Pediatric Leukemia

Leukemia is the most common type of cancer in both children and teens. It makes up about one-third of all childhood cancer, but it’s still a rare disease. 

Leukemia is cancer of the blood cells. Most leukemia starts with white blood cells, but it can begin in other blood cells. Blood cells grow and mature in the bone marrow before they are pushed out into the bloodstream to circulate throughout the body. When someone has leukemia, their bone marrow produces abnormal blood cells that begin circulating. These abnormal cells are the leukemia cells. When leukemia cells are first made, they function almost normally. But over time, they can crowd out normal blood cells, making it hard for the normal cells to do their job. Leukemia cells can also make their way throughout the body, to the lymph nodes, organs or central nervous system. All cases of leukemia require treatment – usually in a children’s hospital under the supervision of a children’s cancer specialist (pediatric oncologist).

Leukemia statistics

About 75% of children with leukemia have acute lymphocytic leukemia (ALL), and acute myelogenous leukemia (AML) makes up most of the rest of the cases. Chronic and hybrid forms of leukemia are extremely rare in children. 

ALL tends to happen in early childhood – between the ages of 2 and 4. AML can happen at any time during childhood, but it is more common before the age of 2 and during the teen years. Both boys and girls can get leukemia. ALL is more common in boys, but AML occurs equally across genders.

Types of leukemia

There are four main types of leukemia, which can be classified as acute or chronic. Acute leukemia, when the leukemia cells grow quickly, is the most common childhood leukemia. In fact, almost all childhood leukemia is acute. Chronic leukemia is slow growing. This type is rare in children.

The four main types are:

• Acute myelogenous leukemia (AML) – AML, also called acute myelocytic leukemia, granulocytic leukemia, acute non-lymphocytic leukemia and acute myeloidleukemia, starts in the myeloid cells that form white and red blood cells and blood platelets. In AML, the bone marrow produces too many granulocytes, which are a type of white blood cell. Because there are too many of these cells, they cannot mature normally. When there are too many granulocytes, other blood cells are crowded out and can’t do their job. Children who have some genetic syndromes, like Down syndrome, Bloom syndrome and Fanconi anemia, are at higher risk for developing AML. This type of leukemia accounts for just under 20% of all childhood leukemias.
• Chronic myelogenous leukemia (CML) – CML is rare in children. It begins in the myeloid cells and grows slowly. Like AML, it involves an overgrowth of granulocytes that do not mature correctly and keep normal granulocytes from doing their job of fighting infection. When people have CML, their chromosomes are rearranged, leading to uncontrolled cell growth. People with CML may also have other chromosomal abnormalities.
• Acute lymphocytic leukemia (ALL) – ALL starts from lymphocytes in the bone marrow. The bone marrow makes too many lymphocytes and they don’t mature correctly, so they crowd out normal blood cells. The immature lymphocyte cells are called blasts. Because they aren’t formed correctly, they can’t work well at fighting infection. About 75% of all childhood leukemias are ALL.
• Chronic lymphocytic leukemia (CLL) – CLL is very rare in children. Like ALL, it starts in the lymphocytes, but it grows slowly.

There are hybrid types of leukemia as well, but these only rarely occur in children. These leukemias have characteristics of both ALL and AML.

Juvenile myelomonocytic leukemia (JMML) is rare form of leukemia. It is not characterized as either chronic or acute. It starts in the myeloid cells, but it doesn’t fit into the growth pattern of either acute or chronic leukemia – it grows slower than AML and faster than CML. JMML, when it occurs, tends to affect children under the age of 4.

Signs and symptoms of leukemia in children

Early symptoms of leukemia tend to be related to bone marrow malfunction. The symptoms below are the most common symptoms of leukemia, but not all children will experience all symptoms.

• Anemia – When red blood cells can’t be produced or are low in number, children may have several symptoms, including:
  • feeling tired
  • looking pale
  • breathing rapidly or having an increased breathing rate
  • low red blood cell and hemoglobin numbers
• decreased platelet count (thrombocytopenia) and related symptoms, like:
  • bleeding or bruising 
  • tiny red dots on the skin (called petechiae)
• recurrent infections because infection-fighting white blood cells aren’t working; signs of infections may include:
  • fever
  • runny nose
  • cough
• bone and joint pain from cells overcrowding the bone marrow
• abdominal pain or discomfort from cells collecting in the internal organs; abdominal pain may lead to:
  • appetite loss
  • weight loss
• swollen lymph nodes in the neck, underarms, chest and groin
• difficulty breathing (dyspnea) or chest pain due to cell buildup around the thymus (which occurs in T-cell ALL)

Wheezing, coughing or painful breathing is an emergency. If your child experiences any of those symptoms, call 911 or bring them to the emergency room.

If your child has acute leukemia, symptoms can occur suddenly – in weeks or even days. With chronic leukemia, symptoms tend to develop slowly over months or years.

Diagnosing leukemia in children

If your child has symptoms of leukemia, call the doctor for an appointment. To diagnose leukemia, your child’s pediatrician will take a medical history, perform a physical exam and order some diagnostic tests or procedures.

Tests and procedures for leukemia may include:

• Bone marrow aspiration – This procedure involves removing bone marrow fluid to test the cells for abnormalities.
• Bone marrow biopsy – Biopsy of the bone marrow involves taking a small sample of bone marrow tissue to examine it for abnormal cells.
• Complete blood count (CBC) – This test looks at different blood cells to see check their size, number, maturity and volume of total blood cells.
• Additional blood tests – Your child’s doctor may want to check blood chemistries, do genetic studies or check kidney and liver function. These can all be done with blood tests.
• X-rays – Your child may need to have x-rays taken to check for signs of cancer.
• CT scans – A CT scan may help with diagnosis of leukemia. It provides detailed images of the body, including bones, muscles, organs and fat. The scan shows detailed images of any part of the body, including the bones, muscles, fat and organs.
• MRI scans – MRI scans may also be used. They provide detailed images of the body without radiation.
• Ultrasound – Using ultrasound, doctors can see the function of organs and how the blood is flowing through the blood vessels.
• Lymph node biopsy – This procedure may be done to check for cancer cells in the lymph nodes.
• Lumbar puncture – This test, also known as a spinal tap, can check pressures in the spine and brain and can remove spinal fluid so it can be tested for infection or other abnormalities.

Treating leukemia in children

If your child has leukemia, he or she will need treatment. You and your child’s doctor will work together to find a treatment that’s best for your child’s type of leukemia.

General treatment for leukemia

If your child is very sick when diagnosed with leukemia, he or she will need medical treatment to address problems, such as serious infection, before cancer-curing treatment can begin. This treatment may need to be provided in a hospital. 

Once your child is out of immediate danger, the cancer-killing treatment can begin. The first line of treatment for leukemia is usually chemotherapy. Chemotherapy is a medication used to attack and kill cancer cells throughout the body. Chemotherapy can be given in several ways, but all of them have the same goal: kill all cancer cells in the body. When treating leukemia, chemotherapy is given in two to three stages, depending on the type of leukemia. Those stages are induction, consolidation/intensification and maintenance. Read more about those stages below.

After chemotherapy, your child might have to undergo radiation therapy. Radiation therapy is done to find and kill any remaining cancer cells that weren’t killed by chemotherapy.

For most children, chemotherapy is enough treatment to cure leukemia. However, some children with leukemia need a bone marrow or stem cell transplant. This procedure involves putting healthy bone marrow cells into your child’s body where the cells can begin to grow and eventually replace the abnormal cells.

Stem cell / bone marrow transplants may be used when very high doses of chemotherapy drugs are necessary to kill the cancer cells. Because high dose chemotherapy can kill even the healthy bone marrow cells, some children who receive this type of chemotherapy may need a stem cell transplant in conjunction with the chemotherapy.

If your child doesn’t respond well to traditional treatments, he or she may be a candidate for experimental therapies. Pediatric cancer experts at Beaumont can talk to you about experimental therapies that might be right for your child.

Treatment for ALL

Chemotherapy is the main treatment for children with ALL. ALL treatment usually requires three phases of chemotherapy to kill as many cancer cells as possible and to make sure they don’t come back. The three phases are:

• Induction – The first phase of chemotherapy for ALL is the induction phase, during which chemotherapy kills more than 99 percent of leukemia cells. Your child may need to be hospitalized for the entire induction phase because of risks of infection and other side effects. This phase lasts about one month and it typically kills enough cancer cells to put the cancer in remission. About 95% of children with ALL will go into remission after the induction phase. But because the induction phase doesn’t kill all cancer cells, additional chemotherapy is necessary. That’s where the next phases come in.
• Consolidation or intensification – During this one- to two-month phase, chemotherapy drugs will be changed and prednisone may be added. If your child needs a stem cell transplant/bone marrow transplant, that will probably occur during this phase.
• Maintenance – If your child continues to be in remission after the first two phases, he or she can begin maintenance. The maintenance phase can last for two to three years, but chemotherapy won’t have to be given as frequently and it can usually be given in a pill.

Treatment for AML

If your child has AML, he or she will need a two-phased treatment approach. The phases are induction and consolidation/intensification.

The chemotherapy drugs used for AML are different than those used for ALL. Treatment tends to require higher doses of chemotherapy than ALL, but treatment doesn’t need to last as long. Because of the high doses, children treated for AML need to be treated in a cancer center where they are experienced with AML treatment.

The first part of the induction phase lasts several days. Then there is a break of between 10 days and two weeks after which time the medications must be given for several days again. These treatments are continued until the bone marrow tests don’t show cancer cells. Most children need two or three treatments during this phase. Between 85 and 90% of children with AML go into remission after the induction phase.

During the consolidation phase, your child will need continued treatment. That treatment may include a stem cell transplant. Another important part of the consolidation phase is supportive care to address any side effects of treatment, such as blood transfusions, antibiotics and nutritional support.

Children with AML do not need maintenance care once the consolidation phase is over.

Skandalaris Family Center for Children with Cancer and Blood Disorders

Beaumont Children's pediatric oncology and hematology specialists offer comprehensive diagnosis and treatment for infants, children, adolescents and early young adults with nearly every type of childhood cancer or blood disorder. Our specialists have decades of collective experience and offer the most advanced approaches to treatment of these conditions, including at the Children’s Skandalaris Family Center for Children with Cancer and Blood Disorders at Corewell Health William Beaumont University Hospital.

For a referral to a Beaumont doctor for your child, call 855-480-KIDS (855-480-5437)