What Are the First Signs of Childhood Leukemia?

Pictured are white blood cells under a microscope. Frequent flu-like infections, easy bruising and fatigue may all be signs of leukemia in a child.

Childhood leukemias are cancers that occur when cells that would normally develop into different types of blood cells start to grow out of control. Leukemia usually starts in early forms of white blood cells, but some leukemias start in other blood cell types.

There are different types of leukemia: 

• Acute (fast growing) 
  • Most childhood leukemias are acute
  • They can progress quickly, and usually need to be treated right away
    • Acute lymphocytic (lymphoblastic) leukemia (ALL)
      • About 75% of childhood leukemias are ALL 
      • Originates in early forms of white blood cells called lymphocytes
    • Acute myeloid leukemia (AML) (also called acute myelogenous leukemia, acute myelocytic leukemia, or acute non-lymphocytic leukemia)
      • Accounts for most of the rest of the cases of childhood leukemia
      • Originates in myeloid cells that normally form white blood cells (other than lymphocytes), red blood cells, or platelets
    • Mixed lineage leukemias, (also called acute undifferentiated leukemias, or mixed phenotype acute leukemias [MPALs])
      • Has features of both ALL and AML
      • Usually treated like ALL 
• Chronic (slower growing)
  • Rare in children
  • Tends to grow more slowly and are harder to cure 
    • Chronic myeloid leukemia (CML) (also called chronic myelogenous leukemia, CML)
    • Treatment is similar to that used for adults 
    • Chronic lymphocytic leukemia (CLL)

Early signs of childhood leukemia include: 

• Frequent flu-like symptoms
• Frequent infections
• Persistent bruises
• Lethargy 
• Weakness
• Dizziness
• Frequent or severe nosebleeds
• Headaches
• Feeling unusually cold
• Loss of appetite 
• Weight loss
• Bone or joint pain
• Abdominal swelling

Other symptoms of childhood leukemia may include: 

• Tiredness (fatigue)
• Lightheadedness
• Shortness of breath
• Paler skin
• Fever
• Easy bruising and bleeding
• Gum problems
  • Bleeding
  • Swelling
  • Pain 
• Swollen lymph nodes
• Cough
• Trouble breathing
• SVC syndrome
  • Can be life-threatening and needs to be treated right away
  • Swelling of the face, neck, arms, and upper chest 
  • Sometimes a bluish-red skin color
  • Headaches
  • Dizziness
  • Change in consciousness if it affects the brain
• Seizures
• Vomiting
• Trouble concentrating
• Problems with balance
• Blurred vision
• Rashes (small, dark spots that look like common rashes
• Slurred speech

Most of the symptoms listed are more likely to be caused by a condition other than leukemia but it’s important to have these symptoms checked by a doctor to determine the cause and treatment. 

The cause of childhood leukemias is unknown, but it is believed to be due to genetic changes. The reason for these changes is not understood. 

Risk factors for developing childhood leukemias include: 

• Genetic risk factors
  • Genetic syndromes
    • Down syndrome (trisomy 21)
    • Li-Fraumeni syndrome
    • Neurofibromatosis 
    • Fanconi anemia
    • Some other types of cancers
  • Inherited immune system problems
    • Ataxia-telangiectasia
    • Wiskott-Aldrich syndrome
    • Bloom syndrome
    • Shwachman-Diamond syndrome
  • Having a brother or sister with leukemia
• Lifestyle-related risk factors
  • Many of these are risk factors for adult cancers but may not play a role in childhood cancers
  • Smoking
  • Being overweight/obese
  • Drinking too much alcohol
  • Excessive sun exposure
  • A woman drinking a lot of alcohol during pregnancy (not all studies have shown this to be linked)
• Environmental risk factors
  • Radiation exposure
  • Exposure to chemotherapy 
  • Exposure to certain other chemicals such as benzene (a solvent used in the cleaning industry and to manufacture some drugs, plastics, and dyes) or pesticides
• Immune system suppression
  • Intensive treatment to suppress the immune system (mainly children who have had organ transplants) 

Childhood leukemia is diagnosed with a physical examination, patient history, and tests such as: 

• Blood tests
  • Complete blood count (CBC) 
  • Liver and kidney function 
  • Mineral tests
  • Tests for infections
• Bone marrow aspiration and biopsy
• Lumbar puncture (spinal tap)
• Lymph node biopsy
• Imaging tests
  • Chest X-rays
  • Computed tomography (CT) scan
  • Positron emission tomography (PET) scan
  • PET/CT scan
  • Magnetic resonance imaging (MRI) scan
  • Ultrasound

Treatment for childhood leukemia may include one or more of the following: 

• Chemotherapy 
  • The main treatment for most childhood leukemias
  • Combinations of several chemo drugs are usually given
    • Vincristine
    • Daunorubicin, (daunomycin)
    • Doxorubicin (Adriamycin)
    • Idarubicin
    • Cytarabine (cytosine arabinoside or ara-C)
    • L-asparaginase, PEG-L-asparaginase (pegaspargase)
    • Etoposide
    • 6-mercaptopurine (6-MP)
    • 6-thioguanine (6-TG)
    • Methotrexate
    • Mitoxantrone
    • Cyclophosphamide
    • Corticosteroid drugs such as prednisone, prednisolone, dexamethasone, or hydrocortisone
• Surgery 
  • The role of surgery in treating childhood leukemia is limited
  • Central venous catheter (CVC) or venous access device (VAD) placement
  • Performed before chemotherapy and usually left in place for months 
  • Used to give intravenous (IV) drugs such as chemotherapy and to take blood samples
• Radiation therapy 
  • Not always needed to treat leukemia, but used in certain situations
  • To try to prevent or treat the spread of leukemia to the brain or treat testicles in boys if the leukemia has reached them
  • Used (rarely) to treat a tumor that is pressing on the trachea (windpipe)
  • Radiation to the whole body is often part of treatment before a stem cell transplant
• Targeted therapy drugs 
  • Used instead of or along with chemotherapy in some situations
  • BCR-ABL inhibitors for CML (and some cases of ALL)
  • Tyrosine kinase inhibitors (TKIs), such as imatinib (Gleevec), dasatinib (Sprycel), and nilotinib (Tasigna) 
• Differentiation agents for acute promyelocytic leukemia (APL)
  • All-trans-retinoic acid (ATRA, tretinoin)
  • Arsenic trioxide (ATO)
• Immunotherapy 
  • Chimeric antigen receptor (CAR) T-cell therapy
  • Tisagenlecleucel (Kymriah)
  • Monoclonal antibodies
    • Blinatumomab (Blincyto)
    • Gemtuzumab ozogamicin (Mylotarg)
  • High-dose chemotherapy and stem cell transplant 
    • Allogeneic stem cell transplant