Leukemia in Children: Symptoms, Treatment Options, and Coping Strategies

Leukemia in children is a type of cancer that starts in the bone marrow and affects the blood cells. It is the most common cancer in children and adolescents, accounting for about 30% of all childhood cancers. Leukemia occurs when bone marrow produces an excessive number of abnormal white blood cells, which crowd out normal blood cells and lead to various health issues. The signs and symptoms of leukemia in children can overlap with symptoms of other common childhood illnesses, making early diagnosis challenging. However, awareness of the potential symptoms and prompt medical evaluation are crucial for effective treatment and improving outcomes. In the following section of the blog, you will get to know about causes, risk, symptoms, treatment options, and coping strategies of luekemia in children.

Cause and factor of Leukemia

Leukemia occurs when changes or mutations in the DNA of bone marrow cells cause them to grow and divide uncontrollably, forming abnormal white blood cells. While most cases of childhood leukemia are not linked to any identifiable risk factors, certain factors may increase a child's likelihood of developing the disease.

Causes of Childhood Leukemia

• Genetic Mutations:
  • Leukemia is primarily caused by genetic mutations in the DNA of blood cells. These mutations can be acquired (developing after birth) or inherited (present at birth).
  • These mutations can lead to the overproduction of immature or abnormal white blood cells, which can crowd out healthy blood cells in the bone marrow.
• Chromosomal Abnormalities:
  • Some children with leukemia have specific chromosomal abnormalities. For example, the Philadelphia chromosome (translocation between chromosomes 9 and 22) is associated with certain types of leukemia, including chronic myeloid leukemia (CML) and some cases of acute lymphoblastic leukemia (ALL).
• Environmental and Chemical Exposures:
  • Exposure to high levels of radiation, such as from nuclear accidents or radiation therapy, can increase the risk of leukemia.
  • Exposure to certain chemicals, such as benzene (found in industrial settings or cigarette smoke), has been linked to an increased risk of leukemia.

Risk Factors for Childhood Leukemia

While most children with leukemia have no known risk factors, certain conditions or exposures may increase the risk:

Genetic Disorders:

Children with certain genetic conditions are at a higher risk of developing leukemia. There are several ways to get affected with genetic disorder some are as follow:

• Down syndrome: Children with Down syndrome have a 10 to 20 times greater risk of developing leukemia, particularly ALL or acute megakaryoblastic leukemia (a type of AML).
• Li-Fraumeni syndrome: An inherited condition caused by a mutation in the TP53 tumour suppressor gene.
• Neurofibromatosis type 1 (NF1): A genetic disorder that increases the risk of certain types of cancer, including leukemia.
• Fanconi anaemia and bloom syndrome: Rare genetic disorders that affect DNA repair and increase the risk of developing leukemia.

Family History:

• A family history of leukemia may slightly increase a child's risk, especially if a sibling has had leukemia.
• Certain inherited genetic mutations can run in families and increase leukemia risk.

Previous Cancer Treatment:

• Children who have undergone chemotherapy or radiation therapy for other cancers are at a higher risk of developing secondary leukemia, especially AML.

Immune System Suppression:

• Children with weakened immune systems, such as those who have had an organ transplant and are on immunosuppressive drugs, are at increased risk for leukemia.

Exposure to High Levels of Radiation:

• High-dose radiation exposure, such as from radiation therapy or nuclear accidents, increases the risk. However, everyday exposures like X-rays or CT scans pose a much lower risk.

Exposure to Chemicals:

• Prolonged exposure to certain chemicals, such as benzene, is associated with an increased risk of leukemia. However, such exposures are more common in industrial settings.

In Utero Exposures:

• Some studies suggest that certain prenatal exposures, such as to X-rays or certain chemicals, may increase the risk, although these risks are generally low.

Common Symptoms of Leukemia in Children

Fatigue and Weakness:

• One of the most common symptoms is persistent fatigue and weakness. This occurs because leukemia can cause anaemia (a low red blood cell count), reducing the body's ability to carry oxygen.

Frequent Infections and Fever:

• Children with leukemia often have frequent infections because the abnormal white blood cells do not function properly to fight off infections. Recurrent fevers that are unexplained by other causes may also be a sign.

Easy Bruising or Bleeding:

• Due to low platelet counts (thrombocytopenia), children with leukemia may bruise easily, have frequent nosebleeds, or experience prolonged bleeding from minor cuts. They may also have tiny red or purple spots on the skin (petechiae), which are small bleeds under the skin.

Bone and Joint Pain:

• Leukemia cells can accumulate in the bone marrow, causing pain in the bones or joints. This is often reported as persistent pain in the legs or arms, which can interfere with normal activities.

Swollen Lymph Nodes:

• Swelling of the lymph nodes (glands) in the neck, underarms, or groin can occur as leukemia cells spread to these areas. Swollen lymph nodes can be painless but may be visible or felt as lumps.

Swelling or Pain in the Abdomen:

• Enlargement of the spleen (splenomegaly) or liver (hepatomegaly) can cause swelling or pain in the upper left or right side of the abdomen. This can also lead to a feeling of fullness or loss of appetite.

Pale Skin:

• Pale or sallow skin may be a sign of anaemia caused by a reduction in healthy red blood cells. This symptom is often accompanied by fatigue and shortness of breath.

Loss of Appetite and Weight Loss:

• Children with leukemia may experience a decreased appetite, leading to weight loss. This could be due to an enlarged spleen or liver pressing on the stomach, causing a feeling of fullness after eating small amounts.

Night Sweats:

• Night sweats, or excessive sweating during sleep, can be another symptom of leukemia. These can be quite severe and may lead to soaked bedding.

Headaches, Dizziness, or Seizures:

• If leukemia cells spread to the central nervous system (CNS), they can cause symptoms like headaches, dizziness, blurred vision, vomiting, difficulty concentrating, or even seizures.

Shortness of Breath or Difficulty Breathing:

• Anaemia or an enlarged thymus (a gland in the chest that can press on the windpipe) can cause respiratory symptoms, including shortness of breath or difficulty breathing.

Less Common Symptoms

Rashes or Gum Problems:

• Some children may develop skin rashes or have swollen or bleeding gums due to the spread of leukemia cells to these areas.

Unexplained Limping or Difficulty Walking:

• Pain in the legs or bones can lead to difficulty walking or limping, especially in younger children.

When to Seek Medical Attention

The symptoms of leukemia can resemble those of other, more common childhood illnesses, parents may not immediately suspect cancer. However, if a child exhibits multiple symptoms, or if symptoms persist without an obvious cause, it's important to seek medical attention. A paediatrician will typically perform a physical examination and may order blood tests, such as a complete blood count (CBC), to check for abnormal blood cell levels. If leukemia is suspected, further tests, such as a bone marrow biopsy, may be conducted to confirm the diagnosis.

Diagnosis of luekmia in Children

The diagnosis of leukemia in children involves a series of tests and evaluations to confirm the presence of leukemia cells, determine the type and subtype, and guide the treatment plan. The diagnostic process typically starts with a thorough medical history and physical examination, followed by various laboratory tests, imaging studies, and specialized procedures.

Steps in the Diagnosis of Leukemia in Children

• Medical History and Physical Examination:
  • The physician begins by taking a detailed medical history, including any symptoms the child has been experiencing, their duration, and any family history of leukemia or other cancers.
  • A physical examination may reveal signs of leukemia, such as pale skin, enlarged lymph nodes, spleen, or liver, bruising, or rashes.
• Laboratory Tests:
  • Several blood and laboratory tests are conducted to detect abnormalities that might suggest leukemia.

1. Complete blood count (CBC):

• A CBC is the first and most common blood test used to help diagnose leukemia. It measures the levels of different types of blood cells, including red blood cells (RBCs), white blood cells (WBCs), and platelets.
• Findings that may indicate leukemia include:
  • High or low white blood cell count
  • Low red blood cell count (anaemia)
  • Low platelet count (thrombocytopenia)

b.  Peripheral blood smear:

• A drop of blood is examined under a microscope to look for the presence of blast cells and any other abnormalities in the size, shape, and appearance of blood cells.
• Blast cells are immature cells that are normally found in the bone marrow but are rarely seen in the peripheral blood. Their presence in significant numbers may indicate leukemia.

Bone Marrow Aspiration and Biopsy:

• If blood tests suggest leukemia, a bone marrow aspiration and biopsy are usually performed to confirm the diagnosis.
• A sample of bone marrow is taken from the hip bone using a needle (aspiration) and a small piece of bone marrow tissue is removed (biopsy).
• The samples are examined under a microscope to identify the number and type of abnormal cells (blast cells) and to determine the type of leukemia (e.g., ALL, AML).
• Special stains and genetic tests may be performed on these samples to further characterize the leukemia.

Lumbar Puncture (Spinal Tap):

• A lumbar puncture is done to check if leukemia cells have spread to the cerebrospinal fluid (CSF), which surrounds the brain and spinal cord.
• A small amount of CSF is collected from the lower back using a thin needle and is examined for the presence of leukemia cells.

Immunophenotyping (Flow Cytometry):

• This test uses antibodies to detect specific proteins on the surface of cells, helping to identify the type of leukemia.
• Flow cytometry can differentiate between different types of leukemia (e.g., ALL versus AML) by identifying specific markers on the surface of the leukemia cells (immunophenotyping).

Cytogenetic and Molecular Testing:

• Cytogenetic analysis looks for specific chromosomal abnormalities in leukemia cells, such as translocations, deletions, or additions.
• Fluorescence in situ hybridization (FISH): A more advanced test that looks for specific genetic abnormalities in the cells.
• Polymerase chain reaction (PCR): A highly sensitive test that can detect specific genetic mutations or translocations, such as the Philadelphia chromosome, which can help guide treatment decisions.

Imaging Tests:

• Chest X-ray
• Ultrasound or CT scan
• Magnetic Resonance Imaging (MRI)

Other Tests:

• Blood chemistry tests: To assess the function of organs like the liver and kidneys and detect any electrolyte imbalances or high levels of uric acid (which can occur due to rapid cell turnover in leukemia).
• Human leukocyte antigen (HLA) typing: May be done if a stem cell transplant is being considered as part of the treatment plan.

Staging and Classification

Once leukemia is confirmed, it is classified based on its type and subtype, which is crucial for determining the appropriate treatment plan. Childhood leukemia are not "staged" like other cancers; instead, they are categorized based on specific features, including:

• The type of affected blood cell (lymphoid vs. myeloid).
• The genetic mutations or chromosomal abnormalities.
• The presence or absence of leukemia cells in the central nervous system (CNS).

Importance of Accurate Diagnosis

An accurate and comprehensive diagnosis is essential for selecting the most effective treatment strategy for each child. The diagnosis helps determine whether the child needs standard treatment, more intensive therapy, or participation in a clinical trial for new treatments.

Treatment for Leukemia

The treatment of childhood leukemia varies based on the type of leukemia, the child’s age, overall health, genetic abnormalities in the leukemia cells. The goal of treatment is to achieve remission (no detectable leukemia cells) and ultimately cure the child. Modern treatments for childhood leukemia are highly effective.

Treatment Options for Childhood Leukemia

Chemotherapy

• Chemotherapy: is the cornerstone of treatment for most types of childhood leukemia, especially for ALL and AML. It involves the use of drugs to kill rapidly dividing leukemia cells.

Phases of Chemotherapy for ALL:

• Induction phase: The first phase aims to kill most leukemia cells in the blood and bone marrow, achieving remission. This phase typically lasts 4-6 weeks.
• Consolidation (Intensification) phase: Once remission is achieved, this phase focuses on eliminating any remaining leukemia cells and preventing relapse. It involves more intensive chemotherapy and may last several months.
• Maintenance phase: This phase uses lower doses of chemotherapy to keep the leukemia in remission. It usually lasts 2-3 years and includes regular oral and occasional intravenous chemotherapy.
• Chemotherapy for AML: Treatment for AML generally involves similar phases, but induction chemotherapy is more intense, and consolidation therapy often includes a stem cell transplant.

Targeted Therapy

• Targeted therapy uses drugs that specifically target abnormal proteins or genes in leukemia cells, reducing damage to normal cells.
• Examples of targeted therapies:
  • Tyrosine kinase inhibitors (TKIs): Such as imatinib (Gleevec) and masitinib, used for leukemia cells with the Philadelphia chromosome (Ph+ ALL or CML).
  • Monoclonal antibodies: Drugs like blinatumomab and Inotuzumab ozogamicin target specific proteins on leukemia cells, such as CD19 or CD22.
• Targeted therapies are often used in combination with chemotherapy for better outcomes.

Radiation Therapy

• Radiation therapy uses high-energy X-rays to destroy cancer cells or prevent their growth. It is less commonly used in treating childhood leukemia but may be necessary in certain cases.
• Uses of radiation therapy:
  • If leukemia has spread to the central nervous system (CNS), testicles, or other areas.
  • Prior to a stem cell transplant to prepare the bone marrow.
  • In cases of high-risk or relapsed leukemia where localized control is needed.

Stem Cell Transplant (Bone Marrow Transplant)

• A stem cell transplant involves replacing the diseased bone marrow with healthy stem cells from a donor. This allows for the use of high-dose chemotherapy and/or radiation to kill all leukemia cells.
• Types of Stem Cell Transplants:
  • Allogeneic stem cell transplant: Stem cells come from a matched donor (often a sibling). This is the most common type for leukemia.
  • Autologous stem cell transplant: The child’s own stem cells are collected before intensive treatment and then re-infused after treatment.
• Stem cell transplants are more commonly used for AML, high-risk ALL, or when leukemia relapses after initial treatment.

Immunotherapy

Immunotherapy- harnesses the body’s immune system to recognize and destroy leukemia cells.

• Types of Immunotherapies:
  • CAR T-Cll herapy (Chimeric Antigen Receptor T-Cell Therapy): This innovative treatment modifies a patient’s own T-cells to target and kill leukemia cells. It has been particularly effective in treating relapsed or refractory ALL.
  • Monoclonal antibodies: Drugs that bind to specific proteins on leukemia cells, marking them for destruction by the immune system (e.g., rituximab, blinatumomab).

Corticosteroids:

• Steroids: like prednisone and dexamethasone are often used in combination with chemotherapy to help kill leukemia cells and reduce inflammation. They are a critical component of treatment, especially for ALL.

Supportive Care

Treatment for leukemia can be intensive and lead to various side effects. Supportive care is essential for managing symptoms and complications, ensuring the child's overall well-being. So, there are some extra ways to provide supportive care which are as follows:

• Antibiotics and antivirals: To prevent or treat infections, as the immune system is weakened during treatment.
• Blood transfusions: Red blood cells or platelets may be given to manage anaemia or bleeding issues.
• Growth factors: Medications like granulocyte colony-stimulating factor (G-CSF) may be used to stimulate the production of white blood cells and reduce the risk of infection.
• Nutritional support: Ensuring proper nutrition to help the child maintain strength and support recovery.
• Psychosocial support: Counselling, support groups, and psychological services to help children and families cope with the emotional impact of the disease and its treatment.

Coping with Children

Coping with a diagnosis of childhood leukemia can be incredibly challenging for both the child and their family. Addressing the emotional needs of the child and family, managing daily routines, and navigating the healthcare system are all critical components of coping.

Emotional Strategies for Coping with Childhood Leukemia

Open Communication:

• Allow the child to express their feelings, fears, and questions. Use age-appropriate language to help them understand what is happening.
• Be honest about the diagnosis, treatment, and potential side effects, which can help reduce fear and anxiety.

Emotional Support for the Child:

• Validate their feelings: Children may experience a range of emotions, from fear and anger to sadness and confusion.
• Use creative outlets: Encourage children to express their emotions through art, play, or storytelling.
• Therapeutic support: Child psychologists, counsellors, or play therapists specializing in paediatric oncology can help children process their emotions, cope with fear, and manage anxiety.

Support for Parents and Caregivers:

• Seek emotional support: Support groups, counselling, or therapy can provide a safe space to express these emotions.
• Practice self-care: Taking care of your own physical and emotional health is essential includes: rest, healthy eating, regular exercise, or seeking support when needed.
• Stay informed: Understanding the disease, treatment options, and potential side effects can empower parents and reduce anxiety.

Sibling Support:

• Include siblings in the Process: Involve them in discussions, encourage them to ask questions, and keep them informed in an age-appropriate manner.
• Provide Emotional Outlets: Counselling or support groups specifically for siblings can help them navigate their feelings.

Create a Sense of Normalcy:

• Maintain Routines: Try to keep regular routines and structures as much as possible. This helps provide stability and normalcy for the child and the family.
• Encourage Social Interaction: Staying connected with friends and classmates, when feasible, helps children feel less isolated and maintain a sense of normalcy.

Psychosocial Support:

• Hospitals often have social workers, psychologists, child life specialists, and support programs specifically for paediatric cancer patients and their families. These resources can help navigate emotional, social, and practical challenges.

Practical Strategies for Coping with Childhood Leukemia

• Understanding the treatment plan:
  • Stay organised
  • Ask questions
• Managing side effects:
  • Prepare for Common Side Effects
  • Nutrition and Hydration
• Practical support for daily life:
  • Financial Assistance
  • Childcare and Household Help
  • Flexible Work Arrangements
• Managing hospital stays and frequent Visits:
  • Pack Comfort Items
  • Prepare a “Hospital Bag”
• Educational support:
  • Maintain Schooling
  • Communicate with Educators
• Building a support network:
  • Seek Out Support Groups
  • Use Community Resources
• Navigating the healthcare system:
  • Understand Insurance Coverage
  • Advocate for Your Child
• Building resilience and hope
  • Celebrate Milestones
  • Stay Positive but Realistic
  • Focus on What You Can Control

Conclusion

While a leukemia diagnosis in children is a daunting and life-altering event, ongoing medical advances and comprehensive care approaches provide significant hope. With timely and effective treatment, many children with leukemia can achieve long-term remission and lead healthy, fulfilling lives. It is crucial to focus on both the medical and emotional needs of the child and family, building resilience and hope throughout the journey. Collaboration with healthcare professionals, access to resources, and support from family, friends, and community can make a profound difference in the experience and outcome of those affected by childhood leukemia.