A malignant progressive disease in which the bone marrow and other blood-forming organs produce increased numbers of immature or abnormal leucocytes. These suppress the production of normal blood cells, leading to anemia and other symptoms. The incidence of childhood ALL is approximately 3- 4 cases per 100,000 children under the age of 15 years

1. LEUKEMIA
INTRODUCTION:
Leukemia is a malignant progressive disease in
which the bone marrow & other blood forming
organs produce increased number of
immature/abnormal leucocytes, these suppresses
the production of normal blood cells, leading to
anemia & other symptoms.
DEFINITION:
Leukemia is a malignant disease of the blood-
forming organs or uncontrolled neoplastic
proliferation of leucocyte precursors.
INCIDENCE
 Common malignancy found in 15 years of
children.
 Peak level found in 4 years of children.
 More common in males than the female
child. (1.3:1)
 Twice risk in white children than the black
children.
 70-75% cases are acute lymphatic
leukemia.
 20% of acute nonlymphatic leukemia.
 4% of chronic myelocytic leukemia and its
rare in nature.
ETIOLOGY:
 Genetic factors: Down’s syndrome,
Fanconi’s anemia, Bloom syndrome.
 Viral infection: Human Papilloma virus,
Epstein-Barr virus.
 Exposure to radiation.
 Familial predisposition.
 Chromosomal abnormalities.
CLASSIFICATION:
Acute Leukemia:
Acute Lymphoid/Lymphocytic (80%):
 T-cell
 B cell
 Pre B cell
 Null cell
Acute Myeloid/Nonlymphocytic (10-20%):
 Acute myeloblastic
 Acute Promyeliocytic
 Acute Myelomonocytic
 Acute monocytic
 Acute erythrocytic
Chronic Leukemia:
Chronic Lymphoid/Lymphocytic
Chronic Myeloid/Myelocytic leukemia
 Juvenile type ( congenital leukemia)
Acute Lymphoid/Lymphocytic Leukemia:
Most common form of leukemia in children. It
accounts for 80% of all childhood leukemia.
The lymphoid cell line is affected in this disease.
Types:
 10-15% of children get affected with T-
Cell leukemia.
 1-2% of children with B-Cell leukemia.
 Pre-B cell has good prognosis on clinical
features.
 75% of children most commonly affected
with Null leukemia.

2. LEUKEMIA
Pathophysiology
Clinical Manifestation:
 General & initial Symptoms: Fever,
anorexia, malaise, weakness, petechiae,
purpura, ecchymosis and bleeding,
abdominal pain
 Progressive symptoms: Pallor, decreased
activity level, weight loss and muscle
wasting.
 Leukemic in bone marrow: bone, joint pain
and sternal tenderness.
 Hepatosplenomegaly, hematemesis, melena,
hematuria
 Rarely lymphadenopathy may found in T-
cell ALL or leukemic transformation of
lymphoma.
 Central nervous system (CNS): Headache,
vomiting, drowsiness, unconsciousness,
convulsions, cranial nerve involvement,
papilledema, blurred double vision.
Diagnostic Evaluation:
 History Collection: Family, Past & present
medical history.
 Physical examination: Head-foot
assessment.
 Hematological examination:
 Peripheral blood examination:
Reduced Hb level, RBC, hematocrit,
platelet and WBC count may be
decreased, elevated or normal.
 Bone marrow study shows large numbers
of lymphoblasts and lymphocytes with
hypercellular condition of bone marrow.
 Chest X - ray helps to diagnose mediastinal
mass.
 CSF study determines CNS involvement
with presence of leukemic cells.
Management:
Pharmacological Management:
Alkylating agents:
1. Cyclophosphamide
Anti-tumor antibiotics (anthracycline):
1. Daunorubicin
2. Doxorubicin
Anti-metabolites:
1. Cytarabine
2. 6-mercaptopurine
3. Methotrexate
Abnormal growth of nongranular fragile leukocytes in the
blood forming tissues, particularly in the bone marrow,
spleen and lymph nodes.
Normal bone marrow elements are replaced by the
leukemic cells.
Formation of RBCs, WBC's and platelets are decreased
Infiltration of leukemic cells into lymph nodes, spleen and
liver results in enlargement
Expansion and hyperplasia of bone marrow and
infiltration of leukemic cells into bone causes pain
Clinical manifestation
Corticosteroids:
1. Prednisolone
2. Dexamethasone
Mitotic inhibitors
1. Vincristine

3. LEUKEMIA
Other therapies:
1. Cranial radiation
2. Intrathecal methotrexate or cytarbine
Nursing management:
 Special care during chemotherapy &
radiation therapy.
 Post operative care during bone marrow
transplantation.
 Supportive and symptomatic management
to be provided to prevent complications.
Acute Nonlymphocytic/ myeloid Leukemia
A group of malignant disease, abnormality is a
generalized progressive proliferation of immature
monocytes and myelocytes from the bone marrow
that invade the blood and other tissues.
 About 15% of childhood leukemia.
They can be classified as follows:
 M1-Acute myelocytic (no maturation)
leukemia.
 M2-Myelocytic (some maturation)
leukernia.
 M3-Promyelocytic leukemia.
 M4-Myelomonocytic leukemia
 M5-Acute monocytic leukemia.
 M6-Erythroblastic leukemia.
 M7 – Megakaryocytic leukemia.
Clinical Manifestations
 Anemia: progressive pallor.
 Leucopenia: Fever, Active bleeding,
Gingival swelling due to infiltration of
leukemic cells, Infections
 Thrombocytopenia: GI tract disturbances
 Bone pain
 Hepatosplenomegaly
 Lymphadenopathy
 Orbital swelling producing proptosis
 CNS involvement as headache, blurred
vision, fundal haemorrhage & paresis.
 Life threatening symptoms as sludging,
hyperuricemia.
Diagnosis Evaluation:
 History collection:
 Physical examination:
 Blood examination
 Bone marrow study
Management
Anti-tumor antibiotics (anthracyclins):
 Daunorubicin
 Doxorubicin
 Idarubicin
 Mitoxantrone.
Podophyllotoxin:
 Etoposide
 Retinoid
 Tretinoin.
Anti-metabolites:
 Cytarabine
 6-Thioguanine
Chemotherapy:
 Cystosine arabinoside continuous IV
infusion for 7 days
 IV Daunorubicin før 3 days

4. LEUKEMIA
Other management:
 Intrathecal CNS prophylaxis may be
indicated in case of CNS involvement.
 Heparin therapy
 Cranial irradiation
 Bone marrow Transplantation
Supportive treatment:
Blood, Platelet transfusion and intravenous
antibiotic therapy
Chronic Myelocytic Leukemia:
A slowly progressing and uncommon type of
blood-cell cancer that begins in the bone marrow.
Incidence:
 CML constitutes 2% of all leukemias
in children younger than 15 years.
 9% of all leukemias in adolescents
between 15 and 19 years.
Clinical Manifestation:
 Infections: tonsillitis, Fever
 Tiredness and weakness
 Lymphadenopathy
 fever due to infections
 Thrombocytopenia: Easy bruising or
bleeding
 Bone and joint pain
 Arthritis, Priapism, Retinopathy, Skin
infiltration
Diagnostic Evaluation:
 History collection
 Physical examination
 Blood examination shows anemia,
thrombocytosis.
 Excess leukocytic count with remarkable
eosinophilia and basophilia.
 Presence of philadelphia chromosome is
very important diagnostic finding.
 Bone marrow study helps to confirm the
diagnosis and shows hyperplasia.
Management:
Biologic / targeted therapy:
 Imatinib
 Dasatinib
Miscellaneous:
 Hydroxyurea
Combination chemotherapy including any of:
 Daunorubicin
 Methotrexate
 Prednisone
 Vincristine
 L-asparaginase
 6-mercaptopurine
Other therapies:
 Radiation (total body / spleen)
Nursing Diagnosis:
 Risk for infections and bleeding related to
abnormal bone marrow functions.
 Maintaining aseptic technique, like
hygienic measures, general
cleanliness, good hand-washing
practices.
 Administering antibiotics, as
prescribed.

5. LEUKEMIA
 Oral and IV route to be used.
 Precautions to be taken during blood
transfusion.
 Avoiding injury, Soft toothbrush can
be used for dental care.
 Breaking of skin and mucous
membrane to be avoided.
 Alternation of body temperature, more
than normal due to infections.
 Tepid sponge in high fever, airy
environment, adequate fluid intake,
avoiding overclothing.
 Administering antipyretics and other
prescribed drugs.
 Recording vital signs 4 hourly.
 Avoiding use of rectal thermometer.
 Pain related to infiltration of leukemic
cells.
 Relieving pain by rest, comfort,
minimizing exertion promoting
relaxation and diversion.
 Assisting in activity of daily living
(ADL)
 Altered nutrition, less than body
requirement related to anorexia, nausea
and gingival ulcers.
 Promoting adequate nutritional
intake with high nutritious diet with
small frequent feed.
 Avoiding high salty food, when
steroids are given.
 Antiemetics to be given to prevent
vomiting.
 Diet should be attractive and tasty to
promote intake of more amount.
 Alternation of body image related to
alopecia, as side effect of chemotherapy.
 Necessary information’s and
instructions to be given to the parents
and family members.
 Fear of the child related to various
diagnostic and treatment procedures.
 Allowing parent with them during
procedures.
 Improving IPR and allowing play
materials.
 Knowledge deficit of the parent related to
continuation of long - term care.
 Health maintenance regarding regular
blood testing.
 Chemotherapy or other mode of
management.
 Warning signs, necessary medical
help and follow – up.
REFERENCE:
1. Parul Datta, “Pediatric Nursing”, 3rd
Edition, Page No. 329-332.
2. Marlow’s “Pediatric Nursing”, 2013
edition, page no.808-811.
3. https://www.slideshare.net/AbhishekYad
av503/leukemias-87800696