Pediatric Oncology Nursing (eBook)

Dedication 5
Preface 6
Contributors 7
Contents 9
Part I: Leukemia 20
Chapter 1 21
Leukemia 21
1.1 Introduction 22
1.2 Acute Lymphoblastic Leukemia 23
1.2.1 Epidemiology 23
1.2.2 Etiology 24
1.2.2.1 Genetic Factors 24
1.2.2.2 Environmental Factors 24
1.2.3 Molecular Genetics 26
1.2.4 Symptoms and Clinical Signs 27
1.2.5 Diagnostics 28
1.2.6 Staging and Classifi cation 29
1.2.6.1 Risk Classifi cation 29
1.2.6.2 Cell Morphology 30
1.2.6.3 Cytochemistry 30
1.2.6.4 Immunophenotyping 30
1.2.6.5 Cytogenetics 31
1.2.7 Treatment 32
1.2.7.1 Induction 33
1.2.7.2 Consolidation 34
1.2.7.3 Reintensifi cation 34
1.2.7.4 CNS-Directed Therapy 35
1.2.7.5 Maintenance/Continuing Treatment 35
1.2.7.6 Allogeneic Stem Cell Transplant 36
1.2.8 Prognosis 36
1.2.9 Follow-Up 36
1.2.10 Future Perspectives 37
1.2.11 Relapsed ALL 37
1.3 Acute Myeloid Leukemia 39
1.3.1 Epidemiology 39
1.3.2 Etiology 39
1.3.2.1 Genetic Factors 39
1.3.2.2 Environmental Factors 40
1.3.3 Molecular Genetics 40
1.3.4 Symptoms and Clinical Signs 40
1.3.5 Diagnostics 41
1.3.6 Staging and Classifi cation 41
1.3.7 Treatment 42
1.3.8 Prognosis 44
1.3.9 Follow-Up 44
1.3.10 Future Perspectives 44
1.4 Chronic Myeloid Leukemia 45
1.4.1 Epidemiology and Etiology 45
1.4.2 Molecular Genetics 45
1.4.3 Symptoms and Clinical Signs 45
1.4.4 Diagnostics 46
1.4.5 Treatment 46
1.4.6 Prognosis 46
1.4.7 Future Perspectives 46
1.5 Juvenile Myelomonocytic Leukemia 46
1.6 Langerhans Cell Histiocytosis 47
1.6.1 Epidemiology and Etiology 47
1.6.2 Diagnostics 48
1.6.3 Symptoms and Clinical Signs 48
1.6.4 Treatment 49
1.6.5 Prognosis 49
References 49
Chapter 2 53
Lymphoma 53
2.1 Lymphoma 53
2.2 Hodgkin Lymphoma 53
2.2.1 Epidemiology 54
2.2.2 Etiology 54
2.2.3 Molecular Genetics 54
2.2.4 Symptoms and Clinical Signs 54
2.2.5 Diagnostics 56
2.2.6 Staging and Classification 58
2.2.7 Treatment 59
2.2.8 Prognosis 62
2.2.9 Follow-Up 63
2.2.10 Relapsed/Refractory HL 63
2.2.11 Future Perspectives 64
2.3 Non-Hodgkin Lymphomas 64
2.3.1 Epidemiology 64
2.3.2 Etiology 65
2.3.3 Molecular Genetics 65
2.3.4 Symptoms and Clinical Signs 66
2.3.5 Diagnostics 68
2.3.6 Staging and Classification 70
2.3.7 Treatment 70
2.3.8 Prognosis 74
2.3.9 Follow-Up 74
2.3.10 Treatment of Relapsed/Refractory NHL 75
2.3.11 Future Perspectives 75
References 76
Chapter 3 78
Solid Tumor 78
3.1 Ewing’s Sarcoma Family of Tumors 79
3.1.1 Epidemiology 79
3.1.2 Etiology 79
3.1.3 Molecular Genetics 79
3.1.4 Symptoms and Clinical Signs 80
3.1.5 Diagnosis 80
3.1.6 Staging and Classifi cation 82
3.1.7 Treatment 82
3.1.7.1 Chemotherapy 82
3.1.7.2 Surgery 82
3.1.7.3 Radiotherapy 82
3.1.7.4 Metastatic Disease 82
3.1.8 Prognosis 83
3.1.9 Follow-Up 84
3.1.10 Future Perspectives 84
3.2 Osteosarcoma 84
3.2.1 Epidemiology 85
3.2.2 Etiology 85
3.2.3 Molecular Genetics 85
3.2.4 Signs and Symptoms 86
3.2.5 Diagnostics 86
3.2.6 Staging and Classifi cation 87
3.2.7 Treatment 87
3.2.8 Prognosis 90
3.2.9 Follow-Up 90
3.2.10 Future Perspectives 90
3.3 Liver Tumors 91
3.3.1 Epidemiology 91
3.3.2 Etiology 91
3.3.3 Molecular Genetics 91
3.3.4 Symptoms and Clinical Signs 91
3.3.5 Diagnostics 92
3.3.6 Staging and Classifi cation 93
3.3.7 Treatment 94
3.3.7.1 Surgery 94
3.3.7.2 Chemotherapy 94
3.3.7.3 Radiotherapy 95
3.3.8 Prognosis 95
3.3.9 Follow-Up 95
3.3.10 Future Perspectives 96
3.4 Neuroblastoma 96
3.4.1 Epidemiology 96
3.4.2 Etiology 96
3.4.3 Molecular Genetics 96
3.4.3.1 Gains in Genetic Material 97
3.4.3.2 Losses of Genetic Material 97
3.4.3.3 Mutations in Gene Expression 97
3.4.4 Symptoms and Clinical Signs 98
3.4.5 Diagnostics 99
3.4.6 Staging and Classifi cation 100
3.4.7 Treatment 101
3.4.7.1 Low Risk 102
3.4.7.2 Intermediate Risk 102
3.4.7.3 High Risk 102
3.4.7.4 Chemotherapy 102
3.4.7.5 Surgery 103
3.4.7.6 Myeloablative Therapy and Autologous Stem Cell Rescue 103
3.4.7.7 Radiotherapy 103
3.4.7.8 Differentiation Therapy 103
3.4.7.9 Biological Therapies and Immunotherapy 104
3.4.8 Prognosis 104
3.4.9 Follow-Up 104
3.4.10 Future Perspectives 105
3.5 Renal Tumors 105
3.5.1 Epidemiology 105
3.5.2 Etiology 106
3.5.3 Molecular Genetics 106
3.5.4 Symptoms and Clinical Signs 106
3.5.5 Diagnostics 107
3.5.6 Staging and Classifi cation 108
3.5.7 Treatment 108
3.5.7.1 Surgery 108
3.5.7.2 Chemotherapy 109
3.5.7.3 Radiotherapy 111
3.5.8 Prognosis 111
3.5.9 Follow-Up 112
3.5.10 Future Perspectives 112
3.6 Retinoblastoma 112
3.6.1 Epidemiology 112
3.6.2 Etiology 113
3.6.3 Molecular Genetics 113
3.6.4 Signs and Symptoms 113
3.6.5 Diagnostics 114
3.6.6 Staging and Classifi cation 115
3.6.7 Treatment 115
3.6.8 Prognosis 118
3.6.9 Follow-Up 119
3.6.10 Future Directions 119
3.7 Rhabdomyosarcoma 119
3.7.1 Epidemiology 119
3.7.2 Etiology 120
3.7.3 Molecular Genetics 120
3.7.4 Symptoms and Clinical Signs 120
3.7.5 Diagnostics 120
3.7.6 Staging and Classifi cation 122
3.7.7 Treatment 122
3.7.7.1 Local Therapy 123
3.7.7.2 Chemotherapy 124
3.7.8 Prognosis 125
3.7.9 Follow-Up 125
3.7.10 Future Perspectives 125
3.8 Non-Rhabdomyosarcomatous Soft-Tissue Sarcomas 126
3.8.1 Alveolar Soft-Part Sarcoma 127
3.8.2 Desmoid Tumor (Aggressive Fibromatosis) 127
3.8.3 Desmoplastic Small Round Cell Tumor 127
3.8.4 Infantile Fibrosarcoma 128
3.8.5 Infantile Hemangiopericytoma 128
3.8.6 Infantile Myofi bromatosis 128
3.8.7 Leiomyosarcoma 128
3.8.8 Liposarcoma 128
3.8.9 Malignant Peripheral Nerve Sheath Tumor 129
3.8.10 Synovial Sarcoma 129
3.9 Germ Cell Tumors 129
3.9.1 Epidemiology 130
3.9.2 Etiology 130
3.9.3 Molecular Genetics 131
3.9.4 Symptoms and Clinical Signs 131
3.9.5 Diagnostics 131
3.9.6 Staging and Classifi cation 132
3.9.7 Treatment 132
3.9.7.1 Surgical Considerations 133
3.9.7.1.1 Ovarian Tumors 133
3.9.7.1.2 Testicular Tumors 133
3.9.7.1.3 Extragonadal Tumors 133
3.9.7.2 Chemotherapy 134
3.9.8 Prognosis 134
3.9.9 Follow-Up 134
3.9.10 Future Perspectives 135
3.10 Rare Tumors 135
3.10.1 Adrenocortical Carcinoma 135
3.10.2 Melanoma 136
3.10.3 Nasopharyngeal Carcinoma 137
3.10.4 Pleuropulmonary Blastoma 137
3.10.5 Thyroid Carcinoma 138
References 138
Chapter 4 147
Central Nervous SystemTumors 147
4.1 Causes/Epidemiology 147
4.2 Distribution/Classification 147
4.3 Staging 148
4.4 Molecular Genetics of Brain Tumors 148
4.5 Diagnosis 148
4.6 Specialist Referral 148
4.7 Hydrocephalus 148
4.8 Treatment 149
4.8.1 Surgery 149
4.8.2 Radiotherapy 149
4.8.2.1 Conventional Radiotherapy 149
4.8.3 Chemotherapy 150
4.9 Prognosis 150
4.10 Specific Tumors 150
4.10.1 PNETs/Medulloblastomas 150
4.10.2 Astrocytomas/Glial Tumors 151
4.10.3 Malignant Gliomas 152
4.10.4 Other High-Grade Gliomas 152
4.11.1 The Late Effects and Rehabilitation of Survivors 156
4.11 Follow-Up 156
4.11.2 Palliative Care 157
4.11.3 Future Perspectives/New Innovations 157
References 158
Part II: Anemias 159
Chapter 5 160
Anemias 160
5.1 Anemia 161
5.2 Iron-Deficiency Anemia 165
5.2.1 Epidemiology 165
5.2.2 Etiology 165
5.2.3 Molecular Genetics 165
5.2.4 Symptoms/Clinical Signs 165
5.2.5 Diagnostic Testing 166
5.2.6 Treatment 167
5.2.7 Transfusion 167
5.2.8 Erythropoietin (Epogen) 167
5.2.9 Prognosis 168
5.3 Sickle Cell Disease 168
5.3.1 Epidemiology 168
5.3.2 Etiology 168
5.3.3 Molecular Genetics 168
5.3.4 Symptoms/Clinical Signs 168
5.3.5 Diagnostic Testing 169
5.3.6 Complications of SCD 170
5.3.6.1 Vaso-Occlusive Crisis/Episode 170
5.3.6.1.1 Diagnostic Test/Differential Count 171
5.3.6.1.2 Treatment 171
5.3.6.2 Acute Sequestration Crisis 171
5.3.6.3 Aplastic Crisis 171
5.3.6.4 Infection 172
5.3.6.5 Acute Chest Syndrome 173
5.3.6.6 Acute Abdominal Pain 174
5.3.6.7 Acute Central Nervous System Event 174
5.3.6.8 Preparation for Surgery 176
5.3.6.9 Hydroxyurea Therapy 176
5.3.7 Prognosis 177
5.3.8 Future Perspectives 177
5.4 Thalassemia 177
5.4.1 Alpha ( alpha )-Thalassemia 177
5.4.1.1 Epidemiology 177
5.4.1.2 Etiology 177
5.4.1.3 Molecular Genetics 177
5.4.2 Beta Thalassemia (Cooley Anemia) 178
5.4.2.1 Epidemiology 178
5.4.2.2 Etiology 178
5.4.2.3 Molecular Genetics 178
5.4.3 Diagnostic Testing 179
5.4.4 Treatment 179
5.4.5 Treatment of Hemosiderosis(Iron Overload) 179
5.4.6 Chelation Therapy 180
5.4.6.1 Initiation of Chelation Therapy 180
5.4.6.2 Chelation Regimens 180
5.4.6.3 Complicationsof Chelation Medications 180
5.4.7 Clinical Advances (Hemosiderosis) 180
5.4.8 Prognosis 180
5.4.9 Follow-Up 181
5.4.10 Future Perspectives 181
5.5. Hemolytic Anemia 181
5.5.1 Hereditary Spherocytosis 181
5.5.1.1 Epidemiology 181
5.5.1.2 Etiology 181
5.5.1.3 Molecular Genetics 181
5.5.1.4 Symptoms/Clinical Signs 181
5.5.1.5 Diagnostic Testing 182
5.5.1.6 Treatment 182
5.5.1.7 Prognosis 182
5.5.1.8 Follow-Up 182
5.5.1.9 Future Perspectives 182
5.5.2 Autoimmune Hemolytic Anemia 183
5.5.2.1 Epidemiology 183
5.5.2.2 Etiology 183
5.5.2.3 Molecular Genetics 183
5.5.2.4 Symptoms/Clinical Signs 183
5.5.2.5 Diagnostic Testing 183
5.5.2.6 Treatment 183
5.5.2.7 Prognosis 184
5.5.2.8 Future Perspectives 184
5.5.3 Glucose-6-Phosphate Dehydrogenase Deficiency 184
5.5.3.1 Epidemiology 184
5.5.3.2 Etiology 184
5.5.3.3 Molecular Genetics 184
5.5.3.4 Symptoms/Clinical Signs 185
5.5.3.5 Diagnostic Testing 185
5.5.3.6 Treatment 185
5.5.3.7 Prognosis 186
5.6 Bone Marrow Failure Syndromes 186
5.6.1 Aplastic Anemia 186
5.6.1.1 Acquired Aplastic Anemia 186
5.6.1.1.1 Epidemiology 186
5.6.1.1.2 Etiology 186
5.6.1.1.3 Molecular Genetics 186
5.6.1.1.4 Symptoms/Clinical Signs 186
5.6.1.1.5 Diagnostic Testing 186
5.6.1.1.6 Treatment 187
5.6.1.1.7 Supportive Treatment 188
5.6.1.1.8 Prognosis 188
5.6.1.2 Inherited Aplastic Anemia 188
5.6.1.2.1 Epidemiology 188
5.6.1.2.2 Etiology 188
5.6.1.2.3 Molecular Genetics 188
5.6.1.2.4 Symptoms/Clinical Signs 188
5.6.1.2.5 Diagnostic Testing 188
5.6.1.2.6 Treatment 189
5.6.1.2.7 Prognosis 189
References 189
Chapter 6 192
Neutropenia 192
6.1 Epidemiology 192
6.2 Etiology 193
6.3 Symptoms and Clinical Signs 194
6.4 Diagnostic Testing 194
6.5 Treatment 195
6.6 Prognosis 196
6.7 Follow-Up 197
References 197
Resources 197
Chapter 7 198
Thrombocytopenia 198
7.1 Epidemiology 198
7.2 Etiology 199
7.3 Symptoms and Clinical Signs 199
7.4 Diagnostic Testing 201
7.5 Treatment 201
7.6 Prognosis 203
7.7 Follow-Up 203
7.8 Future Perspectives 203
References 203
Chapter 8 205
Bleeding Disorders 205
8.1 Hemophilia 205
8.1.1 Epidemiology 205
8.1.2 Etiology 205
8.1.3 Genetics 206
8.1.4 Symptoms and Clinical Signs 206
8.1.5 Diagnostic Testing 208
8.1.6 Treatment 209
8.1.7 Prognosis 212
8.1.8 Follow-Up 212
8.1.9 Future Perspectives 212
8.2 von Willebrand Disease 212
8.2.1 Epidemiology 212
8.2.2 Etiology 213
8.2.3 Genetics 213
8.2.4 Symptoms and Clinical Signs 213
8.2.5 Diagnostic Testing 214
8.2.6 Treatment 217
8.2.7 Prognosis 218
8.2.8 Follow-Up 218
References 219
Part III: Chemotherapy 220
Chapter 9 251
Chemotherapy 251
9.1 Introduction 252
9.2 Cancer Cell Characteristics 252
9.2.1 The Cell Cycle 252
9.2.2 Cell Cycle Control 253
9.3 Chemotherapy 254
9.3.1 Principles 254
9.3.2 Resistance 254
9.3.3 The Principles of Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics 254
9.3.4 Chemotherapy Techniques 255
9.4 Clinical Trials 255
9.4.1 Phase I Clinical Trials 256
9.4.2 Phase II Clinical Trials 256
9.4.3 Phase III Clinical Trials 256
9.4.4 Phase IV Clinical Trials 256
9.5 Chemotherapy Agents 256
9.5.1 Antimetabolites 259
9.5.1.1 Mechanism of Action 259
9.5.1.2 Side Effects 259
9.5.1.3 Long-Term Effects 264
9.5.2 Alkylating Agents 264
9.5.2.1 Mechanism of Action 264
9.5.2.2 Side Effects 265
9.5.2.3 Long-Term Effects 265
9.5.3 Antitumor Antibiotics 265
9.5.3.1 Mechanism of Action 265
9.5.3.2 Side Effects 266
9.5.3.3 Long-Term Effects 266
9.5.4 Anthracycline Antibiotics 266
9.5.4.1 Mechanism of Action 266
9.5.4.2 Side Effects 266
9.5.4.3 Long-Term Effects 266
9.5.5 Plant Derivatives 266
9.5.5.1 Mechanism of Action 266
9.5.5.2 Side Effects 267
9.5.5.3 Long-Term Effects 267
9.5.6 Antiangiogenic Agents 267
9.5.6.1 Mechanism of Action 267
9.5.6.2 Side Effects 268
9.5.7 Miscellaneous Agents 268
9.5.7.1 Corticosteroids 268
9.5.7.1.1 Mechanism of Action 268
9.5.7.1.2 Side Effects 268
9.5.7.1.3 Long-Term Effects 268
9.5.7.2 Enzymes: Asparaginase 268
9.5.7.3 Targeted Growth Inhibitors 268
9.5.7.4 Differentiating Agents 268
9.6 Chemotherapy Protectants 269
9.6.1 Allopurinol (Zyloprim) 269
9.6.2 Amifostine (Ethyol) 269
9.6.3 Dexrazoxane (Zinecard) 269
9.6.4 Leucovorin Calcium (LCV, Wellcovorin, Citovorum Factor, Folic Acid) 269
9.6.5 Mesna (Mesnex) 269
9.6.6 Palifermin 270
9.7 Administration of Chemotherapy Agents 270
9.7.1 Preparation 270
9.7.2 Administration and Practice Considerations 271
9.7.2.1 Documentation 272
9.8 Professional Guidelines to Minimize the Risk of Medication Errors 272
9.8.1 Prescribing Errors 272
9.8.1.1 Compounding 272
9.8.1.2 Dispensing 272
9.8.1.3 Administration 272
9.9 Safe Practice Considerations 272
9.9.1 Mixing Chemotherapeutic Agents 273
9.9.2 Transporting Cytotoxic Agents 273
9.9.3 Safe Handling After Chemotherapy 273
9.9.4 Disposal of Cytotoxic Materials 273
9.9.5 Spill Management 274
9.9.6 Procedures Following Accidental Exposure 274
9.9.7 Storage 274
9.9.8 Medical Management 274
9.10 Administration of Chemotherapy in the Home 274
9.11 Immediate Complications of Chemotherapy Administration 274
9.11.1 Extravasation 275
9.11.1.1 Pathophysiology of Extravasation 275
9.11.1.2 Risk Factors of Extravasation 275
9.11.1.3 Assessment and Treatment of Extravasation 275
9.11.1.4 Signs and Symptoms of Extravasation 275
9.11.1.5 Treatment for Extravasation 275
9.11.2 Acute Hypersensitivity Reactions (HSRs) to Chemotherapy 278
9.11.3 Risk Factors for Hypersensitivity, Flare Reactions, or Anaphylaxis 278
9.11.4 Recommended Steps to Prevent HSRs 278
9.11.5 Emergency Management of HSR/Anaphylaxis 278
9.12 Summary 279
References 279
Chapter 10 281
Radiotherapy 281
10.1 Introduction 281
10.2 Radiation 281
10.3 Principles of Treatment 282
10.4 Treatment Planning 282
10.4.1 CT Simulation 282
10.4.2 Simulation 282
10.5 Treatment Methods 283
10.5.1 External Beam Radiotherapy (Teletherapy) 283
10.5.1.1 Ensuring Accuracy of Treatment Delivery 283
10.5.1.2 Marking 283
10.5.1.3 Patient Immobilization 284
10.5.2 Fractionation 285
10.5.3 Total Body Irradiation (TBI) 285
10.5.4 Brachytherapy 285
10.5.5 Sealed Sources 285
10.5.6 Unsealed Sources 285
10.6 Side Effects of Radiotherapy 286
10.6.1 Acute Effects 286
10.7 Special Considerations 288
10.7.1 Preparation of Children and Young People 288
10.8.2 Intra-Operative Radiotherapy 288
10.8.3 Proton Radiotherapy (PRT) 288
References 289
Chapter 11 290
Hematopoietic Stem Cell Transplantation 290
11.1 Principles of Treatment 290
11.2 Stem Cell Collection (Harvest) 291
11.2.1 Bone Marrow Stem Cells 291
11.2.2 Peripheral Blood Stem Cells 293
11.2.3 Umbilical Cord Blood Stem Cells 293
11.3 Donor Stem Cell Typing/Tissue Typing 294
11.4 Donor Stem Cell Sources 295
11.5 Stem Cell Processing and Infusion 296
11.5.1 ABO Mismatch 296
11.5.2 Graft vs. Leukemia 298
11.6 Description of Treatment 298
11.7 Potential Side Effects 300
11.7.1 Early Side Effects 300
11.7.1.1 Hematologic Complications 300
11.7.1.2 Gastrointestinal Complications 301
11.7.1.3 Cutaneous Complications 301
11.7.1.4 Infectious Complications 301
11.7.1.5 Urologic and Renal Complications 302
11.7.1.6 Pulmonary Complications 302
11.7.1.7 Hepatic Complications 304
11.7.1.8 Nervous System Complications 304
11.7.2 Intermediate Side Effects 304
11.7.2.1 Infectious Complications 304
11.7.2.2 Graft vs. Host Disease 305
11.7.2.3 Graft Failure 306
11.7.2.4 Pulmonary Complications 306
11.7.3 Late Side Effects 308
11.7.3.1 Immunosuppression 308
11.7.3.2 Graft vs. Host Disease 308
11.7.3.3 Pulmonary Complications 309
11.7.3.4 Endocrine Complications 309
11.7.3.5 Cataracts 309
11.7.3.6 Disease Recurrence and Secondary Malignancies 309
11.8 Special Considerations 310
11.9 Future Perspectives 311
Chapter 12 315
Surgical Approaches to Childhood Cancer 315
12.1 Principles of Treatment 315
12.2 Method of Delivery 316
12.2.1 Preoperative Evaluation 316
12.2.2 Postoperative Nursing Care 317
12.3 Potential Side Effects 317
12.3.1 Complications of Medical Therapy Requiring Surgical Evaluation 317
12.3.2 Complications Arising from Surgical Management of Solid Tumors 318
12.4 Special Considerations 319
12.4.1 Vascular Access Devices 319
12.5 Future Perspectives 320
12.5.1 New Surgical Techniques and Directions for Future Research 320
References 321
Chapter 13 322
Cell and Gene Therapy 322
13.1 Introduction 322
13.2 Principles of Treatment 323
13.2.1 Genetic Defi cit Repair 323
13.2.2 Viral-Mediated Gene Transfer 323
13.2.3 Drug-Resistant Genes 323
13.2.4 Angiogenetics Inhibitors 324
13.2.5 Gene Marking 324
13.2.6 Cell Therapy 324
13.3 Method of Delivery 324
13.3.1 Viral Vectors 325
13.3.2 Plasmid Vectors 325
13.4 Potential Side Effects 325
13.5 Special Considerations 326
13.6 Future Perspectives 326
References 326
Chapter 14 328
Biological and Targeted Therapies 328
14.1 Introduction 328
14.2 Principles of Treatment 329
14.3 Description of Treatment 330
14.3.1 Cytokines 330
14.3.2 Interferons 330
14.3.3 Interleukins 331
14.3.4 Colony-stimulating Factors 331
14.3.5 Fusion Proteins 331
14.3.6 Monoclonal Antibodies 332
14.4 Cancer Vaccines 333
14.5 Other Immunomodulating Agents 333
14.5.1 Nonspecifi c Immunomodulating Agents 333
14.5.2 Retinoids 334
14.5.3 Thalidomide 334
14.6 Adoptive Immunotherapy 334
14.7 Molecular Targeted Therapy 334
14.8 Method of Delivery 335
14.9 Potential Side Effects 336
14.10 Future Perspectives 337
References 338
Chapter 15 340
Complementary and Alternative Medicine 340
15.1 Introduction 340
15.2 CAM Modalities 341
15.2.1 Acupuncture 341
15.2.1.1 Indications 342
15.2.1.2 Potential Risks/Side Effects/Requirements 342
15.2.1.3 Nursing Role 342
15.2.2 Biological Therapies 342
15.2.2.1 Indications 342
15.2.2.2 Potential Risks/Side Effects 343
15.2.2.3 Nursing Role 344
15.2.3 Mind–Body Therapies 344
15.2.3.1 Indications 344
15.2.3.2 Resources 345
15.2.3.3 Nursing Role 345
15.2.4 Movement Therapies 345
15.2.4.1 Indications 345
15.2.4.2 Potential Risks/Side Effects 345
15.2.4.3 Resources 345
15.2.4.4 Nursing Role 346
15.2.5 Aromatherapy 346
15.2.5.1 Indications 346
15.2.5.2 Potential Risks/Precautions/Side Effects 346
15.2.5.3 Nurse’s Role 346
15.2.6 Massage 347
15.2.6.1 Indications 347
15.2.6.2 Potential Risks/Side Effects 347
15.2.6.3 Resources 347
15.2.6.4 Nursing Role 347
15.2.7 Energy Therapies 348
15.2.7.1 Indications 348
15.2.7.2 Potential Risks/Side Effects 348
15.2.7.3 Resources for Nurses 348
15.3 Future Perspectives 348
References 349
Chapter 16 351
Clinical Trials 351
16.1 The Role of Clinical Trials 351
16.1.1 The Need for Research 351
16.1.2 Phases of Clinical Trials 352
16.1.3 Study Types 352
16.1.4 Research Ethics: Principles, Policies, and Guidelines 352
16.1.5 Legal and Ethical Issues Regarding Participation of Children in Research 354
16.1.6 Research in Pediatrics 356
16.2 Research Networks 356
16.2.1 Cooperative Group Research 356
16.2.1.1 History of COG 357
16.2.1.2 History of UKCCSG 357
16.2.1.3 History of BFM 357
16.2.2 Importance of Participationin Clinical Trials 358
16.3 Progress Made Through Clinical Trials 359
16.3.1 Treatments and Therapy Delivery 359
16.3.2 Quality of Life Measuresand Supportive Care 363
16.3.3 Complementary and Alternative Medicine 364
16.3.4 Late Effects 365
16.3.5 Palliative Care 365
16.4 Perception of Clinical Trials 366
16.5 Future of Clinical Trials 368
16.6 The Role of the Clinical Research Associate 368
16.6.1 Introduction 368
16.6.2 Clinical Research Associate 369
16.6.3 The Role of the CRA 370
16.6.4 The Role of the Clinical Research Nurse 372
References 373
Part IV: Metabolic System 380
Chapter 17 381
Metabolic System 381
17.1 Cancer Cachexia 381
17.1.1 Incidence 381
17.1.2 Etiology 382
17.1.3 Treatment 382
17.1.4 Prognosis 383
17.2 Obesity 383
17.2.1 Obesity in Survivors of Leukemia 383
17.2.1.1 Incidence 383
17.2.1.2 Etiology 383
17.2.1.3 Treatment 384
17.2.1.4 Prognosis 384
17.3 Inferior Outcomes and Obesity 384
17.3.1 Incidence 384
17.3.2 Etiology 385
17.4 Tumor Lysis Syndrome 385
17.4.1 Incidence 385
17.4.2 Etiology 385
17.4.3 Treatment 387
17.4.3.1 Patient Assessment 388
17.4.3.2 Preventative Measures 388
17.4.3.3 Management of Metabolic Abnormalities 390
17.4.4 Prognosis 391
17.5 Hypercalcemia 391
17.5.1 Incidence 391
17.5.2 Etiology 391
17.5.3 Treatment 391
17.5.4 Prognosis 392
17.6 Impaired Glucose Tolerance 392
17.6.1 Incidence 392
17.6.2 Etiology 392
17.6.3 Treatment 393
17.6.4 Prognosis 393
References 393
Chapter 18 396
Gastrointestinal Tract 396
18.1 Mucositis 397
18.1.1 Incidence 397
18.1.2 Etiology 397
18.1.2.1 Iatrogenic 397
18.1.2.2 Bacterial 399
18.1.2.3 Viral 399
18.1.2.4 Fungal 400
18.1.3 Prevention 400
18.1.4 Treatment 400
18.1.5 Prognosis 401
18.2 Dental Caries 401
18.2.1 Incidence 401
18.2.2 Etiology 401
18.2.2.1 Iatrogenic 401
18.2.3 Prevention and Treatment 402
18.2.4 Prognosis 402
18.3 Nausea and Vomiting 402
18.3.1 Incidence 402
18.3.2 Etiology 402
18.3.3 Prevention 403
18.3.4 Treatment 403
18.3.5 Delayed Nausea and Vomiting 404
18.3.6 Anticipatory Nausea and Vomiting 404
18.3.7 Radiation-Induced Nausea and Vomiting 405
18.3.8 Other Causes of Nausea and Vomiting 406
18.3.9 Nonpharmacological Management 406
18.3.10 Prognosis 407
18.4 Constipation 407
18.4.1 Incidence 407
18.4.2 Etiology 407
18.4.2.1 Iatrogenic 407
18.4.2.2 Primary Constipation 407
18.4.2.3 Secondary Constipation 407
18.4.3 Prevention 408
18.4.4 Treatment 408
18.4.5 Prognosis 409
18.5 Diarrhea 409
18.5.1 Incidence 409
18.5.2 Etiology 409
18.5.2.1 Iatrogenic 409
18.5.2.1.1 Chemotherapy-Induced Diarrhea 409
18.5.2.1.2 Radiation-Induced Diarrhea 411
18.5.2.1.3 Other Iatrogenic Causes of Diarrhea 411
18.5.2.2 Viral 411
18.5.2.3 Bacterial 411
18.5.2.4 Other Infectious Etiologiesof Diarrhea 411
18.5.3 Prevention 411
18.5.4 Treatment 411
18.5.5 Prognosis 412
18.6 Typhylitis 412
18.6.1 Incidence 412
18.6.2 Etiology 413
18.6.2.1 Iatrogenic 413
18.6.2.2 Fungal 413
18.6.2.3 Bacterial 413
18.6.3 Prevention 413
18.6.4 Treatment 413
18.6.5 Prognosis 414
18.7 Perirectal Cellulitis 414
18.7.1 Incidence 414
18.7.2 Etiology 414
18.7.2.1 Iatrogenic 414
18.7.2.2 Bacterial 414
18.7.3 Prevention 414
18.7.4 Treatment 414
18.7.5 Prognosis 415
18.8 Acute Gastrointestinal Graft Vs. Host Disease 415
18.8.1 Incidence 415
18.8.2 Prevention 415
18.8.3 Treatment 416
18.9 Chemical Hepatitis 417
18.9.1 Incidence 417
18.9.2 Etiology 417
18.9.3 Prevention 417
18.9.4 Treatment 417
18.9.5 Prognosis 418
18.10 Pancreatitis 418
18.10.1 Incidence 418
18.10.2 Etiology 418
18.10.3 Prevention 418
18.10.4 Treatment 418
18.10.5 Prognosis 418
References 419
Chapter 19 421
Bone Marrow Function 421
19.1 Introduction 422
19.2 Anemia 422
19.2.1 Incidence and Etiology 422
19.2.2 Treatment 422
19.2.2.1 Transfusion 422
19.2.2.2 Use of Recombinant Human Erythropoietin 423
19.3 Neutropenia 423
19.3.1 Incidence and Etiology 423
19.3.1.1 Fever (Pyrexia) and Neutropenia 424
19.3.2 Treatment 424
19.3.2.1 Antibiotic Management 425
19.3.2.2 Special Consideration for the Management of Indwelling Intravenous Catheters 427
19.3.2.3 Management of Candidiasis (Oropharyngeal Candidiasis and Candida Esophagitis) 427
19.3.2.4 Infections Due to Aspergillus Species 428
19.3.2.5 Management of Viral Infections 428
19.3.2.6 Infections Due to Pneumocystis jiroveci (Formerly Pneumocystis carinii ) 428
19.3.2.7 Use of Colony Stimulating Factors in Children with Neutropenia 430
19.3.2.8 Isolation 431
19.4 Thrombocytopenia 431
19.4.1 Incidence and Etiology 431
19.4.2 Treatment 431
19.5 Transfusion Issues 432
19.5.1 Granulocyte Transfusions 432
19.5.1.1 Transfusion-Related Acute Lung Injury 432
19.5.2 Transfusion-Associated Graft vs. Host Disease 433
19.5.3 Cytomegalovirus and Transfusions 434
19.5.3.1 Treatment 434
19.5.4 Platelet Refractoriness 434
19.5.4.1 Treatment 435
19.6 Disseminated Intravascular Coagulation 435
19.6.1 Etiology and Manifestation 435
19.6.1.1 Diagnosis 436
19.6.2 Treatment 436
19.7 Septic Shock 437
19.7.1 Etiology 437
19.7.2 Treatment 437
19.7.3 Prognosis 438
19.8 Immune Suppression 438
19.8.1 Polymorphonuclear Leukocytes 438
19.8.2 Lymphocytes 439
19.8.3 Spleen and Reticuloendothelial System 440
19.8.4 Other Factors Contributing to Immunocompromised States 440
References 440
Chapter 20 443
Respiratory System 443
20.1 Pneumocystis Pneumonia 443
20.1.1 Incidence 443
20.1.2 Etiology 444
20.1.3 Treatment 444
20.1.4 Prognosis 446
20.2 Pneumonitis 446
20.2.1 Incidence 446
20.2.2 Etiology 446
20.2.3 Prevention 447
20.2.4 Treatment 447
20.2.5 Prognosis 447
20.3 Fibrosis 448
20.3.1 Incidence 448
20.3.2 Etiology 448
20.3.3 Prevention 448
20.3.4 Treatment 448
20.3.5 Prognosis 448
20.4 Compromised Airway 449
20.4.1 Incidence 449
20.4.2 Etiology 449
20.4.3 Prevention 449
20.4.4 Treatment 450
20.4.5 Prognosis 450
References 450
Chapter 21 452
Renal System 452
21.1 Nephrectomy 453
21.1.1 Incidence 453
21.1.2 Etiology 453
21.1.2.1 Neoplasms 453
21.1.2.2 Bacterial 453
21.1.3 Treatment 453
21.1.3.1 Preoperative Care 453
21.1.3.2 Surgery 455
21.1.3.3 Postoperative Care 455
21.1.4 Prognosis 457
21.2 Cytotoxic Drug Excretion 458
21.2.1 Pharmacokinetics/Dynamics 458
21.2.2 Metabolism 459
21.2.3 Excretion 459
21.2.4 Drug Interactions 461
21.2.5 Dose Modifi cation 461
21.2.6 Safe Handling of Cytotoxic Excreta 465
21.3 Nephrotoxicity 466
21.3.1 Incidence 466
21.3.2 Etiology 467
21.3.2.1 Iatrogenic 467
21.3.2.1.1 Radiation 467
21.3.2.1.2 Chemicals 467
21.3.2.2 Fungal 468
21.3.2.3 Viral 468
21.3.2.4 Bacterial 468
21.3.3 Prevention 468
21.3.4 Treatment 471
21.3.4.1 Fluid Overload 471
21.3.4.2 Metabolic Acidosis 472
21.3.4.3 Electrolyte Imbalance 472
21.3.5 Prognosis 473
21.4 Hemorrhagic Cystitis 473
21.4.1 Incidence 473
21.4.2 Etiology 474
21.4.2.1 Iatrogenic 474
21.4.2.1.1 Radiation 474
21.4.2.1.2 Chemical 474
21.4.2.2 Fungal 475
21.4.2.3 Viral 475
21.4.2.4 Bacterial 475
21.4.3 Prevention 475
21.4.4 Treatment 476
21.4.5 Prognosis 478
References 478
Chapter 22 481
Cardiovascular System 481
22.1 Cardiac Toxicity/Cardiomyopathy 481
22.1.1 Incidence 481
22.1.1.1 Recommendations During Treatment 482
22.1.1.2 Modifi cation of Chemotherapy 482
22.1.2 Etiology 483
22.1.3 Treatment 485
22.1.4 Prevention 485
22.1.4.1 Limiting the Effects of Myocardial Concentrations of Anthracyclines and Their Metabolites 485
22.1.4.2 Concurrent Administration of Cardioprotective Agents 486
22.1.4.3 Developing Less Cardiac Toxic Therapies 486
22.1.4.4 Lifestyle Advice 486
22.1.4.5 Guidelines for Long-Term Follow-Up 486
22.1.5 Prognosis 487
22.2 Veno-Occlusive Disease 487
22.2.1 Hepatic Veno-Occlusive Disease 487
22.2.1.1 Incidence 487
22.2.1.2 Diagnosis 488
22.2.1.3 Etiology 488
22.2.1.4 Treatment 488
22.2.1.5 Prevention 489
22.2.1.6 Prognosis 489
22.2.2 Pulmonary Veno-Occlusive Disease 489
22.2.2.1 Incidence 489
22.2.2.2 Etiology 490
22.2.2.3 Treatment 490
22.2.2.4 Diagnosis 490
22.2.2.5 Prognosis 490
References 490
Chapter 23 492
Central Nervous System 492
23.1 Spinal Cord Compression 492
23.1.1 Incidence 492
23.1.2 Etiology 492
23.1.3 Treatment 493
23.1.4 Prognosis 493
23.2 Fatigue 493
23.2.1 Incidence 494
23.2.2 Etiology 494
23.2.3 Treatment 495
23.2.4 Prognosis 496
23.3 Cognitive Deficits 497
23.3.1 Incidence 497
23.3.2 Etiology 497
23.3.3 Prevention and Treatment 497
23.3.4 Prognosis 498
23.4 Diabetes Insipidus 498
23.4.1 Incidence 498
23.4.2 Etiology 499
23.4.3 Treatment 499
23.4.4 Prognosis 499
References 499
Chapter 24 502
Musculoskeletal System 502
24.1 Bone Tumors 502
24.1.1 Limb Salvage Procedures 502
24.1.1.1 Incidence 502
24.1.1.2 Procedure 503
24.1.1.3 Management 503
24.1.2 Amputation 503
24.1.2.1 Incidence 503
24.1.2.2 Procedure 503
24.1.2.3 Rotationplasty 506
24.1.2.4 Management 507
24.1.3 Comparison of Limb Salvage and Amputation 508
24.1.3.1 Duration of Survival 508
24.1.3.2 Immediate and Ultimate Morbidity 508
24.1.3.3 Function 508
24.1.3.4 Quality of Life 509
24.2 Altered Bone Mineral Density and Increased Fracture Risk 509
24.2.1 Incidence 509
24.2.2 Etiology 510
24.2.3 Prevention and Treatment 510
24.2.4 Prognosis 511
24.3 Osteonecrosis 511
24.3.1 Incidence 512
24.3.2 Etiology 513
24.3.3 Treatment 513
24.3.4 Prognosis 514
References 514
Chapter 25 516
Skin: Cutaneous Toxicities 516
25.1 Alopecia 516
25.1.1 Etiology 516
25.1.3 Treatment 517
25.1.4 Prognosis 518
25.2 Altered Skin Integrity Associated with Radiation Therapy 518
25.2.1 Incidence 518
25.2.2 Etiology 518
25.2.3 Prevention 518
25.2.4 Treatment 519
25.2.5 Prognosis 520
25.3 Radiation Sensitivity and Recall 520
25.3.1 Incidence 520
25.3.2 Etiology 520
25.3.3 Clinical Features 520
25.3.4 Treatment 520
25.3.5 Prognosis 521
25.4 Ultraviolet Recall Reaction/Photosensitivity 521
25.5 Cutaneous Reactions Associated with High-Dose Cytosine Arabinoside 521
25.5.1 Incidence 521
25.5.2 Etiology 521
25.5.3 Prevention and Treatment 521
25.6 Nail Dystrophies 522
25.7 Graft Vs. Host Disease 522
25.7.1 Incidence and Etiology 522
25.7.2 Prevention 524
25.7.3 Treatment 525
25.7.4 Prognosis 525
References 525
Chapter 26 528
Endocrine System 528
26.1 Introduction 528
26.2 Hypothalamic–Pituitary Dysfunction 528
26.2.1 Incidence and Etiology 528
26.3 Growth Hormone Deficiency 530
26.3.1 Treatment 531
26.3.1.1 Investigation 531
26.3.1.2 Growth Hormone Replacement Therapy 531
26.3.2 Prognosis 531
26.4 Hypothalamic–Pituitary–Gonadal Axis 532
26.4.1 Gonadotrophin Deficiency 532
26.4.2 Early or Precocious Puberty 532
26.4.2.1 Treatment 532
26.4.2.2 Prognosis 533
26.5 Thyroid Disorders 533
26.5.1 Treatment 533
26.6 Hypothalamic–Pituitary–Adrenal Axis 534
26.6.1 Treatment 534
26.7 Other Pituitary Hormones 534
26.7.1 Fertility 535
26.7.1.1 Testicular Failure 535
26.7.1.2 Ovarian Failure 535
26.7.2 Treatment 535
26.7.2.1 Assessment of Gonadal Function 535
26.7.2.2 Treatment for Gonadal Dysfunction 535
26.7.3 Prognosis 536
References 538
Chapter 27 539
Ototoxicity 539
27.1 Introduction 539
27.2 Prevention and Treatment 543
27.3 Future Perspectives 545
27.4 Prognosis 546
References 546
Chapter 28 548
Ocular Complications 548
28.1 Ocular Toxicity Associated with High-Dose Cytarabine Arabinoside 548
28.1.1 Incidence and Etiology 548
28.1.2 Prevention 549
28.1.3 Treatment 549
28.1.4 Prognosis 549
28.2 Cataracts 550
28.2.1 Incidence 550
28.2.2 Etiology 550
28.2.3 Prevention 550
28.2.4 Treatment 550
28.2.5 Prognosis 550
References 550
Part V: Nutrition and Hydration in Children with Cancer 552
Chapter 29 553
Nutrition and Hydration in Children with Cancer 553
29.1 Introduction 553
29.2 Nutritional Assessment 554
29.2.1 Hydration Needs 554
29.2.2 Nutrition Needs 554
29.2.3 Nutritional History 555
29.2.4 Physical Examination 556
29.2.5 Anthropometric Measurements 556
29.2.6 Laboratory Evaluation 557
29.3 Principles of Treatment for Dehydration and Malnutrition 557
29.3.1 Rehydration 557
29.3.2 Oral Nutrition Replacement 558
29.3.3 Enteral Nutrition Replacement 558
29.3.4 Total Parenteral Nutrition/Hyperalimentation 559
29.4 Special Considerations 562
29.4.1 Common Hydration Complications 562
29.4.1.1 Fluid Overload 562
29.4.1.2 Electrolyte Abnormalities 562
29.4.2 Common Complications of Oral/Enteral Nutritional Supplementation 562
29.4.2.1 Nausea/Vomiting, Bloating, Reflux, and/or Diarrhea 562
29.4.2.2 Gastroparesis 562
29.4.2.3 Aspiration Pneumonia 563
29.4.2.4 Skin Irritation 563
29.4.2.5 Feeding Tube Obstruction 563
29.4.3 Common Complications of Total Parenteral Nutrition/Hyperalimintation 563
29.4.3.1 Electrolyte Abnormalities 563
29.4.3.2 Hepatic Dysfunction 563
29.4.3.3 Mechanical Complications 563
29.4.4 Common Complications of Enteral and Parenteral Nutritional Supplementation 565
29.4.4.1 Refeeding Syndrome 565
29.4.4.2 Glycemic Abnormalities 565
29.4.5 Specific Nutritional Concerns of Long-Term Survivors 565
29.4.6 Specific Nutritional Concerns During Palliative Care 565
References 566
Chapter 30 567
Pain in Children with Cancer 567
30.1 Introduction 567
30.2 Causes of Pain in Childhood Cancer 567
30.3 Assessment 568
30.4 Cultural Issues 574
30.5 Principles of Treatment 574
30.6 Treatment 575
30.6.1 By the Ladder 575
30.6.1.1 Step I: Mild Pain 575
30.6.1.2 Step II: Mild to Moderate Pain 575
30.6.1.3 Step III: Moderate to Severe Pain 576
30.6.1.4 Intractable Pain 576
30.6.2 By the Route 576
30.6.3 By the Clock 576
30.6.4 Opioids 576
30.6.5 Equianalgesia 576
30.6.6 Procedure-Related Pain 578
30.6.7 Patient-Controlled Analgesia (PCA) 578
30.6.8 Adjuvant Medications 580
30.6.9 Nonpharmacologic Treatment 580
Summary 581
References 582
Chapter 31 583
Blood Transfusion Therapy 583
31.1 Introduction 584
31.2 Blood Screening Guidelines 584
31.3 Blood Product Processing 584
31.3.1 Irradiation 585
31.3.2 Washed Red Blood Cells 585
31.4 Transfusion Complications 585
31.4.1 Hemolytic Reactions 585
31.4.2 Febrile Nonhemolytic Transfusion Reactions 586
31.4.3 Allergic Reactions 586
31.4.4 Transfusion Associated Graft vs. Host Disease 587
31.4.5 Circulatory Overload 587
31.4.6 Bacterial Contamination 587
31.4.7 Transfusion-Acquired Infections 588
31.4.7.1 Cytomegalovirus 588
31.4.7.2 Transfusion-Related Acute Lung Injury 588
31.4.8 Iron Overload from Chronic Transfusion 589
31.5 Red Blood Cell Transfusion 589
31.5.1 Packed Red Blood Cells 589
31.5.1.1 Indications 589
31.5.1.2 Dosing/Transfusion Guidelines 589
31.5.1.3 Crossmatching 589
31.5.1.4 Nursing Implications 590
31.5.2 Whole Blood 590
31.5.2.1 Indications 590
31.5.2.2 Dosing/Transfusion Guidelines 590
31.5.2.3 Crossmatching 590
31.5.2.4 Nursing Implications 590
31.5.3 Exchange Transfusion 590
31.6 Platelet Transfusion 590
31.6.1 Indications 590
31.6.2 Procurement 591
31.6.3 Dosing/Transfusion Guidelines 591
31.6.4 Crossmatching 591
31.6.5 Nursing Implications 591
31.7 Granulocyte Transfusion 591
31.7.1 Indications 592
31.7.2 Dosing/Transfusion Guidelines 592
31.7.3 Crosssmatching 592
31.7.4 Nursing Implications 592
31.8 Albumin (5 or 25% solution) and Plasma Protein Fraction (5% solution) 592
31.8.1 Indications 592
31.8.2 Dosing/Transfusion Guidelines 592
31.8.3 Crossmatching 593
31.8.4 Nursing Implications 593
31.9 Fresh Frozen Plasma 593
31.9.1 Indications 593
31.9.2 Dosing/Transfusion Guidelines 593
31.9.3 Crossmatching 593
31.9.4 Nursing Implications 593
31.10 Cryoprecipitate 593
31.10.1 Indications 593
31.10.2 Dosing Guidelines 594
31.10.3 Crossmatching 594
31.10.4 Nursing Implications 594
31.11 Intravenous Immunoglobulin 594
31.11.1 Indications 594
31.11.2 Dosing/Transfusion Guidelines 594
31.11.3 Crossmatching 594
31.11.4 Nursing Implications 594
31.12 Erythropoietin 594
31.13 Indications 595
31.14 Dosing Guidelines 595
31.15 Nursing Implications 595
31.16 Palliative Care Issues for Transfusion Therapy 595
31.16.1 Anemia and Thrombocytopenia 595
References 595
Chapter 32 597
Cytokines 597
32.1 Principles of Treatment 597
32.2 Future Perspectives 601
References 602
Chapter 33 603
Care of the Dying Child and the Family 603
33.1 Children’s Understanding of Death 603
33.1.1 Infants (0–12 Months) and Toddlers (12–24 Months) 603
33.1.2 Preschool Children (3–5 Years) 604
33.1.3 School-Age Children (6–11 Years) 605
33.1.4 Adolescents (12–19 Years) 605
33.2 Explaining Death to Children 605
33.3 Pediatric Palliative Care 606
33.3.1 Principles 606
33.3.2 Locations of Care 606
33.4 Grief 607
33.4.1 Principles 607
33.4.2 Assessment of Child and Family 607
33.4.3 Interventions 609
33.5 Cultural and Spiritual Care 609
33.5.1 Principles 609
33.5.2 Assessment of Child and Family 609
33.5.3 Interventions 609
33.6 Nearing Death 611
33.6.1 Physical Symptoms Near the End of Life 611
33.6.2 Death-Related Sensory Experiences 612
33.7 Care Following the Child’s Death 613
33.7.1 Interventions Immediately Following the Child’s Death 613
33.7.2 Bereavement Interventions 613
33.8 Resources 613
33.8.1 Resources for Children 613
33.8.2 Resources for Adults 614
References 614
Subject Index 617