Guideline for the prevention of oral and oropharyngeal mucositis in children receiving treatment for cancer or undergoing haematopoietic stem cell transplantation

Enhancing Standardized Practices for Oral Mucositis Prevention in Pediatric Hematopoietic Stem Cell Transplantation: A Best Practice Implementation Project

Background

Oral mucositis (OM) poses a significant challenge in children undergoing hematopoietic stem cell transplantation (HSCT). There is a gap between clinical practice and the evidence, and nursing practices is not standardized.

Objective

This study aims to evaluate the effectiveness of applying the evidence for preventing HSCT chemotherapy-induced OM in children and to elevate the nurses' compliance to the evidence.

Methods

Following the clinical evidence practice application model of the Joanna Briggs Institute (JBI) evidence-Based Care Center. The process included reviewing literature, extracting evidence, identifying gaps, developing audit criteria, conducting a baseline audit, creating an action plan, implementing evidence-based interventions, and assessing outcomes.

Results

After the evidence implementation, 6 out of 12 audit criteria with poor compliance are significantly improved, with statistically significant differences (P<0.05). The incidence of OM decreases, with a statistically significant difference (66.6% vs 36.7%, P=0.02). The incidence of grade I, II, III, and IV OM also decreases (30% vs 23.3%, 23.3% vs 13.4%, 10% vs 0%, and 3.3% vs 0%). Ultimately, the standardized oral care practice routine and workflows to prevent OM were established.

Conclusion

Bridging the gap between evidence and clinical practice can standardize nurse behavior, decrease the incidence of OM, and lower the OM severity in children undergoing HSCT.

Utilization of Photobiomodulation for the Prevention and Treatment of Oral Mucositis

Background: Oral mucositis is a significant and common toxicity experienced by patients who receive high-dose chemotherapy as a preparatory regimen for a hematopoietic cell transplant (HCT). Photobiomodulation (PBM) has been found to be feasible with significant efficacy in preventing the progression of oral mucositis in adult patients undergoing HCT. The purpose of this study was to determine the feasibility and efficacy of PBM in pediatric oncology patients undergoing HCT. Method: Forty children and adolescents admitted to the transplant unit for an allogeneic HCT for acute lymphoblastic leukemia or acute myeloid leukemia were treated daily at six sites until day + 20 or engraftment. Results: There were 1,035 patient encounters, with successful treatment of four or more sites during 979 patient encounters for a feasibility 93.3% CI [0.926, 0.039]. We had estimated a meaningful effect size of 20% for PBM and estimated 51% of patients treated with PBM would have at least one day or more of Grade 3 mucositis. The rate of patients who received PBM and developed Grade 3 mucositis was 20% CI [0.091, 0.356]. Patients treated with PBM had fewer days of hospitalization (p = .009) and less severe mucositis in comparison to the matched control group (p = .03). Conclusion: PBM is feasible and effective in preventing and treating oral mucositis and is now supported by the Children's Oncology Group for prevention and treatment of oral mucositis in patients undergoing an allogeneic HCT or receiving head/neck radiation.

Cryotherapy for oral mucositis in cancer: review of systematic reviews and meta-analysis

BACKGROUND

One of the most common side effects of cancer treatment is oral mucositis. Although studies have shown that oral cryotherapy has a favourable effect on oral mucositis, the reliability of the results is questionable.

OBJECTIVE

The goal of this umbrella review was to provide insight into the effects of oral cryotherapy against oral mucositis in patients with cancer, as well as to assess the certainty of this evidence.

METHOD

Studies were searched for through PubMed, Scopus and Web of Science, with no restrictions until August 2021. The risk ratio (RR) and 95% CI for each meta-analysis were recalculated using a random-effects model, and the certainty of the evidence was judged using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Ten meta-analyses including 25 original RCTs that fit our inclusion criteria were included. The use of oral cryotherapy markedly reduced the occurrence of overall (RR 0.72, 95% CI 0.64 to 0.83, n=20 trials), moderate to severe (RR 0.60, 95% CI 0.45 to 0.80, n=16 trials) and severe oral mucositis (RR 0.48, 95% CI 0.34 to 0.67, n=16 trials), as well as average severity score of oral mucositis (standardised mean difference=-0.94, 95% CI -1.28 to -0.59, n=4 trials) in comparison to a control group; however, the certainty of evidence for all outcomes was rated very low.

CONCLUSION

In patients with cancer, oral cryotherapy appears to greatly lower the severity and occurrence of oral mucositis, but, with very low certainty of evidence.

A hospital-based oral health education program impacts in pediatric cancer patients-A pilot study

OBJECTIVES

To assess the impact of an oral health education and preventive program (OHEPP) for pediatric cancer patients.

METHODS

This was a single-arm study with 27 children and adolescents undergoing antineoplastic treatments. Patients were followed up for 10 weeks, and their oral health conditions were evaluated using the Modified Gingival Index (MGI), Visible Plaque Index (VPI), and the modified Oral Assessment Guide (OAG). Audiovisual resources, storytelling, and ludic instruments were used to provide oral health education to patients and parents/caregivers.

RESULTS

The patients' mean age was 9.41 (±4.49) years, and acute lymphoblastic leukemia was the most prevalent diagnosis (22.2%). Mean MGI and VPI values were 0.82 (±0.59) and 54.11% (±19.92%) at baseline and 0.33 (±0.29) and 19.83% (± 11.47%) after 10 weeks, respectively (p < .05). The mean OAG score was 9.51 (±2.54) and 36 cases (19.8%) of severe oral mucositis (SOM) were documented. Patients with higher MGI were more likely to develop SOM.

CONCLUSION

The OHEPP had a positive impact on pediatric patients undergoing cancer therapy by improving their periodontal health, reducing biofilm accumulation, and preventing the development of OM lesions.

A bibliometric analysis of chemotherapy and pain in pediatric patients over the last decade

Background

Chemotherapy is an important treatment for children with cancer, and chemotherapy-induced pain is an important role in affecting patients' quality of life. In our study, bibliometric analysis was used to identify current research hotspots and future research trends of chemotherapy and pain in children over the last decade. Our findings can provide a reference for the research in the field of chemotherapy and pain in children.

Method

Publications of chemotherapy and pain in children were collected from the Web of Science Core Collection database. CiteSpace was used to analyze publication characteristics from 2013 to 2022.

Results

We identified 1,130 eligible publications in the field of chemotherapy and pain in children, with an increasing trend of publications over the last decade. In the field of chemotherapy and pain in children, the United States had the most publication with 346, followed by China with 135. The author with the most published papers was Pamela S Hinds (n = 8) from the United States. The journals that published the most papers were the Journal of pediatric hematology oncology (n = 44) and Medicine (n = 44). The Journal of Clinical Oncology was cited the most frequency (n = 422). St. Jude Children's Research Hospital had the most publication (n = 23). The specific keywords related to the field of chemotherapy and pain in children were "children", "chemotherapy", "management", "childhood cancer", "randomized controlled trial" and "efficacy". Emerging research focuses predominantly on symptomatic and supportive interventions for chemotherapy and pain in children.

Conclusion

Attention to chemotherapy and pain in children with cancer was insufficient. This bibliometric analysis showed the upward trend of chemotherapy and pain in children over the last decade. More studies are needed to improve the quality of life in children with chemotherapy-induced pain. This study may provide useful information to guide future research on chemotherapy and pain in children.

Describing taste changes and their potential impacts on paediatric patients receiving cancer treatments

OBJECTIVES

Taste changes are common among paediatric patients receiving cancer treatments although specific descriptions and associations are uncertain. Primary objective was to describe the number of paediatric patients receiving cancer therapies who experienced taste changes, its impact on food intake and enjoyment of eating, and coping strategies.

METHODS

This was a cross-sectional study that included English-speaking paediatric patients aged 4-18 years with a diagnosis of cancer or haematopoietic stem cell transplantation recipients receiving active treatment. Using a structured interview, we asked participants about their experience with taste changes, impacts and coping strategies. The respondent was the paediatric patient.

RESULTS

We enrolled 108 patients; median age was 11 years (IQR 8-15). The taste changes reported yesterday or today were food tasting bland (34%), bad (31%), different (27%), bitter (25%), extreme (19%), metallic (15%) or sour (12%). Taste changes were associated with decreased food intake (31%) and decreased enjoyment in eating (25%) yesterday or today. The most common coping strategies were eating food they liked (42%), eating strong-tasting food (39%), drinking liquids (35%), brushing teeth (31%) and sucking on candy (25%). Factors significantly associated with food tasting bad were as follows: older age (p=0.003), shorter time since cancer diagnosis (p=0.027), nausea and vomiting (p=0.008) and mucositis (p=0.009).

CONCLUSIONS

Among paediatric patients receiving cancer treatments, taste changes were common and were associated with decreased food intake and enjoyment in eating. Common coping strategies were described. Reducing nausea, vomiting and mucositis may improve taste changes.

Nursing care approaches to oral mucositis in pediatric oncology clinics: a cross-sectional study from Türkiye

PURPOSE

It is important to determine the approaches for oral mucositis (OM) care in pediatric oncology clinics to reflect the profile of practices. The aim of this study was to report on current nursing care approaches for OM in Türkiye.

METHODS

The descriptive, cross-sectional study was conducted with nurse managers in pediatric oncology centers in Türkiye between April and December 2022. The data were obtained online by reaching pediatric oncology nurse managers. The data was collected with the "Oral Mucositis Care Application Form" developed by the researchers based on current literature.

RESULTS

The study reached approximately 60% (n = 41) of pediatric oncology clinics across Türkiye. Oral assessment of children was mainly conducted by nurses (95.1%), and 53.7% of clinics used the WHO Oral Mucositis Assessment Scale. To prevent OM, oral care routines were performed twice a day (36.6%) using sodium bicarbonate (61%) and 0.9% sodium chloride (26.8%) agents. For oral mucositis management, pharmacological agents included glutamine (oral) (51.2%), chlorhexidine (43.9%), and benzydamine hydrochloride (36.6%), while non-pharmacological agents included black mulberry syrup (41.5%), honey (19.8%), and chewing gum (9.8%). Chlorhexidine and benzydamine hydrochloride were used for all mucositis grades, while glutamine was frequently used for grades 2 and above.

CONCLUSIONS

The study revealed that the practices related to preventing and managing oral mucositis in pediatric oncology clinics in Türkiye are heterogeneous. These findings will contribute to the existing literature on the multidisciplinary, systematic, and evidence-based approaches used in oral mucositis care in Türkiye.

Low-Level Laser Therapy for the Treatment of Oral Mucositis Induced by Hematopoietic Stem Cell Transplantation: A Systematic Review with Meta-Analysis

Oral mucositis is a common and debilitating side effect induced by stem cell transplantation that is experienced by cancer patients undergoing chemotherapy or radiation therapy. This condition involves inflammation and ulceration of the oral mucosa, leading to pain, difficulty with eating and speaking, and an increased risk of infections. Mucositis not only compromises the quality of life for cancer patients, but also affects treatment outcomes and may necessitate dose reductions or treatment delays. This scientific article provides a comprehensive overview of mucositis. The purpose of this literature review with a meta-analysis is to evaluate the efficacy of laser therapy in treating post-transplant mucositis. Materials and methods: A search of the literature from 3 May 2023 was carried out on three online databases, PubMed, Scopus, and Web of Science. Only studies that treated patients with laser therapy were considered; only studies with the placebo-treated control group were considered. Review Manager version 5.2.8 (Cochrane Collaboration) was used for the pooled analysis. We measured the std. mean difference between the two groups (laser and placebo). Results: There were 230 papers included in this review. Two hundred twenty-seven were excluded. Furthermore, a manual search was performed. After the search phase, three articles were considered in the study. The overall effect showed differences in the degree of mucositis in the laser-treated patients compared with the placebo group. The meta-analysis shows a reduction in the degree of mucositis in the patients treated with laser therapy (std. mean difference -1.34 [-1.98; -0.98]; C.I. 95%). Conclusions: The application of laser therapy results in decreased severity of oral mucositis from radiation and chemotherapy. Our study shows that the application of low-level laser therapy in the treatment of transplant mucositis has excellent efficacy in relieving the symptoms and severity of mucositis.

Chemo assist for children mobile health application to manage chemotherapy-related symptoms in acute leukemia in Indonesia: a user-centered design approach

BACKGROUND

A mobile health (mHealth) application can encourage parents and pediatric patients to be involved in caring for their child's health condition by providing the ability to identify and actively manage chemotherapy-related symptoms in their child. Several monitoring systems available today are diverse in features and system basis. This study aimed to develop and trial the Chemo Assist for Children (CAC) mHealth application for symptom management in children with acute lymphoblastic leukemia (ALL).

METHODS

In this study, the development of the CAC application went through multiple phases and methods. Study phases included: (1) development of the application's feature based on the need assessment, (2) creation of content of application based on literature review, (3) develop prototyping of CAC, (4) expert review and feedback on the application content, (5) usability testing by targeted end-user.

RESULTS

Based on need assessment, it was determined that parents with leukemia children were interested in symptom management of chemotherapy and preferred mobile applications. Therefore, a mHealth application was designed to include features to identify symptoms and provide recommendation strategies to manage the symptom. Usability evaluation by end-user revealed that mHealth is a valid, accessible, and appropriate application for users.

CONCLUSIONS

The CAC mHealth application developed can meet the needs of technology users to identify symptoms and manage chemotherapy-related symptoms in children with ALL. The CAC mHealth application can accommodate data not recorded at out-of-hospital care, increase the independence of symptom management, and improve communication between parents of children with ALL and health workers.

Viable Bifidobacterium tablets for the prevention of chemotherapy-/radiation-induced mucositis in patients undergoing haematopoietic stem cell transplantation

PURPOSE

Mucositis is a frequent and severe complication in haematopoietic stem cell transplantation (HSCT). The effectiveness of probiotics in mucositis has been indicated by several clinical trials, but the results are still controversial. To date, studies on the influence of probiotics in HSCT are limited. Therefore, we conducted this retrospective study to evaluate the impact of viable Bifidobacterium tablets on the incidence and duration of chemotherapy-/radiation-induced mucositis in patients undergoing HSCT.

METHODS

Clinical data of 278 patients who underwent HSCT between May 2020 and November 2021 were retrospectively analysed. They were divided into a control group (138) and a probiotic group (140) according to whether they took viable Bifidobacterium tablets. First, we analysed the baseline data of the two groups. Then, we compared the incidence, severity and duration of mucositis between the two groups by using Mann-Whitney U test, chi-square test and Fisher's exact test according to the type of data. In order to exclude the influence of confounding factors, we further evaluated the efficacy of oral probiotics in preventing oral mucositis by Binary logistic regression analysis.

RESULTS

The use of viable Bifidobacterium tablets markedly reduced the incidence of oral mucositis (OM) (62.9% vs. 81.2%, p = 0.001) and mainly reduced the incidence of grades 1-2 OM (74.6% vs. 58.6%, p = 0.005). There was no significant difference in the incidence of severe (grades 3-4) OM between the two groups (6.5% vs. 4.3%, p = 0.409). The median duration of OM was shorter in the probiotic group (10 vs. 12 days, p = 0.037). The incidence and duration of diarrhoea did not differ between the two groups. Moreover, the use of viable Bifidobacterium tablets had no influence on engraftment.

CONCLUSIONS

Our results suggested that viable Bifidobacterium tablets could effectively reduce the incidence of grades 1-2 OM and duration of OM during the transplant process without affecting the outcome of HSCT.

Validation of healthcare professional proxy-reported children's International Mucositis Evaluation Scale

OBJECTIVE

The objective was to describe the reliability and validity of the healthcare professional proxy-report version of the Children's International Mucositis Evaluation Scale (ChIMES).

METHODS

We included pediatric patients who were between 4 and 21 years of age and scheduled to undergo hematopoietic cell transplantation. Mucositis was evaluated by trained healthcare professionals who scored ChIMES, the World Health Organization oral toxicity scale, mouth, and throat pain visual analogue scale, National Cancer Institute-Common Terminology Criteria and the Oral Mucositis Daily Questionnaire. Measures were completed daily and evaluated on days 7-17 post-stem cell infusion for this analysis. Psychometric properties examined were internal consistency, test-retest reliability (days 13 and 14), and convergent construct validity.

RESULTS

There were 192 participants included. Cronbach's alpha was 0.90 for ChIMES Total Score and 0.93 for ChIMES Percentage Score. Test-retest reliability were as follows: intraclass correlation coefficient (ICC) 0.82 (95% confidence interval (CI) 0.77-0.85) for ChIMES Total Score and ICC 0.82 (95% CI 0.77-0.86) for ChIMES Percentage Score. In terms of construct validation, all correlations between measures met or exceeded those hypothesized (all p < 0.05).

CONCLUSIONS

The healthcare professional proxy-report version of ChIMES is reliable and valid for children and adolescents undergoing hematopoietic cell transplantation.

Probiotics for the Management of Oral Mucositis: An Interpretive Review of Current Evidence

Mucositis is one of the major side effects of anti-cancer therapies. Mucositis may lead to other abnormalities such as depression, infection, and pain, especially in young patients. Although there is no specific treatment for mucositis, several pharmacological and non-pharmacological options are available to prevent its complications. Probiotics have been recently considered as a preferable protocol to lessen the complications of chemotherapy, including mucositis. Probiotics could affect mucositis by anti-inflammatory and anti-bacterial mechanisms as well as augmenting the overall immune system function. These effects may be mediated through anti microbiota activities, regulating cytokine productions, phagocytosis, stimulating IgA releasement, protection of the epithelial shield, and regulation of immune responses. We have reviewed available literature pertaining to the effects of probiotics on oral mucositis in animal and human studies. While animal studies have reported protective effects of probiotics on oral mucositis, the evidence from human studies is not convincing.

A Cross-sectional Survey to Review Food Safety Practices Within Pediatric Oncology and Stem Cell Transplant Centers in the United Kingdom

FOOD SAFETY AND PEDIATRIC CANCER

Neutropenia is a common complication of chemotherapy, which poses a high risk of infection and mortality. Neutropenic diet has historically been recommended for those undergoing chemotherapy. The rationale is to reduce the risk of foodborne infection by avoiding foods considered to be of high microbial risk. However, evidence for this diet is limited, and there is a lack of national consensus guidelines.

AIM

Ascertain food safety advice across specialist centers providing high-dose chemotherapy for malignancy or stem cell transplants in the United Kingdom.

MATERIALS AND METHODS

Dietitians at 22 centers were contacted to complete a questionnaire regarding food safety guidance implemented at their center for pediatric patients undergoing high-dose chemotherapy or stem cell transplants. Questions related to restricted foods, specific guidelines implemented, ward food provision, and timings of food provision.

RESULTS

Sixteen centers responded (73%). Many aspects of neutropenic diet were consistent across centers; avoidance of unpasteurized dairy products (94%), raw/undercooked meat (94%), and unpasteurized pâté (88%). There was a lack of consistency regarding water sources used on wards and unpeeled fruits and vegetables.

CONCLUSIONS

Food safety guidance for neutropenic patients differs across centers, with some practices seeming outdated and nonevidence based. A national review of food safety guidance should be considered to provide a standardized approach.

Photobiomodulation for Chemotherapy-Induced Oral Mucositis in Pediatric Patients

Oral mucositis (OM) is a common side effect in patients undergoing chemotherapy (CT), especially in children due to their rapid epithelial mitotic rate. It has been associated with a significant reduction in life quality since it leads to pain, an inadequate intake of nutrients, an increased risk of opportunistic infections, and interruptions of CT. Photobiomodulation (PMB) with low-level laser therapy (LLLT) has shown faster healing, reduction in pain, and the reduced use of analgesic compared to placebo groups. The purpose of this review is to analyze and compare the existing clinical trials and identify their shortcomings in hope to make future research easier. Using MeSH terms and keywords, the Embase, Medline, and PubMed databases we searched for the period of the last 5 years. We identified a total of 15 clinical trials, with a total of 929 pediatric patients analyzed in this review. We compared different light sources and other laser technique characteristics used in clinical trials such as wavelength, energy and power density, spot size, irradiation time, PBM protocol, and OM evaluation. The main findings show inconsistent laser parameter quotations, differences in the PBM protocol along with a laser application technique, and a lack of clinical trials. Based on that, more studies with a high methodological quality should be conducted in order to provide a unified PBM protocol suitable for the pediatric population.

Prevention and the treatment of oral mucositis: the efficacy of sodium bicarbonate vs other agents: a systematic review

INTRODUCTION

Oral mucositis (OM) is a major side effect of cancer therapy, which is associated with significant symptoms, treatment delays and increased costs for the health system. It is an important component of the quality of life of cancer patients and, until now, there has been no gold standard regarding prevention or treatment of this pathology. Notwithstanding the paucity of treatment guidelines (due to limited evidence from high-quality, rigorous studies), sodium bicarbonate (SB) rinses are one of the most used agents for OM management.

OBJECTIVES

A systematic review (2000-2022) was performed in order to compare and examine different agents versus sodium bicarbonate (SB) in preventing or treating OM.

SOURCES

Eleven randomized controlled trials (RCT) were evaluated: four were conducted for the prevention and seven for the management of OM. The risk of bias of RCTs was assessed using the revised Cochrane risk of bias tool for randomized trials.

STUDY SELECTION

According to the RoB2 evaluation for randomized trials, four RCTs were judged to be at a high risk of bias, two were rated as 'problematic', while five were deemed to be a low risk of bias.

CONCLUSIONS

The results revealed that there was no evidence for supporting SB in OM treatment regarding management and prevention.

CLINICAL SIGNIFICANCE

Results showed in this review takes on a strategic importance in the use of SB for OM management or prevention; indiscriminate use of SB could be counterproductive because it causes a sudden pH increase and it delays proper OM pharmacological treatment.

A Novel Oncodental Collaborative Team: Integrating Expertise for Central Line-Associated Bloodstream Infection Prevention in Pediatric Oncology Patients

PURPOSE

Pediatric oncology and bone marrow transplant patients are at high risk of infection, and limitations to dental expertise among medical providers render patients vulnerable to central line-associated bloodstream infections from oral pathogens. Traditionally, oral health maintenance relied on patients and bedside nurses; however, routine methods are often suboptimal to prevent central line-associated bloodstream infection in high-risk patients. Limited overlap of medical and dental expertise, and limited dental resources in typical oncology units, prevent optimal oral care for children with cancer, requiring novel solutions to better integrate specialties.

METHODS

Here, we outline the creation of a novel Pediatric oncodental team to address oral-systemic infection prevention strategies for high-risk patients.

RESULTS

Our oncology and dental teams created a systematic approach for increasing oral surveillance and treatment in select high-risk patients. Supervised pediatric dental residents participated in scheduled oncology rounds, and a permanent oral health educator with a background in dental hygiene was also hired as a dedicated dental professional within our oncology department.

CONCLUSION

Our pediatric oncodental team aims to sustain optimal oral complication prevention strategies to reduce the risk of infection, provide education on the significance of the oral-systemic link in cancer care, and improve access and continuity of care.

Randomized cross-over study investigating the tolerability and side effects of an intra-oral air-cooling device compared to ice in healthy volunteers

Oral cryotherapy (OC) is a common preventive treatment of oral mucositis (OM) and is recommended in international guidelines. Ice and air OC have previously been shown to result in temperature reductions of 8.1-12.9 °C, and 14.5 °C, respectively, in healthy volunteers. However, no direct comparison between these two modalities has been performed. The primary aim was to investigate the tolerability and side effects of air OC using an intra-oral air-cooling (IOAC) device compared with ice OC. The secondary aim was to evaluate the temperature reduction in the mouth for the two respective methods. Cross-over study with randomization to order of treatment, in 15 healthy volunteers. We evaluated the self-reported intensity, frequency, and discomfort for 13 pre-defined side effects used in previous studies. All participants were able to complete both OC sessions, although one participant required reduced airflow in the air OC arm. The subjects reported more discomfort from being cold, having sensitive teeth, and numbness in the ice OC group, while they reported more discomfort from swallowing when subjected to air OC. No significant difference in the median temperature reduction was detected in the two modalities, except for the dorsal posterior part of the tongue where temperature reduction was larger in the ice OC group. We found that oral cooling using a new IOAC device was tolerated and seems to be safe in healthy volunteers.

Use of Daily Patient-Reported Outcome Measurements in Pediatric Cancer Care

IMPORTANCE

Patient-reported outcome measurements (PROMs) are emerging as an important component of adult cancer care, but little has been done with regard to PROMs for pediatric cancer care.

OBJECTIVES

To identify pediatric patients with cancer who are at risk of severe adverse effects of treatment and provide individualized supportive care using PROMs.

DESIGN, SETTING, AND PARTICIPANTS

This single-center cohort study with PROMs implemented in daily clinical routine was conducted from May 1, 2020, to November 15, 2021, among pediatric patients with a cancer diagnosis or their proxies. Inclusion criteria were treatment with chemotherapy and at least 30 days of active participation. Patients were followed up until completion of therapy or through ongoing therapy until November 15, 2021; data were analyzed from November 15, 2021, through January 31, 2022.

EXPOSURES

Cancer treatment, including chemotherapy, surgery, and radiotherapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was occurrence and severity of ubiquitous complications of cancer treatment, such as nausea, appetite loss, pain, sleep disturbance, and deterioration of physical functioning. The secondary outcome was the identification of early and appropriate clinical interventions based on detection of cancer-related symptoms via PROMs.

RESULTS

A total of 4410 daily PROMs from 7082 therapy days for 40 children (35 children aged 5-18 years and 5 proxies for children aged 1-4 years) (median age, 9.1 [IQR, 6.3-12.2] years; 26 [65.0%] male) were analyzed during a median follow-up of 145.5 (IQR, 103.8-244.5) days. All participants were White. The overall median completion rate was 60.1% (IQR, 37.9%-81.0%); this rate was slightly lower during home care vs inpatient stay (57.5% [IQR, 30.7%-85.9%] vs 65.0% [IQR, 49.6%-92.5%], respectively; P = .01), with a decreasing trend over time (65.6% [IQR, 51.6%-85.9%] for the first 90 days vs 42.9% [IQR, 29.3%-82.3%] for beyond 90 days; P < .001). Severe symptoms were reported on 657 days (14.9%); most symptoms were associated with physical functioning, followed by pain, sleep disturbance, and nausea and appetite loss. In total, 321 adverse events (AEs) and cases of health deterioration were documented, and PROMs were completed for 251 (78.2%) of these events. Across all AEs, self-reported pain was the most useful marker, particularly when analyzed on the day before onset, and was associated with an odds ratio of 3.65 (95% CI, 1.54-8.62; P = .005) for the presence of mucositis.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that PROMs reflect daily symptoms in pediatric patients with cancer and assist in clinical management and intervention for AEs.

Photobiomodulation for chemotherapy-induced oral mucositis in leukemic children: A randomized controlled clinical trial

OBJECTIVES

Evaluation of the effectiveness of Photobiomodulation(PBM) for chemotherapy-induced oral mucositis (OM) in leukemic children.

MATERIALS AND METHODS

A randomized controlled clinical study including forty-four leukemic children diagnosed with chemotherapy-induced OM at the Hematology/Oncology inpatient unit at Alexandria University Children's Hospital, Alexandria, Egypt. Patients were randomly assigned to either the control or test groups with a 1:1 ratio. The control group received conventional symptomatic treatment, while the test group was treated with PBM in addition to the symptomatic treatment. The response to both treatment modalities was evaluated according to the reduction of pain and lesions severity from baseline to 5, 10, and 14 days after treatment.

RESULTS

A significant reduction of pain was recorded on day 10 in the test group compared to the control group (p < 0.001). There was also a significant decline in the OM grades between the two groups on day14 (p = 0.003). No adverse events were reported.

CONCLUSIONS

The use of PBM along with the conventional treatment was effective in reducing pain and in the recovery of OM lesions in children receiving chemotherapy for the treatment of ALL. It was also safe and applicable to children.

Prevention and Treatment of Oral Complications in Hematologic Childhood Cancer Patients: An Update

Cancers have a highly negative impact on the quality of life of paediatric patients and require an individualised oral treatment program for the phases of the disease. The aim of this study was to update existing research on oral care in children diagnosed with cancer. We carried out a literature search (in English, Spanish and Portuguese) in the Pubmed, Cochrane Library, EBSCO, WOS, SciELO, Lilacs, ProQuest, and SCOPUS databases and the websites of hospitals that treat childhood cancers. We found 114 articles and two hospital protocols. After review, we describe the interventions necessary to maintain oral health in children with cancer, divided into: phase I, before initiation of cancer treatment (review of medical record and oral history, planning of preventive strategies and dental treatments); phase II, from initiation of chemo-radiotherapy to 30-45 days post-therapy (maintenance of oral hygiene, reinforcement of parent/patient education in oral care, prevention and treatment of complications derived from cancer treatment); phase III, from 1 year to lifetime (periodic check-ups, maintenance, and reinforcement of oral hygiene, dental treatments, symptomatic care of the effects of long-term cancer treatment). The use of standardised protocols can avoid or minimise oral cancer complications and the side effects of cancer therapies.

Low-level laser therapy for oral mucositis in children with cancer

OBJECTIVE

To assess the efficacy of oral low-level laser therapy (LLLT) - also known as photobiomodulation - in the reduction of oral mucositis experienced by children and young people with cancer undergoing chemotherapy.

DESIGN

A systematic review to evaluate the efficacy of oral LLLT for oral mucositis in children with cancer and the safety of oral LLLT in any age with cancer (International Prospective Register of Systematic Reviews/PROSPERO registration: CRD42018099772). Multiple databases and grey literature were screened. Randomised controlled trials were considered for assessing efficacy, and all studies were considered for assessing safety. Primary outcomes included severity of oral mucositis, oral pain and adverse events. Where results were compatible, meta-analysis was performed using a random-effects model. A narrative synthesis considered other outcome measures.

RESULTS

14 studies (n>416 children) were included in the narrative synthesis of LLLT efficacy. 5 studies (n=380 children and young people) were included in the meta-analyses. Results demonstrate that LLLT may reduce the severity of oral mucositis and the level of oral pain, but further randomised controlled trials are needed to confirm or deny this. There is vast variation in different trial protocols. Insufficient blinding between LLLT or sham therapy/control led to a strong risk of performance bias. 75 studies (encompassing 2712 patients of all ages who had undergone LLLT) demonstrated minor and infrequent adverse reactions, but most studies had significant areas of weakness in quality.

CONCLUSION

LLLT appears to be a safe therapy, but further evidence is needed to assess its efficacy as a prevention or treatment tool for oral mucositis in children with cancer.

Addressing Common Pain Syndromes in Pediatric Stem Cell Transplant: A Review

Assessment and management of pain for pediatric patients receiving stem cell transplants can be challenging for a health care team. Diagnostic evaluation and interventions vary between institutions and individual provider practices. In this review, we investigate and describe approaches to pain management for the most common sources of pain in pediatric patients undergoing stem cell transplants. Mucositis pain, abdominal pain, and hemorrhagic cystitis emerged as the most frequent sources of acute pain in children during conditioning and transplantation periods. Furthermore, psychosocial distress and psychological pain or distress constitute significant components of the total pain experienced by children undergoing stem cell transplantation. We will expand upon appropriate usage and escalation of opioids, as well as complementary interventions and timely initiation of interventions, in order to help control pain in these clinical syndromes.

What do patients experience? Interprofessional collaborative practice for chronic conditions in primary care: an integrative review

BACKGROUND

Improving the patient experience is one of the quadruple aims of healthcare. Therefore, understanding patient experiences and perceptions of healthcare interactions is paramount to quality improvement. This integrative review aimed to explore how patients with chronic conditions experience Interprofessional Collaborative Practice in primary care.

METHODS

An integrative review was conducted to comprehensively synthesize primary studies that used qualitative, quantitative, and mixed methods. Databases searched were Medline, Embase, CINAHL and Web of Science on June 1st, 2021. Eligible studies were empirical full-text studies in primary care that reported experiences or perceptions of Interprofessional Collaborative Practice by adult patients with a chronic condition, in any language published in any year. Quality appraisal was conducted on included studies using the Mixed Method Appraisal Tool. Data on patients' experiences and perceptions of Interprofessional Collaborative Practice in primary care were extracted, and findings were thematically analyzed through a meta-synthesis.

RESULTS

Forty-eight (n = 48) studies met the inclusion criteria with a total of n = 3803 participants. Study quality of individual studies was limited by study design, incomplete reporting, and the potential for positive publication bias. Three themes and their sub-themes were developed inductively: (1) Interacting with Healthcare Teams, subthemes: widening the network, connecting with professionals, looking beyond the condition, and overcoming chronic condition collectively; (2) Valuing Convenient Healthcare, subthemes: sharing space and time, care planning creates structure, coordinating care, valuing the general practitioner role, and affording healthcare; (3) Engaging Self-care, subthemes: engaging passively is circumstantial, and, engaging actively and leading care.

CONCLUSIONS

Patients overwhelmingly had positive experiences of Interprofessional Collaborative Practice, signaling it is appropriate for chronic condition management in primary care. The patient role in managing their chronic condition was closely linked to their experience. Future studies should investigate how the patient role impacts the experience of patients, carers, and health professionals in this context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020156536.

The broadening scope of oral mucositis and oral ulcerative mucosal toxicities of anticancer therapies

Oral mucositis (OM) is a common, highly symptomatic complication of cancer therapy that affects patients' function, quality of life, and ability to tolerate treatment. In certain patients with cancer, OM is associated with increased mortality. Research on the management of OM is ongoing. Oral mucosal toxicities are also reported in targeted and immune checkpoint inhibitor therapies. The objective of this article is to present current knowledge about the epidemiology, pathogenesis, assessment, risk prediction, and current and developing intervention strategies for OM and other ulcerative mucosal toxicities caused by both conventional and evolving forms of cancer therapy.

An exploration of the use of photobiomodulation for management of oral mucositis in children and young people undergoing cancer treatment in the UK

PURPOSE

Oral mucositis affects up to 80% of children and young people (CYP) receiving chemotherapy. This can result in pain, reduced oral intake and, in severe cases, hospitalisation for parental nutrition and pain relief. Photobiomodulation is recommended by multiple bodies for mucositis management for those undergoing cancer treatments. The current use of photobiomodulation within the UK, and the barriers and facilitators to implementation is unknown.

METHOD

An online mixed-methods survey was administered to representatives from the Children's Cancer and Leukaemia Group (CCLG) between October 2021 and March 2022. This explored: use of photobiomodulation, planned future use, barriers and facilitators to implementation and dental assessment. Quantitative data underwent descriptive statistics. Barriers and facilitators to the implementation of photobiomodulation were analysed using the Theoretical Domains Framework (TDF).

RESULTS

All UK CCLG centres responded (n = 20, a response rate of 100%). Two units in Scotland were delivering photobiomodulation. A further four units were planning to implement a service. Most units, 65% (n = 13) utilised specialist Paediatric Dentistry services for dental assessment. In the TDF analysis, five domains were most frequently populated: knowledge, skills, environmental context and resources, social influences, and social/professional role and identity.

CONCLUSION

Photobiomodulation was only available in Scotland in two children's cancer units. Lack of knowledge and skills, and insufficient environmental resources were identified as barriers. Collaboration with paediatric dental services was identified as a facilitator. The establishment of a national network of Paediatric Dentists and Oncologists would promote collaboration to standardise protocols and to address the identified barriers to wider implementation of photobiomodulation.

Evaluation of topical morphine for treatment of oral mucositis in cancer patients

Introduction

Oral mucositis is a painful side effect to chemotherapy. Orally applied opioids may offer analgesia with fewer side effects than systemic opioids.

Methods

A randomized trial comparing the analgesic effect of a morphine oromucosal solution (OM) to placebo and a positive control group receiving intravenous (IV) morphine as an add-on treatment to morphine patient-controlled analgesia (PCA) in a mixed population of paediatric and adult haematology patients. All patients in the study were equipped with a morphine PCA pump and the participating patients were instructed to use this pump as an escape. Primary outcome was morphine consumption (mg/kg/hour) on the PCA pump. Secondary outcomes included pain intensity difference at rest and when performing oral hygiene, time to first PCA bolus, nutrition intake and adverse events.

Findings

A total of 60 patients (38 children <18 years) were randomized. Thirty patients were allocated to morphine OM/placebo IV (group MO), 15 patients to placebo OM/morphine IV (group MI) and 15 patients to placebo OM/placebo IV (group P). The median morphine consumption in the MO group (22.7 mcg/kg/hour 95% confidence interval (CI) 19.4-29.4 mcg/kg/hour, p = 0.38) was not significantly different from the placebo group (24.6 mcg/kg/hour 95% CI 16.8-34.4 mcg/kg/hour, p = 0.44) or the MI group (13.7 mcg/kg/hour 95% CI 9.7-37.8 mcg/kg/hour). For the secondary outcomes, the analysis of summed pain intensity difference after the first, third and fourth administrations of study medication indicated a reduction in pain for the MI group compared to the P and MO groups. No serious adverse events were reported.

Conclusion

The findings indicate that the analgesic effect of peripherally applied morphine is not significantly different from placebo, and parenteral opioids should continue to be the standard of care.

A Narrative Review about Nutritional Management and Prevention of Oral Mucositis in Haematology and Oncology Cancer Patients Undergoing Antineoplastic Treatments

Cancer is a prevalent disease worldwide, and treatments such as radiotherapy and chemotherapy sometimes lead to adverse events. Oral mucositis is one of the most disabling adverse events, and clinical guidelines do not take into account nutritional interventions. The primary endpoint was to gather the evidence about the efficacy of nutritional interventions in the prevention and/or treatment of antineoplastic-induced oral mucositis in oncological patients. A bibliographic review was carried out in the PubMed data base by combining MeSH terms with Boolean operators. Articles were selected based on inclusion and exclusion criteria; 50 final articles were found. Although further evidence is needed, glutamine, honey, and vitamins appear to be good therapeutic options. The rest of the compounds presented controversial or insufficient results, making it difficult to draw conclusions over their utilization as prevention or treatment options. Little evidence is reported about oral mucositis nutritional interventions in spite of them being attainable and affordable compounds. Scarce evidence is shown in paediatric patients compared with adults. Developing higher quality studies and combinations with the compounds researched is necessary for creating a stronger body of evidence.

Clinical practice guideline for the prevention of oral and oropharyngeal mucositis in pediatric cancer and hematopoietic stem cell transplant patients: 2021 update

PURPOSE

To update the 2015 clinical practice guideline for the prevention of oral mucositis in pediatric cancer or hematopoietic stem cell transplant (HSCT) patients.

METHODS

We performed seven systematic reviews of mucositis prevention. Three reviews included randomized controlled trials (RCTs) conducted in pediatric and adult patients evaluating cryotherapy, keratinocyte growth factor (KGF) or photobiomodulation therapy with a focus on efficacy. Three reviews included studies of any design conducted in pediatric patients evaluating these same interventions with a focus on adverse events and feasibility. One review included all RCTs of any intervention for mucositis prevention in pediatric patients. Primary outcome was severe oral mucositis.

RESULTS

We included 107 unique studies of cryotherapy (22 RCTs and 4 pediatric studies); KGF (15 RCTs and 12 pediatric studies); photobiomodulation therapy (29 RCTs and 8 pediatric studies) and any intervention (31 pediatric RCTs). Effects on severe mucositis reduction from RCTs were cryotherapy risk ratio (RR) 0.49 and 95% confidence interval (CI) 0.31-0.76; palifermin RR 0.81 and 95% CI 0.69-0.95 and photobiomodulation therapy RR 0.40 and 95% CI 0.27-0.60. Cryotherapy was not feasible in young children while photobiomodulation therapy was feasible across age groups. Palifermin was associated with adverse effects.

CONCLUSIONS

Cryotherapy should be used for older cooperative pediatric patients who will receive short infusions of melphalan or 5-fluorouracil. Intraoral photobiomodulation therapy (620-750 nm spectrum) should be used in pediatric patients undergoing autologous or allogeneic HSCT and for pediatric head and neck carcinoma patients undergoing radiotherapy. Palifermin should not be used routinely in pediatric cancer or HSCT patients.

Efficacy of Oral Cryotherapy in the Prevention of Oral Mucositis Associated with Cancer Chemotherapy: Systematic Review with Meta-Analysis and Trial Sequential Analysis

BACKGROUND

This review aimed to evaluate the efficacy of oral cryotherapy in the prevention of chemotherapy-induced oral mucositis using meta-analysis and trial sequential analysis, as well as to assess the quality of the results by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

METHODS

A comprehensive search of three databases including Medline, Embase and Central was performed to identify randomized controlled trials that used oral cryotherapy for the prevention of chemotherapy-induced oral mucositis. The primary outcome was the incidence of oral mucositis for trials employing oral cryotherapy as the intervention for the prevention of oral mucositis. The meta-analysis was performed using the random-effects model and random errors of the meta-analyses were detected by trial sequential analysis.

RESULTS

A total of 14 RCTs with 1577 participants were included in the present meta-analysis. Patients treated with oral cryotherapy were associated with a significantly lower risk of developing oral mucositis of any grade (risk ratio (RR), 0.67 (95% CI: 0.56-0.81, p < 0.05)). Findings from the subgroup analyses showed that oral cryotherapy significantly reduced the risk of oral mucositis in patients undergoing bone marrow transplantation (RR 0.69, CI: 0.54-0.89, p < 0.05) as well as chemotherapy (RR 0.66, CI: 0.58-0.75, p < 0.05). Findings from the trial sequential analysis suggested that the evidence on oral cryotherapy as a preventive intervention for oral mucositis in patients with solid malignancies receiving conventional chemotherapy was conclusive.

CONCLUSION

Oral cryotherapy is effective in preventing oral mucositis in patients undergoing chemotherapy for the management of solid malignancies. The use of oral cryotherapy in preventing oral mucositis in bone marrow transplantation settings showed promising efficacy, but the evidence is not conclusive and requires more high-quality randomized controlled trials.

A Prospective Cohort Study Comparing Long-Term Outcomes with and without Palifermin in Patients Receiving Hematopoietic Cell Transplantation for Hematologic Malignancies

The incidence of debilitating oral mucositis (OM) can be as high as 99% after myeloablative conditioning regimens preparing patients with hematologic malignancies for hematopoietic cell transplantation (HCT). Palifermin (KGF) is a recombinant human keratinocyte growth factor that reduces the incidence and duration of severe OM. The long-term safety of KGF has not been well established, however. In this long-term prospective matched-cohort study, patients who received KGF (cases) and underwent autologous or allogeneic HCT for hematologic malignancies between 2006 and 2013 were matched 1:1 to patients who did not receive KGF (controls). The primary outcome was overall survival (OS). Other outcomes were disease relapse, new malignancies, pancreatitis, renal failure requiring dialysis, pulmonary complications, cataract surgery, and acute and chronic graft-versus-host disease (GVHD). The analysis population comprised 2191 matched pairs with a wide range of diseases and donor types that received diverse conditioning and GVHD preventive regimens, representing contemporary practice patterns. The median duration of follow-up was 8 years (range, 1 to 12.5 years). In multivariate analyses, the probabilities of OS (relative risk [RR], 1.01; 95% confidence interval [CI], 0.91 to 1.12), relapse (RR, 1.06; 95% CI, 0.94 to 1.18), new malignancies (RR, 0.89; 95% CI, 0.67 to 1.18), and cataract surgery (RR, 1.05; 95% CI, 0.74 to 1.50) were not statistically significantly different between cases and controls. In univariate analyses, no increased risks were observed for renal failure requiring dialysis, pancreatitis, acute GVHD, chronic GVHD, interstitial pneumonitis/acute respiratory distress syndrome/idiopathic pneumonia syndrome, or bronchiolitis obliterans/cryptogenic organizing pneumonia/bronchiolitis obliterans organizing pneumonia among cases compared with controls. This long-term prospective safety cohort study demonstrates that the KGF group had no increased risk of overall mortality, relapse, new malignancies, or any other key outcome. The broad inclusion criteria allow the results to be generalized to contemporary practice for patients with a wide range of diseases and receiving a wide range of HCT conditioning regimens and graft sources from diverse donor types.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment

OBJECTIVES

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care.

DATA SOURCES

Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer.

CONCLUSION

Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

Identifying clinical practice guidelines for symptom control in pediatric oncology

BACKGROUND

Children with cancer commonly experience distressing symptoms such as pain, fatigue and nausea. Improvements in patient outcomes have been associated with implementation of clinical practice guideline-consistent care across several domains. The objective of this study was to develop a process to identify symptom management clinical practice guidelines (CPGs) applicable to children and adolescents receiving cancer treatments.

METHODS

We focused on identifying CPGs to manage 15 symptoms. The process defined three Tiers of CPGs based upon applicability to pediatric cancer patients and ease of identification: Tier 1: endorsed by the Children's Oncology Group; Tier 2: housed in the Emergency Care Research Institute repository, or developed by the American Society of Clinical Oncology or National Institute for Health and Care Excellence; and Tier 3: identified by systematic review. We first searched for CPGs published 2015-2020 and identified Tiers 1 or 2 CPGs. If unavailable or scope was too narrow, we proceeded to Tier 3. If CPGs were not identified, we repeated these steps for CPGs published 2010-2014.

RESULTS

There were six Tier 1 and 13 Tier 2 CPGs published 2015-2020 across the 15 symptoms. Four symptoms required progression to Tier 3 because CPGs were absent (anger) or because scope was too narrow (pain, anorexia/excessive hunger and diarrhea). The systematic review identified three CPGs for pain and none for the other three symptoms. In total, CPGs were identified for 14 of 15 symptoms. None were identified for anger.

CONCLUSION

We created a process to identify supportive care CPGs for pediatric cancer symptom management and were able to identify CPGs that addressed 14 of 15 symptoms. Future work should focus on evaluating implementation techniques for these CPGs and determining the impact of these CPGs on provider and patient outcomes.

[Chemo-induced mucositis in pediatric oncology: Perspectives?]

Mucositis is defined as inflammatory and/or ulcerative lesions of the oral and/or gastrointestinal tract. It occurs in approximately 40% to 50% of adults patients receiving conventional chemotherapy and up to 75% of patients receiving high dose chemotherapy as conditioning for hematopoietic stem cell transplantation. It is a toxic side effect, which strongly impairs quality of life and leads to refractory pain, increasing risk of infection and even therapeutic modifications. Despite improvements made, the management of mucositis remains a challenge and is still not consensual. A multicentric survey of practices concerning the preventive and curative management of chemo-induced mucositis in pediatric oncology department in France was carried out using a standardized questionnaire. Results confirm heterogeneous practices and the small progress made during the last decade. This national survey and an analysis of the recent literature leads to propose guidelines for the prevention and treatment of oral mucositis in children receiving treatment for cancer.

Cutaneous reactions to pediatric cancer treatment: Part I. Conventional chemotherapy

Chemotherapies often cause side effects of the skin, nails, and mucosal surfaces. These mucocutaneous toxicities contribute to morbidity and affect quality of life. Identification and management of these drug-induced eruptions is vital to allow for continuation of essential therapies. This review demonstrates the wide range of chemotherapy-induced cutaneous toxicities in children and includes clues for diagnosis as well as tips for counseling and management.

Improving symptom control and reducing toxicities for pediatric patients with hematological malignancies

The continuing improvement in pediatric cancer survival over time is largely attributable to the availability of intensive therapies. Increasing attention has been focused on addressing the physical and psychosocial impacts of cancer and cancer treatments. Evidence from adult oncology suggests that routine symptom screening and feedback to health care providers can improve patient-clinician communication, reduce distress, and improve quality of life and may even increase survival. Many questions remain regarding implementation of routine symptom screening in pediatric cancer care, including the best symptom assessment instrument and the reporter type and feasibility of integration with electronic health records (EHRs). Nonsymptom adverse events are also important, for both routine clinical care and adverse event reporting for patients enrolled in clinical trials. However, traditional mechanisms for reporting adverse events lead to substantial inaccuracies and are labor intensive. An automated approach for abstraction from EHRs is a potential mechanism for improving accuracy and reducing workload. Finally, identification of symptom and nonsymptom toxicities must be paired with prophylactic and therapeutic strategies. These strategies should be based on clinical practice guidelines that synthesize evidence and use multiprofessional, multidisciplinary expertise to place this evidence in clinical context and create recommendations. How best to implement clinical practice guidelines remains a challenge, but EHR order sets and alerts may be useful. In summary, although survival is excellent for pediatric patients receiving cancer therapies, more focus is needed on identification of symptoms and nonsymptom toxicities and their management. The EHR may be useful for promoting better supportive care through these mechanisms.

Effect of zinc on oropharyngeal mucositis in children with acute leukemia undergoing chemotherapy

Background

Oropharyngeal mucositis (OM) is one of the main side-effects of oncological therapy. There is no treatment to prevent its occurrence, but some zinc-based therapies have been proven to help in decreasing its intensity. The objective of this study was to determine the effect of zinc in OM in children with acute leukemia in the early stages of oncological treatment.

Material and Methods

This quasi-experimental study evaluated OM in 2 groups (control group: conventional hospital management, and experimental group: administration of 50 mg of zinc gluconate daily plus conventional hospital management). OM severity was recorded at a two-month follow-up.

Results

Forty-nine patients (26 in the control group and 23 in the experimental group) were included. The mean age of the patients was 11.1 ± 2.7 years; 65.3% had a diagnosis of pre-B acute lymphoblastic leukemia. The incidences of OM in the control group and the experimental group were 46.2% and 26.1%, respectively, but the difference was not significant. Based on a negative binomial regression model, females had, on average, 1.5 more days with OM (p = 0.002), and patients assigned to the experimental group had, on average, 2 less days with OM than the control group (p = 0.001). The pain score was higher in the control group (p = 0.0009), as was the mean score on the WHO scale (p = 0.0012).

Conclusions

Zinc facilitated a reduction in the severity and duration of OM; further studies focusing on children are needed to confirm the effects of this trace element.

Key words:Oropharyngeal, mucositis, zinc, chemotherapy, children, leukemia.

Polaprezinc for prevention of oral mucositis in patients receiving chemotherapy followed by hematopoietic stem cell transplantation: A multi-institutional randomized controlled trial

Oral mucositis is a common and distressing complication in patients receiving high-dose chemotherapy followed by hematopoietic stem cell transplantation (HSCT). We reported previously in a single-center retrospective analysis that zinc-L-carnosine (polaprezinc [PZ]) reduced the incidence of oral mucositis associated with HSCT. To verify the accuracy of the prophylactic effect of PZ against oral mucositis, we carried out a multi-institutional prospective randomized controlled study. Patients were randomly allocated to either the prevention group, in which PZ lozenge treatment was started before chemotherapy, or the control group, in which administration of PZ lozenges was initiated immediately after the onset of Grade 2 oral mucositis. Oral mucositis was evaluated daily from the start of chemotherapy to 35 days after transplantation. A total of 91 patients were enrolled, and 88 patients (47 in the control group and 41 in the prevention group) were eligible for data analysis. The incidence of Grade ≥2 but not Grade ≥3 oral mucositis was significantly reduced in the prevention group compared to the control group (44.7% in control group vs 22.0% in the prevention group, P = .025). There were no significant differences in the incidence rates of other adverse events or the rate of engraftment (95.6% vs 97.2%, P = .693) between the two groups. These findings suggest that PZ lozenge is effective for prophylaxis against Grade ≥2 oral mucositis associated with chemotherapy in patients undergoing HSCT without any influence on the HSCT outcome.

Development of the SPARK family member web pages to improve symptom management for pediatric patients receiving cancer treatments

Background

Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web-based application that facilitates symptom screening and access to supportive care clinical practice guidelines (CPGs) for children and adolescents receiving cancer treatments. Objective was to develop SPARK family member web pages for pediatric patient family members accessing: (1) proxy symptom screening and symptom reports, and (2) care recommendations for symptom management based on CPGs.

Methods

SPARK family member web pages were developed and included access to symptom screening and care recommendations sections. Care recommendations for fatigue and mucositis were created. These were iteratively refined based upon cognitive interviews with English-speaking family members ≥16 years of age until less than two participants incorrectly understood sections as adjudicated by two independent raters.

Results

A total of 100 family members were enrolled who evaluated the SPARK family member web pages (n = 40), fatigue care recommendation (n = 30) and mucositis prevention care recommendation (n = 30). Among the last 10 participants, none said that the SPARK family member web pages were hard or very hard to use, one incorrectly understood one web page, none said either care recommendation was hard to understand and none were incorrect in their understanding of the care recommendations.

Conclusions

We successfully developed SPARK web pages for use by family members of pediatric patients receiving cancer treatments. We also developed a process for translating CPG recommendations designed for healthcare professionals to lay language. The utility of SPARK family member web pages after clinical implementation could be a focus for future research.

Effects of cryotherapy on high-dose melphalan-induced oral mucositis in pediatric patients undergoing autologous stem cell transplantation

Cryotherapy is a conventional method for preventing melphalan-induced oral mucositis (OM) in adult patients. We retrospectively examined the clinical benefits of cryotherapy in 41 pediatric patients undergoing autologous stem cell transplantation using a melphalan-etoposide-carboplatin regimen. Twenty-two patients received cryotherapy. The cumulative incidence of grade 3-4 OM was significantly lower in the cryotherapy group (57.1%) than in the noncryotherapy group (89.5%; P = .041). Multivariate analyses identified cryotherapy and the melphalan dose as independent factors for the lower occurrence of OM. The present study demonstrates the clinically significant efficacy of cryotherapy for preventing melphalan-induced OM in pediatric patients.

Mucosal barrier injury-associated bloodstream infections in pediatric oncology patients

BACKGROUND

Single-center reports of central line-associated bloodstream infection (CLABSI) and the subcategory of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) in pediatric hematology oncology transplant (PHO) patients have focused on the inpatient setting. Characterization of MBI-LCBI across PHO centers and management settings (inpatient and ambulatory) is urgently needed to inform surveillance and prevention strategies.

METHODS

Prospectively collected data from August 1, 2013, to December 31, 2015, on CLABSI (including MBI-LCBI) from a US PHO multicenter quality improvement network database was analyzed. CDC National Healthcare Safety Network definitions were applied for inpatient events and adapted for ambulatory events.

RESULTS

Thirty-five PHO centers reported 401 ambulatory and 416 inpatient MBI-LCBI events. Ambulatory and inpatient MBI-LCBI rates were 0.085 and 1.01 per 1000 line days, respectively. Fifty-three percent of inpatient CLABSIs were MBI-LCBIs versus 32% in the ambulatory setting (P  <  0.01). Neutropenia was the most common criterion defining MBI-LCBI in both settings, being present in ≥90% of events. The most common organisms isolated in MBI-LCBI events were Escherichia coli (in 28% of events), Klebsiella spp. (23%), and viridans streptococci (12%) in the ambulatory setting and viridans streptococci (in 29% of events), E. coli (14%), and Klebsiella spp. (14%) in the inpatient setting.

CONCLUSION

In this largest study of PHO MBI-LCBI inpatient events and the first such study in the ambulatory setting, the burden of MBI-LCBI across the continuum of care of PHO patients was substantial. These data should raise awareness of MBI-LCBI among healthcare providers for PHO patients, help benchmarking across centers, and help inform prevention and treatment strategies.

Pediatric Aggressive Mature B-Cell Lymphomas, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Pediatric aggressive mature B-cell lymphomas are the most common types of non-Hodgkin lymphoma in children, and they include Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL). These diseases are highly aggressive but curable, the treatment is complex, and patients may have many complicated supportive care issues. The NCCN Guidelines for Pediatric Aggressive Mature B-Cell Lymphomas provide guidance regarding pathology and diagnosis, staging, initial treatment, disease reassessment, surveillance, therapy for relapsed/refractory disease, and supportive care for clinicians who treat sporadic pediatric BL and DLBCL.

Prophylactic photobiomodulation therapy using 660 nm diode laser for oral mucositis in paediatric patients under chemotherapy: 5-year experience from a Brazilian referral service

The use of photobiomodulation therapy (PBMT) in the prevention of oral mucositis (OM) in paediatric care has increased. In this article, we report data of paediatric oncology/haematopoietic stem cell transplantation (HSCT) patients treated with PBMT to prevent chemotherapy-induced OM. A retrospective study was conducted at a Brazilian referral service. Prophylactic PBMT was used in children and adolescents (≤ 17 years) following the protocol: InGaAIP, 660 nm, 100 mW, 2 J, 3.33 W/cm², and 20 s per point. Demographic data and OM severity scores were assessed. A regression model tested the association between OM with prophylactic PBMT and antineoplastic therapy. A total of 148 individuals who had undergone 358 chemotherapy cycles were analysed. A higher occurrence of OM was observed in HSCT and osteosarcoma (OS) patients. Except for HSCT, OM was associated with methotrexate (MTX) use in all disease groups. PBMT significantly reduced OM severity in acute lymphoblastic leukaemia (ALL) and OS patients. OM grade was 3.16 and 5.45 times higher among individuals with ALL and OS, who had not undergone prophylactic PBMT compared with those who had undergone prophylactic PBMT (p < 0.001). PBMT prevented chemotherapy-induced OM. Individuals who used MTX and did not undergo prophylactic PBMT were at increased risk of OM.

Prevention of oral mucositis with cryotherapy in children undergoing hematopoietic stem cell transplantations-a feasibility study and randomized controlled trial

PURPOSE

To evaluate the feasibility of oral cryotherapy (OC) in children and to investigate if OC reduces the incidence of severe oral mucositis (OM), oral pain, and opioid use in children undergoing hematopoietic stem cell transplantation (HSCT).

METHODS

Fifty-three children, 4-17 years old, scheduled for HSCT in Sweden were included and randomized to OC or control using a computer-generated list. OC instructions were to cool the mouth with ice for as long as possible during chemotherapy infusions with an intended time of ≥ 30 min. Feasibility criteria in the OC group were as follows: (1) compliance ≥ 70%; (2) considerable discomfort during OC < 20%; (3) no serious adverse events; and (4) ice administered to all children. Grade of OM and oral pain was recorded daily using the WHO-Oral Toxicity Scale (WHO-OTS), Children's International Oral Mucositis Evaluation Scale, and Numerical Rating Scale. Use of opioids was collected from the medical records.

RESULTS

Forty-nine children (mean age 10.5 years) were included in analysis (OC = 26, control = 23). The feasibility criteria were not met. Compliance was poor, especially for the younger children, and only 15 children (58%) used OC as instructed. Severe OM (WHO-OTS ≥ 3) was recorded in 26 children (OC = 15, control = 11). OC did not reduce the incidence of severe OM, oral pain, or opioid use.

CONCLUSION

The feasibility criteria were not met, and the RCT could not show that OC reduces the incidence of severe OM, oral pain, or opioid use in pediatric patients treated with a variety of conditioning regimens for HSCT.

TRIAL REGISTRATION

ClinicalTrials.gov id: NCT01789658.

Systematic review of oral cryotherapy for the management of oral mucositis in cancer patients and clinical practice guidelines

PURPOSE

To update the 2013 Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) clinical practice guidelines on oral cryotherapy for the management of oral mucositis (OM) caused by cancer therapies.

METHODS

A systematic review was conducted by the Mucositis Study Group of MASCC/ISOO. The evidence for each intervention for specific cancer treatment modalities was assigned a level of evidence (LoE). The findings were added to the database used to develop the 2013 MASCC/ISOO clinical practice guidelines. Based on the LoE, the guidelines were set as: recommendation, suggestion, or no guideline possible.

RESULTS

A total of 114 papers were identified: 44 from PubMed and 70 from Web of Science. After abstract triage and merging with the 2013 database, 36 papers were reviewed. The LoE for prevention of OM with oral cryotherapy in patients undergoing autologous hematopoietic stem cell transplant using high-dose melphalan conditioning protocols was upgraded, and the guideline changed to recommendation. Additionally, the recommendation for prevention of OM with oral cryotherapy in patients receiving bolus 5-fluorouracil for the treatment of solid tumors was confirmed. No guidelines were possible for other clinical settings.

CONCLUSIONS

The evidence supports recommendations for the use of oral cryotherapy for the prevention of OM for either (i) patients undergoing autologous hematopoietic stem cell transplant with high-dose melphalan conditioning protocols or (ii) patients receiving bolus 5-fluorouracil chemotherapy.