Haematological symptoms
Haematological malignancies account for a relatively high
proportion of childhood cancer, so bone marrow involvement and the
symptoms that accompany it are not infrequently encountered.
Optimal management of these complications requires close liaison
with the child's haematologist.
Anaemia
Anaemia may be experienced symptomatically as dyspnoea or
fatigue and the impact on the child's quality of life depends upon
the stage of illness and level of activity. Decisions regarding the
transfusion of packed cells to relieve anaemia should be made on an
individual basis taking into account symptoms, life expectancy and
the child and family's wishes. Early in the palliative phase of
care, transfusion of packed red cells to raise the haemoglobin to
around 10g/dl may relieve distressing symptoms such as tiredness
and may allow the child and family to enjoy a planned event such as
a birthday or holiday. Disease progression will usually lead to a
reduction in activity and thereby in the symptoms of anaemia. At
this later stage, the question of further transfusion should be
discussed with the child and family as it may offer no potential
benefit.
Thrombocytopenia
As with red cell transfusion, the decision to transfuse
platelets should be made on an individual basis and reviewed
frequently. Children and their parents find active bleeding
extremely distressing and efforts to prevent this should be
undertaken. Platelets can be administered rapidly, and for children
who live close to large centres or hospitals with paediatric units,
they can be reserved for bleeding episodes such as epistaxis or
gastrointestinal bleeding. For children whose platelet count runs
at a low level there may be benefit in routine transfusion of
platelets once or twice a week to prevent minor but distressing
complications such as sub-conjuntival haemorrhage, excessive
bruising or petechiae. Regular transfusions are also helpful for
children who live in rural areas where platelets may not be readily
available to manage bleeding episodes. It is possible to provide
platelet transfusions at home provided experienced support is
available.
For major bleeding or when the death of the child is imminent,
supportive measures such as gentle pressure to external bleeding
points are recommended. The use of disposable absorbent pads and
frequent changes of, or in the home setting, the use of dark
coloured towels and linen, to minimise the impression of blood loss
will help to reduce anxiety. Support aimed at reducing child and
family anxiety should be instituted with appropriate administration
of analgesia and sedation to the child to ensure relief of
distress. Morphine and midazolam are an effective combination in
such circumstances.
Bleeding from other
causes
Bleeding can occur as a result of disseminated intravascular
coagulation (DIC), liver disease and the use of medications like
non-steroidal anti-inflammatory agents. If appropriate, treatment
should be directed at the cause of the bleeding and may require the
use of fresh frozen plasma to replace clotting factors.
Catastrophic bleeding is rare but distress to patient and families
can be major. If management of DIC and other clotting disorders is
required, it is better accomplished in a tertiary paediatric
centre.
Neutropenia
The development of neutropenia may predispose the child to
infection. Appropriate antibiotic treatment of infections early in
the palliative phase of a child's illness can extend the time over
which the child and family enjoy a good quality of life. The
treatment of severe infection should be discussed with the family
before or soon after its development as aggressive life support may
be needed, and this may not always be appropriate in the palliative
phase of illness. Some infections will need to be treated with
appropriate intravenous antibiotics and this may require hospital
admission. Once the infection has been controlled however, the
child may be able to receive intravenous antibiotics at home
supported by a community palliative care or Hospital in the Home
team. Where possible, the use of antibiotics which can be
administered once daily can enhance the family's chances of going
home and reduce the number of intravenous injections required. In
the terminal phase of a child's illness, the administration of
antibiotics may offer no benefit to the child or the burdens of
treatment (eg. hospital admission, intravenous insertion, side
effects) may outweigh any potential benefit.
Other Issues
Children with leukaemia sometimes develop extremely high white
cell counts in the terminal phase of their disease. For these
children, red cell transfusion to raise haemoglobin up to around
10g/dl may be contraindicated due to the potential for
hyperviscosity and increased risk of thromboembolic events. These
children require more careful transfusions to raise their
haemoglobin to a lower level to alleviate viscosity problems.
Acknowledgements
The authors would like to acknowledge the contribution of Dr.
Keith Waters, Paediatric Oncologist, Royal Children's Hospital,
Melbourne who kindly reviewed this manuscript.
Resources
RCH Haematology/Oncology
A Practical Guide to Paediatric Oncology Palliative Care ; Royal
Children's Hospital, Brisbane 1999.