Managing Side Effects of Childhood Cancer
Treatment
Rosalind Bryant, MN, RN-CS, PNP
This article focuses on the nurse’s role as a member of the supportive care team for the child diagnosed with cancer and the
family. The most common side effects of the cancer treatment are discussed in depth in this article. The adequate management
of the side effects experienced by the child receiving cancer therapy may greatly influence the child’s quality of life.
Copyright 2003, Elsevier Inc. All rights reserved.
T HE PEDIATRIC ONCOLOGY nurse plays a
major supportive role for the family of a
child diagnosed with cancer in their initial reac-
tions of helplessness, anxiety, guilt, denial, and
anger. Education of the family and child regarding
the treatment plan or protocol (e.g., chemotherapy,
radiotherapy, and/or surgery) is crucial to relieving
parents’ fears and anxieties. Even though the ex-
planation of the diagnosis and treatment plan sup-
ports the hope that their child may survive cancer,
the word cancer still conveys a life-threatening
illness.
As a guide for oncology nurses, the Association
of Pediatric Oncology Nurses published a pam-
phlet entitled Scope and Standards of Pediatric
Nursing Practice (O’Neill, Cleaveland, Forte, et
al., 2000). This pamphlet outlines the role and
responsibilities of the pediatric oncology nurse
across the continuum of care (e.g., physical care,
growth and development, psychologic care, educa-
tion, palliative care, long-term survival, and pre-
vention/early detection) (O’Neill, Cleaveland,
Forte, et al., 2000) and also serves as a guide for all
pediatric nurses caring for the child with cancer.
Oncology nurses educate the family and child re-
garding the diagnosis, treatment plan, and medica-
tions, as well as the recognition and the manage-
ment of side effects. The supportive care team
(physician, nurse, dietician, psychologist, social
worker, child life specialist, and chaplain) assist
the patient and family by working together as a
unit to manage the side effects of therapy. The
most common cancer therapy side effects include
immunosuppression and infection, thrombocytope-
nia, anemia, malnutrition, nausea and vomiting,
Journal of Pediatric Nursing, Vol 18, No 2 (April), 2003
mucositis, pain, and the psychosocial aspects of the
illness.
TREATMENT SIDE-EFFECTS
Immunosuppression and Infection
Immunosuppression is defined as the body’s im-
mune system inability to respond to pathogenic
organisms and tissue damage. Children with cancer
become immune impaired from a number of
causes. Lymphocyte function can be altered by
stem cell defects preventing normal lymphocyte
development. Splenic dysfunction in the cancer
patient can prevent maturation of the blood cells,
and alterations in the inflammatory response can
impair host resistance (Kline, 2002). Cancer ther-
apy can decrease immunoglobulin concentrations
and cause defects in cellular immunity.
Significant neutropenia can develop during che-
motherapy creating an increased risk for infection
in the child with cancer. Neutropenia occurs when
the absolute neutrophil count decreases below 500
cells/mm3 or when the absolute neutrophil count
between 500 and 1,000 cells/mm3 is expected to
decline secondary to cancer therapy (for calcula-
tion of absolute neutrophil count see Table 1).
Neutropenic precautions should be stressed as
From the Texas Children’s Cancer Center, Baylor College of
Medicine, Houston, TX.
Address correspondence and reprint requests to Rosalind
Bryant, MN, RN-CS, PNP, Texas Children’s Cancer Center,
Baylor College of Medicine, One Baylor Plaza, Houston, TX
77030. E-mail: robryant@bcm.tmc.edu.
Copyright 2003, Elsevier Inc. All rights reserved.
0882-5963/03/1802-0005$30.00/0
doi:10.1053/jpdn.2003.11
113
114
Table 1. Calculation of Absolute Neutrophil Count
WBC ⫽ 7.4 K/UL (also expressed as 7,400 UL or 7.4 ⫻
103/mm3); neutrophils (poly/segs) ⫽ 40%; nonsegmented
neutrophils (bands) ⫽ 12%; lymphocytes ⫽ 39%; monocytes ⫽
4%; basophils ⫽ 2%; esinophils ⫽ 3%.
Step 1: Determine total percent neutrophils (poly/segs ⫹ bands)
40% ⫹ 12% ⫽ 52% (0.52)
Step 2: Multiply WBC by % neutrophils
ANC ⫽ 7,400 ⫻ 0.52
ANC ⫽ 3,848 (normal)
WBC ⫽ 0.9 K/ULC 900 or 0.9 ⫻ 103/mm3)
Neutrophils (poly/segs) ⫽ 7%
Nonsegmented neutrophils (bands) ⫽ 7%
Lymphocytes ⫽ 76%; monocytes ⫽ 5%; basophils ⫽ 2%; esinophils
⫽ 3%.
Step 1: 7% ⫹ 7% ⫽ 14% (0.14)
Step 2: ANC ⫽ 900 ⫻ 0.14
ANC ⫽ 126 (severely neutropenic)
WBC, white blood cell; ANC, absolute neutrophil count
part of the nursing care of the cancer patient (see
Table 2).
Most neutropenic patients do not present with a
confirmed site of infection and empirically are
given broad-spectrum antibiotics. Multiple antibi-
otics and growth factors are given to the patients
with prolonged neutropenia (i.e., 7 days or longer)
owing to the increased incidence of developing
secondary infections. Granulocyte colony stimu-
lating factor (G-CSF), a frequently used growth
factor, decreases the duration of neutropenia by
stimulating the proliferation of the progenitor (an-
cestor) cells of the granulocytes, specifically the
neutrophils. The most common dose and route of
administration of G-CSF are 5 mcg/kg/d given
subcutaneously beginning 24 hours after the last
dose of myelosuppressive chemotherapy (Wool-
ery-Antill, 2002). G-CSF is usually discontinued
after the nadir occurs (point of the lowest neutro-
phil count after chemotherapy), at which time the
neutrophil count usually returns to the patient’s
baseline values. Children receiving G-CSF require
close monitoring of blood counts to evaluate the
G-CSF response. Currently, there are no known
long-term side effects, however, the only consis-
tent side effect is bone pain. A dull, transient achy
bone pain most often begins 2 to 3 days after the
initiation of the G-CSF in response to neutrophil
proliferation and is relieved once the neutrophils
appear in the circulating blood (Woolery-Antill).
The American Society of Clinical Oncology rec-
ommend the use of hemapoietic growth factors be
reserved for high-risk patients experiencing pro-
longed fever and neutropenia (Woolery-Antill).
A major challenge for the nurse caring for a
child with fever and neutropenia is monitoring for
ROSALIND BRYANT
signs of sepsis (e.g., peripheral perfusion, temper-
ature of extremities, level of consciousness, vital
signs, and pulse oximetry). Sepsis is defined as the
clinical suspicion of infection with evidence of a
systemic response including hypotension, tachy-
cardia, tachypnea, hyperthermia or hypothermia,
leukocytosis, or leukopenia (Kline, 2002). Fever is
the principal and sometimes only initial indication
of serious infection or sepsis in the immunocom-
promised patient. These children should be exam-
ined daily by the nurse for signs of infection in-
volving the oral cavity, lungs, gastrointestinal tract
including the perineal area, skin, and soft tissues
(Alexander, Freifeld, Walsh, & Pizzo, 2002). Be-
cause most infectious origins develop from the
child’s own endogenous flora, the nurse should
encourage the parents/child to adhere to strict
handwashing practices, perform frequent mouth
care, perianal hygiene, and avoid the use of rectal
thermometers owing to the chance of introducing
pathogens through the rectal mucosa. Protective
isolation and food sterilization have little impact
on decreasing infectious rates in the neutropenic
child. The child and family also are encouraged to
verbalize their fears and anxieties related to the
febrile life-threatening neutropenic event. Pneumo-
cystis carinii pneumonia (PCP) is a serious life-
threatening opportunistic infection that presents
most commonly as a diffuse pulmonary infiltrate in
the immunocompromised patient. This infection is
thought to result from a reactivation of latent PCP
cysts because almost all normal children possess
detectable antibodies to the organism (Alexander
et al., 2002). Children with lymphomas and those
who are maintained on steroids as part of their
therapy for acute lymphocytic leukemia appear to
be at high risk for the development of PCP (Alex-
Table 2. Neutropenic Precautions
Call the Health Care Provider immediately if the child has a fever ⱖ
38.5°C or if persistent fever ⱖ38.0°C over 2 to 3 hours (Pizzo &
Alexander, 1999a, 1999b; Mendelson, 1998).
Maintain strict handwashing by all caregivers before and after
patient care.
Avoid crowded areas and contact with individuals who are known
to have infectious illnesses (e.g., varicella, influenza, respiratory
syncytial virus, adenovirus, or herpes zoster or herpes simplex).
Avoid urinary catheterization.
Avoid rectal temperatures, suppositories, and enemas.
Practice meticulous oral, personal, and perianal hygiene on a daily
basis.
Notify the health care provider immediately if the child is exposed
directly to varicella (e.g., classmate, sibling, playmate, or
hospital/clinic exposure).
Avoid live virus vaccines (e.g., measles, mumps, rubella vaccine.
Implement protective isolation as indicated by institution’s policy.
CANCER TREATMENT SIDE EFFECTS
ander et al., 2002). The incidence of PCP has been
reduced significantly with the use of prophylactic
agents, therefore, the nurse should stress with the
parent and the child the importance of being com-
pliant. Cancer centers routinely recommend tri-
methroprim-sulfamethoxazole 150mg/M2/d di-
vided into two daily doses given 3 consecutive
days per week during therapy. Other alternative
prophylactic regimens include dapsone 2 mg/kg/d
(maximum dose 100 mg/d), or monthly aerosolized
pentamidine 300 mg/dose or intravenous pentam-
idine 4mg/kg/dose monthly (Hockenberry & Kline,
2002).
Varicella Infections
Varicella (chickenpox) is a highly contagious
virus that causes pruritic, maculopapular, vesicular
lesions. Infected persons shed the virus 24 to 48
hours before the lesions appear and continue until
the vesicles have crusted over. The incubation pe-
riod ranges from 7 to 21 days after direct exposure
to the virus. Herpetic zoster (shingles) occurs in
individuals who have had varicella previously. The
virus remains dormant in the nerve roots in the
latent form and can become reactivated during
periods of immunosuppression or stress. Initial
symptoms include pain along the involved derma-
tone and then a vesicular rash on an erythematous
base evolves 48 to 72 hours later. If an immuno-
suppressed child with no history of varicella infec-
tion or varicella immunization has direct contact
with an individual with chickenpox or shingles,
varicella zoster immune globulin should be admin-
istered within 96 hours of the initial exposure
(Pawlik, 1998). The dose of varicella zoster im-
mune globulin is 125 U/10 kg given intramuscu-
larly with a maximum dose of 625 U (Pawlik).
Children who are exposed to varicella or shingles
and treated with varicella zoster immune globulin
require strict isolation from other immunosup-
pressed children for 8 to 28 days after initial ex-
posure (American Academy of Pediatrics, 2000).
The immunosuppressed child on therapy who de-
velops varicella or zoster usually is treated with
intravenous or oral doses of acyclovir. The dose of
acyclovir is 1500 mg/M2/d in divided doses every
8 hours intravenously for 7 days or until lesions
have crusted. Oral acyclovir usually is not used to
treat immunocompromised children with varicella
because of the poor oral bioavailability. However,
some experts have used oral acyclovir in selected
immunocompromised patients at a lower risk for
developing severe varicella such as children with
115
leukemia in whom careful follow-up evaluation is
assured (American Academy of Pediatrics).
Nursing care of the immunosuppressed child
with varicella includes assessing for signs of sec-
ondary bacterial infection (e.g., lesions, lung) and
keeping the child well hydrated to prevent renal
toxicity associated with acyclovir administration.
Airborne and contact precautions should be imple-
mented by using gowns, gloves, and masks as
indicated by the institution. Other interventions,
such as keeping the nails short and clean, applying
topical antipruritics (i.e., calamine lotion, colloidal
oatmeal baths), and administering intravenous flu-
ids or oral antipruritics also are implemented.
Central Venous Access Devices–Related
Infections
Approximately 2 decades ago, central venous
access devices (CVAD) were introduced as an
integral part of the pediatric oncology patient’s
treatment plan. These devices are used for admin-
istration of chemotherapy, blood components, an-
tibiotics, intravenous fluids, total parenteral nutri-
tion, medications, and blood sampling. CVAD-
related infections typically are defined as the
isolation of an organism from a blood sample,
catheter tip, or the catheter exit site (Weiner &
Albanese, 1998). Several types of CVAD includ-
ing external catheters (e.g., Broviac威 and Hick-
man威 [Band Access Systems, Murray Hill, NJ]
catheters) and implantable catheters (e.g., Port-a-
cath [Deltec at deltec.com]) are used in the cancer
patient. More recently, the temporary external
catheters known as percutaneous central venous
catheters are being used. The nurse is in a signif-
icant position to recognize and prevent CVAD-
related infections by:
● Observing and instructing the patient and family
to report signs of catheter infection such as fe-
ver, chills, swelling, pain, drainage, or erythema
immediately;
● Reinforcing with the patient and family to use
aseptic technique in dressing changes and flush-
ing of the external catheter;
● Reinforcing with the patient and family to ad-
here to institutional protocols for CVAD medi-
cation and fluid administration within the home
setting;
● Avoiding trauma to the catheter or catheter site
(e.g., contact sports, pulling catheter line);
● Verifying appropriate needle placement in an
implantable port;
● Observing for signs of catheter occlusions (e.g.,
116
inadequate or no blood return, unable to flush
catheter).
Immunizations
Live vaccines are contraindicated in the immu-
nosuppressed child until the immune system has
recovered, which occurs 3 to 12 months after the
completion of cancer chemotherapy. Administer-
ing inactivated vaccines (e.g., diphtheria, tetanus,
acellular pertussis, and Haemophyllus influenzae
type B) to the immunosuppressed child with an
absolute lymphocyte count greater than 700 mm3 is
at the discretion of the physician because mounting
a response to the vaccination during cancer treat-
ment is questionable (Hockenberry & Kline,
2002). A child’s immune response to a vaccine can
be determined by performing vaccine titers.
Children scheduled for spleen radiation or re-
moval should be immunized with the pneumococ-
cal and meningiococcal vaccines at least 2 weeks
before the planned procedure. The influenza vac-
cine is recommended by cancer centers because it
can be administered safely to the immunosup-
pressed patient as well as the staff that care for
these children. The physician and nurse should
provide guidance to parents regarding which im-
munizations can be given safely to the immuno-
suppressed child.
Anemia
Many children with cancer will develop anemia
or a reduction in red blood cells during the course
of cancer treatment. Some common causes of ane-
mia include erythroid hypoplasia caused by bone
marrow suppression caused by cancer chemother-
apy or radiation therapy. Nutritional deficiencies
(e.g., iron, B12, or folate) and bone marrow infil-
tration with tumor/disease or blood loss may all
contribute to the development of anemia.
Transfusions often are given when the hemoglo-
bin concentration is between 6 to 8 g/dL and de-
clining and/or when the child manifests signs of
anemia such as severe fatigue, headache, irritabil-
ity, or tachycardia. During radiation therapy, many
institutions transfuse to maintain a hemoglobin
level between 8 to 10 g/dL because radiation ther-
apy is felt to be more effective in an oxygen-rich
environment (Rieger & Haeuber, 1995). Transfu-
sion therapy includes administration of leukocyte-
depleted, irradiated, packed red blood cells
(PRBCs) at a dose of 10 mL/kg, which usually
increases the hemoglobin level 2 to 3 g/dL. Chil-
dren with severe anemia (⬍6 g/dL) may need the
PRBCs to be delivered slowly (2-3 mL/kg/h) in
ROSALIND BRYANT
separate small multiple transfusions (aliquots) to
avoid development of congestive heart failure and
pulmonary edema. General guidelines for blood
product administration are found in Table 3.
Methods of reducing the large number of leuko-
cytes in a unit of PRBCs are performed primarily
through filtration and irradiation. The use of mi-
croaggregate filtration during the collection and the
administration of PRBCs removes almost all the
leukocytes without damaging the red blood cells.
Because cytomegalovirus travels by way of the
lymphocytes, the use of the microaggregate filter
has decreased significantly the incidence cytomeg-
alovirus-transmitted infection (Norville & Bryant,
2002). PRBCs also are treated with irradiation
(2,500-3,000 cGy), which renders the donor’s lym-
phocytes incapable of replication, therefore pre-
venting transfusion-associated graft-versus-host
Table 3. Guidelines for Blood Component Administration
Identify the patient.
Obtain the ordered blood component from the blood bank.
Administer premedications if indicated (e.g., acetaminophen,
solunedrol, diphenhydramine hydrochloride). Question whether
steroids can be used for premedication in patient on protocol.
Before administration:
Verify physician order.
Compare donor identification numbers and ABO-Rh compatibility
on transfusion record with information on blood component
and double check with another nurse.
Verify leukoreduction and/or irradiated product. Check with
another nurse.
Identify patient with full name using the identification band.
Compare full name of patient with the identification on blood
component and transfusion record
Do not transfuse component if information does not exactly match
Check expiration date and time on blood component.
Once it is determined that everything is correct, sign the
transfusion record.
Inspect the blood component for color and consistency, turning
component upside down to gently mix its contents.
Prepare filter, tubing, and 0.9% normal saline flush solution.
Record patient’s baseline vital signs.
Start transfusion and record date and time of initiation.
Stay with the patient for the first 5 to 15 minutes to assess for an
acute reaction.
Record patient’s vital signs 15 minutes after the initiation of the
transfusion and as required by institutional policy.
At completion, document patient’s condition, vital signs, and
complete transfusion record.
Place copy of transfusion record in patient’s chart and return copy
to blood bank.
Always use universal precautions when handling blood components
and contaminated equipment.
Disposal of bag and tubing per institutional policy.
Adapted from Jassak, P., & Godwin, J. (1991). Blood component
therapy. In S. B. Baird, R. McCorkle, & M. Grant (Eds.), Cancer
nursing comprehensive textbook (p. 38). Philadelphia: W.B. Saunders
Co.
CANCER TREATMENT SIDE EFFECTS
disease (Rossetto & McMahon, 2000). Graft-ver-
sus-host disease develops when viable T lympho-
cytes attack the host and occurs 1 to 2 weeks after
the transfusion. It is manifested by fever, maculo-
papular skin rash, diarrhea, and hepatitis with or
without jaundice (Rossetto and McMahon). Both
filtration and irradiation methods have reduced
greatly the number of transfusion reactions.
Thrombocytopenia
Thrombocytopenia is defined commonly as a
platelet count less than 100,000 mm3 that develops
as a result of increased destruction, decreased pro-
duction, or loss of platelets (Panzarella, Rasco-
Baggot, & Comeau, et al., 2002). The principal
cause of bleeding in children with cancer is the
suppression of platelet production caused by che-
motherapy or radiation therapy.
The pediatric oncology nurse plays an instru-
mental role in teaching the caregiver thrombocy-
topenic precautions (see Table 4). Platelet infu-
sions are administered in the thrombocytopenic
patient if there is active bleeding or if decreased
platelet counts contribute to bleeding. Platelet
transfusions are indicated for patients undergoing
major surgery with a platelet count less than
50,000 mm3; patients receiving medications that
interfere with platelet production, and brain tumor
patients with platelet counts between 30,000 to
Table 4. Common Thrombocytopenic Precautions
Observe for signs and symptoms of bleeding (excessive bruising,
petechiae, bloody or black stools, hematuria, prolonged
nosebleeds [⬎ 10 min with continuous pressure], gingival
bleeding).
Avoid contact sports and rough activities (e.g., football, soccer,
wrestling, bicycle riding, skate boarding, roller-blading, diving,
tree climbing, trampolines, scooters, and go cart riding).
Provide safe environment to prevent trauma (e.g., use of siderails,
gates, helmets, and knee pads) and avoid rectal manipulation
(thermometers, suppositories, and enemas) and urinary
catheterization.
Avoid oral mucosa trauma (use soft toothbrush or swab stick for
oral care, avoid dental floss and eating sharp food items such as
chips and ice).
Use a nail file instead of clippers for nail trimming.
Notify health care provider before invasive procedures (e.g., dental
work, placement of nasogastric tube, endoscopy).
Use an electric shaver rather than a razor blade (adolescent).
Add stool softeners and increase fiber in diet to prevent
constipation.
Avoid use of aspirin/aspirin-containing products and cautiously use
nonsteroidal anti-inflammatory agents (ibuprofen, motrin) under
medical supervision only.
Invasive procedures (i.e., lumbar puncture and bone marrow
aspiration, nasogastric tube placement) should be performed with
caution.
117
50,000 mm3 to avoid bleeding into the tumor (Nor-
ville & Bryant, 2002). Unless the child is bleeding
or is at a high risk for bleeding, platelet transfu-
sions usually are avoided to decrease the likelihood
of alloimmunization (Norville & Bryant).
The nurse administers the platelet infusions as
rapidly as possible depending on the age and clin-
ical status of the patient. The frequency of taking
vital signs tend to vary among institutions, but
should be assessed before the platelet infusion and
at the end of the infusion. The nurse should fre-
quently assess the child’s skin, gums, emesis, secre-
tions, stool, and urine for blood as well as reinforce
thrombocytopenic precautions (see Table 4).
Malnutrition
Malnutrition in the pediatric oncology popula-
tion has been reported to occur in 8% to 32% of
patients (Han-Markey, 2000). Nutritional require-
ments vary among children with cancer, depending
on the diagnosis, tumor location, and treatment
regimen (e.g., surgery, radiation, and chemother-
apy). At diagnosis, nutritional goals focus on main-
taining normal growth and development as well as
preventing nutritional deficiencies. These goals are
accomplished by the assessment of the child’s nu-
tritional status and the development of an individ-
ualized nutritional care plan. The initial nutritional
assessment includes a history of the child’s eating
habits, serum albumin/prealbumin levels, food al-
lergies, use of nutritional supplements, and base-
line weight and height measurements. Depending
on the nutritional assessment of the patient, the use
of the nutritional support algorithm can assist in
determining the type of treatments to be used (e.g.,
enteral, parenteral, or a combination of these treat-
ments) (Bowman, Williams, Sanders, et al., 1998)
(see Figure 1).
Enteral feedings, whether used as a supplement
or as the sole means of nutritional intake, are a
highly successful method of reversing malnutrition
and maintaining adequate nutritional status in the
pediatric cancer patient. Enteral feeding preserves
the integrity of the intestinal mucosa by keeping
it functional (Nitenberg & Raynard, 2000). The
nurse should observe for enteral feeding complica-
tions such as nausea, vomiting, diarrhea, constipa-
tion, or tube irritation (nasal or gastrostomy button
site). Treatment of the feeding complications in-
clude using sterile gauze to protect the gastrostomy
button insertion site, adjusting the infusion rate of
the feeds, adjusting the formula strength, adding an
antiemetic, or changing the formula with the addi-
tion of fiber, lactose, or protein.
118 ROSALIND BRYANT

Figure 1. Nutritional support algorithm. Adapted from Bowman, I. C., Williams, R., Sanders, M., et al. (1998). Algorithm for nutritional
support: Experience of the metabolic and infusion support service of St. Jude Children’s Research Hospital. International Journal of Cancer,
11(suppl.), 76-80. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.

Because most pediatric patients have venous
access devices, health care providers tend to use
these devices for parenteral nutritional administra-
tion to avoid additional invasive procedures, and
bleeding or mucosal damage associated with en-
teral feeds. Parenteral feedings are used primarily
for nutritional support when the unavailability of
the gastrointestinal tract owing to surgery, radia-
tion, infection, mucositis, gastroenteritis, or exces-
sive abdominal tumor burden. However, the higher
incidence of septic complications and CVAD-re-
lated infections associated with parenteral feeding
make the enteral feeding a preferred route owing to
its ability to maintain gut integrity without significant
gastroenteritis or mucosal damage (DeSwarte-
Wallace, Firouzbakhsh, & Finkelstein, 2001).
In formulating individualized care plans, the on-
cology nurse should involve input from the multi-
disciplinary team that includes the caregiver, child,
physician, dietary specialist, psychologist, and the
child life specialist. Because intensive dietary
counseling to improve nutritional intake in the
child with cancer has been proven ineffective in
past studies, the teaching focus should be aimed at
the acceptance of the type of nutritional feeding by
the child and family (Nitenberg & Raynard, 2000).
The nurse, along with the dietician and other
multidisciplinary team members, should imple-
ment the following nutritional interventions:
● Ongoing assessment of nutritional status;
● Chart weight/height measurements at each clinic
visit on age-appropriate growth curve;
CANCER TREATMENT SIDE EFFECTS
● Maintain child in a sitting position during meals
if possible;
● Implement enteral feeding at night over 8 to 12
hours or continuously over 24 hours;
● Promote chewing of food during family meals if
possible;
● Avoid administration of medications before
feeding;
● Avoid chemotherapy during feedings;
● Encourage physical activity during the day (e.g.,
walking, swimming, isometric exercises);
● Avoid strong environmental odors (e.g., per-
fumes, cooking, and smoking);
● Encourage expression of feelings related to par-
enteral/enteral feedings (e.g., medical play with
feeding tubes, drawings, or verbal expression).
Nausea and Vomiting
Nausea and vomiting is the most common side
effect of cancer treatment and may be the most
challenging. Nausea is controlled by the vomiting
center in the medulla. Chemotherapy-associated
vomiting is a reflex controlled by the chemorecep-
tor trigger zone that stimulates the vomiting center
in the brain. Nausea and vomiting may be induced
by several factors including tumor location (e.g.,
brain, gastrointestinal tract, and kidney), cancer
therapy, pain, and anxiety. Radiation therapy to the
brain, gastrointestinal tract, chest, and neck also
may cause nausea and vomiting. Anticipatory nau-
sea and vomiting may occur before chemotherapy
and is triggered by sights, smells, tastes, and other
environmental stimuli such as observing needles or
the sight of the clinic. Anticipatory nausea and
vomiting has been controlled by using behavioral
interventions (e.g., guided imagery, muscle relax-
ation, and hypnosis) accompanied with benzodiaz-
epines. Acute nausea and vomiting occurs within
24 hours of treatment whereas delayed nausea and
vomiting occurs greater than 24 hours posttreat-
ment and may last several days (Berde, Billett, &
Collins, 2002).
Several classifications of antiemetics are used to
control nausea and vomiting. The advent of sero-
tonin-receptor antagonists such as ondansetron and
granisetron have produced the most successful
antiemetics available to date. Phenothiazines that
include promethazine and chlorpromazine block
dopamine receptors from stimulating the chemore-
ceptor trigger zone (Berde, Billett, & Collins,
2002). Antihistamines such as diphenhydramine
and hydroxyzine that control extrapyramidal ef-
fects of phenothiazines also have some antiemetic
effects. Benzodiazepines such as lorazepam are
119
anxiolytic agents and central nervous system de-
pressants. The antiemetic action of steroids such as
dexamethasone is uncertain, but these agents are
used in conjunction with other antiemetics to man-
age delayed nausea and vomiting. Cannabinoids
(tetrahydrocannabinol or marinol) cause central
nervous system depression resulting in decreased
nausea and vomiting (Panzarella et al., 2002;
Berde et al., 2002). Most patients benefit from an
individualized plan consisting of a combination of
antiemetic medications. The nurse’s role includes
an accurate assessment of hydration status, admin-
istration of antiemetic before chemotherapy,
around-the-clock antiemetic dosing, anticipation of
delayed nausea and vomiting with certain agents
(i.e., Cisplatin, Doxorubicin), as well as manage-
ment or avoidance of psychogenic factors that can
trigger nausea. Because of the anticipatory nausea
and vomiting some children benefit by administra-
tion of benzodiazepines at bedtime or in the morn-
ing before their visit to the clinic, and other chil-
dren benefit from avoiding the use of such triggers
as alcohol wipes, white uniforms, or laboratory
coats (e.g., most pediatric nurses wear colorful
smocks or shirts). Once the successful antiemetic
regimen is identified, the nurse should document
the plan and review it with the parents and staff.
Other nursing interventions to minimize nausea
and vomiting include frequent oral hygiene, espe-
cially after vomiting, minimizing pungent odors,
encouraging small frequent meals, and avoiding
highly spiced and fatty foods.
Mucositis
Mucositis is a progressive, inflammatory, ulcer-
ative condition of the oral and gastric mucosal
tissue precipitated by chemotherapy, radiation
therapy, physical trauma, poor dental hygiene, neu-
tropenia, thrombocytopenia, or impaired nutri-
tional status (Kennedy & Diamond, 1997). Muco-
sal damage as a result of cancer chemotherapy or
impaired nutritional status occurs owing to the
interruption of the cell renewal process of the ep-
ithelium leading to mucosal atrophy and ulceration
(Madeya, 1996). Thrombocytopenia or physical
trauma may lead to bleeding and further mucosal
damage whereas neutropenia or poor dental hy-
giene predisposes the oral mucosa to secondary
infection. Radiation therapy to the head and neck
destroys the epithelial cells whereas radiation to
other body cells leads to an inflammatory reaction
causing generalized erythema and desquamation of
the mucosal area. An initial assessment of the oral
cavity includes inspecting the condition of teeth
120
and gingival mucosa (see Table 5), obtaining a
history of previous dental care, and assessing the
frequency of routine dental examinations, brushing
and flossing routine, and use of orthodontic appli-
ances. If the child has a previous history of cold
sores or fever blisters, these may recur throughout
treatment (Kennedy & Diamond).
Many institutions have adopted their own treat-
ment plan for the prevention and treatment of
mucositis. Agents used to prevent and/or treat mu-
cositis include salt and soda rinse, chlorhexidine,
and a mouthwash (e.g., diphenhydramine, antacid,
with or without lidocaine). Nurses must be able to
recognize the grade of mucositis and implement
appropriate nursing care (see Table 5). They also
must maintain the child’s nutritional and hydration
status by accurately recording and monitoring in-
take/output and weight measurements. Encourag-
ing fluid intake including popsicles, sodas, jello, or
yogurt can be both soothing and also moisturizing
to lips and oral mucous membranes.
Table 5. Mucositis Care
Grade Description*
Grade 0 Mucosa and gingiva are pink, moist with no
lesions or pain.
Grade I Erythematous oral mucosa or whitish,
swollen gingiva involving ⬍ 25% of
mucosal area with slight or no pain.
Grade II Erythematous focal ulcers or white, swollen
patches involving 25-50% of mucosal
area with mild pain.
*Data from Kennedy, L., Diamond, J. (1997). Assessment and management of chemotherapy-induced mucositis in children. Journal of Pediatric
Oncology Nursing, 14(3), 164-174; Parulekau, W., MacKenzie, R., Bjarnason, G., et al., (1998). Scoring oral mucositis. Oral Oncology, 34, 63-71.
ROSALIND BRYANT
Pain
Pain is an unpleasant sensory and emotional
experience and can be acute or chronic. Acute pain
is a primitive protective response of brief duration
that usually is caused by a well-defined stimulus
(e.g., surgery, trauma) that subsides as healing
occurs (Sentivany-Collins, 2002). Chronic pain is a
nonprotective response with long-term changes of-
ten involving the nervous system and persist for 3
to 6 months or longer (Sentivany-Collins). Four
common types of pain are found in children with
cancer. Tumor-related pain may occur owing to
direct invasion of the bone, impingement of tumor
on nervous tissue, or from metastatic disease
(Patterson, 1992). Treatment-related pain is asso-
ciated with side effects of cancer therapy such as
mucositis, infections, drug-induced neuropathy,
and post–lumbar puncture headaches (Patterson).
Postoperative-related pain is caused by tumor re-
moval or biopsy procedure, amputation, phantom
Nursing Interventions
Assess oral mucosa (condition of buccal cavity, lips and tongue, teeth, gingiva,
comfort status)
Institute preventive dental hygiene after meals and bed time:
Wash hands for 3 minutes before performing oral care;
Brush teeth/tongue/gums using fluoride toothpaste, soft toothbrush;
Rinse mouth after brushing with salt and soda solution (1/2 teaspoon salt
and 1 teaspoon baking soda in 1 pint water) or chlorhexidine 5-10 mL)
swish and spit;
Use waxed floss daily if platelet count ⬎ 100,000 and ANC ⬎ 1,000;
Apply lip moisturizer as needed;
Avoid food and beverages for at least 30 minutes after oral rinsing;
Avoid lemon-glycerin swabs and hydrogen peroxide owing to drying effect
and irritation of grandulating tissue;
Avoid electric toothbrushes and water piks;
Removal of all orthodontic appliances usually is recommended to avoid
mucosal trauma.
Record observations and interventions.
Assess oral mucosa (condition of buccal cavity, lips and tongue, teeth, gingiva,
comfort status).
Continue preventive dental hygiene as described under grade 0.
Record observations and interventions.
Assess oral mucosa (erythema, swelling, lesions [describe], discomfort, ability to
eat or drink).
Monitor weight, vital signs, and laboratory studies (e.g., complete blood count,
ANC, platelet count, electrolytes).
Continue preventive measures listed under grade 0 but increase gentle brushing
and rinse to include before AM meal and after all snacks.
Use topical anesthetics in mouthwash (equal parts diphenhydramine/antacid
suspension with or without viscus lidocaine) every 4-6 h and as needed.
Acetaminophen, acetaminophen with codeine, or an opoid infusion may be
ordered for pain control.
Record observations and interventions
CANCER TREATMENT SIDE EFFECTS
pain, and central line placement. Procedural-re-
lated pain, identified by many children as the most
anxiety provoking of all cancer-related pain, is
caused by bone marrow aspiration and biopsy pro-
cedure, lumbar puncture, venous access, subcuta-
neous or intramuscular injection, and finger sticks
(Macpherson & Lundbald, 1997). Because the pe-
diatric oncology patient usually experiences some
pain during the course of treatment, the nurse’s
assessment of pain must include the child’s de-
scription of pain, a history of previous measures
used to manage pain, cultural influences, parental
responses to the child’s pain, and the child’s age
and developmental stage to provide appropriate
explanations and effective interventions (see Table
6). Uncontrolled pain often is managed best by a
multidisciplinary pain team that includes patient
and family, physicians, nurses, child life specialists,
psychologists, psychiatrists, and social workers.
The most effective pain management strategies
reported by children with cancer include the use of
effective pain medications combined with ade-
quate rest and sleep, massage, heat, distraction, and
social support. Pharmacologic interventions should
be based on frequent assessment and the step by
step approach to pain as described by the World
Health Organization (Galloway & Yaster, 2000;
Hellsten, 2000) (see Figure 2).
Nonopioid medications act to block the periph-
eral generation of afferent nerve impulses in sen-
sory neurons related to tissue injury and/or inflam-
mation (Patterson, 1992). The most commonly
used nonopioid medication in the pediatric cancer
patient is acetaminophen. Salicylates are avoided
because they affect platelet function and nonsteroi-
dal anti-inflammatory agents are used with caution
owing to effects on platelet aggregation. Children
with analgesic dose requirements that exceed rea-
sonable oral dosing or for whom oral medications
are not tolerated should receive pain medications
by an alternate route (Hockenberry-Eaton, Barrera,
Brown, Bottomley, & O’Neill, 1999) other than
intramuscular, subcutaneous, or rectal routes. It has
been proven that patient-controlled analgesia alone
or in conjunction with continuous morphine infu-
sion is effective in children as young as 3 years of age
(Patterson, 1992). It is the nurse’s responsibility to be
familiar with pain medications including the dose,
side effects, potency and onset, and duration of action
to ensure safe and effective pain management.
Fifty percent to 75% of children with cancer
who experience pain state that it is related primar-
ily to procedures and treatment (Wolfe, Grier,
Klar, et al., 2000). One of the most significant
121
improvements in the management of procedural-
related pain is the topical anesthetic cream EMLA
(Astra Zeneca at Astrazeneca-us.com), a eutectic
mixture of local anesthetics (lidocaine and prilo-
caine in a 1:1 ratio) (Wong, Hockenberry, Wilson,
Winklestein, & Schwartz, 2001). A thick layer of
EMLA® cream of at least 2 mm is applied to the
intact skin site and covered with an occlusive
transparent dressing for a minimum of 1 hour. The
nurse, however, must be aware that a 90- to 120-
minute application of EMLA® is needed for pro-
cedural pain involving deeper skin penetration
(e.g., bone marrow aspiration, lumbar puncture,
intramuscular injection) or in dark-skinned chil-
dren owing to their thicker statum corneum
(Macpherson & Lundbald, 1997). The total anes-
thesia duration of the EMLA® is approximately 4
hours with mild side effects such as pallor, ery-
thema, or edema at the application site. The nurse
should assess the skin site after removal of the
anesthetic cream just before implementation of the
procedure for sensitivity by tapping or lightly
scratching the skin to show the child that the nee-
dle will not be felt (Wong et al., 2001). In situa-
tions that are immediate or require a deeper anes-
thetizing effect, buffered or warmed lidocaine,
which decreases stinging, used alone or in conjunc-
tion with EMLA® is indicated.
The nurse, child life specialist, and multidisci-
plinary pain team prepares the child and parents for
the invasive procedure. The purpose and descrip-
tion of the procedure is discussed with the parent
and an appropriate explanation of the procedure is
given to the child. Developmentally appropriate
interventions (see Table 6) are taught to the parent
ranging from keeping the infant swaddled and
warm, staying in the child’s view, using a soothing
voice with the toddler and preschooler, or using
distraction with the school-aged and adolescent
child (Dahlquist, Busby, Slifer et al., 2002). Mod-
erate to deep sedation for pediatric patients under-
going invasive procedures allows the child to en-
dure repeated painful procedures with minimal
discomfort and anxiety. Fentanyl or morphine with
midazolam (see Table 6) is used to provide ade-
quate sedation. However, the most frequently used
safe, effective analgesic agents for deep sedation
are ketamine or propofol alone or in combination
with an opioid such as fentanyl or midazolam
(Jayabose et al., 2001; Tyc, Bieberich, Hinds, &
Sifford, 1998). Regardless of the type of sedation,
the nurse must evaluate vital signs, oxygen satura-
tion, level of consciousness, cardiovascular status,
and comfort level during administration of seda-
 Table 6. Childhood Cancer Pain

Nursing Interventions

Assess signs and symptoms of pain before and after interventions

Acute pain (heart rate, respiratory rate, blood pressure changes, dilated pupils, diaphoresis, location, intensity, duration)
Chronic/prolonged pain (vital signs may normalize)
Pain behaviors: facial expression (grimace, cry, moan) posture (rigidity, flair, stoic, squirming, tense), and signs of regression, aggression,
decreased appetite. Self-report using:
Pain-rating scales (Faces scale, Oucher scale ⱖ 3 y)
Number scale ⱖ 8 y
Verbal description (parent and child)
Environmental factors (e.g., temperature, equipment, noise)
Pharmacologic treatment
Oral nonopioids:
Use acetaminophen 10-15 mg/kg/dose every 4 h pm (maximum, 650 mg/dose) (take temperature before use to avoid masking signs of
infection)
Avoid salicylates and use NSAIDS sparingly owing to potential for bleeding
NSAIDS: 10 mg/kg every 6-8 h pm (maximum, 800 mg/dose) with food
Oral opioids:
Codeine: 0.5-1 mg/kg every 4-6 h pm (maximum, 60 mg/dose)
Morphine:
starting doses 0.2-0.5 mg/kg every 4 h or sustained release 0.3-0.6 mg/kg every 12 h
Intravenous analgesics (avoid intramuscular subcutaneous injections to treat pain)
MSO4 0.05-0.1 mg/kg intravenous continuous or every 1-2 h
Fentanyl 0.5-3 mcg/kg every 1-2 h
For postsurgical pain: institute MSO4 or fentanyl patient-controlled anesthesia intravenously then slowly switch to oral opioids and/or
NSAIDS
Adjuvant therapy:
Antiseptics and mouthwash for mucositis
Stool softener/laxative
Antifungal, antiviral, antibacterial agents
Anitemetics
Antipruritics
Tricyclic antidepressants (e.g., amitriptyline, imipramine, or nortriptyline)
Corticosteroids (e.g., prednisone or dexamethasone)
Palliative radiation
Nonpharmacologic interventions:
Deep slow breathing and relaxation techniques
Massage, positioning, heat
Imagery and hypnosis
Play therapy
Lying flat for 30 minutes after lumbar puncture
Increase oral fluid intake for 24 hours after lumbar puncture
Daily oral care/institutional guidelines
Distraction using video games, television, music
Record response to interventions
Invasive procedure
Explain procedure to parents and child and use nonpharmacologic interventions listed above
Use of oral analgesics
Diazepam 0.1-0.3 mg/kg by mouth (maximum, 10 mg) at least 1 hour before procedure
or Lorazapam 0.03-0.1 mg/kg every 4-6 h or 1 h before procedure (maximum 2 mg/dose)
Midazolam 0.2-0.4 mg/kg every (maximum, 15 mg) 30-45 minimum,
Use of local anesthesia:
Lidocaine (1% subcutaneously 4-5 minimum before procedure)
Emla (Lidocaine 2.5% and prilocaine 2.5%) cream at least 1-1 1/2 h before procedure
Use of IV sedation*
MSO4 0.05-0.1 mg/kg IV 5 minimum before procedure or fentanyl 0.5-1 ␮gm/kg IV 3 minimum before procedure
Midazolam 0.05 mg/kg IV initial dose with subsequent doses 0.05 mg/kg IV pm (maximum, 0.15 mg/kg)
Reversal agents available for conscious sedation:
Naloxone 0.01 mg/kg IV repeat every 2-3 minimum for reversal MSO4 and fentanyl (maximum, 0.2 mg)
Flumazenil 0.2 mg/kg IV every 1 min repeated (maximum, dose 3 mg/kg) for reversal of midazolam
Record response to interventions

*The American Academy of Pediatrics has set specific recommendations for monitoring of patients during conscious sedation: oxygen, pulse
oximetry, suction, ambu bag, reversal agents, crash cart, and staff all available during procedure.
American Academy of Pediatrics, Committee on Drugs. (1992). Guidelines for monitoring and management of pediatric patients during and after
sedation for diagnostic and therapeutic procedures. Pediatrics, 89 (6), 1110-1115.
NSAID, nonsteroidal anti-inflammatory drugs; IV, intravenous
CANCER TREATMENT SIDE EFFECTS
Figure 2. Therapeutic ladder for pain management. Reprinted with permission from the World Health Organization and IASP. (1998). Cancer
pain relief and palliative care in children. Geneva: World Health Organization.
tion. Other nursing responsibilities include main-
taining a patent airway, stimulating the child to
breathe, and administering 100% oxygen via mask
as needed, and administering reversal agents (see
Table 6) for prolonged sedation or respiratory dis-
tress. A combination of nonpharmacologic, phar-
macologic, and adjuvant measures must be imple-
mented by the nurse to provide a comprehensive
management of cancer-related pain.
End-of-life pain occurs in the dying child and
may comprise any of the four previously discussed
types of cancer-related pain. Children with termi-
nal cancer often experience considerable pain and
suffering before they die (Morgan & Murphy,
2000). Suffering in the dying patient has been
attributed partially to health care providers and
family members who administer inadequate pain
management owing to fears of addiction, respira-
tory depression, apnea, and death from analgesics,
especially when analgesics exceeded maximum
dosages (Hellsten, 2000; Sentivany-Collins, 2002).
Because the nurse has close contact with the dying
child, the nurse is in the best position to educate
123
other health care providers and the family regard-
ing proper pain management. It is the responsibility
of the nurse to assess the pain status and share knowl-
edge of pharmacologic and nonpharmacologic inter-
ventions with both family and health care providers.
Allowing the family to participate in the child’s
pain management will keep the focus on maintain-
ing comfort regardless of the analgesic dosage.
Psychosocial Aspects
The nurse plays an instrumental role in the sup-
portive care team by encouraging the child and
family to express their feelings regarding side ef-
fects of cancer treatment. The nurse creates a car-
ing atmosphere by using listening skills, support-
ing the family, and providing resources for
emotional support. The family and caregiver con-
vey less anxiety to the child if taught the use of
anxiety-reducing strategies (e.g., soothing words,
gentle strokes, calm voice, holding the child, and
providing warmth and nourishment) by the nurse.
Before any medical procedure, both the pre-
schooler and school-aged child require brief and
124
honest descriptions of the procedure. It is impor-
tant for children to express fears and anxieties by
using play (i.e., imaginative and medical) with
dolls, drawing and group games, as well as be
given the opportunity to participate in the proce-
dure (i.e., hold Band-Aid, choice of thigh for in-
jection). Some children request a description of
each action during the invasive procedure whereas
others prefer music, story-telling, videos, or com-
plete silence, all of which may provide comfort.
Most school-aged children and adolescents are
able to understand the diagnosis, treatment plan,
side effects, and the purpose of the invasive pro-
cedures. Because these children have an awareness
of their bodies, the effects of cancer therapy such
as alopecia, weight gain or loss, or skin changes
may change the child’s acceptance of self. Even
though the supportive care team encourages the
older child to express verbally feelings of anger,
fear, denial, and disbelief, it is still more difficult
for these children to accept the diagnosis and side
effects of therapy than the younger child. Alopecia
is the side effect of chemotherapy and radiation
therapy that most children find devastating to their
self-image. The nurse can help the child cope with
the changed appearance by suggesting the use of
hats, scarves, wigs, and allowing the child an op-
portunity to express feelings of anger and sadness
related to hair loss. Also, the nurse should allow
the child the opportunity to participate in medical
decision making with the parents and encourage
them to focus on future goals, promoting a healthy
self-image and self-esteem despite having cancer.
Because most children with cancer grow up to
become well-adjusted adults, the nurse encourages
the child and family to focus on the child’s work
by encouraging a return to school as soon as med-
ically possible. School re-entry can be a difficult
task to accomplish by the child newly diagnosed
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SUMMARY
Over the past several decades, increased survival
for childhood cancer has become a reality. These
survivors of childhood cancer have experienced
significant side effects including immunosuppres-
sion and infection, anemia, thrombocytopenia,
malnutrition, nausea and vomiting, mucositis, pain,
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