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International Journal of Blood Research and Disorders





DOI: 10.23937/2469-5696/1410018



The Management of Mucositis of Pediatric Hematopoietic Stem-Cell Transplantation

CÌFTCÌOGLU Sule and EFE Emine*


Akdeniz University Nursing Faculty, Trukey


*Corresponding author: Professör Emine EFE, Akdeniz University Nursing Faculty, Campus, Antalya, Turkey, Tel: 0905337798302, E-mail: eefe@akdeniz.edu.tr
Int J Blood Res Disord, IJBRD-2-018, (Volume 2, Issue 2), Perspective; ISSN: 2469-5696
Received: July 21, 2015 | Accepted: September 21, 2015 | Published: September 23, 2015
Citation: Sule C, Emine EFE (2015) The Management of Mucositis of Pediatric Hematopoietic Stem-Cell Transplantation. Int J Blood Res Disord 2:018. 10.23937/2469-5696/1410018
Copyright: © 2015 Sule C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



Hematopoietic stem-cell transplantation (HSCT) is used primarily for hematologic and lymphoid cancers but also for many other disorders [1]. Autologous HSCT (in which stem cells are derived from the patient) is mainly used to treat chemosensitive malignancies. Allogeneic HSCT (in which the stem cells are derived from a donor) is often the preferred treatment option, particularly in patients with acute leukaemia [2]. Oral complications are a significant cause of morbidity and potential mortality for children undergoing HSCT. Oral complications can occur at all stages of HSCT and can interfere significantly with transplant recovery [3]. Oral mucositis is a major complication of HSCT and it is highly distressing to patients, and associated with significant local and systemic complications [2]. In children treated with standard chemotherapy mucositis incidence was between 25-33%, in children who underwent bone marrow transplantation, this rate rises to 100% [4].

Oral mucositis begins approximately 5-10 days following myeloablative conditioning therapy, and resolves within 2-3 weeks in over 90% patients [2]. Oral mucositis is an important clinical problem because of the pain, the requirement for parenteral nutrition and the risk of mucosal infection and subsequent septicaemia [5]. The most severe grade of oral mucositis has been shown to be significantly associated with the number of days of parenteral opioid therapy, the number of days of total parenteral nutrition, the incidence of significant infection, the number of days with fever, the overall time in hospital, and the total inpatient charges [6]. The children suffer oral mucositis-related symptoms during haematopoietic stem cell transplantation and these are: dry lips, taste perception, oral pain, mouth blisters and mouth sores [7].

The management of oral mucositis starts with a pretreatment oral assessment aimed at reducing pre-existent oral infection and trauma-inducing factors. Education on the importance of performing good oral hygiene should be undertaken at this time, and should be reinforced during the HSCT procedure [2]. Basic oral care components are; brushing teeth with a soft toothbrush, cleaning between the teeth with dental floss (if the number of platelets lower than 500.000 mm3 or there are bleeding gums, not using toothbrush and dental floss) and mouthwashing with sterile water, saline or sodium bicarbonate [8-11] Additionally, in a study is found that laser therapy is well tolerated with remarkable reduction in pain associated with oral mucositis after 1-2 days of laser therapy [12]. The guide of the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO) recommends that:

• Recombinant human keratinocyte growth factor-1 (KGF-1/palifermin) be used to prevent oral mucositis (at a dose of 60 lg/kg per day for 3 days prior to conditioning treatment and for 3 days after transplant) in patients receiving high-dose chemotherapy and total body irradiation, followed by autologous stem cell transplantation, for a hematological malignancy.

• Low-level laser therapy (wavelength at 650 nm, power of 40 mW, and each square centimeter treated with the required time to a tissue energy dose of 2 J/cm2), be used to prevent oral mucositis in patients receiving HSCT conditioned with high-dose chemotherapy, with or without total body irradiation.

• Patient-controlled analgesia with morphine be used to treat pain due to oral mucositis in patients undergoing HSCT.

• Oral cryotherapy be used to prevent oral mucositis in patients receiving high-dose melphalan, with or without total body irradiation, as conditioning for HSCT.

• Intravenous glutamine not be used to prevent oral mucositis in patients receiving high-dose chemotherapy, with or without total body irradiation, for HSCT.

• Granulocyte-macrophage-colony-stimulating factor mouthwash not be used to prevent oral mucositis in patients receiving high-dose chemotherapy, for autologous or allogeneic stem cell transplantation.

• Systemic pentoxifylline, administered orally, not be used to prevent oral mucositis in patients undergoing bone marrow transplantation.

• Systemic pilocarpine, administered orally, not be used to prevent oral mucositis in patients receiving radiation therapy for head and neck cancer, or in patients receiving high-dose chemotherapy, with or without total body irradiation, for HSCT [13].

These measures are not to prevent mucositis, but to ensure that the oral cavity is maintained as clean and healthy as possible in the event that ulceration does occur. Consequently, efficacy data derived from multi-centre, randomized, placebo-controlled double-blind studies is, for the most part, non-existent for these products. While it is possible that patients might benefit from their use, it is impossible to recommend their application (at significant cost) based on the available anecdotal data [14].


References
  1. Copelan EA (2006) Hematopoietic stem-cell transplantation. N Engl J Med 354: 1813-1826.

  2. Elad S, Raber-Durlacher J, Shapira MY (2010) Oral complications of haematopoietic stem cell transplantation: Oral Complications of Cancer

  3. Majorana A, Schubert MM, Porta F, Ugazio AG, Sapelli PL (2000) Oral complications of pediatric hematopoietic cell transplantation: diagnosis and management. Support Care Cancer 8: 353-365.

  4. Maloney AM (2010) Gastrointestinal tract: Pediatric Oncology Nursing Advanced Clinical Handbook (2nd edn) Springer-Verlag Berlin Heidelberg, 354.

  5. Wardley AM, Jayson GC, Swindell R, Morgenstern GR, Chang J, et al. (2000) Prospective evaluation of oral mucositis in patients receiving myeloablative conditioning regimens and haemopoietic progenitor rescue. Br J Haematol 110: 292-299.

  6. Vera-Llonch M, Oster G, Ford CM, Lu J, Sonis S (2007) Oral mucositis and outcomes of allogeneic hematopoietic stem-cell transplantation in patients with hematologic malignancies. Support Care Cancer 15: 491-496.

  7. Kamsvag-Magnusson T, Thorsell-Cederberg J, Svanberg A, von Essen L, Arvidson J, et al. (2014) Parents and children's perceptions of distress related to oral mucositis during haematopoietic stem cell transplantation. Acta Paediatr 103: 630-636.

  8. Can G (2007) Mukozit: Onkoloji Hemsireliginde Kanita Dayali Semptom Yonetimi. 3P Pharma Publication Planning, Istanbul, 81-96.

  9. Dagdemir A (2009) Agiz bakimi: Pediatrik Onkoloji El Kitabi. (1st edn) Gunes Tip Kitabevleri, Ankara, 59-68.

  10. Sevinir B (2009). Mukozit: Pediatrik Onkoloji. Nobel Tip Kitabevleri, Istanbul, 1283-1300.

  11. Hockenberry MJ, Wilson D (2007) Wong's Nursing Care of Infants and Chidren. (8th edn), Mosby Inc, USA, 1578-1579.

  12. Chermetz M, Gobbo M, Ronfani L, Ottaviani G, Zanazzo GA, et al. (2014) Class IV laser therapy as treatment for chemotherapy-induced oral mucositis in onco-haematological paediatric patients: a prospective study. Int J Paediatr Dent 24: 441-449.

  13. Lalla RV, Bowen J, Barasch A, Elting L, Epstein J, et al. (2014) MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer 120: 1453-1461.

  14. Sonis S, Treister N (2010) Oral mucositis: Oral Complications of Cancer and its Management, Oxford University Press Inc, New York, 141-149.

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