How to manage mucus in children undergoing standard chemotherapy?

Management of Mucus in Children Undergoing Standard Chemotherapy

Oral cryotherapy (ice chips) for 30 minutes during administration of bolus 5-FU chemotherapy is the most effective intervention for preventing mucositis in children undergoing standard chemotherapy. 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 2

• Regular pain assessment using validated instruments should be conducted at least daily 2

Prevention Strategies

For Standard-Dose Chemotherapy

1. Oral Cryotherapy:

   • 30 minutes of oral cryotherapy for children receiving bolus 5-FU chemotherapy 1
   • 20-30 minutes for children treated with bolus doses of edatrexate 1

2. Oral Care Protocol:

   • Systematic oral care with soft toothbrush replaced regularly 1, 2
   • Non-medicated saline mouth rinses 4-6 times daily 2
   • Avoid alcohol-based mouth rinses 2

3. Medications NOT Recommended for Prevention:

   • Acyclovir and its analogues are not recommended 1
   • Chlorhexidine is not recommended 1

For High-Risk Patients (HSCT/High-Dose Chemotherapy)

1. Palifermin (keratinocyte growth factor-1):

   • 60 μg/kg/day for 3 days before conditioning treatment and for 3 days post-transplant 1, 2
   • For patients with hematological malignancies receiving high-dose chemotherapy 1

2. Cryotherapy for patients receiving high-dose melphalan 1

3. Low-Level Laser Therapy (LLLT) for patients undergoing high-dose chemotherapy before HSCT 1

   • Note: Recent meta-analysis suggests LLLT may not be effective for prevention of OM grade ≥II in children 3

Treatment Approaches

Pain Management (Stepped Approach)

1. Mild Pain:

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

2. Moderate Pain:

   • Immediate-release oral opioids 2
   • 0.2% morphine mouthwash for patients receiving chemoradiation therapy 2

3. Severe Pain:

   • Patient-controlled analgesia with morphine (recommended as treatment of choice for oral mucositis pain in HSCT patients) 1
   • Transdermal fentanyl for continuous pain control 2

Nutritional Support

• Individualized nutritional counseling and oral nutritional supplements are critical 2
• For Grade 3-4 mucositis:
  • Consider enteral nutrition via nasogastric tube or percutaneous endoscopic gastrostomy (PEG) 2
  • PEG is associated with lower risk of tube dislodgement compared to nasogastric tubes 2
  • Parenteral nutrition only if oral/enteral nutrition is not possible 2

Hydration

• Maintain adequate hydration throughout treatment 2
• Aggressive hydration for patients with severe mucositis 2
• A liquid diet may be necessary for patients with Grade 3 mucositis 2

Management of Gastrointestinal Mucositis

• For epigastric pain: Either ranitidine or omeprazole are recommended following treatment with cyclophosphamide, methotrexate and 5-FU 1
• For diarrhea: Octreotide at a dose of at least 100 μg s.c. twice daily when loperamide fails to control diarrhea 1

Special Considerations

Treatment Duration

• For mild mucositis (Grade 1-2): 7-10 days of treatment is typically sufficient 2
• For moderate to severe mucositis (Grade 3-4): Treatment may need to extend to 14 days or until resolution of symptoms 2

Risk Factors to Monitor

• Lower body weight prior to chemotherapy 4
• Neutropenia (lower nadir neutrophil count) 4
• Elevated serum creatinine 4
• Children with leukemia have higher risk of severe mucositis compared to adults 5

Pitfalls and Caveats

• Neglecting oral care can lead to severe complications, including shedding of oral mucosa as reported in a child with pre-B ALL 6
• Mucositis can limit the patient's ability to tolerate chemotherapy, compromising treatment outcomes 7
• Honey may be a promising treatment for oral mucositis in children, showing effectiveness in shortening hospital stay in severe cases 3
• Guaifenesin can help loosen phlegm and thin bronchial secretions to make coughs more productive, but is not specifically indicated for chemotherapy-induced mucositis 8

By following this comprehensive approach to managing mucus and mucositis in children undergoing chemotherapy, clinicians can significantly reduce the severity and duration of this common and debilitating side effect, improving quality of life and potentially improving treatment outcomes.