Common side effects of chemotherapy

Hair loss occurs when hair follicles are damaged by chemotherapy. Hair loss can
include scalp hair, eyelashes, eyebrows, axillary and pubic hair. The loss may be
gradual, or it may happen all at once. Hair loss from chemotherapy is usually
temporary; the hair will return, but it may regrow having different characteristics
such as a change in color or texture.
Mouth and throat sores are caused by the destruction of mucosal cells lining the
mouth and esophagus. They can result in minor to severe pain.
Nausea and vomiting are due to a number of factors related to the effect of
chemotherapy on the gastrointestinal tract and the brain. Currently, several antinausea drugs can be given prior to chemotherapy administration that will help
prevent this symptom.
Diarrhea may occur after chemotherapy because of damage to the intestinal
mucosa and changes in the intestine's ability to reabsorb liquid. Constipation can
result from chemotherapy's effects on the nerves of the intestines, which slows
peristalsis, or the elimination of waste.
Destruction of red blood cells by chemotherapy can lead to anemia. This can
cause excessive tiredness, pale skin color, shortness of breath, irritability,
decreased attention span, headaches and dizziness. These symptoms are primarily
due to the decrease in oxygen going to the brain and other body tissues.
Destruction of the blood platelets can result in bruising and bleeding. Known
as thrombocytopenia, this is caused by a lack of sufficient platelets to form a clot
and stop bleeding.
Destruction of white blood cells can result in infections. White blood cells destroy
bacteria, viruses and other pathogens, and are a major defense against infection.
When white blood cells are low, infections can occur quickly and become very
serious.
Chemotherapy drugs may affect organs such as the heart, lungs, kidneys, liver,
and brain, causing temporary or permanent damage. Some drugs may affect
hearing. It will help to discuss each drug with your oncologist, to understand
potential side effects and the probability that they will occur.

Sharon Frierdich, RN, MS, CPNP, University of Wisconsin Children's Hospital

Hair loss
Hair loss is called alopecia
Some chemotherapy causes hair loss or thinning of the hair. Radiation can also cause hair
loss in the area being irradiated. This may start 7 to 10 days after the treatment is given.
In some cases, a child may lose all the hair on their head (older children may experience
loss of body hair as well). Unfortunately, there is nothing that can be done to prevent the
hair from falling out. Some children and parents prefer to cut the hair as short as possible
when the hair loss begins. Others prefer to shave the head completely to avoid dealing
with the gradual hair loss.
Some things that may be helpful in coping with the loss of hair include wearing hats or
scarves. Other children prefer to wear a wig. The child's social worker or child life
specialist can provide information regarding obtaining a wig or hair accessory.
Hair grows back when the cancer treatments are complete, or in some cases, when the
treatment becomes less intense. In many cases, the hair may be a slightly different color
or texture (curlier, thicker or thinner) than before the cancer treatment. In a few cases
associated with high doses of radiation, the hair may not grow back. The child's health
team can provide an estimate of when hair regrowth is likely to begin.

Stomatitis
Mouth Care
The cells in the mouth can be affected by chemotherapy and by radiation therapy to the
head and neck. Keep the mouth as clean as possible to make the child feel more
comfortable and to help avoid any infections from growing in the mouth.
Ways to improve the condition of the mouth:

Brush teeth after meals and before bed with a soft toothbrush.
Use alcohol-free mouthwashes. Alcohol dries out the mouth.
If your child has a dry mouth, give him or her a choice of hard candies.

How to care for mouth sores

While the child is receiving chemotherapy and/or radiation therapy to the head and neck,
be aware that the child may develop mouth sores. The inside lining of the mouth and the
tongue may be red, and there may be white "plaques" (small raised areas) in the mouth
and on the tongue. These plaques are signs of a fungal infection known as thrush.

Strategies to care for mouth sores:

Avoid hot, spicy or acidic foods.

Serve foods cold or at room temperature.
Try foods that are soft, tender or pureed (beaten or blended).
Cut foods into small pieces.
Avoid dry or coarse foods.
Offer a straw for drinking liquids.
Use alcohol-free mouthwash, and rinse the mouth with water at least four times
each day.
Antifungal medicine may be prescribed to treat the mouth sores. If the mouth
sores are painful, pain medicine may also be prescribed.
Children should be evaluated if they cannot drink fluids, swallow saliva (spit) or
if the pain medicine does not help take away the pain.

Nausea, vomiting and dehydration

Nausea and vomiting can be caused by chemotherapy or radiation, either through direct
irritation to the stomach lining, or by stimulation of the vomiting center in the brain.
Antinausea medicines called antiemetics are given before chemotherapy or radiation
sessions to help decrease nausea and vomiting.
Chemotherapy agents vary in the amount of nausea and vomiting that they cause. The
type and amount of antinausea medicine will be based on your childs treatment plan and
the expected reaction. Prior to any treatment, you should discuss the expected effect of
the chemotherapy being given, and its management with your doctor or nurse.
Ways to help decrease nausea and vomiting:

Encourage the child to eat small meals or snacks

Provide foods that are easy to digest (crackers, rice, Jello)
Have the child take sips of cool, clear liquids
Avoid offering fried, spicy or very rich foods
Give the child food in a room that is free from cooking smells or other odors
Rinse the childs mouth after vomiting

If the child has diarrhea, tell your doctor or nurse the color, amount and number of times
it happens in one day. Here are a few ways to help decrease diarrhea:

Give the child a soft, bland diet (crackers, soup, rice)

Encourage the child to eat small amounts of food more often, instead of large
meals
Avoid spicy, fried or fatty foods
Avoid juices, milk or milk products (ice cream, cheese)
Avoid foods that are high in fiber (fruits, vegetables, salad)

Offer foods high in potassium (tomatoes, papaya, butternut squash)

Limit the amount of high-sugar foods (juices, candies)

Causes and signs of dehydration

Nausea, vomiting and diarrhea can lead to dehydration (loss of fluids in the body),
especially if the child cannot drink an amount sufficient to replace the fluid that is lost.
Some common signs of dehydration include:

Dry skin or mouth

No tear production when crying
Infrequent urination or small amounts of dark-colored urine
If the child wears diapers, count the hours between wet diapers

Call the doctor if the child has any of the signs of dehydration.

How to increase food and fluid intake at home

If the child is at home and is experiencing vomiting or diarrhea:

Offer small amounts of clear fluids to drink every 30 minutes

Provide foods that are easy to digest (crackers, rice, toast, soup), and avoid foods
with strong odors
Ask the doctor about medicines to decrease nausea

Nausea, vomiting and dehydration

Nausea and vomiting can be caused by chemotherapy or radiation, either through direct
irritation to the stomach lining, or by stimulation of the vomiting center in the brain.
Antinausea medicines called antiemetics are given before chemotherapy or radiation
sessions to help decrease nausea and vomiting.
Chemotherapy agents vary in the amount of nausea and vomiting that they cause. The
type and amount of antinausea medicine will be based on your childs treatment plan and
the expected reaction. Prior to any treatment, you should discuss the expected effect of
the chemotherapy being given, and its management with your doctor or nurse.
Ways to help decrease nausea and vomiting:

Encourage the child to eat small meals or snacks

Provide foods that are easy to digest (crackers, rice, Jello)
Have the child take sips of cool, clear liquids
Avoid offering fried, spicy or very rich foods
Give the child food in a room that is free from cooking smells or other odors
Rinse the childs mouth after vomiting

If the child has diarrhea, tell your doctor or nurse the color, amount and number of times
it happens in one day. Here are a few ways to help decrease diarrhea:

Give the child a soft, bland diet (crackers, soup, rice)

Encourage the child to eat small amounts of food more often, instead of large
meals
Avoid spicy, fried or fatty foods
Avoid juices, milk or milk products (ice cream, cheese)
Avoid foods that are high in fiber (fruits, vegetables, salad)
Offer foods high in potassium (tomatoes, papaya, butternut squash)
Limit the amount of high-sugar foods (juices, candies)

Causes and signs of dehydration

Nausea, vomiting and diarrhea can lead to dehydration (loss of fluids in the body),
especially if the child cannot drink an amount sufficient to replace the fluid that is lost.
Some common signs of dehydration include:

Dry skin or mouth

No tear production when crying
Infrequent urination or small amounts of dark-colored urine
If the child wears diapers, count the hours between wet diapers

Call the doctor if the child has any of the signs of dehydration.

How to increase food and fluid intake at home

If the child is at home and is experiencing vomiting or diarrhea:

Offer small amounts of clear fluids to drink every 30 minutes

Provide foods that are easy to digest (crackers, rice, toast, soup), and avoid foods
with strong odors
Ask the doctor about medicines to decrease nausea

Anemia
Anemia means a low red blood cell count
Red blood cells carry oxygen throughout the body. Oxygen enters the lungs with each
breath, and binds (attaches) with hemoglobin in the red blood cells. Hemoglobin delivers
the oxygen to all the organs and tissues in the body. Two laboratory tests are used to
measure the number and function of red blood cells.

Hemoglobin shows how much oxygen the red blood cells are able to carry. A
normal hemoglobin level is between 12 and 16.

Hematocrit is the percentage of red blood cells in the blood. A normal hematocrit
is between 36 and 50.

Signs of a low red blood cell count

When the red blood cell count is low, the body is not able to get as much oxygen to
different parts of the body. Some of the symptoms include:

Feeling of tiredness
Shortness of breath
Headache
Fast heart rate
Paleness of the skin or gums
Dizziness

Thrombocytopenia
Thromboctyopenia means a low platelet count
Platelets stop bleeding in the body by forming clots. A normal platelet count is between
150,000 and 300,000. When the platelet count is low, a child is at risk of bleeding.

Signs of a low platelet count

If a child has a low platelet count, you may see any of the following signs:

Bruising or petechiae (small red, pinpoint freckles on the skin)

Bleeding (from the nose, gums or central venous access device) that doesnt stop
with pressure within 10 minutes
Black stools or vomit (this means there is some bleeding in the stomach or bowel)

CANCER CONTROL ACTIVITIES

A. INFECTION AND MUCOSITIS
Cancer itself is the main cause of death in most cancer patients. However, infection is the
second most common cause of death in some children who require very intensive
treatment. These infections are caused by common bacteria and/or fungi that are present
in everyones mouths and intestines or in the air.

Cancer Control is proposing a study to prevent fungal infections in children with

acute myeloid leukemia by giving children an antifungal agent, Caspofungin,
when the immune system is very weak.

Mucositis or mouth sores is an important side effect of some chemotherapy and may be a
risk factor for infection as it allows bacteria normally present in the mouth to enter the
bloodstream.

We have completed a randomized trial of Traumeel, a homeopathic mouth rinse in

children undergoing stem cell transplantation. Preliminary analysis indicates that
Traumeel is not effective at preventing mucositis in this setting.
We are about to start a randomized study of keratinocyte growth-factor, a normal
human protein developed through recombinant DNA technology, that replenishes
the cells in the mouth damaged by chemotherapy. This study will include children
undergoing stem cell transplantation and is expected to open in the Spring of
2009.

B. NUTRITION
In the nutrition domain, we have three foci of activity. First, we are studying agents to
prevent or ameliorate malnutrition in children undergoing chemotherapy. Second, we are
trying to preserve weight by preventing nausea and vomiting which are common side
effects of chemotherapy. Third, obesity has become a common problem in healthy
children. Obese children with cancer have poorer outcomes compared to normal weight
children. The activities of CCLS also include trying to understand why obese children
have poorer outcomes.

We completed one study of Periactin for malnutrition and found that

administration was associated with a significant increase in weight after a four
week treatment period.

We have two studies to prevent chemotherapy related nausea and vomiting.

An ongoing CureSearch COG study asks if electro-acupuncture can help control

delayed vomiting in patients with solid tumors.
We are planning a study to determine whether a newer drug called Palonosetron
can reduce nausea and vomiting in children undergoing stem cell transplantation.

CCLS is conducting two studies to try and determine why obese children have worse
outcomes by measuring the amount of drug in the blood in obese, middleweight and
underweight children

One study examines chemotherapy drug levels according to height and weight
(body mass index ) in children with acute lymphoblastic leukemia.
We also are studying drug levels of a common chemotherapy called daunorubicin
in children who have different body mass indices.