Association of Neutropenia with Oral Mucositis Development in Children with Acute Lymphoblastic Leukemia Undergoing Induction Chemotherapy

Background: While treating pediatric patients with Acute Lymphoblastic Leukemia (ALL), the adoption of multimodal and intense chemotherapeutic regimens has led to an eminent increase in patients’ survival. However, there are some cytotoxic side effects associated with these protocols. Among them, neutropenia and Oral Mucositis (OM) have a major impact on prognosis and treatment outcomes.

Aim: To find out the association between neutropenia and the development of Oral Mucositis (OM) in children with Acute Lymphoblastic Leukemia (ALL) receiving induction chemotherapy

Method: This prospective observational study was conducted at the Department of Pediatric Hematology and Oncology (PHO), Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, following ethical approval. A total of 44 children (5-18 years) with Acute Lymphoblastic Leukemia (ALL) on the induction phase of chemotherapy were enrolled in this study. After taking informed written consent from patients and parents, a detailed history, thorough clinical examination, and necessary investigations were carried out in each child. All of them received chemotherapy drugs and supportive care according to the PHO BSMMU protocol. Data were collected in a semi-structured questionnaire. Absolute Neutrophil Count (ANC) was also recorded throughout the induction period. After collection, these data were analyzed by SPSS 24.0. A p-value <0.05 was considered statistically significant.

Result: Of the 44 children with ALL, the mean age of the patients was 8.6±3.1 years, with male predominance (75%), and the common variety (81.8%) was ALL (B cell). 52.3% of parents had a monthly income between >10,000 and <40,000 taka. 29.6% of fathers and 36.4% of mothers had up to secondary level education, while 40.9% of patients before diagnosis had some idea about oral hygiene but did not adhere to it rigorously. A family history of cancer was present in 11.4% of the patients. Only 18.2% of patients were not neutropenic during the induction period, compared to approximately 36.5% of patients had neutropenia prior to beginning treatment. During follow- up, overall, 38.6% had developed OM who had a longer induction period. No significant correlation found between the onset of OM and the patient’s characteristics. Among 38.6% patients with OM, 5.9% patients had mild, 5.9% had moderate, 29.4% patients had severe, and 52.9% patients had very severe neutropenia. Mean ANC level was also significantly lower amongst the patients with OM.

Conclusion: Neutropenic pediatric patients with Acute Lymphoblastic Leukemia (ALL) are more prone to develop Oral Mucositis (OM).