How to manage mucus in children undergoing standard chemotherapy?

Management of Mucus in Children Undergoing Standard Chemotherapy

For children undergoing standard chemotherapy, oral cryotherapy for 30 minutes during administration of bolus 5-FU chemotherapy and systematic oral care protocols with regular saline rinses are the most effective interventions for managing mucus and preventing severe mucositis. 1

Assessment and Grading

• Use the WHO Oral Mucositis Scale to assess severity:

  • Grade 1: Soreness/erythema
  • Grade 2: Erythema, ulcers, able to eat solids
  • Grade 3: Ulcers, able to eat liquids only
  • Grade 4: Alimentation not possible 2

• Daily inspection of oral mucosa is essential to monitor for mucositis development and excess mucus production 2

Prevention Strategies

Oral Care Protocol

1. Basic oral hygiene:

   • Use a soft toothbrush that is replaced regularly 1
   • Non-medicated saline mouth rinses 4-6 times daily 2
   • Avoid alcohol-based mouth rinses 2

2. Preventive measures for specific chemotherapy regimens:

   • For bolus 5-FU chemotherapy: 30 minutes of oral cryotherapy (ice chips) 1
   • For edatrexate: 20-30 minutes of oral cryotherapy 1

3. Radiation-specific prevention (if combined with chemotherapy):

   • Use of midline radiation blocks and three-dimensional radiation treatment 1, 2
   • Benzydamine oral rinse for patients receiving moderate-dose radiation therapy 1, 2

Treatment Approaches

Mild to Moderate Mucositis (Grade 1-2)

1. Pain management:

   • Topical anesthetics (e.g., lidocaine) for short-term relief 2
   • Acetaminophen for mild pain 2
   • 0.5% doxepin mouthwash may be effective for pain relief 2

2. Mucus management:

   • Regular saline rinses to clear excess mucus 2
   • Guaifenesin (5-10 mL every 4 hours for children 6-12 years; 2.5-5 mL every 4 hours for children 2-6 years) to help loosen phlegm and thin bronchial secretions 3
   • Maintain adequate hydration to keep secretions thin 1, 2

Severe Mucositis (Grade 3-4)

1. Pain management:

   • Patient-controlled analgesia with morphine is recommended for severe oral mucositis pain in patients undergoing HSCT 1
   • 0.2% morphine mouthwash for pain due to oral mucositis 2
   • Transdermal fentanyl for continuous pain control 2

2. Nutritional support:

   • Enteral nutrition via nasogastric tube or percutaneous endoscopic gastrostomy (PEG) 2
   • Parenteral nutrition only if oral/enteral nutrition is not possible 2

3. Advanced interventions:

   • For patients undergoing HSCT: Palifermin (keratinocyte growth factor-1) at 60 μg/kg/day for 3 days before conditioning treatment and for 3 days post-transplant 1, 2
   • Low-level laser therapy (LLLT) for patients receiving high-dose chemotherapy or chemoradiotherapy before HSCT 1

Special Considerations for Different Chemotherapy Regimens

• High-risk regimens with greater mucositis risk:

  • TAC (docetaxel + adriamycin + cyclophosphamide): 4.92% risk of grade 3-4 oral mucositis 1
  • FOLFIRI (5-FU + leucovorin + irinotecan): 4.43% risk of grade 3-4 oral mucositis 1
  • IROX (irinotecan + oxaliplatin): 1.48% risk but 24.33% risk of grade 3-4 diarrhea 1

• For gastrointestinal mucositis:

  • Ranitidine or omeprazole for prevention of epigastric pain following treatment with cyclophosphamide, methotrexate and 5-FU 1
  • Octreotide (at least 100 μg s.c. twice daily) when loperamide fails to control diarrhea 1

Risk Factors to Monitor

Children at higher risk for developing severe mucositis include:

• Those with neutropenia (lower nadir neutrophil count) 4
• Children with elevated serum creatinine 4
• Those with lower body weight prior to chemotherapy 4
• Patients receiving high-dose chemotherapy with HSCT 5

Common Pitfalls and Caveats

• Do not use:

  • Chlorhexidine to treat established oral mucositis 1
  • Acyclovir and its analogues to prevent mucositis caused by standard-dose chemotherapy 1
  • Antimicrobial lozenges for prevention of radiation-induced oral mucositis 1

• Critical monitoring:

  • Assess for signs of secondary infections, which can worsen mucositis 2
  • Monitor nutritional status, as neglecting nutritional support can worsen outcomes 2
  • Regular pain assessment using validated instruments should be conducted at least daily 2

• Treatment modifications:

  • Consider temporary dose reduction or treatment interruption for severe mucositis that doesn't respond to supportive care 2

Oral mucositis in childhood is more frequent and severe compared to adults, especially in children with leukemia 6. Proper management is essential as it can drastically affect cancer treatment as well as the patient's quality of life 5. Early intervention and consistent oral care are key to preventing severe complications.