Paediatric Oncology Nursing Guide

Acute Lymphoblastic Leukaemia (ALL)

Risk Stratification

ALL Treatment Phases

Phase 1: Induction (4–8 Weeks)

Goal: Achieve complete remission (no morphologically detectable disease, ANC >1.0, platelets >100). Standard 3- or 4-drug regimen:

• Vincristine IV weekly × 4
• Prednisolone (or Dexamethasone) oral daily
• L-Asparaginase (pegylated or native) IM/IV
• Intrathecal Methotrexate (with/without AraC and hydrocortisone) — CNS prophylaxis
• High risk: + Anthracycline (Daunorubicin / Doxorubicin) IV

Phase 2: Consolidation (Variable Duration)

• High-dose Methotrexate (HDMTX) cycles with leucovorin rescue
• 6-Mercaptopurine (6-MP) continuous
• Further intrathecal therapy
• CNS radiation now largely replaced by intrathecal chemotherapy (to reduce late neurocognitive effects)

Phase 3: Maintenance (2–3 Years)

• Daily 6-Mercaptopurine (oral — monitor TPMT enzyme status before starting)
• Weekly Methotrexate (oral)
• Monthly Vincristine + steroid pulses
• Periodic intrathecal MTX
• Regular FBC monitoring — dose adjust for ANC target 0.5–1.5×10⁹/L

Drug Side Effects — Nursing Management

Vincristine

L-Asparaginase

• Anaphylaxis / hypersensitivity: Most common with native E.coli asparaginase. Have adrenaline, antihistamine, hydrocortisone at bedside. Monitor for 1h post-dose. Pegylated asparaginase (Oncaspar) has lower immunogenicity but still requires monitoring.
• Pancreatitis: Acute severe — monitor amylase/lipase; abdominal pain is a red flag. May be fatal. Consider dose discontinuation.
• Thrombosis: Cerebral venous sinus thrombosis (CVST), DVT — due to depletion of clotting factors. Monitor neurological symptoms: severe headache, focal neurology. Prophylactic anticoagulation in some protocols.
• Hyperglycaemia: Reduced insulin production — monitor BGL; may need insulin sliding scale.
• Hepatotoxicity: Transaminase rise — monitor LFTs.

Steroids (Prednisolone / Dexamethasone)

• Mood and behaviour changes: Steroid-induced personality change — aggression, irritability, depression; distressing for families. Reassure — resolves when steroids stop. Consider child psychology support.
• Hyperglycaemia: BGL monitoring during induction; 4-hourly checks on high-dose dexamethasone
• Immunosuppression: PCP prophylaxis with co-trimoxazole (Septrin) is mandatory during steroid-containing phases
• Hypertension: Monitor BP daily during high-dose steroid weeks
• GI effects: Ranitidine / PPI gastric protection; avoid NSAIDs
• Avascular necrosis: Hip/knee pain post-treatment — monitor in survivors

Methotrexate (Intrathecal & High-Dose IV)

• Mucositis: Oral assessment tool (OMAS) twice daily during HDMTX. Oral hygiene protocol. Magic mouthwash (lidocaine/diphenhydramine/antacid) for comfort.
• Myelosuppression: Leucovorin (folinic acid) rescue after HDMTX — timing and dose is critical; do NOT omit. Monitor MTX serum levels until <0.1 µmol/L.
• Hepatotoxicity: Weekly LFTs during maintenance MTX; dose hold if ALT >3× upper limit
• Nephrotoxicity: Alkalinise urine (sodium bicarbonate IV/oral) and hydrate aggressively before/during HDMTX to ensure renal elimination
• Neurotoxicity: Leukoencephalopathy (rare but serious) — watch for confusion, seizures post intrathecal MTX

Febrile Neutropaenia (FN) in Paediatric Oncology

Time-Critical Response — "1-Hour Bundle"

1. Triage immediately — do not wait in general paediatric ED queue
2. Bloods: FBC, blood cultures (peripheral + each CVAD lumen), CRP, PCT, LFTs, U&E, urine MC&S
3. Empirical IV antibiotics within 60 minutes of arrival: Piperacillin-Tazobactam (Pip-tazo) or Ceftazidime as first-line
4. Add Vancomycin if: port access site infection, skin/soft tissue infection, haemodynamic instability, known MRSA colonisation
5. Assess for sepsis: NEWS2/PEWS, BP, HR, cap refill, mental status — escalate to HDU/PICU if septic shock signs

MASCC Risk Score (see Calculator tab)

Mucositis Management

Prevention

• Palifermin (KGF): Keratinocyte growth factor — approved for haematological malignancies undergoing SCT; reduces severe mucositis
• Oral cryotherapy: Ice chips during short-infusion agents (e.g., high-dose melphalan) — reduces mucosal blood flow and drug exposure
• Oral hygiene protocol: Soft toothbrush 4× daily; fluoride toothpaste; avoid mouthwash with alcohol

Oral Assessment — OMAS Tool

Anti-Emesis in Paediatric Oncology

Nutrition in Paediatric Oncology

• Malnutrition risk: Up to 50% of children with cancer are at nutritional risk — impacts treatment tolerance, infection risk, wound healing and survival
• Screening: STAMP or PYMS paediatric nutrition screening tool at diagnosis and weekly during treatment
• Enteral tube feeding: Preferred route — NG tube or PEG (percutaneous endoscopic gastrostomy) for prolonged feeding. Maintains gut mucosal integrity. Polymeric feeds unless malabsorption.
• Parenteral nutrition: Indicated if enteral not tolerated (severe mucositis grade 3–4, GI obstruction, ileus, radiation enteritis). Via CVAD. Monitor electrolytes, glucose, LFTs closely.
• High-calorie oral supplements: First-line approach; child and family-centred; consider cultural preferences (halal-certified products for Muslim families in GCC)
• Dietitian review: Minimum weekly during active treatment; anthropometry (weight, height, BMI, mid-upper arm circumference) at each visit

Tumour Lysis Syndrome (TLS) Prevention

• Risk highest: ALL with high WBC, Burkitt lymphoma, large tumour bulk
• Cairo-Bishop criteria: Laboratory TLS = ≥2 of: uric acid ≥476 µmol/L, K ≥6.0, PO4 ≥1.45, Ca ≤1.75 (within 3 days before or 7 days after chemotherapy)
• Prevention: IV hyperhydration (3 L/m²/day), allopurinol (xanthine oxidase inhibitor); rasburicase (recombinant uricase) for high-risk or established hyperuricaemia — rapid uric acid reduction; monitor electrolytes q4–6h initially
• Nursing: Strict fluid balance; avoid unnecessary potassium supplements; cardiac monitoring for hyperkalaemia (peaked T waves, wide QRS); watch for tetany with hypocalcaemia

Central Venous Access Devices (CVADs) in Paediatric Oncology

Totally Implanted Port (Port-a-Cath)

• Most common in paediatric oncology — subcutaneous reservoir attached to catheter in SVC/right atrium
• Access: Non-coring (Huber) needle only — angled bevel prevents coring of silicone septum. Palpate port; clean site with chlorhexidine 2% in 70% alcohol; use ANTT; insert through skin at 90° angle until needle hits back plate; confirm blood return
• Heparin lock: Protocol-specific (e.g., 100 units/mL heparin or 0.9% NaCl); flush after each use; access minimum monthly to maintain patency if not in active treatment
• Topical anaesthesia: EMLA cream applied 60–90 min before access — mandatory in paediatrics; consider Entonox or Ametop
• Complications: Port infection (remove if persistent fever/CRBSI), port thrombosis (fibrin sheath — thrombolysis with alteplase), needle dislodgement → extravasation

PICC (Peripherally Inserted Central Catheter)

• Inserted via cephalic/basilic/brachial vein — tip at cavoatrial junction; confirmed by CXR or fluoroscopy
• Paediatric challenges: Active children — rigorous securement (StatLock + transparent dressing); assess daily for migration, phlebitis, dressing integrity
• Skin protection under securement device — skin can be fragile with steroids/malnutrition
• No weight-bearing or swimming with PICC

Tunnelled Catheters (Hickman / Broviac)

• Tunnelled subcutaneously from cephalic/jugular vein; external exit site on chest wall
• Exit site care: Sterile dressing change twice weekly or when soiled; assess for erythema, exudate, cuff extrusion; clean with chlorhexidine
• Clamping: Clamp above catheter split-septum when not in use; replace Luer-lock caps each access episode
• Single or double lumen — label each lumen clearly for chemotherapy vs blood products vs fluids

Blood Sampling from CVAD

Discard Technique (Open System)

• Withdraw and discard 3–5 mL (or 2× dead space volume) before sampling to clear flush solution and heparin from lumen
• Collect samples in order: blood cultures first (before discard if bacteraemia suspected — per local protocol), then coagulation, then other tubes
• Flush with 10 mL 0.9% NaCl after sampling using push-pause technique (turbulent flow clears catheter)

Closed System Needleless Connectors

• Reduces needlestick injury and CRBSI risk
• Swab connector with chlorhexidine alcohol for minimum 15 seconds — allow to dry fully before accessing

Intrathecal Chemotherapy — Critical Safety

Lumbar Puncture Procedure — Nursing Role

• Sedation/anaesthesia: Children require sedation (midazolam + ketamine, or propofol GA) — nil by mouth per anaesthetic guidelines (typically 2h clear fluids, 4h breast milk, 6h solids)
• Positioning: Lateral decubitus — maximal foetal position (knees to chest) to open interspinous spaces; or sitting position in older children. Nurse holds child safely and reassuringly.
• Post-procedure care: Lie flat 2–4 hours post-LP — reduces post-LP headache. Encourage oral fluids when recovered from sedation.
• Watch for: Post-LP headache (worse upright, relieved supine — CSF leak); nausea/vomiting; neurological symptoms; haematoma at LP site
• Drug verification: Double-check intrathecal drug(s) with second nurse before handing to clinician performing LP

Procedural Sedation Agents

Extravasation Management

• Signs: Pain/burning at site, swelling, redness, cessation of infusion flow, blood return absent
• Immediate action: Stop infusion. Do NOT remove cannula — aspirate residual drug. Apply cold pack (except vinca alkaloids — warm). Elevate limb. Document. Contact pharmacist and medical team.
• Antidotes: Dexrazoxane for anthracycline extravasation; hyaluronidase for vinca alkaloids; DMSO (dimethyl sulphoxide) topical for anthracyclines (some protocols)
• Plastic surgery referral if significant tissue necrosis develops

Late Effects of Childhood Cancer Treatment

Cardiotoxicity — Anthracyclines

• Doxorubicin, daunorubicin, epirubicin — dose-dependent cardiomyopathy (dilated cardiomyopathy)
• Cumulative dose threshold: >250–300 mg/m² significantly increases risk; no entirely safe dose exists
• Monitoring: Baseline ECHO before treatment; ECHO at cumulative 200–250 mg/m²; repeat at end of treatment; then at 1, 2, 5 years and lifelong in survivors
• Dexrazoxane (cardioprotectant) — used in some protocols for high-dose anthracycline regimens
• Nurse education: Survivors should avoid excess alcohol, maintain healthy weight, have regular BP and cholesterol checks. Report dyspnoea, oedema, palpitations.

Neurotoxicity

• Vincristine peripheral neuropathy: Persists in some survivors — foot drop, sensory changes, decreased reflexes
• Cognitive effects (neurocognitive late effects): Particularly in CNS-treated ALL (intrathecal chemotherapy, cranial radiation in historical cohorts) — learning difficulties, attention problems, reduced processing speed; commoner in younger children at treatment
• Neuropsychological assessment at school age — educational support referral

Endocrine Late Effects

Fertility Impairment

• High-dose alkylating agents (cyclophosphamide, busulfan, procarbazine) most gonadotoxic
• Fertility preservation: Semen cryopreservation for post-pubertal males before treatment. Oocyte/embryo freezing for post-pubertal females. Ovarian tissue cryopreservation (experimental) for pre-pubertal girls. Gonadal shielding during radiotherapy where feasible.
• Discuss fertility risks with parents and age-appropriate counselling for adolescents before treatment begins
• GCC consideration: Islamic scholars have generally approved gamete preservation in the context of treatment-related infertility; consult hospital ethics/religious advisors

Secondary Malignancy

• Risk ~3–6× that of general population, cumulative risk ~3–4% at 30 years
• Highest risk: breast cancer post chest radiation (Hodgkin lymphoma survivors), myeloid leukaemia post alkylating agents/topoisomerase II inhibitors, thyroid cancer post neck radiation
• Annual skin check; mammography from age 25 (or 8 years post chest RT); annual bloods

Hearing Loss (Ototoxicity)

• Agents: Cisplatin (most ototoxic), carboplatin (high dose), aminoglycoside antibiotics
• High-frequency sensorineural hearing loss — may progress after treatment completion
• Monitoring: Audiometry (DPOAE + pure tone audiogram) before, during (every 1–2 cycles of cisplatin) and after treatment; annually in survivorship
• Hearing aids / educational support if significant loss

Survivorship Clinic Model

Multidisciplinary Team

• Lead oncologist / survivorship nurse specialist
• Endocrinologist (growth, puberty, thyroid, diabetes)
• Cardiologist (ECHO, cardiac monitoring)
• Neurologist / neuropsychologist (cognitive function, neuropathy)
• Psychologist / social worker (psychological sequelae, QoL, anxiety, PTSD)
• Fertility specialist / reproductive medicine
• Physiotherapist (neuropathy, bone health, deconditioning)
• Dietitian (obesity prevention — common in ALL survivors on steroids)

Transition from Paediatric to Adult Care

• Begin transition preparation at age 14–16
• Provide written survivorship care plan (SCP): what treatment was received, what monitoring is needed, what symptoms to report
• Introduce adult team before transfer; designated liaison nurse

School Reintegration

• Coordinate with school nursing and teachers before return
• Phased return; individualized educational plan (IEP) if cognitive difficulties
• Peer education — normalise the child's experience, reduce stigma
• Manage fatigue, immunosuppression (avoid class if contagious illness circulating)
• GCC private/international schools: provide documentation of educational needs in English and Arabic

Leading Paediatric Oncology Centres in GCC

GCC vs Home Country Treatment — Expat Families

• Interruption of chemotherapy protocols — even short breaks during maintenance can significantly increase relapse risk
• Differing treatment protocols between countries — dose modifications, drug substitutions
• Loss of ongoing monitoring (MRD, echocardiography, endocrine)
• Nursing role: Provide comprehensive treatment summary at any transfer; explain risks clearly but non-judgementally; explore visa/insurance solutions; connect with hospital social work; contact receiving centre in advance
• Ensure family has written protocol summary, drug names (generic and brand), emergency contact details for receiving centre
• Some families have no insurance — GCC government hospitals may provide treatment; NGOs such as Rahma and Children's Cancer Fund (UAE) provide support

Community Awareness & Late Presentation

• Childhood cancer awareness remains low across GCC communities — symptoms frequently attributed to anaemia, malnutrition, viral illness
• Cultural tendency to delay seeking specialist care; preference for traditional/herbal remedies in some communities
• Up to 40% of children in some GCC series present with advanced-stage disease
• Nurse Advocacy: Paediatric nurses in primary care and general paediatric wards are gatekeepers. Know the red flag symptoms. Refer early. Do not reassure without investigation for persistent symptoms.
• Gold Ribbon childhood cancer awareness campaigns (September) — nurses can participate in community education

Religious & Cultural Aspects of Childhood Cancer in GCC

Spiritual Distress

• "Why has God given my child cancer?" — a universal question that takes on particular depth in Islamic faith context
• Islamic belief: illness as a test (ibtilaa) from God, not punishment; the Prophet (PBUH) taught that patience in illness brings reward and forgiveness of sins — a source of comfort for some families
• Referral to hospital chaplain (Imam) is appropriate and welcomed; ensure spiritual care is documented in care plan
• Families may seek religious healing (Ruqyah, reading Quran over child) in parallel with medical treatment — respect this; only intervene if it delays critical medical care
• Cultural expectation of same-gender care where possible — particularly for adolescent patients and when intimate care is required

Truth-Telling & Disclosure

• In some GCC and Arab family cultures, parents prefer that the child not be told the diagnosis directly — particularly younger children and some adolescents
• This creates ethical tension with child's right to know and informed assent
• Approach sensitively; explore family wishes; involve ethics committee for complex cases; work with patient gradually and with family consent for age-appropriate disclosure

Palliative Care for Dying Children in GCC

End-of-Life Care Principles

• Shifting goals from curative to comfort-focused care requires sensitive family conversations — often led by senior medical staff but nurses are central to implementing and sustaining comfort care
• Symptom management: Pain — oral/IV morphine titrated to comfort; dyspnoea — low-dose morphine, anxiolytics; nausea — antiemetics; agitation — midazolam; avoid unnecessary investigations
• Do Not Attempt Resuscitation (DNAR) orders — culturally sensitive discussions; in Islamic jurisprudence, withdrawing treatment that prolongs the dying process (without prospect of benefit) is generally permissible; actively shortening life is not. Involve Islamic ethics consultant where needed.
• Home death: Increasingly requested; requires coordination with community nursing, medication supply, family education on syringe driver management; 24h hospice phone support where available

Islamic Funeral for a Child

• In Islam, the body should be washed (Ghusl) and shrouded promptly after death — hospital should facilitate preparation of the body respectfully
• Allow family time with the child after death; do not rush removal of the body
• Prayer (Janazah prayer) is performed; burial ideally within 24 hours — timing impacts death certificate processing; liaise with medical examiner team proactively for GCC families
• Children who die before puberty (age of religious accountability) are considered in Paradise in Islamic belief — this is a powerful source of comfort for Muslim families and may be mentioned gently by chaplain or nurse

Bereavement Support

• Offer bereavement follow-up: 1–2 week phone call from named nurse; 6-week appointment with social worker or psychologist
• Grief may be complicated in families far from home (expats); community support networks (mosque community, embassy, national community groups) can be signposted
• Sibling grief — often neglected; offer sibling support group referral

MASCC Febrile Neutropaenia Risk Score

Multinational Association for Supportive Care in Cancer (MASCC) score. ≥21 = low risk; <21 = high risk. Validated for adult oncology patients; used as a guide in adolescents/young adults. For young children (<12 yrs), clinical judgement and local protocol take precedence.

Chemotherapy Side Effect Grader (CTCAE v5)

Select a drug class and symptom to see CTCAE grading and nursing management guidance.

Practice MCQs — Paediatric Oncology Nursing

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