Young People with Cancer
A Handbook for Parents

National Cancer Institute
National Institutes of Health

Common Health Issues

A number of routine health-related matters are common to all young people with cancer. Some of these are discussed below and should provide you with general information on issues of concern to you. You may want to check with your physician or others in the treatment center to see how these general statements apply to your child's specific situation.

Infections

Because of lowered white blood cell counts from chemotherapy, infections can be particularly serious. There is the potential for the development of serious and unusual infections, and any sign of infection, such as fever, should be reported to your child's physician as soon as possible.

To determine the cause of the infection, the physician may ask that cultures be taken of any sores as well as of the blood, urine, throat, and stool. If it is a bacterial infection, antibiotics will be given to control it. These may be given either orally or intravenously. Depending on the severity of the infection and your physician's policy, your child may be hospitalized. The cultures taken earlier will usually be repeated to check the course of the infection and the effectiveness of the antibiotic treatment.

Antibiotics will not be used if the infection is caused by a virus, because antibiotics are ineffective in treating viral infections. In these cases, chemotherapy may be stopped for a time and medication given to ease the symptoms while your child's blood counts and general condition are closely monitored.

Some viral infections, such as chickenpox, can be particularly dangerous to a child receiving chemotherapy, because complications from the infection may arise. Notify your child's physician immediately if your child has been exposed, because certain measures can be taken such as decreasing drug doses or using a special gamma globulin. If your child attends school, teachers should know to inform you at once if a schoolmate develops chickenpox.

Most children who have had chickenpox are immune for life and will not contract it, even if exposed while in relapse or on chemotherapy. However, some children on chemotherapy who have already had chickenpox may, when exposed to it again, develop shingles. This is a blistery-like skin rash that resembles chickenpox but, instead of appearing all over the body, is confined to one area. Although complications from shingles are less likely than from chickenpox, notify your physician if you suspect your child has shingles.

Regular or red measles (also known as rubeola or hard 9-day measles) may also be more serious for a child on chemotherapy. If the child is exposed to this type of measles, your physician should be notified. Regular gamma globulin may be given in an attempt to prevent or control the infection.

There is no evidence that infections play any role in activating the cancer or causing a relapse. As stated earlier, your child will tolerate most infections as well as if he or she did not have cancer. Chemotherapy may be stopped during the period of infection, depending on the severity of the infection and the child's white cell count. Your physician will be the best judge of whether this should be done.

Your child may miss some oral medications because of a gastrointestinal infection. Contact the physician or treatment center if this occurs. Brief interruptions of medicine for such reasons do not seem to jeopardize the welfare of the child.

Activities

Cancer and its management may seem to consume an overwhelming amount of your time. For the child, however, the best antidote to this unwelcome (and at times painful) attention is to encourage your child to live as normal and active a life as possible. Check with your physician to see if any special precautions should be taken.

If your child feels well, there is no need to insist on extra rest. However, there may be days, especially after chemotherapy or radiation therapy, when your child may seem lethargic or appear to need more rest. This is a normal result of the treatment. Other days normal levels of energy will return, and you should encourage your child to get regular rest and pursue normal activities.

In complete remission, there are usually no restrictions on activity.

Diet

Good nutrition is an important part of your child's treatment. In general, your child's normal diet should be continued during cancer treatment unless your physician gives you a special one. A few diet hints are listed below:

• Build meals around your child's favorite foods. Variety is not as important as intake.
  
• Small, frequent meals and snacks are attractive to most children. You can freeze portions of a favorite dish and serve them when desired.
  
• Smaller bites and frequent sips of water, milk, or other unsweetened drinks will make chewing and swallowing easier.
  
• Avoid empty calorie foods such as soft drinks, chips, and candy that can reduce your child's appetite without providing nutrients. By contrast, milkshakes, yogurt, fruit, juices, or instant breakfasts provide extra calories and protein.
  
• Some types of chemotherapy may temporarily alter your child's sense of taste. Well-seasoned foods such as spaghetti, tacos, and pizza may seem especially good at times. Sometimes adding extra salt or sugar, or using less, may make foods taste better. However, because of fluid retention, patients on cortisone drugs should limit salt in their diets.
  
• A decrease in appetite is common to some types of chemotherapy. (See the drug chart for examples.) But this must be countered with an increase in fluid intake beginning a few days before the chemotherapy and continuing for a few days after it.
  
• If your child is taking oral medication at home, the time of day that medication is given may be critical. Some are best given in the morning, some at midday, some on a full stomach. Be sure to ask your doctor when and how medications should be administered.

Immunizations

Live virus vaccines (regular measles, German measles or rubella, mumps, polio) should not be given. They may be dangerous to a young person who is under medication that suppresses the normal response to these vaccines. Diphtheria, whooping cough, and tetanus immunizations (DPT or DT shots) are not "live" and are considered by some to be safe for those being treated for cancer. Ask your physician before allowing any immunizations to be given. If your child has never received the regular measles vaccine, report this to the physician.

Other Medications

A young person under treatment should not take any other medications without the physician's approval. It is important to note that some medications ordinarily used to treat common conditions should be avoided. For instance, when the child's platelet count is low, avoid aspirin and glyceryl guaiacolate (present in certain cough syrups). If your child is on prednisone or dexamethasone, avoid aspirin, because it may stimulate bleeding. If fever, pain, or aches are present, acetaminophen (aspirin-free pain reliever) may be used, but the presence of the condition (fever, pain, etc.) should be reported to the physician.

Mouth Care

It is especially important to keep the young person's teeth, mouth, and gums clean to protect from tooth decay and infection. Also, a child with a poor appetite who receives mouth care before meals may feel better about eating.

Teeth should be brushed after each meal, using a soft toothbrush. After each use, the brush should be rinsed well with cold water, shaken thoroughly, and hung to dry on the toothbrush rack. Disposable paper cups should be used for rinsing out the mouth. Dental floss may be used, if care is taken not to cut the gums.

To prevent the severe tooth decay that can result when saliva flow is reduced from radiation to the head and neck, older children should use a fluoride mouth rinse as often as recommended by the physician or dentist. Fluoride gels may be prescribed for home use.

Children whose treatment has not included radiation to the head and neck should also use a mouth rinse frequently during the day. One suggested mouth rinse is a mixture of salt and baking soda (1/4 teaspoon of each in a cup of water).

Infants and toddlers can be given mouth care by wrapping a soft cloth around your finger and gently wiping the teeth and gums with a solution of mouth rinse.

When the young person has low blood counts, mouth care should be especially gentle. Very soft bristle toothbrushes should be used. If you prefer a Toothette (a spongy swab), discard it after use. Water jet devices or dental floss should not be used when blood counts are low and your child is prone to infection. Watch for sore areas or red and white patches. Alert the physician to any red or white patches, mouth sores, or irritated areas that develop in the mouth.

When mouth sores, bleeding areas, or irritated areas are present, only the mouthrinse described above or one prescribed by your doctor is appropriate. Moreover, they should be used at least every 2 to 3 hours. Your child should rinse the mouth out well after every meal and before bedtimes. Also, Q-tips or glycerin swabs can help remove food particles.

If mouth sores become painful, a local anesthetic ordered by your physician may help and can be applied as often as recommended. When your child has mouth sores, it may be easier to eat if you apply an anesthetic directly to sore gums or to other small areas in the mouth immediately before meals. If used as a rinse or applied to the back of the throat, however, give it to your child at least 1 hour before meals. Otherwise, the normal gag-reflex may be suppressed, and there could be a danger of choking.

If your child has dry lips, petroleum jelly or a lip pomade can prevent cracking.

Dental Care

Ideally, your child should have a thorough oral examination and any necessary dental work before cancer treatment begins. This is not always possible. Although dental work may have to be delayed because of the cancer and side effects of treatment, it should not be neglected.

When blood counts are normal, dental work is an important part of overall health care, but you should cheek with the physician before scheduling dental work. Even checkups should be avoided when the blood count is low.

Bleeding

A low platelet count may predispose your child to bleeding. In that case, special precautions should be taken to curtail "contact" activities. For the older child, it is wise to limit activities such as football, soccer, skateboarding, or rollerskating. To control episodes of sustained bleeding, remember the following:

• Apply pressure until the bleeding stops-a clean towel, handkerchief, or cloth firmly applied to the wound will slow or stop the bleeding.
  
• For nosebleeds, have the child sit up. Don't let your child lie down. Pinch the bridge of the nose over the bone for 10 minutes. The pressure must be tight on both sides to be effective.
  
• Notify the doctor promptly if bleeding continues.

Transfusions

If necessary, transfusions of whole blood or specific components of blood can be given to cancer patients. Blood transfusions may be given to control the anemia that may result from a low red blood cell count. The blood may be given as whole blood, which includes the plasma or liquid portion of the blood, or as "packed cells," a transfusion of blood from which the plasma has been removed.

Platelet transfusions may be given if your child has a low platelet count because of the disease or its treatment and is at increased risk for bleeding. Plate let transfusions are most commonly given if the patient is bleeding or is in a situation that will predispose to bleeding, such as preparing for surgery.

 

Because each individual has a characteristic blood type, tests are run to be sure the donor's blood is compatible with the recipient's. This process is called blood typing and cross-matching.

In transfusions of white blood cells, the need for compatible tissue type between donor and recipient is greater, and siblings and parents of the patient often serve as donors. White cell transfusions may be given to a patient with a low white count and a serious infection that is not responding to treatment.

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