Most harm during childhood cancer treatment comes from its effects on rapidly dividing normal cells: bone marrow (neutropenia, thrombocytopenia, anemia), mucosa (mucositis, nausea, diarrhea), and hair follicles (alopecia). The nurse's work centers on preventing and catching these effects, controlling pain and other symptoms, and supporting the child's development and family throughout — including when cure is no longer possible.
Palliative care is care that relieves suffering — physical, emotional, social, and spiritual — for children with serious illness and their families. It starts at diagnosis and runs alongside curative treatment; it is not limited to the last days of life. Hospice care is the end-of-life part of palliative care.
Nadir — the lowest blood counts usually occur about 7–14 days after most chemotherapy doses; infection and bleeding risks peak then.
Febrile neutropenia — the leading infection emergency
- Fever of 38.3 °C (101 °F) once or 38.0 °C (100.4 °F) sustained for 1 hour with an absolute neutrophil count (ANC) below 500/µL (0.5 × 10⁹/L) or expected to fall below that
- Fever may be the only sign — redness, pus, and infiltrates may be absent. Look at the mouth, central line site, perianal area, lungs, and skin
- Early sepsis: tachycardia, tachypnea, delayed capillary refill, cool extremities, altered behavior; hypotension is a late sign in children
Other effects to assess each visit
- Mucositis: oral pain, ulcers, drooling, refusing food or fluids
- Bleeding: petechiae, bruising, nosebleeds, gum bleeding, blood in urine or stool
- Anemia: pallor, fatigue, tachycardia
- Nutrition: weight trend, intake, nausea and vomiting, taste change
- Bowel pattern (vincristine and opioids cause constipation)
- Pain with a developmentally appropriate tool: FLACC (behavioral; preverbal or nonverbal children), FACES scale (about 3–4 years and older), numeric 0–10 (school age and older)
- Emotional state, sleep, school, peers, siblings, family coping
Signs that death is approaching: increasing sleep and withdrawal, decreased intake, reduced urine output, cool and mottled extremities, changes in breathing (pauses, irregular pattern), noisy upper-airway secretions. Hearing may persist to the end.
- CBC with differential before each cycle; ANC = WBC × (% segmented neutrophils + % bands) ÷ 100
- With fever: blood cultures from every lumen of the central line (and peripheral culture per policy), CBC, chemistry, lactate as ordered, urinalysis and culture, chest X-ray if respiratory signs
- Drug levels and organ function as required by the protocol
- In palliative care, tests are ordered only when the result will change comfort or care; avoid burdensome blood draws in the last days
Febrile neutropenia — broad-spectrum IV antibiotics within 60 minutes of arrival (e.g., an antipseudomonal beta-lactam such as cefepime or piperacillin-tazobactam; vancomycin added for specific indications); antifungals for persistent fever.
Supportive therapies
- Blood products: irradiated and leukoreduced red cells and platelets for children on chemotherapy or after HSCT; platelets prophylactically at low counts (commonly below 10,000/µL (10 × 10⁹/L) in stable children) or for bleeding. Transfusion reaction monitoring as for any transfusion
- Growth factors (filgrastim): bone pain; report left upper abdominal or shoulder pain (rare splenic rupture)
- Antiemetics given before chemotherapy and on a schedule: ondansetron (constipation, headache, QT prolongation), dexamethasone when allowed by the protocol, aprepitant for highly emetogenic regimens
- Prophylaxis: trimethoprim-sulfamethoxazole against Pneumocystis pneumonia in many protocols (rash, marrow suppression)
Pain management
- WHO two-step approach for children: mild pain — acetaminophen (or ibuprofen only when platelets and kidney function allow); moderate to severe — a strong opioid, usually morphine, dosed by weight and titrated
- Codeine and tramadol are not used in children under 12 (unpredictable metabolism → respiratory depression and death), nor after tonsillectomy or adenoidectomy under 18, and are avoided at 12–18 years with obesity, obstructive sleep apnea, or lung disease
- Give around the clock for persistent pain, plus rescue doses; oral route when possible; PCA for school-age children who can use it; avoid IM injections (painful, bleeding risk)
- Opioid safety: sedation usually precedes respiratory depression — assess sedation level and respiratory rate and depth; naloxone available; start a bowel regimen with the first opioid dose; watch for pruritus, nausea, urinary retention
- Procedures (LP, bone marrow aspiration, port access): topical anesthetic cream applied ahead of time, sedation or anesthesia as ordered, comfort positioning, distraction
End-of-life symptom control — opioids and a fan for dyspnea; repositioning and anticholinergic drugs for secretions; anxiolytics; antiseizure drugs if needed; stop treatments that no longer bring benefit (e.g., routine vital signs, lab tests, forced feeding).
Listed in priority order.
- Febrile neutropenia is an emergency — assess airway, breathing, and circulation first (SpO₂ and vital signs in a child with fever and dyspnea), obtain cultures, and start antibiotics within 60 minutes. Do not delay antibiotics for imaging or results
- Infection prevention
- Hand hygiene by everyone is the single most important measure
- No rectal temperatures, suppositories, or enemas; no IM injections when neutropenic or thrombocytopenic
- Central line: sterile dressing changes, needleless connector scrubbing, daily review of need; flush per protocol
- Private room when profoundly neutropenic; screen visitors for illness; safe food handling; no fresh flowers or standing water per policy
- Bleeding precautions (low platelets) — soft toothbrush or sponge, no flossing when very low, electric razor, avoid aspirin and NSAIDs, pressure on puncture sites, safe play (no contact sports), stool softeners
- Mucositis care
- Frequent gentle oral care with a soft toothbrush and bland rinses (saline or sodium bicarbonate)
- Avoid alcohol-based mouthwash, hydrogen peroxide, lemon-glycerin swabs, and hot, spicy, acidic, or rough foods
- Keep mucosa moist with frequent sips; lip balm; soft, cool foods
- Analgesia for eating — topical agents as prescribed, systemic opioids for severe mucositis
- Extravasation — stop the infusion immediately at the first sign of pain, burning, or swelling; follow the vesicant protocol
- Nutrition — small, frequent, high-calorie, high-protein meals; favorite foods; weekly weights; enteral feeds if losing weight; food safety
- Anemia and fatigue — cluster care, rest periods, transfusion as ordered
- Body image and development — prepare for hair loss (hair usually regrows after treatment, sometimes different in color or texture); hats, scarves, wigs; maintain school contact and friendships; play and age-appropriate choices
- Palliative and end-of-life care — relieve pain and dyspnea promptly; honest communication; involve the child in decisions at a developmental level (assent); respect cultural and spiritual practices; create memories (handprints, photos, recordings); keep the family together; bereavement follow-up
Children's understanding of death
| Age | Typical understanding | Nursing approach |
|---|
| Infant–toddler | No concept of death; senses separation and parental distress | Keep routines and parents close; comfort touch |
| Preschool (3–5) | Death seen as temporary or reversible; may think it is a punishment (magical thinking) | Simple, concrete words ("died," not "went to sleep"); reassure that nothing they did caused it |
| School age (6–12) | Gradually understands death is permanent, universal, and irreversible (by about 9–10); fears the unknown and bodily harm | Honest answers; allow control and questions; involve in plans |
| Adolescent | Adult-like understanding; struggles with independence, identity, and loss of future | Privacy; respect decisions and advance care planning; peer contact |
- Fever: take temperature (oral or axillary) whenever the child feels unwell; call the oncology team immediately for 38.0 °C (100.4 °F) or higher — do not give fever medicine before calling (it can mask fever)
- Avoid crowds and sick contacts; wash hands often; no live vaccines for the child during treatment. Siblings and household members should receive routine vaccines, including yearly inactivated influenza; MMR and varicella vaccines are generally safe for siblings (if a vaccine rash develops, avoid contact); after rotavirus vaccine in an infant sibling, use careful hand hygiene with diapers
- Report chickenpox or measles exposure at once — post-exposure protection may be needed
- Bleeding precautions and when to seek care (nosebleed over 10 minutes, blood in urine or stool)
- Mouth care routine; nutrition tips; constipation prevention
- Opioids at home: dose exactly as prescribed, lock up the medicine, give the laxative daily, report excessive sleepiness or slow breathing
- Returning to school: most children can attend between treatment phases; the school must notify the family about chickenpox or measles cases
- Palliative care is not "giving up" — it can be provided together with cancer treatment
- Talk honestly with the child and siblings; siblings may feel neglected, jealous, or guilty and need their own support
| Red flag | Concern |
|---|
| Fever in a child on chemotherapy | Febrile neutropenia — antibiotics within 60 minutes |
| Tachycardia, cool extremities, altered behavior with fever | Septic shock (hypotension is late) |
| Fever with dyspnea and hypoxemia | Pneumonia, fungal infection |
| Sedation increasing, respiratory rate falling on opioids | Opioid toxicity — stop dose, stimulate, naloxone |
| Headache or altered consciousness with very low platelets | Intracranial hemorrhage |
| Pain, swelling at the infusion site | Extravasation |
| Unable to swallow saliva, severe mouth pain | Severe mucositis — dehydration risk |
| Uncontrolled pain or distress at end of life | Urgent palliative review |
- Chemotherapy nadir about 7–14 days; fever may be the only sign of infection
- Febrile neutropenia: 38.3 °C once or 38.0 °C for 1 hour + ANC < 500 → cultures and antibiotics within 60 minutes
- Hand hygiene is the top infection-prevention measure; no rectal temperatures
- Fever + dyspnea in a child on chemotherapy → SpO₂ and vital signs first
- Mucositis: soft toothbrush, saline or bicarbonate rinses; no hydrogen peroxide or alcohol mouthwash
- Extravasation: stop the infusion immediately
- Pain: acetaminophen/ibuprofen → morphine; no codeine or tramadol under 12
- Opioids: sedation precedes respiratory depression; start a bowel regimen; naloxone
- No live vaccines for the child; household contacts get inactivated influenza yearly
- Palliative care begins at diagnosis and runs alongside curative care
- Preschoolers see death as reversible; permanence is understood by about 9–10 years
Country Notes
United States
- Under the Affordable Care Act, children in Medicaid and CHIP can receive hospice care while continuing curative treatment ("concurrent care").
- Codeine and tramadol carry FDA contraindications for children under 12 and after tonsillectomy or adenoidectomy under 18, with warnings against use at 12–18 years with obesity, obstructive sleep apnea, or lung disease.
Philippines
- Families often provide much of the bedside care in hospital wards; include them in hand hygiene, food safety, and fever teaching.
- Oral morphine availability may be limited outside major centers, and prescribers need special controlled-substance prescription forms — plan discharge analgesia early.
- Faith and family traditions strongly shape end-of-life decisions; ask about prayers, sacraments, or rituals the family wants and support them.