Acute lymphoblastic leukaemia (ALL) in children: symptoms, tests and how treatment works

NHS inform explains that blood cells are made in the bone marrow, and that in ALL some of the blast cells that should develop into healthy infection-fighting lymphocytes are abnormal and do not develop fully. These leukaemia cells fill the bone marrow so there is not enough room to make the usual numbers of healthy white cells, red cells and platelets. The NHS calls it a rare cancer that affects the blood and bone marrow, and says how serious it is depends on the type, the person's age and general health.

NHS inform describes two main types, B-lymphoblastic (the most common) and T-lymphoblastic, and a subtype called Philadelphia positive ALL, a gene change inside leukaemia cells that is not inherited and cannot be passed on to children. It says ALL does not run in families.

The NHS says symptoms are not always obvious at first and can be similar to other conditions, usually appearing over a few weeks. They include:

• feeling tired or weak

• bleeding or bruising easily or for no reason

• looking more pale than usual

• getting ill a lot or taking longer than usual to recover

• a high temperature

• swollen glands, usually in the neck, armpits and groin

• pain in the bones or joints

• loss of appetite or weight loss

• shortness of breath, or a swollen, uncomfortable tummy

The NHS stresses that these symptoms are very common and can be caused by many conditions, so having them does not mean a child has leukaemia, but it is important to get them checked because finding cancer early may make it easier to treat. It says to see a GP for symptoms, to ask for an urgent GP appointment or call 111 if a child is bleeding or bruising easily or for no reason, and to call 999 or go to A&E for a sudden swollen, red face, neck, arms or hands or sudden swollen veins in the neck or chest. At the GP appointment, the doctor may examine swollen or painful areas, listen to the chest, arrange an urgent blood test and refer for tests or to a hospital specialist; sometimes a child has to go to hospital straight away.

NHS inform adds that swollen lymph nodes that remain swollen for 6 weeks or more, drenching night sweats and infections that keep returning are among the symptoms to report to the GP practice.

The NHS says if a GP refers a child to a specialist, tests may include blood tests and taking a small sample of bone marrow with a needle (biopsy). With a bone marrow biopsy there is usually a local anaesthetic and possibly sedation, while young children may be given a general anaesthetic. Results can take a few weeks, and a long wait does not definitely mean anything is wrong. A group of specialists looks after the family, including a clinical nurse specialist as the main point of contact.

After diagnosis, the NHS says more tests are usually needed, which may include a lumbar puncture, scans, more blood tests and a saliva sample. NHS inform says a haematologist tests blood and bone marrow, and further tests such as immunophenotyping and cytogenetic tests identify the type of leukaemia and genetic changes, which can affect the type of drug treatment.

The NHS says ALL is often treatable and that treatment usually needs to start quickly. It depends on the type of ALL, the age and the general health, and usually includes steroids and chemotherapy, and may include targeted medicines, immunotherapy or a stem cell or bone marrow transplant. Steroids aim to get rid of leukaemia cells and are usually taken for up to a week before chemotherapy starts. Supportive treatments include antibiotics to prevent or treat infections, blood transfusions, growth factors to help the bone marrow make blood cells, and vaccines.

NHS inform says a multidisciplinary team meets to decide the treatment plan and that treatment is usually in three phases: induction to get rid of leukaemia cells and reach remission, consolidation to clear any remaining cells in areas like the brain or spinal cord, and maintenance, with tablets for 2 to 3 years to help prevent the leukaemia coming back. Chemotherapy is given into a vein through a line, as tablets, and into the fluid around the spine and brain (intrathecal) to prevent spread. Tests during treatment check for minimal residual disease. Drug regimens for children are set by the specialist team.

The NHS says it is not always clear what causes ALL. Possible risk factors include being a child or young adult, genetic conditions such as Down's syndrome, past chemotherapy, high radiation exposure and a weakened immune system. NHS inform lists Down's syndrome, Fanconi's anaemia, Bloom's syndrome and ataxia-telangiectasia, and very high levels of radiation, and says doctors do not know the cause of ALL.

The NHS says families are supported throughout treatment by a group of specialists and the clinical nurse specialist can advise on local support. National charities named by the NHS include Blood Cancer UK, Leukaemia Care, the Children's Cancer and Leukaemia Group, which provides resources for parents and carers of children with cancer, Macmillan Cancer Support, Cancer Research UK and Marie Curie. The NHS also says that if treatment is not able to cure the cancer, a palliative care or symptom control team will help keep a child comfortable.