Nursing care of children with leukemia
Introduction
Leukemia is cancer of the blood and develops in the
bone marrow. The bone marrow is the soft, spongy center
of the long bones that produces the three major blood cells:
 white blood cells to fight infection;
 red blood cells that carry oxygen;
 Platelets that help with blood clotting and stop bleeding.
When a child has leukemia, the bone marrow, for an
unknown reason, begins to make white blood cells that do
not mature correctly, but continue to reproduce themselves.
Normal, healthy cells only reproduce when there is enough
space for them to fit. The body can regulate the production of
cells by sending signals when to stop. With leukemia, these
cells do not respond to the signals to stop and reproduce,
regardless of space available.
These abnormal cells reproduce very quickly and do not
function as healthy white blood cells to help fight infection.
When the immature white blood cells, called blasts, begin to
crowd out other healthy cells in the bone marrow, the child
experiences the symptoms of leukemia (i.e., infections,
anemia, bleeding).
Incidence of leukemia
Leukemia is the most common form of cancer in childhood.
30 percent of childhood cancers are leukemia.
Leukemia can occur at any age, although it is most
commonly seen in children between 2 and 6 years of age.
The disease occurs slightly more frequently in males than in
females.
Causes of leukemia in children
The majority of childhood leukemia are acquired genetic
diseases.
exposure to certain viruses, environmental factors, chemical
exposures, and various infections have been associated with
damage to the immune system and thus leukemia.
With the exception of specific genetic syndromes, little is
known about the causes of childhood leukemia.
Types of leukemia
There are three main types of leukemia, including the
following:
Acute Lymphocytic Leukemia (ALL)
Acute lymphocytic leukemia (ALL), also called lymphoblastic
or lymphoid, accounts for about 75 to 80 percent of the
childhood leukemias. In this form of the disease, the
lymphocyte cell line is affected. . With acute lymphocytic
leukemia, the bone marrow makes too many of these
lymphocytes and they do not mature correctly. The
lymphocytes overproduce, thus, crowding out other blood
cells. Immature blood cells (blasts) do not work properly to
fight infection. Acute leukemia can occur over a short period
of days to weeks.
Acute Myelogenous Leukemia (AML)
Acute myelogenous leukemia (AML), also called
granulocytic, myelocytic, myeloblastic, or myeloid, accounts
for about 20 percent of the childhood leukemias. Acute
myelogenous leukemia is a cancer of the blood in which too
many granulocytes, a type of white blood cell, are produced
in the marrow. crowding out other blood cells. Acute
leukemia can occur over a short period of days to weeks.
Children with certain genetic syndromes are at a higher risk
of developing AML than other children.
Chronic Myeloblastic Leukemia (CML)
Chronic myeloblastic leukemia (CML) is uncommon in
children. Chronic myeloblastic leukemia is cancer of the
blood in which too many granulocytes, a type of white blood
cell, are produced in the marrow. . The marrow continues to
produce these abnormal cells which crowd out other healthy
blood cells. Chronic myeloblastic leukemia can occur over a
period of months or years.
The type of leukemia is determined by where the cell is in
the stage of development when it becomes malignant, or
cancerous.
The stem cell matures into either the lymphoid or myeloid
cells. The lymphoid cells mature into either B-lymphocytes or
T-lymphocytes. If the leukemia is among these cells, it is
called acute lymphocytic leukemia (ALL)..
The myeloid cells develop into platelets, red blood cells, and
specialized white blood cells called neutrophils and
macrophages. There are many classifications of AML. The
type of leukemia is determined by the stage of development
when the normal cells become leukemia cells.
Symptoms of leukemia
Because leukemia is cancer of the blood-forming tissue
called the bone marrow, the initial symptoms are often
related to irregular bone marrow function.
Anemia
Bleeding and / or Bruising
Recurrent Infections
Bone and Joint Pain
Abdominal Distress
Abdominal pain may also be a symptom of leukemia.
Leukemia cells can collect in the kidney, liver, and spleen,
causing enlargement of these organs. Pain in the abdomen
may cause a child to have loss of appetite and weight loss.
Swollen Lymph Nodes
The child may also have swelling in the lymph nodes under
the arms, in the groin, chest, and in the neck. Lymph nodes
are responsible for filtering the blood. Leukemia cells may
collect in the nodes, causing swelling.
Difficulty Breathing (dyspnea)
With T-cell ALL, these leukemia cells tend to clump together
around the thymus. This mass of cells present in the middle
of the chest can cause pain and difficulty breathing
(dyspnea). Wheezing, coughing, and/or painful breathing
requires immediate medical attention.
With acute leukemia (ALL or AML), these symptoms may
occur suddenly in a matter of days or weeks. With chronic
leukemia (CML), these symptoms may develop slowly over
months to years.
Diagnosis of leukemia
In addition to a complete medical history and physical
examination, diagnostic procedures for leukemia may
include:
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Bone marrow aspiration and biopsy - marrow may be
removed by aspiration or a needle biopsy under local
anesthesia. In aspiration biopsy, a fluid specimen is
removed from the bone marrow. In a needle biopsy,
marrow cells (not fluid) are removed. These methods are
often used together.
Complete blood count (CBC)
Additional blood tests - may include blood chemistries,
evaluation of liver and kidney functions, and genetic
studies.
Computerized tomography scan (Also called a CT or
CAT scan.)
Magnetic resonance imaging (MRI)
X-ray
Ultrasound
Lymph node biopsy
Spinal tap/lumbar punctures.
Treatment for Leukemia
Specific treatment for leukemia will be determined based on:
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child's age, overall health, and medical history
the extent of the disease
child's tolerance for certain medications, procedures, or
therapies
Expectations for the course of the disease
Treatment usually begins by addressing the presenting
symptoms such as anemia, bleeding, and/or infection. In
addition, treatment for leukemia may include (alone or in
combination) the following:
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Chemotherapy
Intrathecal medications / chemotherapy (medications
are inserted through a needle into the spinal cord into the
area called the subarachnoid space)
Radiation therapy
Bone marrow transplantation
Biological therapy
Medications (to prevent or treat damage to other
systems of the body caused by leukemia treatment)
Medications (for nausea and side effects of treatment)
Blood transfusions (red blood cells, platelets)
Antibiotics (to prevent/treat infections)
Continuous follow-up care (to determine response to
treatment, detect recurrent disease, and manage late
effects of treatment)
Stages of leukemia treatment
There are various stages in the treatment of leukemia,
including:
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Induction - a combination of chemotherapy and/or
radiation and medications given to stop the process of
abnormal cells being made in the bone marrow.
Remission is the goal in this stage of treatment.
Remission means the leukemia cells are no longer being
made. This phase may last approximately one month and
can be repeated if the goal is not achieved.the drugs
used for ALL are corticosteroids especially
prednisone,vincristine,L-asparaginase with without
doxorubicin.drug for AML includes doxorubicin or
daunomycin and cytosine arabinoside .this period last for
4-6 weeks
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Intensification - continued treatment even though
leukemia cells may not be visible. The leukemia cells
may not be visible in a blood test or bone marrow
examination, but it is possible that the cells are still
present in the body. Intrathecal and systemic
chemotherapy with Lasparaginase.methotrexate,cytarabine,vincristine and
mercaptopurine over a period of several months.
Maintenance - the stage that maintains leukemia-free
bone marrow by continuing less intense chemotherapy
for a longer duration. This phase can last months to
several years.combined drug regimen include daily
mercaptopurine,weekly methotrexate,and periodic
intrathecal therapy. Regular visits to child's physician are
required in order to determine response to treatment,
detect any recurrent disease, and manage any side
effects of the treatment.
Relapse - may occur even with aggressive therapy.
Relapse is when the bone marrow begins making
abnormal cells again. Relapse can occur during any of
the stages of treatment, or may occur months or years
after treatment has ended.Therapy includes reinduction
with prednisone and vincristine along with other drugs.
Prognosis
Depends on:
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The extent of the disease
Disease response to treatment
Genetics
Age and overall health of the child
child's tolerance of specific medications, procedures, or
therapies
New developments in treatment