What is leukemia in children?

Leukemia is cancer of the blood. It’s the most common form of cancer in
childhood. The cancer cells grow in bone marrow and go into the blood. The
bone marrow is the soft, spongy center of some bones. It makes blood cells.
When a child has leukemia, the bone marrow makes abnormal blood cells that
don’t mature. The abnormal cells are usually white blood cells (leukocytes). The
bone marrow also makes fewer healthy cells. The abnormal cells reproduce
very quickly. They don’t work the same as healthy cells.
The types of blood cells include:

 Red blood cells (erythrocytes). Red blood cells carry oxygen. When a child
has a low level of healthy red blood cells, this is called anemia. A child may
feel tired, weak, and short of breath.
 Platelets (thrombocytes). Platelets help with blood clotting and stop
bleeding. When a child has low levels of platelets, he or she bruises and
bleeds more easily.
 White blood cells (leukocytes). These fight infection and other disease.
When a child has low levels of white blood cells, he or she is more likely to
have infections.

There are different types of leukemia in children. Most leukemias in children are
acute, which means they tend to grow quickly. Some of the types of leukemia
that occur in children include:

 Acute lymphocytic (lymphoblastic) leukemia (ALL). This is the most

common type of leukemia in children.
 Acute myelogenous (myeloid, myelocytic, non-lymphocytic) leukemia
(AML). This is the second most common type of leukemia in children.
 Hybrid or mixed lineage leukemia. This type is rare. It is a mix of ALL and
AML.
 Chronic myelogenous leukemia (CML). This type is also rare in children.
 Chronic lymphocytic leukemia (CLL). This type is extremely rare in children.
 Juvenile myelomonocytic leukemia (JMML). This is a rare type of cancer
that doesn’t grow quickly (acute) or slowly (chronic).

What causes leukemia in children?

The exact cause of leukemia in children is not known. There are certain
conditions passed on from parents to children (inherited) that increase the risk
for childhood leukemia. But, most childhood leukemia is not
inherited. Researchers have found changes (mutations) in genes of the bone
 marrow cells. These changes may occur early in a child's life or even before
birth. But they may occur by chance (sporadic).
Who is at risk for childhood leukemia?
The risk factors for childhood leukemia include:

 Exposure to high levels of radiation

 Having certain inherited syndromes, such as Down syndrome and Li-Fraumeni
syndrome
 Having an inherited condition that affects the body's immune system
 Having a brother or sister with leukemia

What are the symptoms of leukemia in children?

The symptoms depend on many factors. The cancer may be in the bone
marrow, blood, and other tissue and organs. These may include the lymph
nodes, liver, spleen, thymus, brain, spinal cord, gums, and skin.
Symptoms can occur a bit differently in each child. They can include:

 Pale skin
 Feeling tired, weak, or cold
 Dizziness
 Headaches
 Shortness of breath, trouble breathing
 Frequent or long-term infections
 Fever
 Easy bruising or bleeding, such as nosebleeds or bleeding gums
 Bone or joint pain
 Belly (abdominal) swelling
 Poor appetite
 Weight loss
 Swollen lymph glands (nodes)

The symptoms of leukemia can be like other health conditions. Make sure your
child sees a healthcare provider for a diagnosis.

How is leukemia diagnosed in children?

Your child's healthcare provider will ask many questions about your child's
symptoms. He or she will examine your child. Your child's healthcare provider
may recommend blood tests and other tests. A complete blood count (CBC)
provides the number of red blood cells, different types of white blood cells, and
 platelets. If the results are abnormal, your child's healthcare provider may
recommend that your child see a pediatric cancer specialist (pediatric
oncologist). The oncologist may want your child to have additional tests
including:

 Bone marrow aspiration or biopsy. Bone marrow is found in the center of

some bones. It’s where blood cells are made. A small amount of bone marrow
fluid may be taken. This is called aspiration. Or solid bone marrow tissue may
be taken. This is called a core biopsy. Bone marrow is usually taken from the
hip bone. This test is done to see if cancer (leukemia) cells are in the bone
marrow.
 Lab tests of blood and bone marrow samples. Tests like flow cytometry
and immunohistochemistry. These tests determine the exact type of leukemia.
DNA and chromosome tests may also be done.
 X-ray. An X-ray uses a small amount of radiation to take pictures of bones and
other body tissues.
 Ultrasound (sonography). This test uses sound waves and a computer to
create images.
 Lymph node biopsy. A sample of tissue is taken from the lymph nodes. It’s
checked with a microscope for cancer cells.
 Lumbar puncture. A special needle is placed into the lower back, into the
spinal canal. This is the area around the spinal cord. This is done to check the
brain and spinal cord for cancer cells. A small amount of cerebral spinal fluid
(CSF) is removed and sent for testing. CSF is the fluid around the brain and
spinal cord.

When leukemia is diagnosed, the doctor will find out the exact type of leukemia
it is. Leukemia is not assigned a stage number like most other cancers. Instead,
it's classified into groups, sub-types, or both.
ALL (acute lymphocytic leukemia) is the most common leukemia in children. It's
separated into 2 groups based on the type of lymphocyte the leukemia started
in. That would be B cells or T cells. About 8 out of 10 cases of ALL in children
are B-cell ALLs. These can be further classified into sub-types. The other 2 out
of 10 cases are T-cell ALLs.
AML (acute myelogenous leukemia) is the other kind of leukemia that's common
in children. Doctors use 2 different systems to classify AML. The French-
American-British (FAB) system divides AML into 8 sub-types based on how the
cells look under the microscope. The World Health Organization (WHO)
classification system is newer. It groups AML into many groups based on things
like the details of the gene changes in the cancer cells as well as the FAB sub-
types.
 Classifying leukemia is very complex. But it's an important part of making
treatment plans and predicting treatment outcomes. Be sure to ask your child's
healthcare provider to explain the stage of your child's leukemia to you in a way
you can understand.

How is leukemia treated in children?

Your child may first need to be treated for low blood counts, bleeding, or
infections. Your child may receive:

 Blood transfusion with red blood cells for low blood counts
 Blood transfusion with platelets to help stop bleeding
 Antibiotic medicine to treat any infections

Treatment will depend on the type of leukemia and other factors. Leukemia can
be treated with any of the below:

 Chemotherapy. These are medicines that kill cancer cells or stop them from
growing. They may be given into the vein (IV) or spinal canal, injected into a
muscle, or taken by mouth. Chemotherapy is the main treatment for most
leukemias in children. Several medicines are often given at different times. It’s
usually done in cycles, with rest periods in between. This gives your child time
to recover from the side effects.
 Radiation therapy. These are high-energy X-rays or other types of radiation.
They are used to kill cancer cells or stop them from growing. Radiation may be
used in certain cases.
 High-dose chemotherapy with a stem cell transplant. Young blood cells
(stem cells) are taken from the child or from someone else. This is followed by
a large amount of chemotherapy medicine. This causes damage to the bone
marrow. After the chemotherapy, the stem cells are replaced.
 Targeted therapy. These medicines may work when chemotherapy doesn’t.
For example, it may be used to treat children with chronic myeloid leukemia
(CML). Targeted therapy often has less severe side effects.
 Immunotherapy. This is treatment that helps the body's own immune system
attack the cancer cells.
 Supportive care. Treatment can cause side effects. Medicines and other
treatments can be used for pain, fever, infection, and nausea and vomiting.
 Clinical trials. Ask your child's healthcare provider if there are any treatments
being tested that may work well for your child.

With any cancer, how well a child is expected to recover (prognosis) varies.
Keep in mind:

 Getting medical treatment right away is important for the best prognosis.
 Ongoing follow-up care during and after treatment is needed.
 New treatments are being tested to improve outcome and to lessen side
effects.

What are possible complications of leukemia in a

child?
A child may have complications from the tumor or from treatment. They may
also be short-term or long-term.
Treatment may have many side effects. Some side effects may be minor. Some
may be serious and even life-threatening. Your child may take medicines to help
prevent or lessen side effects. You’ll be given instructions about what you can
do at home.
Possible complications of leukemia can include:

 Serious infections
 Severe bleeding (hemorrhage)
 Thickened blood from large numbers of leukemia cells

Possible long-term complications from the leukemia or the treatment can

include:

 Return of the leukemia

 Growth of other cancers
 Heart and lung problems
 Learning problems
 Slowed growth and development
 Problems with the ability to have children in the future
 Bone problems such as thinning of bones (osteoporosis)

What can I do to prevent leukemia in my child?

Most childhood cancers, including leukemia, can’t be prevented. The risk from
X-rays and CT scans is very small. But healthcare providers advise against
them in pregnant women and children unless absolutely needed.
How can I help my child live with leukemia?
A child with leukemia needs ongoing care. Your child will be seen by oncologists
and other healthcare providers to treat any late effects of treatment and to watch
for signs or symptoms of the cancer returning. Your child will be checked with
 imaging tests and other tests. And your child may see other healthcare
providers for problems from the cancer or from treatment.
You can help your child manage his or her treatment in many ways. For
example:

 Your child may have trouble eating. A dietitian may be able to help.
 Your child may be very tired. He or she will need to balance rest and activity.
Encourage your child to get some exercise. This is good for overall health.
And it may help to lessen tiredness.
 Get emotional support for your child. Find a counselor or child support group
can help.
 Make sure your child attends all follow-up appointments.

When should I call my child’s healthcare provider?

Call the healthcare provider if your child has:

 Fever
 Symptoms that get worse
 New symptoms
 Side effects from treatment

Key points about leukemia in children

 Leukemia is cancer of the blood. The cancer cells develop in the bone marrow
and go into the blood. Other tissue and organs that may be affected include
the lymph nodes, liver, spleen, thymus, brain, spinal cord, gums, and skin.
 When a child has leukemia, the bone marrow makes abnormal blood cells that
do not mature. The abnormal cells are usually white blood cells (leukocytes).
And with leukemia, the bone marrow makes fewer healthy cells.
 Common symptoms of leukemia in children include feeling tired and weak,
easy bruising or bleeding, and frequent or long-term infections.
 Leukemia is diagnosed with blood and bone marrow tests. Imaging may be
done to look for signs of leukemia in different parts of the body.
 Chemotherapy is the main treatment for most leukemias in children.
 A child with leukemia may have complications from the leukemia and from the
treatment.
 Ongoing follow-up care is needed during and after treatment.

Next steps
Tips to help you get the most from a visit to your child’s healthcare provider:
 Know the reason for the visit and what you want to happen.
 Before your visit, write down questions you want answered.
 At the visit, write down the name of a new diagnosis, and any new medicines,
treatments, or tests. Also write down any new instructions your provider gives
you for your child.
 Know why a new medicine or treatment is prescribed and how it will help your
child. Also know what the side effects are.
 Ask if your child’s condition can be treated in other ways.
 Know why a test or procedure is recommended and what the results could
mean.
 Know what to expect if your child does not take the medicine or have the test
or procedure.
 If your child has a follow-up appointment, write down the date, time, and
purpose for that visit.
 Know how you can contact your child’s provider after office hours. This is
important if your child becomes ill and you have questions or need advice
Nursing Diagnosis

Risk for Infection

 Nursing Interventions Rationale

Place in a private room. Limit visitors as

indicated. Prohibit live plants or
flowers. Restrict fresh fruits and make
sure they are properly washed or To protect the patient from potential sources of pathogens
peeled. Coordinate patient care so that or infection. Bone marrow suppression, neutropenia, and
leukemic patient doesn’t come in chemotherapy places the patient at high risk for infection.
contact with staff who also care for
patients with infections or infectious
diseases.

Require good hand washing protocol

Prevents cross-contamination and reduces risk of infection.
for all personnel and visitors.

Closely monitor temperature. Note

correlation between temperature
elevations and chemotherapy
treatments. Observe for fever
associated with
tachycardia, hypotension, subtle
mental changes.
Although fever may accompany some forms of
chemotherapy, progressive hyperthermia occurs in some
types of infections, and fever (unrelated to drugs or blood
products) occurs in most leukemia patients. Septicemia
may occur without fever.

Prevent chilling. Force fluids, Helps reduce fever, which contributes to fluid imbalance,
administer tepid sponge bath. discomfort, and CNS complications.

Encourage frequent turning and deep Prevents stasis of respiratory secretions, reducing risk of
breathing. atelectasis or pneumonia.

Auscultate breath sounds, noting

crackles, rhonchi. Inspect secretions for
changes in characteristics: increased
sputum production or change in Early intervention is essential to prevent sepsis in immuno-
sputum color. Observe urine for signs suppressed person.
of infection: cloudy, foul-smelling, or
presence of urgency or burning with
voids.

Handle patient gently. Keep linens dry

Prevents sheet burn and skin excoriation.
and wrinkle-free.

Inspect skin for tender, erythematous May indicate local infection. Open wounds may not
areas; open wounds. Cleanse skin with produce pus because of insufficient number of
antibacterial solutions. granulocytes.
  Risk for Infection
Risk factors may include

 Inadequate secondary defenses: alterations in mature WBCs (low granulocyte

and abnormal lymphocyte count), increased number of
immature lymphocytes; immunosuppression, bone
marrow suppression (effects of therapy/transplant)
 Inadequate primary defenses (stasis of body fluids, traumatized tissue)
 Invasive procedures
 Malnutrition; chronic disease
Desired Outcomes

 Identify actions to prevent/reduce risk of infection.

 Demonstrate techniques, lifestyle changes to promote safe environment,
achieve timely healing.

Risk for Deficient Fluid Volume

Nursing Diagnosis

 Risk for Deficient Fluid Volume

Risk factors may include

 Excessive losses, e.g., vomiting, hemorrhage, diarrhea

 Decreased fluid intake, e.g., nausea, anorexia
  Increased fluid need, e.g., hypermetabolic state, fever; predisposition
for kidney stone formation/tumor lysis syndrome
Desired Outcomes

 Demonstrate adequate fluid volume, as evidenced by stable vital signs;

palpable pulses; urine output, specific gravity, and pH within normal limits.
 Identify individual risk factors and appropriate interventions.
 Initiate behaviors/lifestyle changes to prevent development of dehydration.
 Nursing Interventions
Monitor I&O. Calculate insensible
losses and fluid balance. Note
decreased urine output in presence of
adequate intake. Measure specific
gravity and urine pH.
Weigh daily.
Promote good nutrition.
Monitor BP and HR.
Evaluate skin turgor, capillary refill, and
general condition of mucous
membranes.
Note presence of nausea, fever.
Encourage fluids of up to 3–4 L/day
when oral intake is resumed.
Inspect skin or mucous membranes for
petechiae, ecchymotic areas; note
bleeding gums, frank or occult blood in
stools and urine; oozing from invasive-
line sites.
Implement measures to prevent tissue
injury or bleeding, gentle brushing of
teeth or gums with soft toothbrush,
cotton swab, or sponge-tipped
applicator; using electric razor and
avoiding sharp razors when shaving;
avoiding forceful nose blowing and
needlesticks when possible; using
Rationale
Tumor lysis syndrome occurs when destroyed cancer cells
release toxic levels of potassium, phosphorus, and uric acid.
Elevated phosphorus and uric acid levels can cause crystal
formation in the renal tubules, impairing filtration and
leading to renal failure.
Measure of adequacy of fluid replacement and kidney
function. Continued intake greater than output may indicate
renal insult or obstruction.
Explain that chemotherapy may cause weight loss and
anorexia so encourage the patient to eat and drink high-
calorie, and high-protein foods. Note: Chemotherapy and
adjunctive prednisone may cause weight gain, so dietary
counseling and teachings are helpful.
Changes may reflect effects of hypovolemia (bleeding
or dehydration).
Indirect indicators of fluid status or hydration.
Affects intake, fluid needs, and route of replacement.
Promotes urine flow, prevents uric acid precipitation, and
enhances clearance of antineoplastic drugs.
Suppression of bone marrow and platelet production places
patient at risk for spontaneous or uncontrolled bleeding.
Fragile tissues and altered clotting mechanisms increase the
risk of hemorrhage following even minor trauma.
Acute Pain
Nursing Diagnosis

 Acute Pain
May be related to

 Physical agents, e.g., enlarged organs/lymph nodes, bone marrow packed

with leukemic cells
 Chemical agents, e.g., antileukemic treatments
 Psychological manifestations, e.g., anxiety, fear
Possibly evidenced by

 Reports of pain (bone, nerve, headaches, and so forth)

 Guarding/distraction behaviors, facial grimacing, alteration in muscle tone
 Autonomic responses
Desired Outcomes

 Report pain is relieved/controlled.

 Appear relaxed and able to sleep/rest appropriately.
 Demonstrate behaviors to manage pain.
Nursing Interventions Rationale

Investigate reports of pain. Note

Helpful in assessing need for intervention; may indicate
changes in degree (use scale of 0–
developing complications.
10) and site.

Monitor vital signs, note nonverbal

May be useful in evaluating verbal comments and effectiveness
cues, e.g., muscle tension,
of interventions.
restlessness.

Provide quiet environment and Promotes rest and enhances coping abilities.
reduce stressful stimuli. Limit or
reduce noise, lighting, constant
 Nursing Interventions Rationale

interruptions.

Place in position of comfort and

support joints, extremities with May decrease associated bone or joint discomfort.
pillows or padding.

Reposition periodically and assist

Improves tissue circulation and joint mobility.
with gentle ROM exercises.

Provide comfort measures

(massage, cool packs) and
Minimizes need for or enhances effects of medication.
psychological support,
encouragement, or presence.

Successful management of pain requires patient involvement.

Review patient’s own comfort Use of effective techniques provides positive reinforcement,
measures. promotes sense of control, and prepares patient for
interventions to be used after discharge.

Evaluate and support patient’s Using own learned perceptions or behaviors to manage pain can
coping mechanisms. help patient cope more effectively.

Encourage use of stress

management techniques. Teach
Facilitates relaxation, augments pharmacological therapy, and
relaxation and deep-breathing
enhances coping abilities.
exercises, guided imagery,
visualization.

Assist with and provide diversional

Helps with pain management by redirecting attention.
activities, relaxation techniques.

Monitor uric acid level as Rapid turnover and destruction of leukemic cells during
appropriate. chemotherapy can elevate uric acid, causing swollen painful
 Nursing Interventions Rationale

joints in some patients. Massive infiltration of WBCs into joints

can also result in intense pain.

Administer medications as
indicated: 

Given for mild pain not relieved by comfort measures. Avoid

 Analgesics: acetaminophen aspirin-containing products because they may potentiate
(Tylenol) hemorrhage.

Used around-the-clock, rather than prn, when pain is severe. Use

 Opioids: codeine, of patient-controlled analgesia (PCA) is beneficial in preventing
morphine, peaks and valleys associated with intermittent drug
hydromorphone (Dilaudid) administration and increases patient’s sense of control.

 Antianxiety
agents: diazepam (Valium), May be given to enhance the action of analgesics or opioids.
lorazepam (Ativan).

Activity Intolerance
Nursing Diagnosis

 Activity Intolerance
May be related to

 Generalized weakness; reduced energy stores, increased metabolic rate from

massive production of leukocytes
 Imbalance between oxygen supply and demand (anemia/hypoxia)
 Therapeutic restrictions (isolation/bedrest); effect of drug therapy
Possibly evidenced by

 Verbal report of fatigue or weakness

 Exertional discomfort or dyspnea
  Abnormal HR or BP response
Desired Outcomes

 Report a measurable increase in activity tolerance.

 Participate in ADLs to level of ability.
 Demonstrate a decrease in physiological signs of intolerance; e.g., pulse,
respiration, and BP remain within patient’s normal range.
Nursing Interventions Rationale

Evaluate reports of fatigue, noting Effects of leukemia, anemia, and chemotherapy may be
inability to participate in activities cumulative (especially during acute and active treatment phase),
or ADLs. necessitating assistance.

Encourage patient to keep a diary

of daily routines and energy levels, Helps patient prioritize activities and arrange them around
noting activities that increase fatigue pattern.
fatigue.

Provide quiet environment and

uninterrupted rest periods. Restores energy needed for activity and cellular regeneration
Encourage rest periods before and/or tissue healing.
meals.

Implement energy-saving
techniques (sitting, rather than
standing, use of shower chair). Maximizes available energy for self-care tasks.
Assist with ambulation and other
activities as indicated.

Schedule meals around

chemotherapy. Give oral hygiene
May enhance intake by reducing nausea.
before meals and administer
antimetics as indicated.
 Nursing Interventions Rationale

Recommend small, nutritious,

Smaller meals require less energy for digestion than larger meals.
high-protein meals and snacks
Increased intake provides fuel for energy.
throughout the day.

Maximizes oxygen available for cellular uptake, improving

Provide supplemental oxygen.
tolerance of activity.

Deficient Knowledge
Deficient Knowledge:  Absence or deficiency of cognitive information related to
specific topic.

May be related to

 Lack of exposure to resources

 Information misinterpretation/lack of recall
Possibly evidenced by

 Verbalization of problem/request for information

 Statement of misconception
Desired Outcomes

 Verbalize understanding of condition/disease process and potential

complications.
 Verbalize understanding of therapeutic needs.
 Initiate necessary lifestyle changes.
 Participate in treatment regimen.
 Nursing Interventions Rationale

Review pathology of specific form of Treatments can include various antineoplastic drugs,
leukemia and various treatment transfusions, peripheral progenitor (stem) cell transplant or
options. bone marrow transplant.

Provide psychological support by

establishing a trusting relationship
to promote communication. Allow
Diagnosis of cancer can be devastating to the family.
the patient and family to discuss or
Providing avenues for verbalization can help promote
verbalize their anger
understand and cooperation throughout the course of care.
and depression. Let the family
participate in patient care as much
as possible.

https://www.cedars-sinai.org/health-library/diseases-and-conditions---pediatrics/l/leukemia-in-
children.html#:~:text=Common%20symptoms%20of%20leukemia%20in,different%20parts%20of%20the
%20body.

https://nurseslabs.com/5-leukemia-nursing-care-plans/