Nigeria 🇳🇬

1. LEUKAEMIA IN
CHILDREN
BY NR AMINA USMAN
SPBPN AKTH
2022

2. LEARNING OBJECTIVE
At the end of the lesson, learners are expected to:
• Understanding of leukaemia in children
• Mention the types of leukaemia
• Identify the diagnostic procedure of leukaemia
• Enumurate the management strategies of leukaemia
• List the prognosis of the disease

3. INTRODUCTION
• Leukemia accounts for about 2% of all cancers. Men are more
likely to develop the disease than women, and whites are more
likely to develop it than people of other racial or ethnic groups.
• Adults are much more likely to develop leukemia than
children. In fact, leukemia occurs most often in elderly people.
When the disease occurs in children, it generally happens
before age 10.
• The American Cancer Society estimates that in the United
States in 2020 have about 60,530 new cases of leukemia (of all
types) in adults and children, and about 23,100 deaths.

4. DEFINITION OF LEUKAEMIA
• Leukemia is a malignant condition involving the excess
production of immature or abnormal leukocytes, which
eventually suppresses the production of normal blood
cells and results in symptoms related to cytopenia.
• Leukemia is a cancer of the blood cells
• Leukemia is a malignant progressive disease in which the
bone marrow and other blood-forming organs produce
increase number of immature or abnormal leucocytes and
suppress the production of normal blood cells leading to
anemia and other symptoms

5. PATHOPHYSIOLOGY OF
LEUKEMIA
• Normal blood is made up of fluid called plasma and three main
types of blood cells. Plasma is mainly water, but contains
minerals, proteins and antibodies.
• The three major blood cell types are white cells, red cells and
platelets. Each type of blood cell has a specific function. White
blood cells, also called leukocytes, help the body fight
infections and other diseases. Red blood cells, also called
erythrocytes, make up half the blood’s total volume. They
contain hemoglobin, which picks up oxygen from the lungs
and carries it to the body’s organs. Platelets, or thrombocytes,
help form blood clots to control bleeding.

6. CONT. PATHOPHYSIOLOGY
• Blood cells are produced inside the bones in a spongy space
called the bone marrow. The process of blood cell formation is
called hematopoiesis. All blood cells have a common origin
called a stem cell. Stem cells develop into specific mature
blood cells by a process called differentiation.
• Early immature cells are called blasts, which grow into mature
blood cells. Once the cells are matured, they are released into
the blood where they circulate throughout the body and
perform their respective functions. In healthy individuals, there
are adequate stem cells to continuously produce new blood
cells. Normal production of mature blood cells occurs in an
orderly fashion.

7. CONT. PATHOPHYSIOLOGY
OF LEUKEMIA
• When leukemia occurs, the body produces large numbers
of abnormal or immature blood cells. Leukemia cells look
different and act different than normal blood cells and are
often unable to perform their intended functions. Most
leukemia occur in white blood cells and are classified as
either myelocytic or lymphocytic, depending upon the
type of white blood cell is affected.

8. ETIOLOGY OF LEUKEMIA
• Idiopathic
• Genetic and environmental factors leading to mutation in
the cell of the bone marrow:
• Genetic syndrome
• Radiation exposure
• Chemical and drug exposure
• Inherited immune system problem
• Positive family history of leukemia
• Immune system suppression

9. CLASSIFICATION OF
LEUKEMIA
• The current approach to classifying leukemia is based on
the 2016 World Health Organization (WHO) system
(classification for hematopoietic neoplasms). The WHO
classification is based on a combination of clinical,
morphologic, immunophenotypic, and genetic features.
Leukemia are commonly classified as
• Acute or chronic: Based on the percentage of blasts or
leukemia cells in bone marrow or blood
• Myeloid or lymphoid: Based on the predominant lineage
of the malignant cells isolated.

10. ACCORDING TO AMERICAN
CANCER SOCIETY (2020)
The four most common leukemia and their distinguishing features are
.
• Acute myeloid leukemia (AML): 33%
• Acute lymphoblastic leukemia (ALL): 10%
• Chronic myeloid leukemia (CML): 14%
• Chronic lymphocytic leukemia (CLL): 35%
• Other leukemias: 8%

11. ACUTE LEUKEMIA
• Acute leukemia is an abnormal, malignant proliferation of
WBC precursors, also called “blasts.” These abnormal
cells accumulate in bone marrow, body tissues, and blood
vessels and eventually cause malfunction by
encroachment, hemorrhage, or infection. In addition, they
function inappropriately in response to infection and
prevent normal WBC maturation. Acute leukemia is
invariably fatal, and even with treatment the prognosis
varies

12. ACUTE LEUKEMIA
• Acute leukemias consist of predominantly immature, poorly
differentiated cells (usually blast forms). Acute leukemias are
divided into acute lymphoblastic leukemia (ALL) and acute
myeloid leukemia (AML).
• Acute lymphocytic leukemia (ALL) is the most common type
of leukemia in children, mainly affecting those under age 10.
Adults sometimes develop ALL, but it is rare in people older
than 50. ALL occurs when primitive blood-forming cells called
lymphoblasts reproduce without developing into normal blood
cells. These abnormal cells crowd out healthy blood cells.
They can collect in the lymph nodes and cause swelling.

13. ACUTE MYELOID LEUKEMIA
(AML)
• Acute myeloid leukemia (AML) accounts for half of leukemia
cases diagnosed in teenagers and in people in their 20s.
• It is the most common acute leukemia in adults. AML occurs
when primitive blood-forming cells called myeloblasts
reproduce without developing into normal blood cells.
Immature myeloblasts crowd the bone marrow and interfere
with the production of normal blood cells.
• This leads to anemia, It can also lead to bleeding and bruising
(due to a lack of blood platelets, which help the blood to clot)
and frequent infections (due to a lack of protective white blood
cells).

14. CLINICAL FEATURES OF
ACUTE LEUKEMIA
• High fever,
• diffuse petechiae,
• ecchymosis,
• epistaxis, anorexia, headaches, visual disturbances,
weakness, feeling of abdominal fullness, and lethargy.
• Physical exam: Sternal and bone tenderness on palpation,
splenomegaly, hepatomegaly, palpable lymph nodes,
pallor, and diffuse bleeding of mucous membranes.

15. GOAL MEDICAL
MANAGEMENT
 The goal is the complete remission or reduction in the
number of malignant cells
 Increased number of normal leukocytes by normal
hematopoies

16. CHRONIC LEUKEMIA
• Chronic leukemias are characterized by malignant
proliferation of abnormal immature WBCs. The abnormal
cells eventually infiltrate body tissues and organs and
prevent maturation of normal WBCs, thus preventing
usual and necessary WBC function. Chronic leukemic
cells are a more mature form than is seen in acute
leukemias and accumulate much more slowly.
Chronic leukemia is when the body produces too many
blood cells that are only partially developed. These cells
often cannot function like mature blood cells. There are two
main types of chronic leukemia:

17. ETIOLOGY, CLINICAL
FEATURES
• Causes of chronic leukemia are unclear, although
chromosomal abnormality is suspected in many cases of
myelogenous leukemia. Also implicated are hereditary
factors and immunologic defects.
• CLINICAL FEATURES
• Fatigue, anorexia, weight loss, feeling of heaviness in the
spleen area, malaise, unexplained low-grade fever, and
lymph node enlargement.

18. CHRONIC LYMPHOCYTIC
LEUKEMIA (CLL)
Findings and management differ significantly between chronic
lymphocytic leukemia (CLL) and chronic myeloid leukemia
(CML).
Chronic lymphocytic leukemia (CLL) is rare in people under age
30. Most cases occur in people between ages 60 and 70. In CLL,
abnormal lymphocytes cannot fight infection as well as normal
cells can.
These cancerous cells live in the bone marrow, blood, spleen, and
lymph nodes. They can cause swelling, which appears as swollen
glands. Most often, CLL is discovered when a person has a
routine blood test that shows elevated levels of lymphocytes. It
require treatment, especially if the person has infections or
develops a high white blood cell count.

19. CHRONIC MYELOID
LEUKEMIA (CML)
• Chronic myeloid leukemia (CML) occurs most often in people
between ages 25 and 60. the abnormal cells are a type of blood
cell called myeloid cells, usually involves a defective string of
DNA called the Philadelphia chromosome. (This disease is not
inherited; the change in DNA that causes it occurs after birth.)
The genetic defect results in the production of an abnormal
protein. Drugs called tyrosine kinase inhibitors block the
function of this abnormal protein, improving a person's blood
counts. In some cases, the abnormal genetic defect even seems
to disappear. some cases of CML can be cured with a bone
marrow transplant.

20. CLINICAL FEATURES
Fever, Fatigue
• Aching bones or joints
• Headaches
• Skin rashes
• Swollen glands (lymph nodes)
• Unexplained weight loss
• Bleeding or swollen gums
• An enlarged spleen or liver, or a feeling of abdominal
fullness
• Slow-healing cuts, nosebleeds, or frequent bruises.

21. DIAGNOSTIC PROCEDURE
• Leukemia may not be confirm based on the symptoms
alone. presence of swollen lymph nodes or an enlarged
liver or spleen.
• Routine blood tests, especially blood cell counts,
• A bone marrow biopsy
• More blood tests, to check for abnormal cells
• Tests for genetic abnormalities, such as the Philadelphia
chromosome.

22. TREATMENT STAGES OF ALL
Phase 1 (induction therapy) uses chemotherapy in the hospital to try to
control the disease.
Phase 2 (consolidation) continues chemotherapy, but on an outpatient
basis, to keep the disease in remission. This means that person returns to the
hospital for treatment, but does not stay overnight.
Phase 3 (prophylaxis) uses different chemotherapy drugs to prevent the
leukemia from entering the brain and central nervous system.
Chemotherapy may be combined with radiation therapy.
Phase 4 (maintenance) involves regular physical exams and laboratory tests
after the leukemia has been treated to be sure that it has not returned.
Recurrent ALL uses different doses of various chemotherapy drugs to
combat the disease if it returns. People may need several years of
chemotherapy to keep the leukemia in remission. Some people may receive
a bone marrow transplant.

23. MANAGEMENT
 The treatment of leukemia is among the most intensive of
all cancer therapies...
 the treatment of acute leukemia does not depend on how
far the disease has advanced but on the person's
condition. Has the person just been diagnosed with the
disease? Or has the disease come back after remission
 The goal is the complete remission or reduction in the
number of malignant cells
 increased number of normal leukocytes by normal
hematopoies

24. MEDICAL/SURGICAL MGT
OF LEUKEMIA
ANTIBOITIC: prophylactic in combination with gentamycin, vancomycin
ANTIGUNGAL: Nystatin
PREDNISALONE: synthetic steroid has anti-imflamatory agent 40mg/m2/d
orally x 3wks than reduce gradually and stop by 4wks
VINCRISTINE: it interfere with mitosis, 1-1.5mg/m2 weekly x 3wks, it has
neuro-muscular toxicity causing pains, muscle wasting and constipation.
ALLPURINOL: To prevent nephron damage due to accumulation of uric acid

25. CHEMOTHERAPY/SURGICAL
MGT
• METHOTREXATE: anti-metabolite act as a folic acid
antagonist (prevent maturation of megablast to normoblast)
the dosage varies on age 8-30mg/m2 orally, intrathecal
• CYCLOPHOSPHAMIDE: Nitrogen mustard derivative used
when there is resistant with other agent 6000 unit /m2 I.M 9 X
OVER 21 days
• DAUNORUBICIN: It interfers with DNA synthesis
55mg/m2/d I.V
• CYSTOSITE ARABINASIDE
SPLENECTOMY: May be necessary if the spleen is
destroying platelets.

26. MAINTAINANCE THERAPY
• The maintenance therapy is three years;
• Oral mercoptopurine 75mg/m2/d
• One weekly oral methotrexate 20mg/m2/wk
• Monthly vincristine
• Seven days oral prednisolone 40mg/m2/d in divided dose
• Transfusion of packed RBCs: is preferable to whole
blood . patients may need to tolerate a certain degree of
anemia.
• Bone marrow transplantation

27. STAGING OF CHRONIC
LEUKEMIA
This is called staging. There are five stages of CLL:
• Stage 0. There are too many lymphocytes in the blood.
Generally, there are no other symptoms of leukemia.
• Stage I. The lymph nodes are swollen because there are too
many lymphocytes in the blood.
• Stage II. The lymph nodes, spleen, and liver are swollen
because there are too many lymphocytes.
• Stage III. Anemia has developed because there are too few
red blood cells in the blood.
• Stage IV. There are too few platelets in the blood. The
lymph nodes, spleen, and liver may be swollen. Anemia may
be present.

28. CONT. MANAGEMENT OF
CHRONIC LEUKEMIA
• Treatment of CLL depends on the stage of the disease, as well
as on the person's age and overall health. In stage 0, treatment
may not be needed, but the person's health will be monitored
closely. In stage I or II, observation (with close monitoring) or
chemotherapy is the usual treatment. In Stage III or IV,
intensive chemotherapy with one or more drugs is the standard
treatment. Some people may need a bone marrow transplant.
For CML, tyrosine kinase inhibitors have become standard
therapy, especially for people in the early stage of the disease.
Whether a bone marrow transplant is done depends on the stage
of the disease, the person's health, and whether a suitable bone
marrow donor is available.

29. NURSING MANAGEMENT
• REVERSE BARRIER NURSING
• RESUSCITATION/ STABILIZATION OF PT
• NUTRITION
• PREVENTION OF INFECTION
• CAREFUL OBSERVATION
• SKIN CARE
• PREVENTION OF INJURY
• PAIN MANAGEMENT
• PREPARATION FOR HOME CARE
• PT/ PARENT SUPPORT
• ALLAY OF ANXIETY
• COLLABORATIVE CARE AND SUPPORT

30. PROGNOSIS OF LEUKEMIA
• Long term survival of leukemia varies greatly, depending
upon multiple factors, including type of leukemia and age of
the patient.
• ALL: In general, the disease goes into remission in nearly all
children who have it. More than four out of five children live
at least five years. The prognosis for adults is not as good.
Only 25% to 35% of adults live five years or longer.
• AML: With proper treatment, most people with this cancer
can expect to go into remission. About 80% who go into
remission will do so within 1 month of induction therapy. In
some people, however, the disease will return, lowering the
cure rate.

31. CONT. PROGNOSIS
• CLL: On average, people with this cancer survive 9
years, although some have lived for decades. Remission
occurs in most people with stage I or II disease who are
treated with chemotherapy, although the cancer always
comes back at some point.
• CML: The outlook for people with chronic myeloid
leukemia has improved dramatically over the past 10
years. Survival rates of over 5 years in people treated
with a tyrosine kinase inhibitor have been reported to be
as high as 90%.

32. COMPLICATION OF
LEUKEMIA
• RECURRENT ANAEMIA
• RECURRENT INFECTION
• LEARNING PROBLEMS
• GROWTH RESTRICTION
• INFERTILITY
• OSTEOPOROSIS
• HEART FAILURE
• MESTATITIS PROGRESSIVE CANCER

33. NURSING DIAGNOSIS
• PAINS
• HYPERTHEMIA
• DECREASE TISSUE PERFUSSION
• ACTIVITY INTOLERANCE
• RISK OF INFECTION
• ANXIETY
• KNOWLEDGE DEFICIT
• FATIQUE
• PHOBIA