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Haematological symptoms

  • 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 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.

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    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.

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    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.

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    The authors would like to acknowledge the contribution of Dr. Keith Waters, Paediatric Oncologist, Royal Children's Hospital, Melbourne who kindly reviewed this manuscript.


    RCH Haematology/Oncology

    A Practical Guide to Paediatric Oncology Palliative Care ; Royal Children's Hospital, Brisbane 1999.

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