performed with the aim of investigating the experience of living with a gastrostomy tube with the focus on the mealtime situation. The SAMM was used as a base in the interview guide, which meant that the questions proceeded from the five described aspects in FAMM (the room, the meeting, the product, the management control system and the atmosphere) but with one more aspect, namely inflammation/infection, added. This in order to adapt the FAMM into a model called SAMM with the aim of being appropriate for children with cancer who required a gastrostomy tube.

Data analysis
The transcripts were analysed using the qualitative directed content analysis approach outlined by Hsieh and Shannon [21]. This involved a line-by-line review of the transcripts to develop codes. The codes were abstracted into categories and subcategories and these were then compared with the predetermined categories in the model. After data analysis was completed, it appeared that all of the six aspects, that is, the room, the product, the meeting, the management control system, the atmosphere, and the inflammation/infection were represented in the interviews. During the analysis, it appeared that another category, named 'Other', was necessary, as information had emerged from the text that did not fit into the already predetermined categories. Under this new category, new subcategories and codes then arose. Example of units, codes, categories and subcategories which were represented in the analysis can been seen in Table 1.

The room
The room was an aspect that could affect the mealtime situation for the whole family.
Both the child and her parents mentioned the furniture and their placement in the room as an important factor in terms of the mealtime situation. The parents described the fact that the child, because of her treatment and condition, initially often ate her meals in bed: "She lay in bed or sat up, but she did not want to, it did not taste good" (father). The parentstalked more about where in the room the mealtime situation actually took place, as it did not necessarily have to be around the table. In contrast with this, the parents could also describe the need for adaption and flexibility of the room during the mealtime situation at home, when their child felt a little bit better: "She has been sitting upstairs and eating her food, then she sits and talks with her friend, and you realise it's important for her too" (mother). The child mentioned the opportunity to sit down around the table together with the family at home as something great for the experience of the mealtime situation: "A good day, that's when you sit around the table and just enjoy" (child).

The meeting
The meeting is of importance for the mealtime situation, both for the child and her parents. The meeting in relation to the mealtime situation was central, both at the hospital and at home. The meeting between the child, the parents and the clinicians at the hospital affected the mealtime situation a lot. The meeting at home affected the child, the parents, the siblings and other relatives. The parents mentioned the importance of how the clinicians met with them in the initial phase, in which the tube feeding started. There was a discrepancy between the desire to follow the clinician's advice and meeting the needs and wishes of their children in the mealtime situation. The parents described the need to observe their child's signals: "Because they told us (clinician) it had to go faster (the tube feeding), someone told us, but we soon learned that it does not work with her, it must go slowly, slow and flow" (mother). It was also discovered that much activity around the feeding process and the mealtime situation was ruled by the child's experiences. It was important for the parents that the child got any nutrition at all, so they tried to constantly listen to the child's needs and wishes: "Well I decide, because it's about what I am feeling in my stomach" (child). At home, the child described the importance of participating in and the social meaning of the mealtime situation. She described it like this: "Honestly, I'll stay. Yes, I am sitting and talking" (child). In the interviews, it became clear that the aspect of meeting in relation to the mealtime situation for the parents was very much about meeting the child's new expectations around the mealtime situation: "You cannot count the amount of food she eats, just that she actually wants the food" (mother). They also mentioned the importance of being flexible around the mealtime situation and trying to find different ways to meet and reach the child, to do things in a normal way, like it had been before the gastrostomy tube: "She can be together with us and prepare the food" (father).

The product
When the child talked about the product as a factor, she described the importance of being able to control and influence the times of the meals, but primarily she mentioned the importance of the possibility of controlling the rate of the tube feeding: "I get stomach ache, but then I can only slow down (the rate). If it go too fast, it hurts all the time" (child).In addition, the parents talked about the importance of the child's ability to control the rate of the infusion: "When we lowered or turned off the intake, it became much better" (father)and "She wants it (the tube feeding) at her rate" (father). The temperature of the food was also something which could affect the mealtime situation in the interviews: "Yes, she always wants fresh food, so it's hot" (mother). The visual impression of the food was another thing the parents described as an important factor that affected how much the child actually ate in the mealtime situations: "It should be rejoicing.
Grandmother, she is very, so, it is going to be party, and it should be nice glasses and more. Maybe it's the visual for her" (mother).

The management control system
The parents described the fact that the tube feeding was given at set times according to a specific plan at the hospital: "They started at six in the morning. Then they put on the first tube feeding. And then it was at ten, eleven. And then it was ok, yes, depending on when, yes they had a schedule then that. Yes, she got it all day" (mother). At that specific time in their child's treatment and recovery, it was not necessary to choose or change the time of the day for the mealtime situations. After a while, when the child felt better and started to eat a little orally, it appeared that she was always offered different kinds of food at the hospital. The child had the opportunity to choose between different dishes, but often they did not taste good to her: "Yes, she received her favourite foods at the hospital, but it did not really taste like home. Therefore, she sat watching the iPad. The hospital food did not taste really good" (father). The parents mentioned that they did whatever they could at the hospital in the hope that the child should eat anything at all orally: "We drove to the shops (to buy the food she wanted). Yes. It's getting better, but you'll get what she likes" (mother).
When the child came home, the parents decided that they would try to adapt the times when the child should be tube fed. This was done in order to increase her opportunities to be more active and as free as normal, which they also hoped would increase her appetite: "And then we choose to make it (the tube feeding) in the mornings and evenings" (mother). When the child was at home, the parents were clear that they always prepared and cooked the food according to the child's wishes. They seemed to adapt the food all the time in hope of getting the child to eat anything at all: "Right now it is wished -for food" (father). They also described how relatives always adapted the food and tried to give the child her favourite food in the hope that she would eat: "They (grandmother and grandfather) also ask her what she wants to eat" (mother). In addition, the child described how the food was adapted according to her wishes: "It is like this, everyone can choose, only they like it" (child).
The parents could express their feelings around the mealtime situation, how they tried every day to find out what their child wanted to eat: "It's hard. It is no easy thing when she does not know what she wants" (mother). Adaption of the food was done even though it is clear that the child did not always eat the food, although they had prepared it according to all her wishes: "But we did salmon and potato and then she ate a little, but it was not much" (mother). The parents could also express their feelings around the mealtime situation, when they had adapted the food as required, and the food was left anyway: "That's because if you've done something that she wants, and it does not work anyway" (mother). In summary, the parents clarified that all their waking time revolved around food and thoughts about how to get their child to eat more through her mouth.
According to the management control system, it appeared that the opportunity for the child to request her favourite food was an important factor, as it was crucial that she should eat anything at all through the mouth, both at the hospital as well as at home.

The atmosphere
Something that emerged clearly was how much the smell of the food affected the child when it came to the mealtime situations. The parents related much of the nausea in connection to the mealtime situation at the hospital with the fragrance of the food.
According to the parents, their child was so affected by the food's smell at the hospital that they could sometimes not even could come into the room with it: "She did not want us to bring it into the room. She did not want to smell the aroma" (father). The parents experienced a lot negative emotions regarding their child's smell of the food: "There were many times when we took the food inside, she said 'go out, I feel like throwing up' if she smelt the smell, and it made her feel nauseous, so it is clear, yes" (mother). According to the parents, the food's smell affected both the mealtime situation in general but also feelings of normality and well-being as they could not sit down and eat together as a family. The parents described the mealtime situations like this: "She felt so bad that we (parents) had to go out to eat" (mother). The mealtime situations became a non-existent and abnormal situation where they ate separately and without an experience of wellbeing: "No, we had to sit outside in the dining room and eat. She did not want to smell the food. She thought it was tough" (father). The parents described the mealtime situation as a non-existent situation; one where the child did not want the food. The result became that the child sat with one of them inside the room while the other parent had to eat alone outside the room, and then they shifted: "We (parents) could not eat inside the room but then we (parents) had to go out and eat in the kitchen" (mother).

Inflammation/infection
The child described the gastrostomy tube in both a positive and a negative way. In the beginning, she experienced the gastrostomy tube in relation to certain pain: "It was tender" (child). The other negative thing that hampered the mealtime situation was the abdominal pain caused by the gastrostomy tube and the infusion rate of the tube feeding:"I get stomach ache, but then I can only slow down (the rate). If it is too fast, it hurts all the time" (child).

Other
The child could also describe how the nausea caused by the tube feeding affected the mealtime situation in a negative way: "Yes, but now, when I can feel nausea sometimes, then you are not crazy about food" (child) and "When I eat, I feel nauseated and it does not taste so good (the food)" (child). Nausea influenced her daily life, which thereby affected the mealtime situations in a negative way. In summary, the child could express the fact that the nausea from the tube feeding and the gastrostomy tube negatively affected her will to eat through the mouth. However, the gastrostomy tube was also a positive thing for the child as it played an important part in her survival: "Because if I had not gotten food I would not have made it" (child).
Another prominent thing thatemerged from the child, and the parents, was the positive and negative psychosocial aspects. The child could recognise the medical benefits of the gastrostomy tube: "It's pretty good I think" (child). She also talked about some negative things to do with the tube: "Though it's a bit in the way and so" (child).The gastrostomy tube was associated with drawbacks for the child. She talked about the fact that it now felt difficult to wear the clothes she wanted to, when she did not want the tube to be visible: "If you want a short shirt, then you'll see the tubes, it does not feel so good" (child).
The parents had few negative things to say about the gastrostomy tube. However, they mentioned her pain after the insertion of the tube: "She said that she had a stomach ache (father). The parents mainly associated the tube with safety/security: "Yes, it's a safety/security measure" (father). The safety/security of ensuring that the child actually got all the medications, fluids and food that she needed: "Yes, it is a great deal of safety/security. Then we know if she did not get the right amounts (of food) in the day, then she has it (the gastrostomy tube)" (father). The parents saw the gastrostomy tube as a safety/security measure associated with being able to give their child food and also to avoid weight loss: "Yes, that's fine. Without that (the gastrostomy tube), it would not have been so good, probably because then she'd lose weight" (mother). The parents could even see the gastrostomy tube as a thing that actually facilitated everyday life: "When she does not get the amount of food that she needs, then the gastrostomy tube will make it easier for her. It facilitates medication, fluid and tube feeding and so on" (father). The predominant experiences that the parents related about the gastrostomy tube were positive: "It (the gastrostomy tube) has worked very well" (father). They could talk about how they had expected problems around the gastrostomy tube but that they actually did not have any: "It has worked incredibly well. There have been no problems. It works well.
It is very good to have" (mother).
Step V: Applicability of the conceptual model Research has shown that gastrostomy tubes [12,22] and enteral nutrition [5][6][12][13]] are a good option in patients with cancer [5-6, 12-13, 22]. Because of this, the children's nutritional intake can be optimised and malnutrition can be prevented [5][6][12][13]. The SAMM is based on the FAMM [15][16][17] and has been modified and adapted to childhood cancer and the mealtime situation when the child uses a gastrostomy tube. In the case of childhood cancer, mealtime situations may be demanding and problematic to varying degrees [5,23], which can lead to experiences of stress for the parents [23]. Research has shown that the parents' feelings of stress around food can affect the child and result in both conflicts and negative feelings in relation to the mealtime situation, depending on which strategies the parents use [23]. Because of this, it is especially important to create an appealing mealtime situation in order to meet both the children's desires and their nursing needs.
While there is currently limited knowledge regarding childhood cancer and the use of gastrostomy tubes, the SAMM seems to be an appropriate way to find out and investigate how health care professionals can meet the children's desires and nursing needs with the aim of creating a better mealtime situation. This feels important, as meals are something that children have to go through many times every day, no matter how they feel. Beyond this, it continues to be important, especially when adequate nutrition can be crucial for the treatment to perform optimally, thus ensuring the child's survival.
It is known that common complications that may occur in connection with using a gastrostomy tube in childhood cancer, for example, infections [12,[19][20], skin irritation [12,18] granuloma [12,[18][19][20] and leakage [12,[18][19][20]. Unfortunately, it is not demonstrated how these complications affect the child. A non-inflamed or uninfected gastrostomy tube is probably crucial in creating a good mealtime situation for the child.
This study tries to transfer the SAMM's aspects into a nursing perspective. The aspects of SAMM are considered transferable to achieve an optimal mealtime situation, even for children with cancer and their mealtime situations in the hospital, at home or in other places. The model can be a way to find out how children feel about their mealtime situations, with the aim of meeting their nursing needs in a professional way. The model could help nurses to reflect on the many factors that affect a mealtime situation, which could also help them to find out how to improve the situation and help the children.

Discussion
The environment is of the greatest importance for an optimal chance to get better and achieve health [24]. Research has shown that the physical environment, as well as the personal space, are essential to consider for children who stay in hospital [25]. The environment and the atmosphere are mentioned in the research as important for the individual's experiences of the care they receive [26]. Examples are factors like colours, room space, noise and lighting, as well as the food and drinks, all of crucial importance for children's opportunity to recover and to reach health [25]. The finding that the environment is crucial [24][25][26], coincides with the factors described in the FAMM [15][16][17] and therefore also in the SAMM.
In the interviews, it became clear that all aspects in the described model FAMM [15][16][17], as well as the aspects in the model SAMM, were represented, which intensifies the importance of how factors in the environment affect mealtime situations for children who have undergone a stem cell transplantation and require a gastrostomy tube. The environment affected the mealtime situations for the child as well as her parents during the whole time at the hospital. Research has consequently shown that the environment is a factor that affects the satisfaction with the visit and thereby the whole experience of the hospitalisation [24,27]. In addition, it is known that the parents' feelings of stress can affect children's mealtime situations in a negative way [23]. Because of these findings, it seems to be of the greatest importance to highlight the factors which are described in the FAMM [15][16][17] and therefore also in the SAMM.
An unexpected result that emerged in this study was the extent to which the psychosocial factors around the mealtime situation affected the whole experience, for the child as well as the parents. Many experiences related to the gastrostomy tube did not fit under any of the six predetermined categories, which was the reason why a new category, named 'Other', was created. This category was used to record those findings that could be attributed to psychosocial experiences around the gastrostomy tube and the mealtime situations. Experiences that were associated with psychosocial dimensions were nausea, safety/security, satisfaction and dissatisfaction. A conclusion of this is that the added aspect of inflammation/infection did not seem to be enough; the model should be supplemented with psychosocial factors. Consequently, a seventh aspect should be added to SAMM, that is, the psychosocial aspect (related to the gastrostomy tube).
Research has shown that the hospital ward environment has a negative impact on food intake during the care of children with cancer at hospitals, which is why the psychological aspects are of the greatest importance [5]. Psychosocial factors in relation to the mealtime situation may not be given high priority in the encounter with children in nursing care. This could be because there probably are many other urgent and more highly prioritised medical factors around these children, which all are emphasised in the first acute phase. As a result, it is maybe even more important to highlight and pay attention to the children's needs in relation to the mealtime situation and maintain awareness of the psychosocial factors around these needs in the nursing care. However, the model seems to be complementary to capture the psychosocial findings and experiences of the children and their parents.
Research has shown that it is of greatest importance to maintain a good nutritional status [6-7, 10, 28] in order to provide the opportunity for a child with cancer to complete an optimal course of treatment to ensure their survival [6][7]. With this in mind, it must be of the greatest importance to highlight and further explore the experiences of the children and their parents around the mealtime situations. This model could be a step towards developing and implementing a nursing care model that could help the children and their parents, as well as the nursing practice, to optimise the children's mealtime situation when the child has undergone a stem cell transplantation and requires a gastrostomy tube. A weakness with this study is that it is a case study and members of only one family were interviewed at one hospital unit. Further interviews are of course needed to find out if the results can be generalised. Additional research, knowledge and experiences are needed to find out how the environment affects mealtime situations and how it can be improved and become optimal for these children and their parents. It is important to focus on and emphasise the mealtime situations in relation to the environment for those children who are unable to eat orally. This is a crucial experience in the children's everyday life and it is of the greatest importance for the facilitation of the treatment and the process of recovery.

Conclusions
The psychosocial aspect seemed to affect the mealtime situation to a high degree, both

Declarations
Ethics approval and consent to participate The Regional Ethics Review Board of Gothenburg, University of Gothenburg, approved the study (approval number 937-17, approved 2017-12-13). All the participants received information about the study both verbally and in writing. All parents and children who could read were also given written information. All the participants have gave their written consent to participate in the study. Oral assent was obtained from all the children and written consent was collected from the parents in the child were younger than 16 years old.

Consent for publication
All participants have provided written consent to participating in the study and having parts of the interviews included in scientific articles in a de-identified format.

Availability of data and material
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This work was supported by grants from the Swedish Childhood Cancer Foundation, Ebba Danelius