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The Role of the RD in the Treatment of Pediatric Acute Lymphocytic Leukemia Natalie Navarre, Sodexo Dietetic Intern Agenda Cancer & Leukemia Bone Marrow & Lymphatic System ALL: • Diagnostic techniques • Treatments • Side effects • Common Medications Medical Nutrition Therapy: ADIME Presentation of case study patient One in 300 Boys One in 333 Girls 13,400 Children Annually Cancer & Leukemia Cancer: Abnormal cell proliferation and growth Malignant vs. Healthy cells • Containing damaged DNA • Invasion of tissues and organs Leukemia: Cancer of the blood and bone marrow • Sub-types: ALL, CLL, AML, CML • Rapid invasion of the blood, tissues, and organs Cancer Incidence Statistics Blood Cell Differentiation Lymphatic System B-Cells Proper immune function T-cells & B-cells reside in lymph nodes Filters lymph of toxins, dead cells, debris, infectious organisms T-Cells Acute Lymphocytic Leukemia (ALL) Most common form of childhood leukemia White blood cells only affects lymphocytes • Includes T-lymphocytes and B-lymphocytes Acquired genetic injury to a single cell in the marrow • Presence of damaged DNA leads to over production of lymphoblasts Poor immune function • Immature and abnormal lymphoblasts not able to fight infection Rapid influx of leukemic blasts Decreased healthy blood cells Etiology & Risk Factors NO KNOWN ETIOLOGY! Risk factors of ALL: • Genetic risk factors • Lifestyle risk factors • Environmental risk factors Signs & Symptoms Sign/Symptom Possible Reasoning Fatigue/pale skin -Anemia (low red blood cells) Infections and fevers -Increased immature WBCs Headache, seizures, vomiting -Migration of leukemia cells into CNS Easy bleeding or bruising -Lack of blood platelets Bone or joint pain -Result of bone marrow being too “full” Loss of appetite/Weight loss, Abdominal Pain -Spleen and/or liver enlargement – pushing against stomach Swollen lymph nodes -Collection of lymphoblasts in lymph nodes Dyspnea -Migration of leukemia cells to middle of chest Common Lab Values CBC lab values • White blood cell count • Red blood cell count • Platelets • Hemoglobin • Hematocrit WBC value on CBC determines risk groups • Low/Standard Risk: 110yrs old + less than 50,000mm3 • High Risk: Less than 1yr or older than 10yrs + WBC greater than 50,000mm3 Diagnosing ALL CBC & blood smear Bone marrow biopsy & aspiration Lumbar puncture – cerebrospinal fluid Healthy Lymphocytes Flow cytometry – type of leukemia Cytogenic analysis – presence of genetic abnormalities • ALL Lymphoblast Cells May help determine prognosis Tr e a t m e n t s Chemotherapy Total Body Radiation Bone Marrow Transplant • 1) Induction – goal to achieve remission • 2) Consolidation – lingering leukemia cells • 3) Maintenance • High energy radiation targets and destroys cancerous cells • Infusion of healthy blood stem cells into the bone marrow • High risk ALL and relapsed ALL Bone Marrow Transplant PRE-Bone Marrow Transplant: 4-10 days •High-dose chemotherapy + Total body radiation •Destroys blood forming cells in bone marrow & leukemia cells •Purpose make room for new, healthy cells and destroy immune system POST-Bone Marrow Transplant: Days +0 to +30 •Signs of engraftment – Days 10-20 usually •ANC >500mm3 x 3 days •Platelets 20,000-30,000 per microliter •Pancytopenia – high risk for infection POST-Bone Marrow Transplant: Days +31 to +100 •Increased risk for complications up to day +100 •Blood cell counts increase and immune system gets stronger Side Effects of Treatment Chemotherapy Total Body Radiation Bone Marrow Transplant • Nausea, vomiting, diarrhea, constipation • Mucositis, decreased appetite • Jaw pain, alopecia, fatigue, elevated glucose and triglycerides, hepatic insufficiency • Nausea, vomiting, diarrhea • Mucositis, dysphagia, altered taste/smell • Malabsorption, ↓saliva production, fluid/electrolyte imbalances • Poor intake need for nutrition support • Mucositis, diarrhea, vomiting, low blood counts • C.Difficile – common • Immunosuppression – viral, fungal, bacterial • Exacerabtion of side effects Graft vs. Host Disease (GVHD) Donor stem cells reject recipients body Increased risk with allogeneic transplants Acute GVHD within first +100 days • Abdominal pain, N/V/D, jaundice, skin rash GVHD – stage I Chronic GVHD after first +100 days • Dry mouth, dry eyes, chronic pain, weight loss, muscle weakness Prevention: prophylaxis and immunosuppressive drugs Treatment: steroids and immunosuppressive drugs Common Medications Motility agents gastroparesis, GERD, feeding intolerances Proton Pump Inhibitors ulcers, GERD Anti-Emetics nausea and vomiting Medicated mouth wash mucositis Chemotherapeutic Agents methorexate, cisplatin, PEGAsparaginase Immunosuppressive Agents prevent transplant rejection Prophylactic Agents prevention medications; GVHD, infections Emerging Research Children’s Oncology Group (COG) and National Cancer Institute (NCI) Targeted chemotherapy and high-dose chemotherapy COG-AALL1131: combination chemotherapy with different dosages and combinations COG-ACCL0934: giving specific antibiotics post-transplant prophylactically to prevent infection Survival Rates are INCREASING! • 1976-2006 increased from 41%-67% • Currently more than 85% 5 year survival rate!!! Nutritional Management of Pediatric Acute Lymphocytic Leukemia Role of the RD MAIN GOALS: • Identify malnutrition & growth failure o Direct correlation between malnutrition and intensified treatment regimens o Cancer cachexia • Manage nutrition related side effects • Ensure meeting 100% of needs PO, enterally, or parenterally • Improve patients nutritional status through interventions Nutrition Screening Screening criteria for oncology patients at nutritional risk: • Total weight loss greater than 5% over past month • Under 10th or over 90th %ile for wt. for age & wt. for ht. • Height < 10th %ile • Weight < 90% of IBW • TSF < 10th %ile, MAMC < 5th %ile • BMI < 5th or >85th %ile • Consuming less than 80% of needs Assessment Medical History Anthropometric Data Medical, Surgical, Medication History -Past Procedures or diagnoses that may impact nutrition status -Medications that alter absorption of nutrients, cause GI upset Physical Observations Ins & Outs Dietary History Anthropometric Data -Track weight trends and growth velocity -% wt loss from UBW and % IBW -< 10%ile growth impairment, inadequate nutrition -Fluid shifts Biochemical Data Nutrient Requirements Physical Observations -Signs of Wasting -Edematous -Dry skin, chapped lips -Wound healing -Pale, fatigued -Level of Pain -Frame size Assessment: Biochemical Data Vitamin D & Calcium: • Transplants patients – steroids & TBI alter bone metabolism • Decreased absorption of Calcium and associated with low vitamin D Vitamin K: measured with Prothrombin time • Multiple antibiotics decreased absorption Zinc: low levels related to diarrhea Electrolytes: fluid retention, third spacing, increased excretion Hyperglycemia & Hypertrygliceredemia LFTs Assessment: Nutrient Requirements No specific nutrition Children > 1 year protocols for pediatric oncology • Goals of nutrient Basal Metabolic Rate (BMR) x Stress Factor requirements: 1) Promote growth, prevent catabolism Children < 1 year • 2) Identify/Prevent proteinenergy malnutrition 3) Continuous re-evaluation Estimated Energy Requirement Equations can be found on last page of packet! BMT Nutrient Needs AGE CALORIES 0-12 mo BMR* x 1.6-1.8 1-6 yrs BMR x 1.6-1.8 7-10 yrs BMR x 1.4-1.6 2.5-3 gm/kg/day 2.4 gm/kg/day 11-14 yrs BMR x 1.4-1.6 2 gm/kg/day 15-18 yrs BMR x 1.5-1.6 1.8 gm/kg/day > 19 yrs BEE** x 1.5 1.5 gm/kg/day PROTEIN (g/kg/d) 3 gm/kg/day Source: The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010. Diagnosis P roblem • Inadequate oral intake • Malnutrition • Inadequate protein-energy intake • Predicted suboptimal intake E tiology • Side effects of treatments • Treatments • Side effects of diagnosis Signs/ Symptoms • Intake less than x% of needs • Stool output • Dietary history • Weight loss Example PES Statements (P) Inadequate oral intake related to (E) decreased appetite as evidenced by (S) oral intake meeting only 25% of estimated needs. (P) Atered gastrointestinal function related to (E) radiation therapy as evidenced by (S) stool output exceeding 2,000mL/day Interventions Purpose & Goals: • Manage treatment related side effects • Prevent weight loss and malnutrition • Preserve lean body mass Common side effects requiring intervention: • Nausea/Vomiting • Diarrhea • Neutropenia • Mucositis • Loss of appetite • Nutrition Support • Changes in taste • Triglycerides Nausea/Vomiting Cytotoxic effect on CNS Complications: weight loss, dehydration, electrolyte imbalance, food aversions Interventions • Anti-emetics • Avoid high fat, high sugar food/drinks • Small, frequent feedings Food Aversions Association of food with unpleasant internal response Interventions: • Avoid favorite foods before treatments • ‘Scapegoat’ – prevent changes from normal eating pattern Taste Changes Alteration of taste buds Metallic, chemical, or burnt taste in mouth Increased/Decreased sensitivity to bitter, salty, sweet Interventions: • Bitter/Metallic add sugar, vinegar, citrus juice • Sweet • Add spices/seasonings • Trial different temperatures • Aromatic foods add salt or water Mucositis Inflammation and breakdown of oral mucosa Severely inhibits oral intake & quality of life Interventions • Soft, pureed foods • Avoiding spicy/salty foods • Enteral/Parenteral nutrition Diarrhea May decrease appetite & inhibit intake Dehydration, electrolyte imbalances, malabsorption, altered GI motility Interventions: • Low-fat, low-lactose diet • Avoiding caffeine, high sugar, high osmolality beverages • Provide education • Increase fiber intake • Change formula Triglycerides Medication side effect Monitor weekly Interventions: Omega-3 Fish oil supplement Coromega GVHD Most commonly affected in acute GVHD: skin, gut, liver May lead to mucosal breakdown, malabsorption, protein catabolism May require bowel rest & PN Interventions: • Guide food intake progression back to regular diet • Bowel rest (TPN) Oral feeding Solids Expand diet Resume regular diet • Wean TPN when PO meets 50% of needs Neutropenia Compromised immune system high risk for infection Neutropenic diet first 100 days post-transplant Intervnetions: • Neutropenic diet education • Safe food handling • Safe eating techniques Loss of Appetite/Early Satiety Culmination of side effects & treatment Interventions: • Small frequent meals • Liquid oral supplements between treatment • Calorie count • Appetite Stimulant Appetite Method of Action • Providing favorite foods Stimulant Megace -Progesterone: increases appetite, causes weight gain Marinol -Cannabinoids class: Affects area of brain that controls nausea, vomiting, and appetite Periactin -Antihistamine: side effect of increased appetite High calorie, high protein foods Oral supplements (caution High osmolality) Difficult to meet 100% of needs Indications: mucositis, intake <80% x 3-5 days Shown to reverse malnutrition Formula: -patient’s age -GI function -formula composition -cost/insurance Semielemental & elemental formulas common 3. PARENTERAL NUTRITION Promotes normalized feeding 2. ENTERAL NUTRITION 1. ORAL NUTRITION Nutrition Support Failure to meet needs with EN and orally Increased risk for infection – NOT recommended during chemo TPN via central line Complications: -gut atrophy -infections -cholestasis Enteral & Parenteral Nutrition Enteral Nutrition: • Start at 10cc, increase 10cc every 8 hours to goal • Trophic feeds of 3-5cc/hour for gut integrity Total Parenteral Nutrition: • D: start 5-6mg/kg/min advance by 1-2mg/kg/min every 24hr to max 15mg/kg/min • AA: Start at DRI • IL: 20-60% kcals Post-Bone Marrow Transplant: • Combination of EN and PN acceptable and costeffective option • Candidates: reduced-intensity conditioning regimens, anticipated mucositis, poor nutritional status prior to transplant Monitoring & Evaluation Meeting 100% of estimated needs for growth & development Growth chart trends Intake/Output Management of nutrition related side effects • Prevent malnutrition • Weight maintenance • Route of nutrition support adjusted as needed Case Study Patient J.B. – 13 year old male - Relapsed ALL History & Recent Admissions February, 2008 • Initial admitting Dx: septic shock -N/V on admit •Bone marrow aspiration and flow cytometry Dx ALL with AML1 gene amplification •Tx Plan: COG AALL0331 July, 2012 August, 2012 •Oncology f/u •Treatment finished July, 2011 -ALL in remission •Outpatient weight mgnt clinic •Bone scan Osteopenia •Learned food aversions since chemo •Wt: 66.8kg •Ht: 166.2cm •Primary focus: food aversions History & Recent Admissions November 18, 2012: BMT prep 9/10-9/21/2012 •Presenting with headache •Relapsed ALL 9/30-10/12/2012 •Presenting with mucositis related to chemotherapy 10/23-10/23/2012 •Chemotherapy – induction 3 per AALL1131 •Admitted for BMT prep – TBI •Completed induction phase 3 per AALL1131 increased fatigue, decreased PO intake •Day -12 to Day +0: -Cranial radiation, TBI, Chemotherapy, Imunnosuppressive agent •Medications: Anti-emetics, PPI, Swish & Swallow, Anti-depressant, BP 2/2 to meds •Diet Order: Regular Diet •Seen by nutrition day -7 nutritional status intact – expect decline with therapy regimen 11/26/12: Initial Nutrition Assessment •Diagnosis: intakeALL •Medications: • Monitoring/Evaluation: •J.B. – 13y.o.Inadequate male withoral relapsed prophylaxis, antibiotics, related tofor chemotherapy evidenced 1. Monitor tube feeding tolerance admitted TBI/chemo inasprep for anti-emetics, Swish & swallow, antiby patient report of no appetite today depressant, post-transplant – goal BMT (Day +0) pain meds, BPto tolerate and not eating anything yet today. feeds and reach goal rate 100cc/hr •Active problems: Osteopenia, food •Estimated Requirements: •Intervention: 2. Monitor goalx of weight aversions, overweight, relapsed ALL, 2320 caloriesweight (WHO –REE 1.3nostress 1) Continue and D loss greater than 2% in one week mucositis 2/2 regular chemo,diet vitamin factor) encourage PO intake deficiency 97-130 gm protein (1.5-2 gm 2) Start enteral feeds Day +1 of: protein/kg) Peptamen Jr. PreBio – start at 10cc 2400 ml fluid normal maintenance •Height: 11/18/12: 165 cm and increase 10cc every 8 hours to (needs based on weight at admission of (64.29%ile) goal of 100cc/hr64.8 kg •Weight: 11/26/12: 65kg) --Add 2 –pkts Beneprotein by day 3 (89.06%ile) 127% IBW of feeds •Diet: Regular diet --To provide 2450kcal, 84 gm labs, •Biochemical: low hematological low protein Mg, ALT and GGT, fibrinogen •Medical Course: (+) C. Difficile, and PTT asymptomatic HTN 2/2 to medications, • Food/Nutrient Delivery: 10/10 allogeneic BMT scheduled for PO Pre-BMT; PO + NGT day +1 today 11/29/12: Nutrition Follow-Up •Diagnosis: Inadequate oral intake •Height: 11/18/12: 165 cm related to chemotherapy/stem cell (64.29%ile) transplant as evidenced by PO intake •Weight:11/28/12: 63.9 kg of less than 25% of 64.8 estimated needs. 11/26/12: kg (87.8%ile) – 125% IBW •Intervention: 1) Continue regular diet andlabs still •Biochemical: hematological intake as and desired low,encourage Mg remainsPO low, ALP GGT, 2) TPN to meet 100% of needs – IgG, consistently albumin, 2400ml, D19%, AA5.3%, IL0% Triglycerides 2058kcal, 127gm protein, 4.9mg CHO/kg/min •Medications: prophylaxis meds, antibiotics, anti-emetics, Swish & • Food/Nutrient Delivery: swallow, anti-depressant, pain meds, PO ad neupogen, lib + TPN additional BP +IVIG, antibiotics • Monitoring/Evaluation: 1. Monitor Requirements: tube feeding tolerance •Estimated post-transplant Remained the same– goal to tolerate feeds and reach goal rate 100cc/hr – not met, diet discontinued for now. •Diet: Regular -Peptamen Jr. PreBio at 3cc/hr 2. Monitor weight – goal of no weight loss greater •Medical Course:than DAY2% +3 in one week – met, ongoing -Presenting with rash on face, back, and arms 3. Monitor TPN – goal to receive 100% -Transfusions: IVIG of estimated -C.diff negative needs from TPN 12/04/12: Nutrition Follow-Up #2 •Diagnosis: Altered GI function related • Monitoring/Evaluation: •Height: 11/18/12: 165 cm to TBI and Cranial Radiation as 1. Monitor TPN – meeting goal rate and (64.29%ile) •Estimated Requirements: evidenced by 7 days of loose stools and 100% of needs – met •Weight:12/04/12: 69.5 kg PO&EN: 2320 calories TPN dependence. 11/28/12: 63.9 kg LESS 10% for TPN = 2070kcal 1. Monitor weight – goal of no weight (93.6%ile) – 136% IBW •Intervention: loss greater than 2% in one week – •Diet: Regular diet 1) Continue TPN at maintenance until met, ongoing •Biochemical: hematological labs still •PN: 2400ml – D19% (456gm, 1550kcal), PO intake improves and diarrhea is low, Mg remains low, ALP and GGT, AA5.3% (2gm/kg, 508kcal). TV= resolved – meeting 100% of needs 2. Monitor Intake – goal to improve consistently albumin, 2058kcal 127gm protein, from TPN intake as able Triglycerides, BUN, Na and Cl, 4.9mgCHO/kg/min. *IL held due to high 2) Encourage PO intake as able K, zinc triglycerides 3) Lower CHO containing beverages to help control diarrhea. Spoke with •Medications: prophylaxis meds, •Medical Course: DAY +8 mom about foods to avoid with antibiotics, anti-emetics, Swish & -rash improving – unknown etiology diarrhea swallow, anti-depressant, pain meds, - Triglycerides – unknown etiology BP, IVIG, neupogen, additional -platelet transfusion • Food/Nutrient Delivery: antibiotics PO ad lib + TPN 12/11/12: Nutrition Follow-Up #3 •Diagnosis: Inadequate oral •Height: 11/18/12: 165 cmintake related to mucositis secondary to (64.29%ile) chemotherapy as evidenced •Weight:12/11/12: 74.8 kgby receiving 100% of needs from 12/06/12: 70.2 kg TPN. PO ad lib +Requirements: TPN + NG Trophic feeds •Estimated of Peptamen Jr. PreBio PO+EN: 2320 calories LESS 10% for TPN = 2070kcal • Monitoring/Evaluation: 1.•Diet: Monitor ability to transition to NGT (96.56%ile) – 146% IBW Regular diet Obesity related to fluid retention and feeds – goal– to tolerate without •PN: 2400ml D19% (456gm, 1550kcal), steroids as evidenced by BMI/age nausea, vomiting, diarrhea •Biochemical: hematological labs still AA5.3% (2gm/kg, 508kcal). TV= th above theremains 95 percentile – however in low, Mg low, ALP and GGT, 2058kcal 127gm protein, view of diagnosis, not addressed at present. 2. Monitor fish oil effects on consistently albumin, 4.9mgCHO/kg/min. *IL held due to high triglycerides – goal to decrease Triglycerides, zinc, PTT triglycerides •Intervention: triglyceride level 1)•Medications: Continue maintenance prophylaxisTPN meds, •Medical Course: DAY +15 2)antibiotics, Start trophic NG feeds of 2.-Changing Monitor weight anti-emetics, Swish & nature –ofgoal rashof– no signweight of Peptamen Jr. PreBio at 3cc/hr loss greater than 2% in one week – swallow, anti-depressant, pain meds, engraftment 24 hrs – monitor tolerance. met, ongoing BP,for IVIG, neupogen, additional -platelet transfusion 3)antibiotics, If tolerating NG feeds x 24 hrs – +methotrexate, lasix -Hypertriglyceredemia – normal lipid increase to 5cc/hr for next 24 hours panel – 2/2 to medications • Food/Nutrient Delivery: Lab Trends: 11/25/12 - 12/10/12 Basename 12/10/12 WBC (K/UL) 0.1 <0.1 <0.1 0.1 0.1 0.4 HGB (g/dL) 8.8 7.4 9.6 8.1 9.4 10.4 PLT (K/UL) 11 19 33 19 116 162 NEUTS (%) 0 0 7 1 60 LYMPHS (%) Mg (mg/dL) ALP (u/L) 2 1.7 41 100 1.4 45 --1.4 50 2 1.4 69 2 1.4 64 36 1.5 67 GGT (u/L) 93 110 110 154 160 179 Albumin (gm/dL) Triglycerides (mg/dL) 2.4 2.4 2.7 2.7 2.8 3.0 305 435, 554 on 12/5 552 401 Zinc (mcg/mL) 12/07/2012 12/04/2012 11/29/2012 11/26/2012 11/25/2012 0 0.44mcg/mL on 12/1 Continuation of JB’s Hospital Course December & January Inpatient: • Acute Grade 2 GVHD rash > 50% of body + average 500-1000cc diarrhea/day started on high dose steroids 12/18/12: Concern for EFAD due to ~3 weeks TPN without lipids and minimal lipids in diet 12/20/12: Appetite stimulant started – Megace Discharged home on 12/31/12 Most recently seen by nutrition on 2/18/13: • • • Reverted back to food aversions – only eating chicken nuggets, macaroni and cheese, and grilled cheese Goal to try two new foods a week Will be seen weekly by AIDHC nutrition Date 11/30/12 12/4/12 Coromega: 15gm lipid 12/7/12 12/11/12 12/12/12 12/18/12 12/20/12 EN Regimen PN Regimen Discontinued D19, AA5.3, IL0 =>2058kcal, 127gm protein, 4.9 GIR -- Maintenance Discontinued Maintenance TPN D19, AA5.3, IL0 100% of needs Discontinued Maintenance TPN D19, AA5.3, IL0 100% of needs Peptamen Jr. PreBio 3cc/hr Maintenance TPN D19, AA5.3, IL0 100% of needs Increased to 5cc/hr D17, AA1.8gm/kg, IL0 => ~90% of needs Increased to 10cc/hr D17, AA1.8gm/kg, IL0 => ~90% of needs 10cc/hr D17, AA1.8gm/kg, IL0 => ~90% of needs 1/2/13 Discontinued Providing 700-900kcal (~40% of needs) -Continue weaning 1/6/13 Discontinued 1/7/13 Discontinued 900ml overnight => 664kcal, 36gm pro -- (~32% of needs) Discontinued PO Intake Nothing -Poor -Some cheese puffs and Gatorade -Poor -Slushies, Gatorade -Minimal intake -Minimal intake -Some cheese curls, crackers, and gatorade -Trialing Boost supplements -Megace started -Dry cereal, bowtie pasta, soft pretzel, 24oz fluids -Appx 1,000kcal -Improving with appetite stimulant 100% of needs from PO intake Critical Comments Current research in line with interventions Hospital protocol – allowed for early intervention Anthropometrics: • Consider TSF and MAMC to get better assessment of dry weight Nutrition Counseling – developing relationship with patient; interaction with mom Key Points Meet 100% of patients estimated needs • • Prevent malnutrition Promote growth and development Anticipate side effects – intervene early Manage side effects associated with treatment Promote quality of life to best of our ability A very special Thank You to Michell Fullmer, the pediatric oncology dietitian at AIDHC, for her guidance and support through this case study! & Thank you to ALL of the dietitians at AIDHC for your endless support! Questions? References • • • • • • • • • • Survival Rates for Childhood Leukemia. American Cancer Society Web site. http://www.cancer.org/cancer/leukemiainchildren/overviewguide/childhood-leukemia-overviewsurvival-rates. January 21, 2013. Accessed February 28, 2013. Be The Match: Parents and Families. National Marrow Donor Program Web site. http://marrow.org/Patient/Patients_and_Families.aspx. 2013. Accessed February 28, 2013. Cancer Facts and Figures 2012. American Cancer Society Web site. http://www.acco.org/LinkClick.aspx?fileticket=EcECXIUZyeA%3d&tabid=670. 2012. Accessed February 25, 2013. Childhood Leukemia. American Cancer Society Web site. http://www.cancer.org/acs/groups/cid/documents/webcontent/003095-pdf.pdf. January 18, 2013. Accessed January 20, 2013. Acute Lymphoblastic Leukemia. Leukemia and Lymphoma Society Web site. http://www.lls.org/content/nationalcontent/resourcecenter/freeeducationmaterials/leukemia/pdf/all. pdf. Accessed December 28, 2012. General Information About Childhood Acute Lymphoblastic Leukemia. National Cancer Institute Web site. http://www.cancer.gov/cancertopics/pdq/treatment/childALL/Patient /page1. Accessed January 3, 2013. Acute Lymphoblastic Leukemia. Boston Children’s Hospital Web site. http://www.childrenshospital.org/az/Site759/mainpageS759P0.html. Accessed December 28, 2012. Childhood Acute Lymphoblastic Leukemia. Children’s Hospital Cleveland Clinic Web site. http://my.clevelandclinic.org/childrens-hospital/health-info/diseases-conditions/cancer/hic-childhoodacute-lymphoblastic-leukemia.aspx. Accessed January 3, 2013. Selected Normal Pediatric Laboratory Values. Prentice Hall Web site. http://wps.prenhall.com/wps/media/objects/354/362846/London%20App.%20B.pdf. Accessed January 31, 2013. Sacks N, Wallace E, Desai S, et al. Oncology, Hematopoietic Transplant, and Survivorship. A.S.P.E.N. 2010: 349-373.