Children with cancer: quality of information for returning to school.

A children's oncology unit in the UK carried out an initial audit of the information given by healthcare professionals to children, families, teachers and educational institutions about the return to school of pupils with cancer. The findings were collated and presented to those involved. The audit has led to the provision of more consistent, continuing information to families and schools.

Assessment and management of nutritional challenges in children's cancer care: a survey of current practice in the United Kingdom.

BACKGROUND: The maintenance of an adequate nutritional intake is vital for the child or young person undergoing treatment for cancer. Inability to maintain nutrition can lead to poor tolerance of treatment, increased risk of infectious complications and a potential poorer overall outcome. Good nutritional support is vital however there does not appear to be a national or consistent approach to either nutritional support or assessment. PURPOSE: The Paediatric Oncology Nurses Forum of the Royal College of Nursing and the Paediatric Oncology Dieticians Interest Group surveyed practice in the 21 Children Cancer and Leukaemia Group Centres in the United Kingdom and Ireland with the express aim of reviewing current practice as a first stage towards developing national guidance for nutritional management. METHODS AND SAMPLE: Questionnaires designed to review nutritional assessment and nutritional interventions were distributed to both a nurse and dietician in each CCLG centre. The results were analysed using descriptive statistics. RESULTS: There was a 100% return rate from nurses and 66% from dieticians. The results showed an inconsistent approach in both assessment methods and approaches to nutritional intervention for this group of patients. CONCLUSION: It is recognised that there is a need to adequately assess and provide appropriate nutrition for children and young people receiving cancer therapies. This survey highlights the inconsistencies in practice today as well as the need for consistent and useful guidance especially in the area of nutritional assessment and management of potential malnutrition.

Vascular access for daunorubicin during childhood acute lymphoblastic leukaemia induction treatment: a UKCCSG supportive care group and MRC childhood leukaemia working party survey.

Daunorubicin was reintroduced into induction chemotherapy in UK protocols for intermediate- and high-risk childhood acute lymphoblastic leukaemia in 1999. Concern about the risk of central venous catheter-associated venous thromboembolism led to a recommendation that induction treatment should be given by peripheral venous access wherever possible, whilst recognising anxieties concerning the risk of daunorubicin extravasation. A survey performed to determine how these conflicting concerns influenced practice in the administration of daunorubicin revealed considerable variation. The results highlight that recommendations were not being followed and that local practice and guidance were being utilised in this area of practice. However, there is a need to identify patients at higher risk of venous thromboembolism during induction treatment and better strategies to prevent this complication.

A survey of public transport use by immunocompromised children in the United Kingdom.

BACKGROUND: The advice given to immunocompromised children and their families on the use of public transport at our oncology unit has been inconsistent, with a lack of written or evidence based guidelines. We therefore carried out two surveys, one national and one local on this issue, to determine what advice is given to families. We also undertook an extensive literature search on this subject. METHODS: The first survey was completed by the Paediatric Oncology Nurses Forum link member at each of the 22 United Kingdom Childrens' Cancer Study Group (UKCCSG) centres. We asked their current practice for use of public transport for hospital visits, school attendance, regular weekly use and holidays. We looked at recommendations for travel on holiday in the UK and abroad with reference to neutrophil and platelet counts. The second survey was completed by parents of 64 children attending our outpatient clinic over a 2-week period to ascertain whether the families comply with our verbal recommendations. RESULTS: There was a 100% response from UKCCSG centres. None of the centres had any written or evidence based guidelines. 55% of centres allowed public transport for hospital visits, 82% for school and 90% for holidays. Sixty-eight percent of centres allowed UK travel with a neutrophil count of 0.5-1 x 109/L and 18% if neutrophils <0.5 x 109/L. Eighteen percent of centres allowed foreign travel with a neutrophil count of 0.5-1 x 109/L but only 9% if <0.5 x 109/L. The second survey showed 2% used public transport to attend hospital, 5% for school, 17% for regular use and 50% travelled by plane for holidays. A Pubmed literature search revealed a lack of studies on immunocompromised patients. CONCLUSION: A certain use of public transport is necessary for patients to engage in as normal a life as possible. There is a need for further studies to produce sensible and consistent advice on this issue.

Does the number of exogenous infections increase in paediatric oncology patients when sterile surgical gloves are not worn for accessing central venous access devices?

The aim of this study was to determine whether the routine use of sterile gloves when accessing central venous catheters (CVCs) affects the incidence of exogenous septicaemia in paediatric oncology patients. The 36-month study period ran prospectively from September 2000 to August 2003. During this time the routine use of sterile gloves for accessing CVCs was suspended. Sterile gloves were only used when obtaining blood samples from the line or injecting substances that required direct entry into the lumen with removal of line cap. Surveillance cultures of throat and rectum were obtained to detect carriage of potential pathogens. Exogenous septicaemia was defined as a blood stream infection due to microorganisms not carried by the patient in throat and/or rectum. The incidence of exogenous septicaemia following a change of practice of not routinely using sterile gloves for accessing lines was compared to the incidence of exogenous septicaemia in a historical control group. The number of exogenous septicaemia episodes per inpatient days with gloves and without gloves was calculated for the total number of episodes and for the first episode for each child. The relative incidence and 95% confidence intervals was also calculated for first and total episodes. For both, all episodes and first episodes there was no statistically significant difference in the incidence of exogenous septicaemia comparing the control and study patients. In summary, this study does not support or approve the use of sterile gloves when accessing CVCs in respect of exogenous septicaemia.

Variation in policies for the management of febrile neutropenia in United Kingdom Children's Cancer Study Group centres.

OBJECTIVE: To assess the variation in the current UK management strategies for the treatment of febrile neutropenia in childhood. DESIGN AND SETTING: A postal survey of all 21 United Kingdom Children's Cancer Study Group (UKCCSG) centres assessing and collating local policies, protocols or guidelines relating to the management of febrile neutropenia. Further direct contact was undertaken to clarify any uncertainties. RESULTS: All 21 centres provided information. The policies used to manage febrile neutropenia in the centres around the UK vary in almost every aspect of management. Definitions of fever ranged from a persistent temperature of >37.5 degrees C to a single reading of >39 degrees C. Neutropenia was inconsistently defined as an absolute neutrophil count of <1x10(9), <0.75x10(9 )or <0.5x10(9). Choices of antibiotic approaches, empirical modifications and antistaphylococcal treatment were different in each protocol. The use of risk stratification was undertaken in 11 centres, with six using a policy of reduced intensity therapy in low risk cases. Empirical antifungal treatment was very poorly described and varied even more widely. CONCLUSIONS: There was a great deal of variation in definitions and treatment of febrile neutropenia in the UKCCSG children's cancer treatment centres. A degree of variation as a result of local microbiological differences is to be expected, but beyond this we should seek to standardise the core of our approach to defining fever and neutropenia, risk stratification and duration of empirical therapy in a way that maintains safety, minimises resource utilisation and maximises quality of life.

The use of blood products in paediatric oncology units in the UK.

AIM: The clinical practice group of the Royal College of Nursing paediatric oncology nurses' forum carried out an exploratory study to examine practice in administration of blood products in children's cancer centres across the UK to identify any variances in practice. METHOD: A questionnaire covering the use and administration of red cells, platelets and other supportive measures was distributed to each of the 22 UK Children's Cancer Study Groups centres of which 14 responded (63 per cent). FINDINGS: Variations among the units were found in all aspects of blood product administration including decisions about when to transfuse, methods of transfusion, treatment of adverse reactions and use of supportive products. There were some differences between the practices reported and guidance for transfusion in neonates and older children published by the British Committee for Standards in Haematology Transfusion Task Force (2004); many of these differences were attributable to the specific needs of oncology patients. CONCLUSION: The development of national guidance or minimum safe standards specifically for paediatric oncology patients could assist in reducing practice variations. This study was undertaken in children's cancer units where administration of blood products is a daily occurrence. Variations in practice that were identified here are likely to be found in non oncology/haematology settings.

Constipation in paediatric oncology.

Constipation is a common problem encountered by many children during treatment for childhood cancer. It can be distressing and impact on the quality of life for the child. However, the advice and information they and their families receive can vary enormously. The clinical practice group (a subgroup of the paediatric oncology nurses forum (PONF)) decided to examine the management of constipation throughout the paediatric oncology units in the UK. This paper presents the findings and the subsequent action taken and highlights the need for further work.

Once-daily netilmicin for neutropenic pyrexia in paediatric oncology.

AIM: To establish the safety and efficacy of single daily intravenous netilmicin 6 mg/kg with piperacillin 100 mg/kg every 8 h for empirical, first-line management of children with neutropenic pyrexia following cytotoxic chemotherapy. METHODS: Observational study of children admitted to a regional oncology unit from October 1999-April 2002. Primary outcome measure was temperature 72 h after commencing antibiotic therapy; secondary measures were mortality, nephrotoxicity, symptomatic ototoxicity and serum netilmicin levels. RESULTS: 280 episodes for 128 patients (median age 7.1 y) were documented, and 248 episodes were evaluated and compared with a previous cohort of 100 episodes for which the only difference was administration of netilmicin three times daily. Twenty-seven per cent of single-dose netilmicin episodes remained febrile at 72 h compared to 32% in the comparator group (difference -4.7%; 95 % CI: -6.8% to 16.2%; p = 0.41). No patients died and we were unable to find evidence of nephrotoxicity or ototoxicity. Eighty-nine per cent of "peak" serum netilmicin levels measured 30 min after infusion were 10 mg/l or greater, and 94% and 86% measured 12-16 h after the first and third dose, respectively, were 1 mg/l or less. Peak serum netilmicin level measurements and 12-16-h measurements after the first dose were abandoned after the first 180 episodes. CONCLUSIONS: Netilmicin can safely be given as a single daily dose to children with febrile neutropenia who do not have biochemical evidence of nephrotoxicity. Monitoring peak serum levels of netilmicin is unnecessary. Levels taken 12-16 h after the third dose are adequate to monitor therapy if used in conjunction with a therapeutic guideline detailing the response to abnormal serum creatinine and netilmicin levels.