CareTalk Blog: Nemours Center for Cancer and Blood Disorders

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Leukemia

The term leukemia refers to cancers of the white blood cells (also called leukocytes or WBCs). Leukemias, as a group, make up about a quarter of all pediatric cancers. Luckily, with treatment, most children with leukemia will be free of the disease without it coming back.

Leukemias start in the bone marrow — the soft tissue found inside bones that produces blood cells. When a child is diagnosed with leukemia, it’s because the white blood cells in the body are producing abnormally. These cells (also known as blasts) start to crowd out the healthy cells in the bone marrow. Eventually, the healthy cells have no place to go, so they stop producing. When a child's body no longer produces enough healthy white blood cells it can cause anemia, swollen lymph nodes, and other symptoms of leukemia in children.

Leukemia is classified as being either acute (meaning it’s rapidly developing) or chronic (meaning it’s slowly developing). About 98% of pediatric leukemias are acute.

 
Types of Pediatric Leukemia
Types of leukemia in children include:
  • Acute lymphoblastic leukemia (ALL): This happens when too many lymphoblasts (a certain type of white blood cell) are produced.
    This is the most common type of leukemia, affecting nearly 60% of kids with leukemia.
  • Acute myelogenous leukemia (AML): This occurs when too many immature white blood cells (called myeloid blasts) are made.
    These leukemia cells are abnormal and can’t mature into normal white blood cells.
  • Chronic myelogenous leukemia (CML): This rare form of pediatric leukemia happens because there are too many mature white blood cells.

 
Signs and Symptoms of Leukemia in Children

Although the symptoms of leukemia in each individual child can vary, common symptoms of leukemia in children include:

  • anemia  (when the level of healthy red blood cells in the body becomes
    too low)
  • bleeding and/or bruising
  • frequent or reoccurring infections
  • bone and joint pain
  • abdominal pain
  • swollen lymph nodes (also called “swollen glands”)
  • difficulty breathing
  • excessive fatigue (more tired than usual)
  • poor appetite

IMPORTANT NOTE: Instances of the symptoms of leukemia in children listed above, either together or on their own, do not automatically mean that a child has leukemia or any other kind of cancer. Any or all of these symptoms could be a sign of something else.

 
Diagnosing Leukemia in Children

One of our Nemours pediatric hematologists-oncologists (doctors who treat blood disorders and cancers) will conduct a physical examination on your child to check for symptoms of leukemia in children such as signs of infection, anemia, abnormal bleeding, and swollen lymph nodes.

The doctor will also feel your child's abdomen to see if the liver or spleen is enlarged. We’ll also take a complete medical history by asking about your child’s symptoms, past health, your family's health history, any medications your child is taking, allergies, etc.

After this exam, the doctor will order a CBC (complete blood count) to measure the numbers of white cells, red cells, and platelets in your child's blood. Your child’s blood chemistries will also be checked.

Then, depending on what we find in the exam and blood tests, your child also may need a:

  • bone marrow biopsy and aspiration (when marrow samples are taken for testing, usually from the back of the hip)
  • lymph node biopsy (when lymph nodes are removed and examined under a microscope to look for abnormal cells)
  • lumbar puncture (also called a spinal tap, when a sample of spinal fluid is taken from the lower back and examined for evidence of abnormal cells. This test will show if the leukemia has spread to the brain and spinal cord.)

We know that tests can be scary – for you and your child. Whatever kind of tests your child might need, know that your Nemours pediatric leukemia care team will do everything we can to make the experience as comfortable as possible – physically and emotionally. We’ll give sedation or anesthesia as needed and offer support and guidance at every step.

Learn more about what to expect with certain medical tests »

 
Treating Leukemia in Children

Depending on your child’s age, overall health, extent of the disease, and other factors, treatment may include one or a combination of the following:

  • chemotherapy
  • radiation therapy   
  • blood or bone marrow transplant (also sometimes called a BMT, BBMT, stem cell transplant, or cord blood transplant)
  • medications/antibiotics
  • blood transfusions

At Nemours, we know that getting a cancer diagnosis can be very frightening and overwhelming for your whole family. That’s why Nemours’ board-certified pediatric hematologists-oncologists, specialty nurses, cancer researchers, and other cancer experts are focused on helping not only your child, but your family, as well.

From diagnosis to treatment (and beyond) we’ll be here to help guide your family through your pediatric leukemia journey – and to strive and hope, with you, for a better tomorrow.

Anemia

About Anemia

Anemia, one of the more common blood disorders, occurs when the level of healthy red blood cells (RBCs) in the body becomes too low. This can lead to health problems because RBCs contain hemoglobin, which carries oxygen to the body's tissues. Anemia can cause a variety of complications, including fatigue and stress on bodily organs.

Anemia can be caused by many things, but the three main bodily mechanisms that produce it are:

  1. excessive destruction of RBCs
  2. blood loss
  3. inadequate production of RBCs

Among many other causes, anemia can result from inherited disorders, nutritional problems (such as an iron or vitamin deficiency), infections, some kinds of cancer, or exposure to a drug or toxin.

Anemia Caused by Destruction of RBCs

Hemolytic anemia occurs when red blood cells are being destroyed prematurely. (The normal lifespan of RBCs is 120 days; in hemolytic anemia, it's much shorter.) And the bone marrow (the soft, spongy tissue inside bones that makes new blood cells) simply can't keep up with the body's demand for new cells. This can happen for a variety of reasons. Sometimes, infections or certain medications — such as antibiotics or anti-seizure medicines — are to blame.

In autoimmune hemolytic anemia, the immune system mistakes RBCs for foreign invaders and begins destroying them. Other kids inherit defects in the red blood cells that lead to anemia; common forms of inherited hemolytic anemia include sickle cell anemia, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and hereditary spherocytosis.

  • Sickle cell anemia is a severe form of anemia found most commonly in people of African heritage, although it can affect those of Middle Eastern and Mediterranean descent, as well as others. In this condition, the hemoglobin forms long rods when it gives up its oxygen, stretching red blood cells into abnormal sickle shapes. This leads to premature destruction of RBCs, resulting in chronically low levels of hemoglobin.

    These abnormal red cells can clog small blood vessels, leading to recurring episodes of pain, as well as problems that can affect virtually every other organ system in the body. About 1 out of every 500 African-American children is born with this form of anemia.
  • Thalassemia, which usually affects people of Mediterranean, African, and Southeast Asian descent, is marked by abnormal and short-lived RBCs. Thalassemia major, also called Cooley's anemia, is a severe form of anemia in which RBCs are rapidly destroyed and iron is deposited in the vital organs. Thalassemia minor results in less severe anemia.
  • Glucose-6-phosphate dehydrogenase (G6PD) deficiency most commonly affects males of African heritage, although it has been found in many other groups of people. With this condition the RBCs either do not make enough of the enzyme G6PD or the enzyme that is produced is abnormal and doesn't work well. When someone born with this deficiency has an infection, takes certain medicines, or is exposed to specific substances, the body's RBCs suffer extra stress. Without adequate G6PD to protect them, many red blood cells are destroyed prematurely.
  • Hereditary spherocytosis is a genetic disorder of the RBC's membrane that can cause anemia, jaundice (yellow-tinged skin), and enlargement of the spleen. The RBCs have a smaller surface area than normal red blood cells, which can cause them to break open easily. A family history increases the risk for this disorder, which is most common in people of northern European descent but can affect all races.

Anemia Caused by Blood Loss

Blood loss can also cause anemia — whether it's because of excessive bleeding due to injury, surgery, or a problem with the blood's clotting ability. Slower, long-term blood loss, such as intestinal bleeding from inflammatory bowel disease (IBD), can also cause anemia. Anemia sometimes results from heavy menstrual periods in teen girls and women. Any of these factors will also increase the body's need for iron because iron is needed to make new RBCs.

Anemia Caused by Inadequate Production of RBCs

Aplastic anemia occurs when the bone marrow can't make enough blood cells. This can be due to a viral infection, or exposure to certain toxic chemicals, radiation, or medications (such as antibiotics, anti-seizure drugs, or cancer treatments). Some childhood cancers can also cause aplastic anemia, as can certain genetic and other chronic diseases that affect the ability of the bone marrow to function properly.

High levels of hemoglobin and RBCs help fetal blood carry enough oxygen to developing babies in the relatively oxygen-poor environment in utero. After the child is born, more oxygen is available and the baby's hemoglobin level normally drops to a low point at about 2 months of age, a condition known as physiologic anemia of infancy. This temporary and expected drop in the blood count is considered normal and no treatment is required because the infant's body soon starts making RBCs on its own.

Anemia also occurs when the body isn't able to produce enough healthy RBCs because of an iron deficiency. Iron is essential to hemoglobin production. Poor dietary iron intake (or excessive loss of iron from the body) can lead to iron deficiency anemia, the most common cause of anemia in kids. Iron deficiency anemia can affect kids at any age, but is most common in those younger than 2 years old. Young children who drink excessive amounts of milk are at increased risk for iron deficiency.

Girls going through puberty also have a particularly high risk for iron deficiency anemia because of the onset of menstruation; the monthly blood loss increases the amount of iron they need to consume in their diets.

Signs and Symptoms

If your child has anemia, the first symptoms might be mild skin paleness and decreased pinkness of the lips and nailbeds. These changes may happen gradually, though, so they can be difficult to notice. Other common signs include:

  • irritability
  • fatigue
  • dizziness, lightheadedness, and a rapid heartbeat

If the anemia is caused by excessive destruction of RBCs, symptoms also may include jaundice, a yellowing of the whites of the eyes, an enlarged spleen, and dark tea-colored urine.

In infants and preschoolers, iron deficiency anemia can result in developmental delays and behavioral disturbances, such as decreased motor activity and problems with social interaction and attention to tasks. Research indicates that developmental problems may last into and beyond school age if the iron deficiency is not properly treated.

Diagnosing Anemia

In many cases, doctors don't diagnose anemia until they run blood tests as part of a routine physical examination. A complete blood count (CBC) may indicate that there are fewer RBCs than normal. Other diagnostic tests may include:

  • Blood smear examination: Blood is smeared on a glass slide for microscopic examination of RBCs, which can sometimes indicate the cause of the anemia.
  • Iron tests: These include total serum iron and ferritin tests, which can help to determine whether anemia is due to iron deficiency.
  • Hemoglobin electrophoresis: Used to identify various abnormal hemoglobins in the blood and to diagnose sickle cell anemia, the thalassemias, and other inherited forms of anemia.
  • Bone marrow aspiration and biopsy: This test can help determine whether cell production is happening normally in the bone marrow. It's the only way to diagnose aplastic anemia definitively and is also used if a disease affecting the bone marrow (such as leukemia) could be causing of the anemia.
  • Reticulocyte count: A measure of young RBCs, this helps to determine if RBC production is at normal levels.

In addition to running these tests, your doctor may ask about a family history of anemia and your child's symptoms and medications. This may lead the doctor to perform other tests to look for specific diseases that might be causing the anemia.

Treatment

Treatment for anemia depends on its cause. It's important not to assume that any symptoms your child may be having are due to iron deficiency. Be sure to have your child checked by a doctor.

If your child has iron deficiency anemia, the doctor may prescribe medication as drops (for infants) or as a liquid or tablet (for older kids), which usually must be taken for as long as 3 months to rebuild the body's store of iron. The doctor also may recommend adding certain iron-rich foods to your child's diet or reducing milk intake.

If your teenage daughter is anemic and has heavy or irregular menstrual periods, her doctor may prescribe hormonal treatment to help regulate the bleeding.

Folic acid and vitamin B12 supplements may be prescribed if the anemia is traced to a deficiency of these nutrients, although this is rare in children.

Anemia caused by an infection will usually improve when the infection passes or is treated. If a certain medication appears to be the cause, your doctor may discontinue it or replace it with something else — unless the benefit of the drug outweighs this side effect.

Depending on the cause, treatment for more severe or chronic forms of anemia may include:

  • transfusions of normal red blood cells taken from a donor
  • removal of the spleen or treatment with medications to prevent blood cells from being removed from circulation or destroyed too rapidly
  • medications to fight infection or stimulate the bone marrow to make more blood cells

In some cases of sickle cell anemia, thalassemia, and aplastic anemia, bone marrow transplantation may be used. In this procedure, bone marrow cells taken from a donor are injected into the child's vein; they then travel through the bloodstream to the bone marrow and begin producing new blood cells.

Caring for a Child With Anemia

The type, cause, and severity of your child's anemia will determine what kind of care is needed. Rest assured, though, that kids often tolerate anemia much better than adults.

In general, a child with significant anemia may tire more easily than other kids and therefore need to limit activity levels. Make sure that your child's teachers and other caregivers are aware of the condition. If iron deficiency is the cause, follow the doctor's directions about dietary changes and taking any iron supplements.

If the spleen is enlarged, your child may be prohibited from playing contact sports because of the risk that the spleen could rupture or hemorrhage if your child is hurt. Certain forms of anemia, such as sickle cell anemia, require other more specific kinds of care and treatment.

Preventing Anemia

Whether anemia can be prevented depends on its cause. Currently, there is no way to prevent anemia due to genetic defects affecting the production of RBCs or hemoglobin.

However, you can help prevent iron deficiency, the most common form of anemia. Before following any of these suggestions, be sure to talk them over with your doctor:

  • Cow's milk consumption. During the first 6 months of life, babies are usually protected against developing iron deficiency by the stores of iron built up in their bodies before birth. But after month 6, they often don't get enough iron through breast milk alone or regular cow's milk (which contains less iron than fortified infant formula). Regular cow's milk can cause some infants to lose iron from their intestines, and drinking lots of it can make a baby less interested in eating other foods that are better sources of iron.

    For these reasons, regular cow's milk is not recommended for children until they're 1 year old and eating an iron-rich diet. In addition, they should not drink more than 24–32 ounces (709–946 ml) of milk each day. If you can't get your child to eat more iron-rich foods, speak with your doctor about giving your child an iron supplement.
  • Iron-fortified cereal and formula. These products can help ensure that your baby is getting enough iron, especially during the transition from breast milk or formula to solid foods.
  • Well-balanced diet. Make sure that your kids regularly eat foods that contain iron. Good choices include iron-fortified grains and cereals, red meat, egg yolks, leafy green vegetables, yellow vegetables and fruits, potato skins, tomatoes, molasses, and raisins.

    If your child is a vegetarian, you'll need to make an extra effort to ensure sufficient iron sources because iron found in meat, poultry, and fish is more easily absorbed than iron found in plant-based and iron-fortified foods.

    Also, certain food combinations can inhibit or promote absorption of iron. For example, drinking coffee or tea (including iced tea) with a meal can significantly lower the amount of iron absorbed. On the other hand, vitamin C helps the body absorb iron.

If you have any questions about anemia or you think your child might have it, speak with your doctor.

Reviewed by: Robin Miller, MD
Date reviewed: September 2012