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Acute lymphoblastic leukemia is a disease process that effects the healthy production of white blood cells. The purpose of white blood cells is to provide protection from infection and development of disease. It is when the collaboration of vast amounts of immature white blood cells crowd the bone marrow forcing out the normal white blood cells, is when this disease process begins its attack in the human body.
ALL is a common type of childhood cancer, most often occurring in children ages three to five and affects slightly more boys than girls (St Jude Children’s Research Hospital, n.d.). The most common ethnicity affected by ALL are those children of Hispanic descent, followed by Caucasian and African American.
How it works
The onset of leukemia can vary. In many cases, the child may exude only a few symptoms. For example, leukemia may be diagnosed when a minor infection, such as a cold, fails to completely disappear (Hockenberry, Wilson, & Rodgers, 2014). Children may experience additional symptoms such as loss of appetite, bleeding under the skin, frequent infections, lethargy, irritability, and fever. Causes for concern would be easy bruising, joint and bone pain, and sudden weight loss. There also may be times when the child is experiencing a collection of symptoms for a prolonged period, originally believed to be a result of another origin, such as rheumatoid arthritis, that may subsequently end up leading to a leukemia diagnosis.
Cancers (including ALL) can be caused by mutations (changes) that turn on oncogenes or turn off tumor suppressor genes (American Cancer Society, n.d.). Oncogenes help cells grow, divide, and thrive whereas tumor suppressor genes help to keep growth and division under control. It is these changes that interfere with the normal maturation of bone marrow cells that can lead to the development of cancer, in this case ALL. The cells grow out of control and the process of cancer begins.
Usually DNA mutations related to ALL are acquired during the person’s lifetime, rather than having been inherited (American Cancer Society, n.d.). Outside sources such as exposure to radiation or dangerous chemicals may be the cause of ALL, but not in all cases. Some research has shown that mothers who suffered from Epstein Barr syndrome or Helicobacter pylori during pregnancy may demonstrate a slight higher risk to the child. Other scientific research over the years has shown some increased risk of ALL in children who have been exposed to x-radiation while in the womb as well as exposure to smoking. While it may be obtainable to control some of the potential outside sources, genetic mutation is in fact controlled by human biology, and unfortunately unpredictable.
ALL can have a host of implications on the growth and development of young children with the disease. Children that have ALL typically exhibit decreased functional mobility, weakened lower extremity muscle strength and decreased range of motion within the ?¬?rst year after the diagnosis (Vercher, 2016) Most cognitive side effects are the result of chemotherapy or radiation treatments. Radiation therapy directed to the brain appears to be the most causative factor with regards to difficulty with attention span, slow processing speed, lack of organizational skills, reading comprehension, challenged motor skills, and short-term memory loss.
These effects can occur during treatment, however typically appear years after the treatment has been completed. Research demonstrates that girls five years and younger are more susceptible to learning and memory difficulties with these treatments than that of boys, and neuroscientists are unable to explain why. Psychosocial effects are also a major concern for the child and the parents. Low levels of self-esteem, loss of control, fear of the unknown, dying, or relapse are all important areas to educate and support the child and their parents with coping strategies and skills to assist with positive healthcare prognosis as well maintaining the family bond.
Thankfully with modern day science, there are various methods of testing for ALL in children. Blood work panels such as CBC or complete blood counts are considered universal labs that are drawn that can detect abnormal levels of white blood cells, red blood cells, and platelets. A blood test may also show the presence of blast cells — immature cells normally found in the bone marrow (Mayo Clinic, n.d.).
Bone marrow tests are commonly performed where a practitioner will introduce a needle into the patient’s hip or breastbone and aspirate bone marrow cells. These cells are examined under microscope to determine the presence of leukemia cells. Determination of whether leukemia cells generated from the T lymphocytes or B lymphocytes can assist the practitioner with their treatment planning. Aside from blood work, imaging is also a vital component in diagnosis. Ultrasonography, cat scan, magnetic resonance imaging, and x-ray are all modalities that can help reveal the presence, and/or spread of these cancers to the brain, spinal cord or other significant organs.
A patient may undergo a spinal tap which is a procedure in which a sample of cerebrospinal fluid is aspirated to detect the presence of any cancerous cells located within that spinal fluid. These tests all play an important role in diagnosis, early detection, and prognosis for the ALL cancer patient. The role of the nurse of a child with ALL should be well educated on these procedures and able to effectively communicate to the child what to expect when enduring these tests.
In addition, the nurse should be able to discuss and communicate on a level appropriate for the age of the child. Both the child and their parents should be given opportunities to express their fears and feelings and ask questions regarding their care during these tests that most often are intimidating to the young child. Nursing assessments both pre and post procedure should be implemented by the nurse as well as providing proper procedure health care monitoring.
There are various phases for the medical management of ALL. One aspect of treatment is called induction therapy. This is a therapy designed to eradicate most of the leukemia cells located within the bone marrow and blood with hopes of restoration of normal blood cell production within the body. Some examples of this method would be chemotherapy and targeted therapy. Targeted therapy utilizes specialized drugs to destroy specific chromosomes.
Another course of treatment is called consolidation therapy, which is a post remission therapy. Stem cell transplants, also known as bone marrow transplant, is becoming a common treatment in ALL. This procedure is performed by introducing healthy bone marrow from a healthy donor into the bone marrow of a child with ALL with anticipation of re-establishing new healthy bone marrow growth. This phase of treatment is aimed at destroying any remaining leukemia in the body, such as in the brain or spinal cord (Mayo Clinic, n.d.).
Maintenance therapy, a third phase of treatment, is aimed at preventing the regrowth of leukemia cells. There are also additional measures that can be used for prevention of regrowth of leukemia cells from within the central nervous system, such as direct introduction of chemotherapy agents into the fluid encompassing the spinal cord. Radiation therapy is widely used in many types of cancer, and specifically to those suffering from ALL. It is here that the use of powerful, consolidated x-radiation beams is prescribed to deliver high doses of radiation to target harboring areas of cancer in the body. Lastly, another option is experimental treatments, which provide no guarantee of curability, however may offer hope when other methods have failed to provide positive results or benefits.
Nowadays, prognosis for children with ALL are substantially improved compared to prior years through great achievements through healthcare science. Scientists has been able to extend the lives of those who suffer with the disease as well as provide cures for most patients. About 98 percent of children with ALL go into remission within weeks after starting treatment ( (St Jude Children’s Research Hospital, n.d.). It has been found that about 90 percent of those children are cured, and those that have been in remission for 10 years are also considered cured from ALL.
Remission can be defined as partial or complete remission. Partial remission represents the opportunity for the cancer to return, however the child would be able to restart treatments should this occur. Complete remission is when a child no longer suffers from the signs and symptoms of the disease and is considered cured once they meet the 10-year landmark. There are some factors however that can affect survival of ALL. Age and white blood count at time of diagnosis help to determine an estimation of survival/curable rate. High white blood cell counts at diagnosis tend to show lower survival rates. Healthcare practitioners have found that patients under the age of 35 have a better survival than older adults.
Children have a better chance of survival under the age of 10. Samples of these cancer cells can be examined under a microscope to determine any chromosomal abnormalities. Different types of chromosomal abnormalities are associated with a poorer outlook (Survival Rates and Outlook for Acute Lymphoblastic Leukemia (ALL), n.d.). Ph1-positive t (9;22) and trisomy 8 are some examples of chromosomal abnormalities that can affect ALL survival rates. Many patients who respond to the medical treatments of ALL early on demonstrate higher chances of survival than those who take longer than four weeks of treatment before going into remission. With the changes in technology, health science, and medical treatments, great accomplishments have been made to provide hope and healing to the ALL community.
It is important for the nurse to educate and teach healthcare promotion activities, coping strategies, and alternative methods for comfort, exercise, and mental health. Arrangements for medication scheduling, follow up healthcare appointments, and nutritional needs are also the responsibility of the nurse to ensure that the child and parents have a full awareness of how to care for their healthcare needs in the home environment. Children and parents should have knowledge of the medications, why they are taking them and when they should be taken.
Children should be made aware of appropriate periods of activity or exercise, depending on their abilities, as well as periods of rest. Strategies for activity or exercise can be walking, playing outside, performing ADL’s and socializing with friends are all important in the healing process. The nurse can offer ideas such as watching television, movies, reading, and playing board games as strategies to occupy a child during periods of rest. Alternative methods can be used for comfort and healing from any signs and symptoms the child may be experiencing.
Acupressure could be recommended as a helpful, nonpharmacologic method for some cancer related fatigue and chemotherapy induced nausea vomiting management (Ghezelbash & Khosravi, 2018). Aromatherapy, massage, meditation, and relaxation techniques are other very helpful options the nurse can suggest assisting the child during times of discomfort. While treating the physical body is vital to healing and curability, mental health also plays a very large role as well. The nurse should provide information to the parents of the child for support groups, psychologists, psychiatrists, and social workers to assist with support with living with ALL.
Teaching and receptive learning by the child of ways to cope during challenging times can go a long way in the survival rates of the child. Mediation, relaxation techniques, expression of feelings and fears, and reaching out for outside support can help the entire family cope with the challenges of ALL and its subsequent treatments. With appropriate and comprehensible discharge instructions, this can ensure that the child and their respective parents can provide a solid foundation for both mental and physical health to aid in the best prognosis for survival in the child with ALL
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