Hypoglycemia Associated With PEG-asparaginase and 6-MP Therapy During Treatment of Acute Lymphoblastic Leukemia in Pediatric Patients: A Case Series

BACKGROUND

Asparaginases are a mainstay treatment for pediatric acute lymphoblastic leukemia (ALL). Recent reports identified hypoglycemia associated with asparaginases. Other reports describe hypoglycemia associated with 6-mercaptopurine (6-MP), another fundamental ALL therapy. Little is known about the risk of hypoglycemia associated with ALL therapy, an adverse event that puts children at risk of decreased level of consciousness, seizures, and possibly negative neurocognitive sequelae.

METHODS

We performed a retrospective chart review of 6 children with hypoglycemia during ALL treatment in our institution from May 2016 to August 2019. Timing and duration of hypoglycemia relative to polyethylene glycol (PEG)-asparaginase, 6-MP, and corticosteroids were determined. Laboratory values of the critical sample were collected.

RESULTS

The median age was 2.75 (interquartile range: 1.88 to 3.63) years. Three patients had trisomy 21. The onset of hypoglycemia was 5 to 19 days after the most recent PEG-asparaginase administration or 6 to 7 months after initiating daily 6-MP. Sixteen hypoglycemic events were documented, and 9/16 had a critical sample drawn. Six events were hypoketotic, associated with PEG-asparaginase. Three were ketotic, associated with 6-MP. Two patients required treatment with diazoxide and cornstarch.

CONCLUSIONS

Hypoglycemia associated with PEG-asparaginase occurred later and lasted longer than previous reports with l-asparaginase, with the likely mechanism being hyperinsulinism. 6-MP was associated with ketotic hypoglycemia.

Successful Transjugular Portosystemic Shunt Treatment of Pediatric Sinusoidal Obstruction: Case Report and Review of Literature

Background

In adults with medically refractory sinusoidal obstruction syndrome (SOS), a transjugular intrahepatic portosystemic shunt (TIPS) has been used successfully to improve portal hypertension and symptoms such as ascites. There is limited data on the use of TIPS for SOS in pediatric patients.

Methods

The index case was reviewed retrospectively. PubMed and Medline databases were searched to identify other cases.

Results

A 4-year-old male with high-risk neuroblastoma, developed SOS after tandem autologous stem cell transplant. He was medically managed with defibrotide, diuretics, and peritoneal drainage, but, due to refractoriness, he underwent TIPS day +54 following bone marrow transplant. Hepatic venous pressure gradient improved from 17 to 8 mm Hg following TIPS placement with significant improvement in the patient's clinical status and ascites. However, 15 months later, his shunt remained patent, and he remains clinically well with stable liver enzymes. A literature review identified 13 pediatric cases of TIPS for SOS due to varied causes. TIPS caused a median hepatic venous pressure gradient of 9 mmHg (range, 2-38 mm Hg). The mortality following the procedure was 15%, with 2 cases who died at 2- and 11-days post-TIPS. At the time of the last follow-up (range 8-25 months), 5 patients were alive, and 8 were lost to follow-up.

Conclusion

We present here a pediatric case of SOS due to stem cell transplant treated successfully with TIPS with a review of the literature. A timely, individualized application of TIPS can be effective in treating children with medication-refractory SOS.

Severe iron deficiency anemia in the paediatric emergency department: A retrospective study

Background

Transfusion is discouraged in hemodynamically stable children with severe iron deficiency anemia (IDA). Intravenous (IV) iron sucrose (IS) could be an alternative for some patients; however, there is a paucity of data on its use in the paediatric emergency department (ED).

Methods

We analyzed patients presenting with severe IDA at the Children's Hospital of Eastern Ontario (CHEO) ED between September 1, 2017, and June 1, 2021. We defined severe IDA as microcytic anemia <70 g/L and either a ferritin <12 ng/mL or a documented clinical diagnosis.

Results

Of 57 patients, 34 (59%) presented with nutritional IDA and 16 (28%) presented with IDA secondary to menstrual bleeding. Fifty-five (95%) patients received oral iron. Thirteen (23%) patients additionally received IS and after 2 weeks, the average Hgb was similar to transfused patients. The median time for patients receiving IS without PRBC transfusion to increase their Hgb by at least 20 g/L was 7 days (95%CI 0.7 to 10.5 days). Of 16 (28%) children who were transfused with PRBC, there were three mild reactions, and one patient who developed transfusion associated circulatory overload (TACO). There were two mild and no severe reactions to IV iron. There were no return visits to the ED due to anemia in the following 30 days.

Conclusions

Management of severe IDA with IS was associated with a rapid rise in Hgb without severe reactions or returns to ED. This study highlights a strategy for management of severe IDA in hemodynamically stable children that spares them the risks associated with PRBC transfusion. Paediatric specific guidelines and prospective studies are needed to guide the use of IV iron in this population.

Acute myeloid leukaemia presenting as proptosis in an infant

Paediatric patients with acute myeloid leukaemia (AML) often present with symptoms associated with the disruption of normal haematopoiesis and subsequent cellular deficiencies. Periosteal reactions are common in paediatric leukaemia, but typically manifest as a thin, laminated pattern along long bones. Aggressive periosteal reactions are much less frequently seen. Here, we report a case of paediatric AML initially presenting with proptosis and periorbital swelling caused by aggressive, sunburst periosteal reactions surrounding the sphenoid and zygomatic bones. This unique presentation emphasises the importance of considering leukaemic infiltration in the differential for sunburst periosteal reaction in paediatric patients.

Effect of Eye Masks on Neonatal Stress Following Dilated Retinal Examination: The MASK-ROP Randomized Clinical Trial

Importance

Although screening examinations for retinopathy of prematurity (ROP) prevent blindness, they are physiologically stressful for infants. Photosensitivity during mydriasis may contribute to postexamination stress, and reducing light stimulation may make infants more comfortable.

Objective

To determine the effect of a phototherapy mask worn during mydriasis on infant stress in the 12-hour period following ROP screening.

Design, Setting, and Participants

The Effect of Eyemasks on Neonatal Stress Following Dilated Retinal Examination (MASK-ROP) randomized clinical trial with patient recruitment from April 2016 to June 2017 at neonatal intensive care units at St Michael's Hospital and Sunnybrook Health Sciences Center in Toronto, Ontario, Canada. A consecutive series of infants with birth weight of less than 1500 g and/or gestational age of less than 32 weeks undergoing their first ROP screening were analyzed beginning in July 2017. Analysis was intention to treat.

Interventions

Patients were randomized to wear a phototherapy mask for a minimum of 4 hours after dilating drop instillation in addition to standard comfort measures.

Main Outcomes and Measures

Number of desaturation, bradycardic, or apneic events during the 12-hour postexamination period.

Results

Of 51 infants who were examined, 28 (54.9%) were randomized to the treatment group (ie, used a mask) and 23 (45.1%) to the control group. Overall, 10 (35.7%) and 13 infants (56.5%) received ventilator support at the time of examination in the treatment and control groups, respectively. The mean (SD) gestational age was 27.9 (2.4) weeks, 32 (63%) were boys, and the mean (SD) birth weight was 1058.6 (312.0) g. The number of all stressful events were lower in the treatment group compared with controls in the 12-hour postexamination period, adjusted for events prior to examination and ventilation status (mean [95% CI] events, 1.0 [0.6-1.8] vs 1.7 [1.0-1.7]; rate ratio [RR], 0.57; 95% CI, 0.3-1.2; P = .12). Risk factors associated with increased stress included younger gestational age (RR, 1.32; 95% CI, 1.2-1.5 per week), lower birth weight (RR, 1.39; 95% CI, 1.2-1.5 per 100 g), ventilator support around the time of examination (RR, 2.67; 95% CI, 1.3-5.6), intraventricular hemorrhage (RR, 3.78; 95% CI, 1.9-7.3), and hyponatremia (RR, 3.42; 95% CI, 1.8-6.6). No adverse events occurred while using eye masks.

Conclusions and Relevance

This randomized clinical trial found that light sensitivity may play a role in stress observed in the late postexamination period. However, unequal distribution of infants receiving ventilator support placed certain neonates at higher risk of stress, and the clinical significance of this intervention's benefit could not be concluded with confidence.

Trial Registration

ClinicalTrials.gov identifier: NCT03824782.

THE EFFECT OF EYEMASKS ON REDUCING DISTRESS ASSOCIATED WITH THE RETINOPATHY OF PREMATURITY EXAM

BACKGROUND

Retinopathy of prematurity (ROP) is a disorder of retinal development in the low birthweight preterm infant. Eye screening is routinely performed for infants at risk of developing this disorder. While these examinations help prevent blindness, they can be physiologically stressful for infants, with changes in oxygen saturation, blood pressure and heart rate occurring during the exam and increased apneic episodes reported the 24–48 hours period afterward. The cause of these increased apneic episodes is not currently known.

OBJECTIVES

To evaluate the effect of decreasing light simulation during mydriasis on the frequency of stressful episodes after ROP screening.

DESIGN/METHODS

Multi-centre randomized study. This study was approved by hospital ethics boards at all sites. After informed consent was obtained, infants with a birthweight <1500g or gestational age of ≤32 weeks and scheduled for their first ROP screening were randomized to receive either standard of care or a phototherapy mask during pupil dilation, in addition to routine care. Dilated retinal exams were performed by retinal surgeons and fellows. The primary outcome was the frequency of any desaturation, bradycardic event, or apneic event 12 hours following the examination, compared to a baseline rate 12 hours prior to the exam. Heart rate, respiratory rate and oxygen saturation were recorded for up to 48 hours following the examination and compared to baseline.

RESULTS

A total of 51 infants were enrolled; 28 randomized to the masked group and 23 to the control group. 10 and 13 infants were on ventilator support at the time of examination in each group, respectively. There was a 57.7% decrease in the total number of all stressful events in the masked group compared to controls in the 12 hour post exam period (Rate Ratio 0.42, 95% CI 0.2–0.9, P=0.024). There was a 61.3% decrease in the number of bradycardic events in the masked group compared to controls (RR 0.39, 95% CI 0.2–1.0, P=0.042). Heart rate was significantly higher in both groups after the exam (Effect by time P=0.04), with no difference in between groups (Effect by group P=0.31). There was no significant difference seen in either group in respiratory rate or oxygen saturation at 2 or 4 hours after the ROP examination compared to baseline. Risk factors that were associated with increased stress included: younger gestational age (RR=1.32 95%CI [1.2–1.5] per week), lower birthweight (RR=1.39 [1.2–1.5] per 100g), ventilator support around the time of exam (RR=2.67 [1.3–5.6]), diagnosis of intraventricular hemorrhage (RR=3.78 [1.9–7.3]), and hyponatremia (RR=3.42 [1.8–6.6]). No adverse events occurred while using eye masks.

CONCLUSION

The infants who wore a phototherapy mask during pupillary dilation had lower rates of stressful episodes following screening for retinopathy of prematurity, particularly lower episodes of bradycardia.