Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df

Fig. 11.2 Oral Mucositis Grading Scales. a World Health Organization scoring criteria. b National Cancer Institute Common Terminology Criteria for Adverse Events CTCAE version 4.0. c Oral Mucositis Assessment Scale. d Oral Assessment Guide a World Health Organization WHO Scoring Criteria for Oral Mucositis Grade 1 2 3 4 Description Normal Soreness with or without erythema Ulceration and erythema; patient can swallow a solid diet Ulceration and erythema; patient cannot swallow a solid diet Ulceration and pseudomembrane formation of such severity that alimentation is not possible Adapted from Sonis et al. 2004a With permission from Sonis et al. 1999 b National Cancer Institute Common Terminology Criteria for Adverse Events CTCAE version 4.0 Adverse event Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Oral mucositis definition: a disorder characterized by inflammation of the oral mucosa Asymptomatic or mild symptoms; intervention not indicated Moderate pain; not interfering with oral intake; modified diet indicated Severe pain; interfering with oral intake Life-threatening consequences; urgent intervention indicated Death http:www.acrin.orgPortalsoAdministrationRegulatoryCTACE_4.02_2009-09-15_QuickReference_5x7.pdf c Oral Mucositis Assessment Scale Location UlcerationPseudomembrane circle Erythema circle Upper lip Lower lip Right cheek Left cheek Right ventral and lateral tongue Left ventral and lateral tongue Floor of mouth Soft palatefauces Hard palate 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 Ulcerationpseudomembrane: 0 = no lesion 1 = 1 cm 2 2 = 1 cm 2 –3 cm 2 3 = 3 cm 2 Erythema: 0 = none 1 = not severe 2 = severe d Oral Assessment Guide Numerical and Descriptive Ratings Category Tools for Assessment Methods of Measurement 1 2 3 Swallow Observation Ask patient to swallow. To test gag reflex, gently place blade on back of tongue and depress Normal swallow Some pain on swallow Unable to swallow Voice Auditory Converse with patient Normal Deeper or raspy Difficulty talking or painful Lip Visualpalpation Observe and feel tissue Smooth and pink and moist Dry or cracked Ulcerated or bleeding Tongue Visualpalpation Feel and observe appearance of tissue Pink and moist and papillae present Coated or loss of papillae with a shiny appearance with or without redness Blistered or cracked Saliva Tongue blade Insert blade into mouth, touching the center of the tongue and the floor of the mouth Watery Thick or ropy Absent Mucous membrane Visual Observe appearance of tissue Pink and moist Reddened or coated increased whiteness without ulcerations Ulcerations with or without bleeding Gingiva Tongue blade and visual Gently press tissue with tip of blade Pink and stippled Edematous with or without redness Spontaneous bleeding or bleeding with pressure Teeth Visual Observe appearance of teeth Clean and no debris Plaque or debris in localized area between teeth if present Plaque or debris generalized along gum line Adapted from Eilers et al. 1988 An example of a combined scale that includes both objective and subjective experiences as well as functional dimensions is the Oral Assessment Guide OAG Eilers et al. 1988 . The OAG was designed primarily as a clinical tool and is useful for recording the condition of the oral cavity Eilers et al. 1988 . The OAG consists of numeri- cal and descriptive ratings in eight categories including voice, swallowing, lips, tongue, saliva, mucous membranes, gingivae and teeth. Each descriptive category is assessed on a numeric scale from 1 to 3 with the overall oral assessment score the sum of the eight categories Eilers et al. 1988 Fig. 11.2 . Chen et al. 2004 used the OAG to assess children with leukemia and lym- phoma undergoing chemotherapy and were able to demonstrate content validity of the instrument. Tomlinson et al. 2008a , b , c identifi ed four main areas of concern from the existing litera- ture in mucositis assessment and tool develop- ment in the pediatric oncology population: 1 the challenge of oral assessment in children with relation to age and cooperation; 2 the need for proxy responses, while recognizing the chal- lenges of reporting pain and function attributed to oral mucositis; 3 the need for an instrument that is simple, quick to complete and easy to use in almost all children; and 4 educational con- siderations. To address these concerns, their group developed the Children’s International Mucositis Evaluation Scale ChIMES; Fig. 11.3 , an assessment instrument for both child self- report and parent proxy-report Tomlinson et al. 2009 . ChIMES assesses three main areas: 1 pain i.e., pain assessment, amount of pain medi- cation received, 2 function i.e., effect on eat- ing, droolingpooling of saliva, effect on drinking, and 3 appearance i.e., presence of ulcers Tomlinson et al. 2009 . ChIMES has been shown to be understandable, with content validity and acceptability, and has been prospec- tively validated in a multicenter cohort of chil- dren receiving chemotherapy and after HSCT Tomlinson et al. 2009 , 2011 ; Jacobs et al. 2013 .

11.4 Prevention and Treatment

of Oral Mucositis In recent years there has been an increase in research regarding the prevention and treatment of mucositis. However, evidence-based interven- tions remain limited, especially in pediatric patients. Generally, the clinical focus continues to be on palliation of the symptoms of mucositis Eilers and Million 2011 . In a Cochrane review, Clarkson et al. 2010 showed that there is lim- ited evidence that low-level laser therapy LLLT may be benefi cial in the treatment of OM. In a separate Cochrane analysis Worthington et al. 2011 reported that ten agents showed potential benefi t in OM prophylaxis; these agents were reviewed by Eilers and Million 2011 and are summarized in Table 11.2 .

11.4.1 Palifermin

Palifermin is the fi rst targeted agent approved for the prevention of mucositis in patients receiving high-dose chemotherapy with or without radia- tion therapy as conditioning for HSCT. Palifermin is a recombinant form of keratinocyte growth factor- 1 KGF-1 that binds to its cognate recep- tor, resulting in increased cellular proliferation and mediation of epithelial cell repair Posner and Haddad 2007 . The effi cacy of palifermin to reduce the incidence, duration and severity of mucosal lesions in the oral cavity has been estab- lished in adult patients undergoing autologous and allogeneic HSCT Spielberger et al. 2004 ; McDonnell and Lenz 2007 ; Langner et al. 2008 ; Barasch et al. 2009 . Pediatric data are quite lim- ited. In a phase I study, Srinivasan et al. 2012 showed that palifermin was tolerated at a dose of 90 μgkgday with linear pharmacokinetics in children under going allogeneic HSCT. Lauritano et al. 2014 showed a signifi cant reduction in duration and grade of mucositis in pediatric patients with acute lymphoblastic leukemia PAIN CHILD INTERNATIONAL MUCOSITIS EVALUATION SCALE ChIMES 1. Which of these faces best describes how much pain you feel in your mouth or throat now? Circle one. 2. Which of these faces best shows how hard it is for you to SWALLOW your salivaspit today because of mouth or throat pain? Circle one. 3. Which of these faces shows how hard it is for you to EAT today because of mouth or throat pain? Circle one. Not hard 1 Little bit hard 2 Little more hard 3 Even harder 4 Very hard 5 Can’t swallow No hurt 1 Hurts a little bit 2 Hurts a little more 3 Hurts even more 4 Hurts a whole lot 5 Hurts worst Can’t tell Not hard 1 Little bit hard 2 Little more hard 3 Even harder 4 Very hard 5 Can’t eat Can’t tell Not hard If yes, did you need the medicine because you had a sore mouth or throat? Yes No I can’t tell 5. Have you taken any medicine for any kind of pain today? 6. Please ask an adult to look in your mouth. Can he or she see any mouth sores in your mouth today? 1 Little bit hard 2 Little more hard 3 Even harder 4 Very hard 5 Can’t drink Can’t tell 4. Which of these faces shows how hard it is for you to DRINK today because of mouth or throat pain? Circle one. FUNCTION PAIN MEDICATION You will need some help from your parent or another adult to answer these questions. APPEARANCE The photos shown on the introduction page are examples of what mouth scores may look like. Yes No Yes No Fig. 11.3 ChIMES tool with permission from Tomlinson et al. [ 2010 ]