The common side-effects of different cancer treatments

Chemotherapy, radiotherapy and surgery all have various effects on the body. The severity of these side effects depends on various factors such as  the type and location of the cancer, the intensity of the treatment and the child's age. Children seem to cope far better with the physical side effects  of cancer treatment than adults do. However, school-age children and teenagers will find it difficult to cope emotionally with some of the side effects  like hair loss. It is very important to discuss the possible side effects with your child. Encourage your child to talk about their feelings, listen  empathetically to them and provide constant reassurance. 

Patients respond differently to drugs and treatments, yet many of the side effects are well known. Most side-effects can be treated or dealt with very  successfully. 

Bone marrow suppression

Bone marrow is the soft spongy centre of bones, where most of the blood cells are formed. As the blood cells mature, they are released into the bloodstream.  Because these cells are fast-growing, bone marrow is very sensitive to chemotherapy and radiotherapy. With bone marrow suppression this naturally leads  to reduced functioning of the blood cells in the bloodstream. The following problems can occur. 

Anaemia

Red blood cells carry oxygen from the lungs to the rest of the body. If the red blood cell count becomes low, as a result of bone marrow suppression, the child  will develop anaemia. 

The symptoms of anaemia are paleness, dizziness, weakness and lack of energy, headache and irritability. Red blood cell transfusions are given to treat this  condition. 

Thrombocytopenia (low platelet count)

Platelets help to prevent bleeding by causing the blood to clot. When the platelet count is very low it causes bleeding and easy bruising. The signs of a low  platelet count are tiny red spots under the skin (petechiae), bleeding from the mouth and gums, nosebleeds, pink or red urine and stools that are red or tarry  and black. A platelet transfusion is given when the platelet count is very low.  

Neutropenia (low neutrophil count)

Neutrophils are a type of white blood cell and the body's main defence against infections. If the neutrophil count is low, the child will be very susceptible to  infections. Signs that a child has an infection somewhere in the body include fever, chills, rash, diarrhoea and any area in the body that is red, painful or very  warm to the touch. If any of these signs are present, you must immediately contact your child's doctor. Never take any signs or symptoms of a possible  infection lightly and act immediately. Any type of infection can prove fatal in a child who is receiving cancer treatment and has a low white cell count. 

Tips for parents and how to deal with it. 

• Always use a thermometer to determine your child's temperature.  
• If your child has a temperature greater than 38°C – even if the temperature responds to medication, contact the doctor without delay. 
• Use only drugs containing paracetamol, with or without codeine.  
• Avoid drugs containing salicylates (i.e. aspirin), mefenamic acid, ibuprofen, diclofenac sodium and indomethacin.  
• Antibiotics will be given when there are signs of infection.  
• The two most important ways to prevent infections are:  
  • frequent and thorough hand washing;  
  • avoiding contact with people who have contagious illnesses, such as colds and flu and all childhood diseases, such as measles and chicken  pox.
• Prolonged low blood cell counts can be life-threatening in children receiving cancer treatment. To shorten the duration of bone marrow suppression,  certain drugs called Haematopoietic Growth Factors can be given. These drugs help the blood cells to mature quickly so that they can be released  into the bloodstream sooner than normal. The growth factor used is Neupogen (G-CSF). This can be given as an injection under the skin or as an  intravenous infusion (IV). 
• Severe or prolonged vomiting can lead to dehydration. 
• Prevent dehydration by giving your child lots of fluids to drink. 

Nausea and vomiting

Chemotherapy directly affects the brain's vomiting centre and the stomach's nerve cells. Chemotherapy, therefore, may make your child feel nauseous and  can cause vomiting. The nausea and vomiting occur soon after the chemotherapy drugs have been given and can last for some hours. Different chemotherapy  drugs have different effects on the vomiting centre, and some are more severe than others. Radiotherapy can also affect the vomiting centre, depending on  the site of radiation.

Tips for parents and how to deal with it. 

• Anti-sickness drugs (anti-emetics) are usually successful, especially when given a few hours before the treatment. These should be continued for at  least 24-48 hours after the chemotherapy.  
• If your child is vomiting do not give any liquids or food until the vomiting is under control. 
• Keep the room cool and well-ventilated; older children may prefer a dark, quiet environment. 
• Try to keep your child as comfortable as possible, in a restful position with the head slightly raised. 
• Gently wipe your child's face with a cool cloth. 
• Let your child rinse their mouth with cool water or a mild mouthwash, to remove nasty tastes.  
• Do not force your child to eat and avoid heavy meals for several hours. Instead, give small and frequent amounts of clear liquids, such as water or  non-fizzy drinks.  
• As soon as your child feels better, offer small amounts of plain, bland foods, such as vegetables, fruit, low-fat yogurt, custard, jelly, plain meat like  chicken, cereal, rice, pasta, mashed or baked potatoes, soup, crackers or toast. Avoid spicy, heavy, fatty and fried foods. If food smells bother your  child, use cold or room-temperature foods, use a cup with a lid; and encourage your child to avoid areas where food is cooking.  
• Don't offer solid food and liquids (especially fizzy drinks) at the same time, as this can cause nausea by making your child feel too full. Have them eat  solid food for meals and snacks and give liquids 30 to 60 minutes before or after eating. 

Diarrhoea

Children undergoing chemotherapy or radiotherapy treatment develop diarrhoea because the mucosal cells lining the intestines become irritated and  damaged. Diarrhoea caused by chemotherapy or radiotherapy can start within hours of receiving the treatment and last for several days, usually until the  mucosal cells start to heal. 

In some cases, the damage to the mucosal cells results in sores. When this happens, the intestine cannot absorb nutrients or fluids. The child then has frequent  loose, runny or watery stools. 

Tips for parents and how to deal with it. 

• Prevent dehydration by increasing the amount of liquid given to your child. In some cases, the only way to prevent dehydration is by giving fluids  intravenously through a drip. In this case the doctor will advise and treat the child. 
• If stomach cramps or pain occur, drugs to relieve the pain and discomfort can be given. Bed rest may also help to reduce cramps. 
• Medications to stop diarrhoea are usually not effective because the intestine must heal before the diarrhoea will improve. They are also dangerous  for small children.  
• Babies and young children may develop skin irritation around the anus or in the diaper area. Wash the skin with a mild soap after every stool and  keep it clean and dry. Use a protective barrier cream for sensitive skin.  
• Don't force the child to eat. Instead, give a clear liquid diet for at least 12 hours to allow the bowel to rest while essential fluids are replaced. • As soon as the child improves, offer full liquids like soup; light meals of soft foods, such as white bread, fish, chicken, eggs, puréed vegetables and  canned or cooked fruit. 
• Avoid milk products, fatty, greasy and fried foods, citrus juices, fizzy drinks and raw vegetables or fruit. 

Constipation

Constipation is the infrequent passing of hard, dry stools. This is caused by some chemotherapy drugs, radiation therapy, pain medication and a diet that  lacks adequate fluids. When a child has to stay in bed for a prolonged period of time, a lack of exercise may also cause constipation.  

Tips for parents and how to deal with it. 

• When your child is given medicines that are known to cause constipation, a laxative or stool softener will be given at the same time to prevent severe  constipation and discomfort. Do not give a laxative or any other medication before consulting your doctor. 
• Encourage your child to drink plenty of liquids. A special glass and mug with pictures of a favourite cartoon character can work magic with younger  children, to encourage them to drink.  
• A hot drink in the morning and evening may stimulate a bowel movement, especially drinks containing caffeine such as tea, coffee or cocoa.  
• Give your child foods high in fibre, such as whole-wheat bread and crackers; high-fibre breakfast cereals, whole-wheat pasta and brown rice, fresh  fruit and vegetables, dried fruit or steamed prunes.  
• Encourage your child to get some exercise, if possible, even if just a gentle walk. 
   

Mouth sores, sore throat and dry mouth

The mucosal cells lining the mouth, throat and oesophagus are all fast-growing cells, which are very sensitive to chemotherapy drugs and radiation therapy.  When these cells are damaged this is called oral mucositis. It usually starts in the mouth 7 to 10 days after receiving treatment. The first signs are red and  swollen gums followed by sores in the mouth and throat. Unfortunately, this condition cannot be prevented.  

Tips for parents and how to deal with it. 

• Good mouth care and oral hygiene can help to decrease the severity, prevent infections and speed recovery.  
• Good mouth care means keeping the mouth clean and moist by brushing and rinsing at least four times a day until all the sores are healed. 
• Brushing with a soft toothbrush and toothpaste is very important. Rinsing with a mild mouthwash or even a weak salt solution will help keep the  mouth moist.  
• There are several medications and solutions available to help healing, prevent infections and decrease pain in the mouth. Ask your doctor to prescribe  what your child needs.  
• If your child's mouth is too painful for eating, offer a liquid diet and soft, puréed foods.

Poor appetite and weight loss

Chemotherapy and radiotherapy may make your child feel nauseous and sick because the mucosal cells lining the intestines become irritated and damaged.  In addition, some chemotherapy drugs cause a metallic or foul taste in the mouth while the drugs are administered. This will cause the child to lose their  appetite and experience weight loss. Excessive weight loss can affect the self-esteem of older children and teenagers. Try to reassure your child and remind  them that weight usually returns to normal once treatment is over.  

Tips for parents and how to deal with it. 

• Offer small, appetising meals four or more times a day, consisting of your child's favourite foods, drinks and snacks.  • Give ‘power packed’ food that is, food with high nutritional value. Consult a dietician to help you create a healthy eating plan for your child.
• Give special food shakes or meal replacement drinks, such as Nutriment-T, Paediasure and Ensure.  
• Present your child's food attractively and use special colourful plates, cutlery and napkins, to make mealtimes more fun.
• For smaller children, cut food such as bread, cheese and cold meat into fun shapes and arrange the food to form a ‘food picture’ on the plate. 

Weight gain

Excessive weight gain and a round ‘moon’ face are common side effects of treatment with steroid drugs. Older children and teenagers find this very difficult  to cope with and it can dramatically affect their self-esteem.  

Tips for parents and how to deal with it. 

• Lots of patience and tender, loving care (TLC).  
• Talk to your child and explain this possible side effect before the treatment is started, so that your child knows what to expect. 
• Encourage your child to talk about how they are feeling, and you must really listen. Constantly reassure your child that their weight and appearance  will return to normal as soon as the treatment is over.  
• Avoid salt and salty foods. 

Hair loss (alopecia)

Hair loss or alopecia caused by chemotherapy and radiotherapy usually does not bother small children. Older children of school age and teenagers can find  this devastating.  

Tips for parents and how to deal with it. 

• Lots of patience and tender loving care.  
• Talk to your child and explain this possible side effect before the treatment is started, so that your child knows what to expect. Then decide on a plan  of action: wigs, hats or bandanas.  
• If your child decides on a wig, take them to choose one before their hair falls out, so that it will be as close as possible to your child's natural hair  colour and style.  
• Buy some fun hats or colourful bandanas to cover up your child's bald head.  
• If your child's hair is long, it may be better to cut it shorter as soon it starts falling out, to help it appear less messy. • Reassure your child that the hair will grow back as soon as the treatment is over. In most cases the hair grows back thicker and more beautiful than  before.  
• Maybe the child's dad, sibling or other family members will be willing to shave their hair off to show support. 

Fatigue (tiredness)

Children can experience fatigue during any stage of their cancer treatment even after the treatment is over. Intensive chemotherapy, radiotherapy and  recovery from surgery often cause physical and emotional tiredness and weakness. Side effects such as nausea, vomiting, diarrhoea, pain and poor nutrition  can all cause feelings of weakness and fatigue. Once again, fatigue seems to affect older children and teenagers more than it does younger children and can  interfere with their quality of life.  

Tips for parents and how to deal with it. 

• Try to plan ahead so that your child can have adequate rest periods after their daily activities.  
• Try to deal effectively with other side effects that can contribute to fatigue.  
• Ensure that your child sleeps well at night by making the sleeping environment comfortable, dark and quiet.

Pain

What many parents fear most is to see their child in pain. You may have heard horror stories of how painful cancer is and that nothing can be done to relieve  the pain, fortunately, this is not true. Not all cancers are painful. Not all pain experienced by a cancer patient is from the cancer. Every new pain  your child has does not mean that the cancer has come back. Pain can be controlled very effectively. No child needs to suffer unnecessary pain. Pain from cancer is caused by the tumour pressing on bone, nerves or body organs. As soon as the tumour is removed, the pain often lessens or disappears.

Most procedures involve needles and for children this is a dreaded part of cancer treatment. By having a central venous line put in, the use of needles can be  significantly reduced. Side effects of cancer treatment can include pain after surgery, mouth sores, stomach-ache or nerve damage. There are medications  available that effectively control the various types of pain. Tension, anxiety and fear make pain worse. Always be honest and truthful with your child by  explaining procedures, what to expect and give reassurance that you are there for them. 

Tips for parents and how to deal with it. 

• Encourage your child to speak up about pain as soon as they start feeling it. This is very important because it is much easier to control pain in its early  stages, before it becomes too severe.  
• Reassure your child that you believe them when they tell you that they are in pain. Tell your child that they do not have to hide their pain. Hiding the  pain and not telling you make controlling the pain more difficult. 
• Discuss your child's pain management plan with your doctor and the other staff members involved. This plan may include medications, radiotherapy  or nerve blocks.  
• Many pain medications may cause constipation. See the section on constipation: tips for parents and how to deal with it. 
• Other ways of reducing pain include using a hot or cold pack and giving massages but do check with your doctor before using any of these methods. 
• A psychologist or play therapist can help you and your child by teaching you more about pain control and helping to lessen your child's fear of pain. 
• Give brief and honest explanations about what is happening to your child on a level that suits your child's age, intellectual abilities and personality.  
  Not being truthful or honest and not telling a child that a procedure will be painful, can break down your child's trust in you.  
• You are your child's greatest source of strength. If you are confident that your child's pain can be controlled, your child will be too. 
• If possible, stay with your child during the procedure. It will make your child feel safer and calmer.  
• Give some control back to the child. This can be as simple as saying, “You know this is going to hurt, but if you take a deep breath and blow out slowly,  it may hurt less.” Praise your child for every effort to co-operate and be brave. For instance, you could say, “You were really still during the lumbar  puncture. That was very good.” Offer some form of reward to show your child that you recognise their efforts.  
• Anxiety and tension make pain worse, so lessen your child's anxiety and tension by encouraging activities to promote relaxation. Let your child's age  guide you in choosing suitable activities. Infants might like stroking, swaddling and rocking, a pacifier while toddlers and young children might prefer  singing songs or nursery rhymes or telling stories to distract them during painful procedures. Older children and teenagers might prefer distraction  tools such as iPads, tablets, mobile phones or other electronic devices. Listening to music or thinking of being at a favourite place or with special  friends doing fun activities might help them to relax.