Leukaemia in pediatric

1. Leukemia
Surendra Sharma
Associate Professor
Amity College of Nursing
Amity University, Haryana

2. DEFINITION
Leukemia is a malignant disease of blood
forming organs of the body that results in
uncontrolled growth of immature white blood cells.
The leukemia process in the bone marrow with the
production of normal red cell, white cell and platelets
(Wongs, 2005).
It is leukemia are disorders of uncontrolled
proliferation of leucocyte and their precursors in the
bone marrow with infilteration of lymph nodes,
spleen liver and other body organs (Mosby’s Clinical
Nursing).

3. INCIDENCE
28700 new cases of leukemia occur yearly
Approximately 26500 occur in adults
2200 in children
21600 deaths in childrens approximately.
Etiology
The exact causative agent is unknown
Virus
Rediation
Chemical and drug exposure
Genetic

4. Pathophysiology
Acute lymphoytic leukemia is maliguane
disorder arising from a single lymphoid stem cell,
with impaired maturation and accumulation of the
maligent cells in the bone marrow.
Diagnosis is confirmed by bone marrow
aspiration or biopsy, which typically shows different
stages of lymphoid development.
From, very immature at almost cells.
The degree of immaturity is a guide to the
prognosis, the greater the number of immature
cells, the poorer will be the prognosis.

5. CATEGORIES OF CHILDHOOD LEUKEMIA
Acute Iumphocytic leukemia (AIL)
1. Standard risk all
2. High risk all
T cell ALL
B cell ALL
Acute Nonlymphocytic leukemia (ANLL)
Granhlocytic
Myelocytic
Myelogenous
Monoblastic
Chronic myelocytic leukemia (CML)
Adult form
Chronic phase
blast crisis
Juvenile form
Congenital leukemia

6. Clinical manifestations
Anemia from decreased RBCs
Infection from neutropenia
Bleeding from decreased platelet production
Fever
Weakening of the bone
Fractures
Spleen, liver, lymphglanss demonstrate marked
infiltration, enlargement
Eventually fibrosis
Leukemic cells may also invade the testes,
kidney, prostate, ovaries, GIT tract and lungs

7. Diagnostic evaluation
•History collection
•Physical examination
•Peripheral blood smear (immature forms of
leukocytes)
•Bone marrow aspiration or biospsy.
•Lumpar puncture is performed to determine if
there is any CNS involvement.
Management (Therapeutic)
Treatment of leukemia involves the use of
chemotherapeutic agents, with or without cronial
eradication in four phases:
1. Induction therapy
2. CNS prophylactic therapy
3. Intensification therapy
4. Maintenance therapy

8. Induction therapy
Induction of remission aims at eradication of all
leukemia blast cells, which permits the return of
normal hemetopoisis. A number of genetic or drug
combinations are used.
The most common dug is prenizolone and
vincristile many other drug combinations such as L-
aspanginase and cyclophosphemide with steroids are
also used for chemotherapy.
Maintenance therapy
A complete remission imputes a clinical
haemtological and bone marrow remission. For
remission therapy drugs like, metro percate
cyclophosphemide and 6 mercepto parile code used.
Also during maintenance therapy, periodic CBS are
taken to evaluate the bone marrow’s response to the
drugs.

9. CNS prophylactic therapy
Treatment of the CNS consists of prophylactic therapy
using intrathecal chemotherapy with methotrexate, cytarbine
and hydrocortisone. Sometimes Metrotrexate as well as
cytarabine may be given as single agents intrathecally.
Intensification or consolidation therapy
After complete remission is obtained, a period of
intensified treatment is administered to cradicate residual
leukemic cells, this is followed by delayed intensification to
prevent emergence of resistant leukemia clones.
Chemotherapy including high dose or intermedicate dose
methotrexate, cytarbine is administered over a period of
several months.
Nursing management
Give psychological support to the family members
Encourage child to talk about feelings
Help family as they encourage child to express feelings
Give pain relief therapy
Avoid pressure on painful areas
Keep fresh air circulating in room

10. ACUTE LYMPHOCYTIC LEUKEMIA (ALL)
DEFINITION
ALL is a broad term describing a group of
malignant diseases in which normal bone marrow
elements are replaced by abnormal immature
lymphocytes known as blast cells.
INCIDENCE AND ETIOLOGY
98% children suffering from leukemia have acute
type of the disease.
Mostly in 2 – 5 years old
Both the age groups
Approximately 3,000 new cases each year in the
US.
Viruses
Radiation
Exposure of certain toxic chemicals
Drugs such as benzene and a gentic predisposition
Mostly unknown ALL cases etiology

11. PATHOPHYSIOLOGY
Acute lymphocytic leukemia develops
Single lymphoid cell
Transformation and proliferates uncontrollably
Bone marrow of an individual with ALL the invasion of
these malignant lymphoblast or immature white cells cause
“Crowding out”
Normal red blood cell, platelets and white blood cells
Pancytopenia (Reduction in the number of RBCs and WBCs
and platelets)
Immunosuppression

12. CLINICAL MANIFESTATIONS
Bone marrow
depression
Increased
metabolism
Enlargement of organs
infiltrate by blast
cells
Blast cells crowd
out healthy, WBCs,
RBCs, platelets
1 2 3 Weight
loss
Bones Spleen Liver Glands Kidney
Proliferation of immature white blood cells (Blasts)
1. Decreased WBCs (decreased immunifunction)
2. Decreased RBCs (decreased Oxygen carrying capacity)
3. Patients platelets (decreased clotting capacity)
Pathotlysilogy leading to clinical manifestations in ALL
Source (Polts Nickil, P. No. 926).

13. Enlargement of organs infiltrated by blast cells
Bones
• Bone pain
• Migratory joint pain and swelling
Spleen
• Splenomegaly
• Abdominal fulness
Liver
• Hepatomegly

14. Glands
1. Lymphadenopathy
2. Tenderness
Kidney
Kidney enlargement
Usually no overt signs or symptoms
1. Decreased immune function signs and symptoms
Fever
Infection especially pulmonary, urinary tract
Blood
2. Decreased O2 carrying capacity
Anaemia
Weakness
Malaise
Pallor
Dyspnea
Tachycardia
3. Decreased clotting capacity
Increased bruising/petechiae
Nose bleeds
Bleeding from gums
Haemorrhage

15. Diagnosis
BMA (Bond marrow aspiration)
25% of abnormal lympho blasts in the bone
marrow is diagnostic
Blood count and age at diagnosis are the most
important prognostic signs in ALL.
Best prognosis is WBC less than 5000/mm3 and
the age of 2 – 9 years.
Worst prognosis  WBC of 50000/mm3 younger
than 2 years and older than 10 years.
Lempar puncture is done to assess for the
presence of CNS disease.
Chest X-ray is obtained to detect a mediastinal
mass.
Laboratory findings will show liver or kidney
involvement.

16. Treatment
If includes ALL treated with systemic chemotherapy and
includes three phases:
1. Indication Phases
The goal is the induction phase is to reduce the tumor
burden to an undetectable level, a state known as
remission.
 In remission there is no evidence of leukemia on
physical exam, bone marrow evaluation.
 Peripheral blood counts in the CSF or any other
extramedullary site.
 95% of children with ALL achieve remission
during induction which usually lasts four weeks.
 Remission induction is achieved by
treating the child with the chemotherapeutic
agents, oncoin, lesparaginase and
predinisone children.
 Presenting symptoms such as anaemia, infection
or bleeding are treated at the time of diagnosis.
 Elevation of the uric acid

17. Treatment
 Ailopurinol is also given to aid in the excretion of
uric acid through the kidneys, preventing renal
obstruction and failure.
 WBC high 50000 or greater or extensive
lymphadenopathy.
 Radiation therapy
2. Consolidation phase
 It is eradicating any residual leukemic cells and
starts promptly once remission is attained.
 Chemotherapy is frequently given in high doses
requiring hospitalization during this phase of
treatment.
 ITC inrathecally medications is frequent and
radiation therapy to the brain may be given for CNS
prophylaxis or treatment.
 Children who have extremedullary disease will
receive radiation to those sites at this time.

18. 3. Maintenance phase
 It follows consolidation and maintains control of
the leukemia with most chemotherapeutic agents
administered by oral, IM, IV routes.
 Occasional IV injections of vincristine and
lymbar punctures with IT chemotherapy may be
given.
 Most centres continue therapy for 2 ½ to 3
years after diagnosis.
 Today remission can be induced in 95% of
children.
 And 5 years survival rates are now nearly 80%.
The completion of chemotherapy is a goal that many
caregivers and children look forward to with a hope to
return to a “normal life” again.
 It is also met with high anxiety and fear that if no
further therapy is given the child will promptly relapse.
 The family needs to be assumed that there is no
significant advantage to continuing therapy beyond
this period.

19. Nursing diagnosis
1. Risk for infection related to neutropenia from the
disease process and treatment
Intervention
 Follow the strict asepectic technique for hand
washing procedure.
 Monitor the vital signs frequents for signs of
infection.
 Administer antibiotics as ordered.
 To minimize exposure to infective organism.

20. 2. Risk for injury related to thrombocytopenia
Intervention
 Monitor susceptiability to bleeding
 Assess for signs of bleeding including
petechiaqua and bruishing
 Monitor urine and stool for signs of occult
bleeding
 Do the platiet count daily
 Decreased platiet count bruising, petelachiae
and blood in urine or stool can indicate bleeding
 Monitor for signs of hemorrhage (Decreased BP,
tachycardia, pallor, diaphoresis restlessness)
 Avoid skin punctures when possible. Apply
pressure if punctures necessary for 5 – 10
minutes
 Children with platelet counts below 20000/mm3
are at risk for spontaneous bleeding

21. 3. Pain related to diagnosis, disease process and
treatment
 Assess the painful areas for location, severity
and signs of infection.
 Provide pain medication
 Provide psychological support
 Give play therapy
 Follow the doctors order
4. Imbalanced nutrition : less than body requirement
related to loss of appetite nausea, vomiting and
mucositis
 Give small amount of food frequently
 Encourage high protein and high calorie diet
 Give patient like food
 Administer antiemetics as ordered to decrease
nausea

22. ACUTE MYELOGENOSUS LEUKEMIA
ANIL is the second type of leukemia recognized.
Children with AML have a poorer prognosis than those
with ALL. 70 to 85% of children with this type of
leukemia will achieve remissio, but only 30 – 40% will
become long term survivors.
Incidence and etiology
 15 to 45% approximately of childhood leukemia.
 Etiology is not known.
 Riskfactors such as exposure to radiation therapy
and chemotherapy for the treatment of a
previous cancer, exposure to benzene and genetic
predisposition in children with down syndrome
and fanconis anaemia can be named.

23. Pathophysiology
ALL malignant myeloid blasts crowd out the
normal WBC, platelets and red blood cells causing
neutropenia and immunosuppression,
thrombosytopenia and anaemia.
Clinical manifestation
Resembling the flu, i.e.,
Fever
Fatigue
Malise
Anorexia
Bleeding and severe hemorrhage
DIC (Disaminated intravascular cogulation)
AML and ALL clinical manifestations are same
Difficulty in walking
Incontinuence of urine and stool caused by spinal
cord compression
Enlargement of the liver, spleen
Lymphadenopathy occurs less often

24. Diagnosis
Bone marrow aspiration >25%, malignant myeloid
blasts confirms the diagnosis of AML.
Treatment (Medical)
 Systemic chemotherapy
 The phases of AML treatment are remission
induction and continuation therapy
 Chemotherapy drugs such as cytarabine and an
anthracycline agent.
 After remission is achieved many clinical trials
call for a continuation with intense high dose
chemotherapeutic agents such as cytarabine,
cytoxin anthracyclines
 Bone marrow transplantation
 Radiation to the head may be part of CNS
therapy and prophylaxis

25. Nursing management
 Check the vital signs, decrease the blood
pressure and increase in heart rate.
 Watch for bleeding
 Provide skin care and prevent skin break down.
 Provide pain controlling measures like
modification in the physical environment
positioning use of analgesic etc.
 Provide psychological support to the patients
and parents.
 Isolate the patient and restrict the visitors
 Give light cloth to wear and prevent the
pressure of bed lines
 Use dim light and create minimum sound
environment
 Provide diversional therapies like use of music
relaxation techniques cutaneous stimulation etc.

26. Nursing care plan
1. High risk for infection related to ineffective
immune system.
2. Altered protection related to electrolyte
imbalances secondary to tumour lysis.
3. Activity intolerance related to impaired O2
transport.
4. High risk for injury (internal) related to
inadequate clotting factors (platelts)
5. Anxiety related to unfamilarity with new
diagnosis and treatment plan.
Implementation
1.  Monitor the vital signs
 Prevent constipation and invasive procedures.
 obtained blood via finger tips not venipunture.
 Inspect skin daily for areas of breakdown.
 Monitor blood counts
 Inspact oral cavity for oral candidiasis and
breakdown in the oral mucosal lining.
 Instruct family about signs and symptoms of
infection.

27. 2.  Check the vital signs.
 Give adequate rest.
 Encourage to play.
 Administer packed RBCs as advised by doctor.
 Discuss with parent child signs and symptoms of
anaemia, treatment options.
3.  Monitor platlet count daily.
 Inspect stool urine, gums, sputum, nasal
secretion for any evidence of bleeding.
 Minimize/avoid in vasive procedures
4.  Provide adequate knowledge to the parents about
diagnosis and treatment.
 Introduce family to another family whose child
has similar diagnosis with similar therapy.
Verbally reinforce each day the plan for next 24- 48
hours.
 Provide written and verbal discharge instructions.

28. CHRONIC LYMPHOCYTIC LEUKEMIA
 CLL it is characterized by a proviferation and
accumulation or small, abnormal mature
lymphocytes in the bone marrow.
 It is mainly occurs in adults especially in older
adults (65 years).

29. CHRONIC MYELOGENOUS LEUKEMIA
 It occurs between 25 – 60 years of age.
 Peak incidence is around at 45 years of age.
 Etiology is also unknown.
 Chromosome 22 and 9 is identified in person
diagnosed with CML.
Health education
 Give extra calories and protein rich diet.
 Encourage the child mingle with all children.
 Follow the doctor’s order and take the regular
checkup to the children.
 Avoid injuries and damage to the body’s.
 Explain about the prevention and control of the
further attack to be avoid.