Chapter 48: The Child With Cancer

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Welcome back to The Deep Dive.

Today we are waiting into some difficult waters, but honestly they are necessary ones.

We're pulling apart chapter 48 of the maternal child textbook.

The child with cancer.

That's the one.

And I want to set the expectation right out of the gate here.

When people hear pediatric oncology,

the immediate reaction is emotional, it's fear, it's sadness.

It's the thing no parent ever wants to think about.

But the mission for this deep dive is to put on our clinical hats.

We need to look past the tragedy and focus on the physiology, the pharmacology, and the incredibly specific nursing surveillance required here.

I'm glad you framed it that way.

Because if you really look at the source material, the narrative isn't actually about death anymore.

It's more about chronic illness management.

The five -year survival rate for childhood cancer is approaching 85%.

I mean, that's a monumental shift from where we were, say, 30 years ago.

It is.

But the text opens with a paradox that I think we need to wrestle with a bit.

Cancer in children is statistically rare.

It's about 1 % of all new cancer diagnoses.

Yet it remains the leading cause of death from disease in children past infancy.

So it's rare.

But when it happens, it is the biggest threat they face.

That's the tension we operate in.

It's rare.

So a lot of times, primary care providers might miss the early signs, but it's aggressive.

And unlike adult cancers,

which are largely preventable or lifestyle -driven.

Cooking, diet, sun exposure.

Exactly.

Childhood cancers are almost entirely accidental.

You can't tell a four -year -old they should have eaten more kale to prevent leukemia.

It doesn't work that way.

Right.

The why is the hardest question for parents.

And the text is very clear.

For the vast majority, the etiology is unknown.

We have some genetic triggers like Down syndrome, increasing leukemia risk, or environmental factors like radiation.

But you can't usually point to one single smoking gun.

No.

Although there was one environmental risk factor, the author's flag, that really stood out to me because it directly impacts our current practice.

You're thinking of the CT scans.

Yeah.

The radiation exposure from diagnostic imaging.

It's a significant finding.

The chapter highlights recent research showing a correlation between childhood exposure to CT scans and an increased cancer risk later in life.

Which puts a heavy burden on the health care team.

It really does.

You have to weigh the risk -benefit ratio.

Do we absolutely need this CT or can we get the necessary data from an MRI or an ultrasound?

You know, something that doesn't use ionizing radiation.

It's a massive reminder that our diagnostic tools aren't benign.

But let's get into the pathology itself.

Section one lays the foundation.

When we say cancer in a developing organism, what are we actually talking about at the cellular level?

Well, you have to strip it down to the cell's basic job description.

Every cell in the body has a specific function and a lifespan.

A neoplasm or a tumor is essentially a cell that has gone rogue.

Gone rogue.

It stops doing its job and focuses entirely on reproduction.

It's just uncontrolled, chaotic growth.

So it's a resource drain.

It's worse than that.

It's an invasion.

These cells don't just sit there.

They crowd out the normal cells.

In the bone marrow, they crowd out blood -forming cells.

In the brain, they compress the ventricles.

And then the defining feature of malignancy, metastasis.

They learn to travel through the blood or the lymph and set up shops somewhere else in the body.

Which brings us to diagnosis.

The text calls childhood cancer the great imitator.

This part really struck me as a huge challenge for the nurse in, say, an eye patient setting or the ER.

It's the needle in the haystack problem.

A toddler presents with a fever.

Clinically, that's a virus 99 times out of 100.

Right.

A teenager has leg pain.

That's a sports injury or growing pains.

The symptoms are just so vague and so common.

The chapter splits these into overt and covert signs.

The overt ones seem, well, obvious, a mass you can feel, purpura, which is that deep bruising or that whitish reflection in the eye for retinoblastoma.

Yeah, things you can see.

But the covert signs, headache, fatigue, just feeling off.

And that's where the guilt comes in for families.

Parents often carry this immense guilt because they've been to the pediatrician three times and we're told, oh, it's just the flu.

And then suddenly it's leukemia.

Exactly.

The nurse's role here is so You have to validate that these symptoms are confusing.

They mimic everything else.

It is not the parents' fault.

They didn't jump straight to oncology.

Okay.

Let's give it to the war room or section two.

Therapeutic management.

The text outlines the big weapons we use.

Surgery, radiation and chemotherapy.

And frankly, the section on chemo safety protocols should be required reading for anyone stepping onto a pediatric floor.

Absolutely.

This isn't just giving Tylenol.

It's a high stakes environment for sure.

You have to remember chemotherapy is non -selective.

It targets any rapidly dividing cell.

It doesn't know the difference between the leukemia cell and a hair follicle or the lining of your gut.

Or your bone marrow.

Exactly.

And the administration.

You aren't just hanging a bag.

The text really emphasizes box 48 .2.

First off, the dosing.

We don't just use weight.

In pediatrics, we use body surface area or BSA.

Which is calculated in square meters.

Why the distinction there?

Because weight can fluctuate wildly with things like fluid retention or dehydration.

BSA gives you a more precise physiologic metric for metabolic capability.

And the margin for error in say a 12 kilogram child is just non -existent.

So you verify that BSA calculation against the order.

You check it and then you have another RN check it independently.

Independent double verification.

No exceptions.

And before you even touch the line, you are checking for blood return.

Mandatory.

Yeah.

Because so many of these agents are vesicans.

If a vesicant leaks out of the vein, what we call extravasation, it will literally eat through the tissue, the tendons, the nerves.

Wow.

You can cause permanent loss of function in a limb just from a bad IV site.

So if you don't have good blood return, you do not infuse, period.

That leads us to the aftermath of the chemo, the nadir.

I feel like this concept is often misunderstood by students.

It's not an immediate effect, right?

No, and that's the danger.

The nadir is the point of the lowest blood counts.

White cells, red cells, platelets.

Typically happens seven to 14 days after the infusion.

So they go home feeling okay.

Yeah, they go home, they feel a little better.

And then two weeks later, their immune system basically vanishes.

That is the window where they are most likely to get septic.

We're going to get into the infection protocols in a minute because that is the real meat of the nursing care here.

But I want to touch on radiation first.

The text makes a very specific point about tattoos and skin care.

It does.

They mark the radiation field with indelible ink.

It looks like a little tattoo.

The instinct for a parent, you know, trying to keep their child clean is to try and scrub it off during a bath.

But you can't.

You can't.

That mark is the map for the radiologist.

If you scrub it off, you delay treatment because they have to re -nap the entire field.

And the skin itself, what happens to it?

It's burning, literally.

The skin becomes incredibly fragile, photosensitive, and dry.

So no lotions unless they are prescribed, no powders, definitely no sun exposure,

loose clothing only.

You have to treat it like a serious burn.

And with brain radiation, especially in very young kids, there's this massive trade -off regarding their cognitive development.

It's the save the life, manage the cost scenario.

Radiating the brain of a child under three can be devastating to cognitive development and bone growth.

Lively.

Yeah, it can cause pituitary dysfunction, learning disabilities down the line.

It's often avoided if at all possible, or at least delayed until the brain is more mature.

Let's talk about the kind of nuclear option, hematopoietic stem cell transplantation or HSCT.

This is for when standard chemo fails or the disease is just incredibly aggressive.

You essentially wipe the slate clean.

You use these massive doses of chemo and sometimes radiation

to destroy the child's bone marrow completely.

We call this conditioning.

So they have zero immune system.

Zero.

They are completely vulnerable.

Then you infuse the new stem cells.

If it's autologous, it's their own cells that were harvested earlier.

If it's allogeneic, it's from a donor.

And the big scary complication with allogeneic transplants is GVHD graft versus host disease.

That's the nightmare scenario.

If you use donor cells, those new T cells can wake up, look around, and realize, I'm not in Kansas anymore.

They recognize the child's entire body is foreign and they attack it.

It affects the skin with a horrible rash, the gut with severe diarrhea, and the liver.

It's a systemic immunological war happening inside the patient.

Before we move on to the care plans, we have to mention biologics and steroids,

specifically prednisone and dexamethasone.

They aren't just for inflammation here.

They're actually part of the cancer -killing cocktail.

They are a mainstay of leukemia treatment, for sure, but the side effects.

We call them Cushingoid features, you know, the moon face, the clued retention.

But for the family, honestly, the hardest part is the behavior.

The mood swings.

It's extreme.

A sweet, quiet four -year -old can become enraged, aggressive, and then be sobbing minutes later.

Plus, they get these insatiable appetites.

Nurses have to warn parents, your child might act like a different person.

It is the drug, not the kid.

Okay, let's get into section three, which I think is the most critical part for any nurse listening.

The nursing care plans.

If the treatment works, it also destroys the body's defenses.

The number one enemy is infection.

Specifically, neutropenia, a lack of neutrophils.

Yeah.

These are your body's first responders.

And without them, you don't get the usual signs of infection.

You don't get pus.

You don't get swelling.

You don't get redness.

You just get dead.

That is blunt but accurate.

So fever becomes the only signal.

Fever is everything.

If a neutropenic child spikes a temperature, even a low -grade one, it is a medical emergency.

You have roughly an hour to get blood cultures drawn and broad -spectrum antibiotics on board before sepsis can set in.

The text provides a formula for the ANC, the absolute neutrophil count.

Can you walk us through that?

Because nurses really need to know this math.

Yeah, it's simpler than it looks.

You look at the differential in CBC.

You take the percentage of SEGs, which are mature neutrophils, and bands, the immature ones.

Okay, add those two.

Add those percentages together.

Then you multiply that total percentage by the total white blood cell count.

And that gives you your ANC.

And what's the magic number we're looking for?

500.

If the ANC is below 500, that child is considered severely neutropenic.

They're essentially defenseless.

And that's when we implement neutropenic precautions.

And there are some very specific do -nots in those precautions.

Number one, no rectal temps.

Never.

The rectal mucosa is incredibly thin and fragile from the chemo.

If you cure it with a thermometer, even microtears you can't see, you introduce E.

coli and other gut bacteria directly into the bloodstream of a child who has zero immune system.

You can cause septic shock with a thermometer.

You absolutely can.

And no fresh flowers.

Which seems so counterintuitive.

Flowers are what you bring to sick people.

Not to these sick people.

Fresh flowers in the standing water in the vase are breeding grounds for Aspergillus and Pseudomonas.

Fungal infections in a neutropenic child are often fatal and incredibly hard to treat.

So no flowers.

No flowers.

No humidifiers.

No fresh fruits with thin skins like strawberries.

The rule of thumb is if you can't peel it, you don't eat it.

What about vaccines?

We have a child who is immunocompromised.

Do we vaccinate them?

You cannot give them live vaccines.

So no MMR, no varicella, no rotavirus.

It could actually cause the disease because their system can't suppress the attenuated virus.

But, and this is a huge teaching point, you do vaccinate the siblings.

You have to build this cocoon of herd immunity around your patient.

But there's a catch with the siblings, isn't there?

Right.

If a sibling gets the varicella vaccine and then develops a rash from it, they need to be separated from the immunocompromised child immediately until that rash is gone.

Okay.

Moving to the second major side effect.

Hemorrhage, thrombocytopenia.

Low platelets.

Normal is 150 ,000.

These kids might be walking around with 10 ,000 or 20 ,000.

The text even has this striking image of a child's legs just covered in patechia, those tiny red dots.

And purpura.

And the text lists soft toothbrush as a top intervention.

Seems small.

It sounds minor, but gum bleeding is so hard to stop when you have no platelets.

So soft bristles only, or even just a toothed sponge.

No flossing if the count is critically low.

And absolutely no contact sports.

No wrestling with dad on the living room floor.

You also have to think about the gut again.

Constipation.

Stool softeners aren't just for comfort here.

They are for safety.

Straining at stool increases intracranial pressure and can tear that fragile rectal tissue.

We want everything moving easily to prevent bleeding.

Then we have the GI tract, nausea, and mucositis.

We have Zofran, Ondansetron, which is a miracle drug.

But the text talks about the psychological aspect of eating.

This is a classic mistake parents make.

And it comes from a place of love.

A child is nauseous, they're losing weight, so the parent tries to coax them with their absolute favorite food.

Here honey, have some pepperoni pizza.

And what happens?

The child eats it, they get sick and vomit, and now their brain permanently associates pizza with vomiting.

You have created a permanent food aversion to their favorite food.

So the rule is?

Keep the favorites for the good days.

On the bad days, you stick to bland, cool, clear liquids.

Don't ruin the lasagna forever.

And for mucositis, which is painful ulceration from the mouse all the way down to the anus, we need aggressive pain management.

It's excruciating.

The epithelial cells of the GI tract turn over so rapidly, so chemo just destroys them.

The mouth gets raw and ulcerated, we use bland foods, meticulous mouth care to prevent secondary infections like thrush, and absolutely no alcohol -based mouthwashes.

They just sting and dry out the tissue even more.

Okay, we've covered the general care.

Now I want to zoom in on the specific monsters,

the specific diseases outlined in sections four through seven.

We have to start with leukemia.

It's the most common childhood cancer.

It is.

And to understand leukemia, you have to visualize the bone marrow as a garden.

In a healthy garden, you have different flowers growing in harmony, red blood cells, white blood cells, blightlets.

Okay.

In leukemia, you have these immature white cells called blasts.

They are weeds.

Yeah, they don't do any work.

They're completely useless.

They don't fight infection.

But they grow incredibly fast.

And because the bone marrow is in enclosed space, they just crowd out all the good flowers.

So the symptoms aren't just about a high white count.

No.

In fact, sometimes the total white count isn't even that high.

The symptoms are the result of that crowding out.

You get anemia because of the red cells are crowded out, so the kid is pale and lethargic.

You get bleeding and bruising because the platelets are crowded out.

And you get fever and an infection because even if the white count looks high, they're all functional duds.

They're just useless weeds.

We distinguish between ALL -L, which is acute lymphocytic, and AML, acute myeloid.

Generally, ALL -L has the better prognosis, right?

Yes.

ALL -L has survival rates upwards of 90 % now in many cases.

Right.

AML is tougher, but the outcomes are improving.

Diagnosis for both is the same, though.

A bone marrow aspiration, usually from the iliac crest.

The text mentions sanctuary sites, places where the chemo has a hard time reaching.

Right.

The central nervous system, the CNS, and the testicles.

The blood -brain barrier is great at keeping toxins out of the brain, but that also means it keeps a lot of systemic chemo out, too.

So leukemic cells can hide there where they're safe.

Which explains the treatment protocol.

We don't just give IV chemo.

Right.

A critical part of the plan is intralapical chemotherapy.

We inject methotrexate or another agent directly into the spinal fluid via lumbar puncture to flush out those sanctuary sites and prevent a CNS relapse.

Okay, next up, brain tumors.

The second most common malignancy.

The text divides these by geography.

Infratentorial versus supertentorial.

Why does that location matter so much?

It's all about the symptoms it produces.

Infratentorial is the posterior fossa, the lower part of the brain containing the cerebellum and brainstem.

This is about 60 % of cases.

And the cerebellum controls balance.

Exactly.

So you see ataxia, an unsteady gait, clumsiness, or visual changes, poor coordination.

And supertentorial.

That's the upper brain, the cerebrum.

So there you're more likely to see things like seizures, personality changes, or hemiparesis, which is weakness on one side of the body.

But there is one hallmark symptom mentioned that screams brain tumor.

The morning vomiting?

Yes.

And the mechanism is simple physics.

When you lie flat all night, your intracranial pressure, your ICP, naturally rises slightly.

If you have a tumor taking up space, that pressure spikes even more.

So when they stand up?

When the child stands up in the morning, that sudden positional shift triggers the vomiting center in the brainstem.

Yeah.

It's usually not even accompanied by nausea.

They just vomit and then feel better.

Yeah.

That's a huge, huge red flag.

And post -op positioning is critical.

Oh, critical.

You generally want the head elevated to promote venous drainage and layer that pressure.

You never, ever, ever put a craniotomy patient in Trendel and Berg with their head down.

You will blow their ICP.

And what's the big emergency sign for nurses to watch for?

The pupils.

You watch those pupils like a hawk.

A sluggish, dilated, or unequal pupil is a sign that the brainstem is being compressed, that herniation is happening.

That is a run -don't -walk call to the neurosurgeon.

Let's talk lymphomas.

Hodgkin versus non -Hodgkin.

What's the quick and dirty differentiation?

Hodgkin is usually seen in adolescents.

It's characterized by the Reed -Sternberg cell, this giant multi -nucleated cell you see under the microscope.

And it tends to spread predictably through the lymph nodes, usually starting in the neck.

The supraclavicular nodes.

Right.

And it's very treatable.

And non -Hodgkin or NHL?

NHL is the Wild West.

It's diffuse.

It's aggressive.

The cells replicate incredibly fast.

And because they replicate and die so fast, it sets up the most dangerous metabolic emergency in this entire chapter.

Tumor Lysis Syndrome, TLS.

I want to double -click on this because the text has a huge nursing quality alert about it.

What exactly is happening in TLS?

Okay.

Imagine a tumor cell, it's a little bag, and it's filled with intracellular contents.

Potassium, phosphorus, and uric acid.

You hit that tumor with chemo, the bag bursts, and now imagine billions of those bags bursting all at once.

They dump all those chemicals into the bloodstream.

So you get this massive spike in electrolytes.

You get hyperkalemia, high potassium, which causes cardiac arrhythmias and can cause cardiac arrest.

You get hyperuricemia uric acid crystals that act like sand in the kidneys, causing acute renal failure.

Wow.

And the high phosphorus binds to calcium.

So your calcium levels crash.

Hypocalcemia, which can lead to tetany and seizures.

It's a complete chemical storm.

How do we manage it?

Hydration, massive hydration, one and a half to two times maintenance fluids.

We want to flush those kidneys constantly.

We give allopurinol to stop the uric acid production.

And this is the big one,

no potassium in the high V fluids.

Absolutely not.

Not until you have confirmed that the kidneys are working well and the serum potassium level is safe.

If you add potassium to a kid who is already spiking from cell lysis, you can literally stop their heart.

That is a vital, vital takeaway.

Moving to section seven, the solid tumors.

Let's start with neuroblastoma.

The silent tumor.

It arises from the sympathetic nervous system, usually from the adrenal gland that sits on top of the kidney.

The problem is it's often metastatic by the time we find it because it grows so silently in the abdomen.

The assessment findings are pretty distinct though.

Yes.

You feel this firm irregular mass in the abdomen that crosses the midline.

That's a key feature that distinguishes it from Wilm's tumor, which is another kidney tumor that usually stays on one side.

And the raccoon eyes.

It's very disturbing to see, but it's diagnostic.

The tumor metastasizes to the orbits,

the eye sockets causing bruising all around the eyes, and sometimes proptosis, which is bulging of the eyes.

It looks like the child has been in a fight.

The prognosis here is interesting because age matters so much.

It does.

Infants younger than one year actually have a much better prognosis.

Sometimes the tumor even spontaneously regresses, just goes away on its own.

But in older children, it's much, much harder to treat.

Finally, osteosarcoma.

This seems to target a different demographic completely.

Teenagers.

It happens during the adolescent growth spurt.

The tumor starts in the metaphysis of the long bones, most commonly the distal femur, right above the knee.

Which is exactly why it gets missed.

A 15 -year -old soccer player has knee pain.

Exactly.

Everyone just assumes it's a sports injury.

Go home, ice it, rest it.

But the red flag is pain that wakes them up at night, or pain that just doesn't get better with rest.

The treatment involves surgery,

often amputation, or a limb salvage procedure.

The psychosocial impact there must be massive.

It is.

You're taking a teenager who is already struggling with body image, identity, and fitting in, and you're altering their physical appearance permanently.

They lose their hair from chemo, and they might lose a limb, or have a major scar and an internal prosthetic.

The nurse has to be so incredibly sensitive to that grief.

It's not just about, we saved your life.

It's about, we've now changed your life forever.

That brings us to the final section.

Psychosocial and survivorship.

We aren't just treating the cancer, we are managing the long -term fallout.

We call them late effects.

The cure has a cost.

Chemotherapy, specifically a class called anthracyclines, can damage the heart muscle years later, causing cardiomyopathy.

Radiation can cause secondary cancers or infertility.

These patients never really graduate from care, they just move into long -term surveillance for life.

And the family dynamic.

The text brings up complementary and alternative medicine, or CAM.

Parents are desperate.

They read things on the internet about special herbs, megavitamins, specific diets.

And our instinct as medical professionals is often to say, no, stop that, it's not evidence -based.

But the text advocates for openness.

If you shut them down, they will just hide it from you.

So you have to ask.

They have to say, tell me what you're thinking of using so we can make sure it doesn't interact with the chemotherapy.

You have to keep that line of communication open to ensure safety above all else.

School reentry is another huge topic.

It's not just about catching up on academics.

No, it's about normalcy.

Nurses often coordinate with the school nurse and the teachers.

We have to prepare classmates for the hair loss, the alopecia, or the moon phase from steroids so the child isn't bullied or isolated.

The goal is to get them back to being a kid as soon as it's safe to do so.

It really all comes back to that initial idea we discussed.

The nurse is the lifeline.

Absolutely.

You are the translator of this terrifying new language.

You're the one explaining why the platelets matter, why the sibling needs that vaccine, why the morning vomiting is so significant.

The oncologist prescribes the chemo, but it's the nurse who guides the family through the minefield day by day.

It's a heavy chapter, but it's an essential one.

I think if you can master these safety protocols, the ANC calculation, the chemo safety checks, the TLS monitoring,

you are directly saving lives.

Couldn't have said it better.

It's about vigilance and compassion in equal measure.

That's it for this deep dive into Chapter 48.

Take a breath, review those lab values, and remember, you are the advocate these kids and their families need.

Stay curious.

Thanks for listening from the entire Last Minute Lecture team.

We'll see you next time.