What Are The Most Common Pediatric Cancers?

Patient Presentation
A group of residents were discussing some of the patients they were caring for on their hematology/oncology rotation. They noted that it had been a very busy rotation with several children needing to be admitted with fever and neutropenia, or problems with their central intravenous catheters that were used for their treatments, and the usual number of children who were being admitted for their routine chemotherapy treatment. “Unfortunately we’ve also had a several patients with new diagnoses too. There was one child with ALL, another with rhabdomyosarcoma and another with a brain tumor. They are all so different to treat and think about so we’ve been learning a lot this month about oncology,” one resident remarked.

Discussion
Cancer occurs in all ages including children. Fortunately cancer is much less common in the pediatric age group accounting for <1% of all cancers yearly in the US. Approximately 10,000 US children under age 15 will be diagnosed with cancer in 2016. More than 80% of those children will survive more than 5 years because of advances in direct cancer treatment and treatment of its complications. Survival rates depend on a number of factors including the type of cancer and location. Despite these good numbers, about 1250 children in the US die yearly from pediatric cancer. After accidents, childhood cancer, suicide/homicide and congenital abnormalities cause similar numbers of deaths in children and teens. Known risk factors are few but include certain genetic mutations or syndromes and ionizing radiation. The World Health Organization does keep data on pediatric cancer worldwide but it is not as consistently available worldwide.

Learning Point
The most common pediatric cancers in the U.S. are:

  • Leukemia
    • 30% of all pediatric cancers
    • Acute lymphoblastic leukemia(ALL) and acute myeloblastic leukemia (AML) are the most common leukemias
    • Found in all ages
    • 5 year survival rate is 85% (all survival rates listed here are from 2005-2011)
    • 5 year survival rate is 89% for ALL and 65% for AML
  • Brain and other central nervous system tumors
    • 26% of all pediatric cancers
    • Can occur in all central nervous system locations but are a little more common in the cerebellum and brain stem than in adults
    • Found in all ages
    • 5 year survival rate is 72%
  • Neuroblastoma
    • 6% of all pediatric cancers
    • Can occur in all areas of peripheral nerves but are more common in the abdomen
    • Common in infants and young children. Rare after age 10 years
    • 5 year survival rate is 78%
  • Wilms tumor (or nephroblastoma)
    • 5% of all pediatric cancers
    • Occurs in one or both of the kidneys
    • Common in toddlers and preschoolers. Uncommon after age 6 years
    • 5 year survival rate is 92%
  • Lymphoma (including both Hodgkin and non-Hodgkin)
    • Hodgkin lymphoma is 3% of all pediatric cancers
      • Occurs in lymph nodes
      • Common in adolescents and young adults, with another peak in mid 50s. Rare in children < 5 years.
      • 5 year survival rate is 98%
    • Non-Hodgkin lymphoma is 5% of all pediatric cancers
      • Occurs in lymph nodes
      • Can occur in all pediatric ages but less common in those < 3 years of age
      • 5 year survival rate is 89%
  • Rhabdomyosarcoma
    • 3% of all pediatric cancers
    • Soft tissue sarcoma is most common.
    • Can occur in any location with skeletal muscle. Occurs in all ages
    • 5 year survival rate is 69%
  • Retinoblastoma
    • 2% of all pediatric cancers
    • Can occur in one or both eyes
    • Often occurs around 2 years of age and is uncommon after age 6 years
    • 5 year survival rate is 97%
  • Bone cancer (including osteosarcoma and Ewing sarcoma)
    • 2-3% of all pediatric cancers
    • Osteosarcoma (2%) is the most common bone tumor. Ewing’s sarcoma is also common (1%).
    • Adolescents more commonly have bone tumors but they can occur at any age.
    • 5 year survival rate for osteosarcoma is 69%

Questions for Further Discussion
1. What type of followup care do survivors of pediatric cancer need?
2. How common are second malignancies after treatment for pediatric cancer? For an answer click here
3. Where can comprehensive cancer centers for pediatric treatment be found?
4. What are PDQ®s for cancer? For an answer click here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Cancer in Children.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Cancer Society. What are the most common types of childhood cancers?
Available from the Internet at ancer.org/cancer/cancerinchildren/detailedguide/cancer-in-children-types-of-childhood-cancers (rev. 1/27/16, cited 4/25/16).

Centers for Disease Control. 10 Leading Causes of Death by Age Group, United States 2014.
Available from the Internet at http://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2014_1050w760h.gif (rev.2/25/2016, cited 4/25/16).

American Cancer Society. Cancer Facts and Figures 2016.
Available from the Internet at http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf (rev. 2016 cited 4/28/16).

Centers for Disease Control. United States Cancer Statistics Childhood Cancer. Available from the Internet at https://nccd.cdc.gov/uscs/ChildhoodCancerData.aspx (cited 4/28/16).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Can Melatonin Be Used to Help Sleep?

Patient Presentation
A 20-year-old male came to clinic because of several nights of insomnia. He had several nights where he suddenly significantly changed the time he normally went to sleep, and then for the next 5 evenings when he could restart his normal bedtime, he had a hard time being able to initiate sleep. “I just sit there with my eyes wide awake and just can’t fall asleep,” he said. “I finally get to sleep about 4 hours later and then I can’t get up in the morning. When I do wake up I’m too scared to drive to my college classes,” he related. He denied any depression or anxiety. He said he had normal stress about his classes but was doing well. He was studying software engineering and therefore was often using electronic devices up until the time he went to bed. He denied any medications or drug use. He said that sometimes eating some food would help him fall asleep but a bigger meal made it worse. The past medical history showed a healthy male, who had previous episodes of a similar sleep problem that generally stopped after 1-2 nights. The family history showed some diabetes, and occasional insomnia in the father. There was no history of mental health problems. The review of systems was normal.

The pertinent physical exam showed a healthy male with normal vital signs and physical examination. The diagnosis of a short term sleep-onset problem was made. The patient was counseled to improve his sleep hygiene with careful attention to his schedule and also the amount of screen use he had. “Because you are using computers for school and will be for work, you are going to have to be very aware of the amount of the use, and the timing of the use, as you seem to be more prone to this sleep problem. Having a bedtime routine where you can stop the computers, maybe read or listen to music for a little while in a chair or couch and then go to your bed will probably help,” the pediatrician counseled. “Your bed should be for sleeping and not for other things like coding and homework. You can also try drinking something warm, making sure there is low-lighting in the room,” he added. “Since you are already having a problem you can also try some melatonin for a few days as a sleep aid. You should take it 2 hours before you want to fall asleep and you can do it for about a week if you need to. If it is not working call me. If this happens again, try restarting your schedule and sleep practices, and if needed you can try the melatonin again,” he said.

Discussion
Sleep is regulated by the homeostatic sleep drive and the circadian system which controls periods of activity and inactivity throughout the day. The circadian rhythm is slightly longer than 24 hours in humans and is controlled by the hypothalmic suprachiasmatic nucleus. When the circadian system and the external environment are misaligned, such that sleep occurs outside of normal times, a circadian rhythm sleep disorder can occur.

Everyone experiences disturbances of sleep throughout their lifetime. During adolescence, there is a normal physiologic change so that there is a shift to a later sleep phase for adolescents. Adolescents also commonly have inadequate sleep that occurs on an ongoing basis because of societal norms of having to awaken early in the morning. Pediatric insomnia is defined as “repeated difficulty in sleep initiation, duration, consolation, or quality that occurs despite age-appropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family.” Mild or transient problems are not a sleep disorder or insomnia. The problem must be more consistent, and be developmentally inappropriate.

Adolescents and young adults can have circadian rhythm problems occur.

Delayed sleep phase disorder (DSPD) is the most common in this group with a the prevalence of 7-16%. DSPD delays sleep onset by 3 to 4 hours compared to usual normative evening time (i.e. 10-11 PM). If left alone, the sleep is normal in quality and duration. Sleep wakening is then necessarily delayed causing problems with social needs (e.g. not getting up in time to go to school). The adolescent then has inadequate sleep which then leads to poor sleep hygiene which helps to change the intrinsic circadian rhythm which continues to cause the delayed sleep onset. Overtime, DSPD develops. DSPD is treated using good sleep hygiene but other interventions may be necessary.

  • Chronotherapy delays sleep onset progressively over several days until the normal sleep onset time is achieved and then anchors that new time with post-sleep morning light.
    Light therapy especially in the morning can be helpful.

  • Light in the evening delays sleep onset and light in the morning advances it (i.e. makes it earlier in the evening the next night). Light intensity between 2500-10000 lux will advance circadian rhythms.
  • Melatonin can also be used.

Sleep hygiene including establishing regular sleep routines and timing that can be consistently adhered to (both for sleep onset and duration), limiting technology devices especially those with a blue screen such as television and computers, limiting caffeine and energy-dense food before bedtime, regular exercise during the day and not in the evening and treatment for any underlying problems such as depression or anxiety.

Psychophysiologic insomnia (PPI) is a sleep-onset disorder and is not a circadian rhythm sleep disorder. Individuals have a very hard time initiating sleep and then difficulty in wakening in the morning. PPI and DSPD can be concurrent.

To learn more about circadian rhythms in newborns click here and a review of sleep hygiene for infants can be found here.

Learning Point
Melatonin is an indolamine that is made in the pineal gland and has chronobiotic and hypnotic properties. It also has anti-inflammatory, antioxidant and free radical scavenging abilities. Circulating endogeneous levels are high in childhood and decrease during puberty. It is metabolized by the liver and has a half-life of 45-60 minutes. Medications such as oral contraceptives and cimetidine decrease melatonin metabolism and carbamazepine and ompeprazole can increase melatonin metabolism. In humans endogenous melatonin starts to rise about 2 hours before sleep onset and peaks about 5 hours after sleep onset.

It can be used to help re-entrain short-term or long-term circadian rhythm problems or be used to help prevent sleep disruption following environment insults. It has also been used to treat headaches and seizures.

  • For PPI, melatonin is taken 2 hours before desired sleep onset as a soporific (weak sleep aid). Dosages vary but 0.2-0.5 mg can be used as a starting point.
  • For DSPD, melatonin is taken 5 hours before desired sleep onset to help retrain the system. Dosages vary but small doses have been found to be as effective. For children a 0.2-0.5 starting dose or 0.5- 1 mg in adults, which can be increased by 0.2-0.5 mg weekly until desired effect with a maximum of 3 mg in children/teens 40 kg is one regimen. Once a consistent, desired bedtime is achieved, smaller dose (such as 0.2-0.5 mg) given 2 hours before desired sleep onset helps to establish the circadian pattern.
  • For jet lag in adults 3 mg is often prescribed.
  • In children with long-term insomnia such as those with neurological disease can benefit. Melatonin should be re-evaluated at not less than 1 month after starting to determine effectiveness. Melatonin treatment is recommended to be stopped for at least 1 week yearly to again evaluate need for ongoing treatment.
    Long-term therapy can be stopped just before or after puberty.

Melatonin is considered safe but side effects can include drowsiness, headache, hypothermia, dizziness, diarrhea, enuresis, and rash.

Questions for Further Discussion
1. What health problems are associated with inadequate sleep? For a review click here.
2. What sleep hygiene recommendations do you offer families?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sleep Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bartlett DJ, Biggs SN, Armstrong SM. Circadian rhythm disorders among adolescents: assessment and treatment options. Med J Aust. 2013 Oct 21;199(8):S16-20.

Reiter J, Rosen D. The diagnosis and management of common sleep disorders in adolescents. Curr Opin Pediatr. 2014 Aug;26(4):407-12.

Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol. 2014 Sep;39(8):932-48.

Bruni 0, Alonso-Alconada D, et.al. Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol. 2015 Mar;19(2):122-33.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What are Paraphilias and How Common is Zoophilia in Adolescents?

Patient Presentation
After seeing several adolescents in an afternoon, some residents and an attending were having a general discussion about adolescent sexuality. The attending noted it was important to gain the appropriate trust from the teen or young adult. “I try to be open to anything an adolescent may tell me and not to be surprised. Sometimes they will say something just to see if they can shock you, but most are saying something that is important to them or have questions because they just want to know about it. Often they are wondering if their bodies or their thoughts they are normal,” the attending said. He also stated that it was important to keep in mind that just because a person has sexual thoughts, feelings or performs certain sexual acts, these do not necessarily define the sexual orientation or sexual practices of an individual. He went on, “There is a difference between someone being curious or seeking novelty and more consistent or less common sexual practices.” One of the residents said, “I grew up around a lot of farms, and it was always the high school joke that some of the boys had their first sexual experiences with some of the animals on the farm. While it might have happened because of the opportunity, I don’t know how common it actually was or is.”

Discussion
Teens may also have normal curiosity and thoughts about sexuality and various sexual practices. They may also have the opportunity to explore or engage in some practices in person or through the Internet. For example, a teen inadvertently or purposefully watches sexual intercourse between his/her parents or between peers at a party. This is not a paraphilia or an atypical sexual interest.

“Paraphilias are defined as intense and persistent sexual interests outside of foreplay and genital stimulation with phenotypically normal, consenting adults.” Examples of paraphilias are voyeurism, exhibitionism, and fetishism. Most people with paraphilias do not have a mental disorder and people with paraphilias may or may not act on the interest. Paraphilic disorders are distinct from paraphilias. Paraphilic disorders occur when the atypical sexual interest causes distress or is bothersome to the individual, or in some way causes distress or injury to another individual. There are numerous paraphilias and paraphilic disorders that are named based on the sexual interest.

Learning Point
Zoophilia is a persistent sexual interest in animals. Bestiality is “the legal term for the criminal offense of engaging in sexual relations with an animal or animals.” Bestiality laws are common because of the harm to animals who obviously cannot provide consent. There is not a great deal of medical professional literature on the subject and overall the practice appears to be rare.

Three of the studies below (Holoyda and Newman, Ranger and Fedoroff, and Satapathy et.al.), cited the 1948 Kinsey report where he “…reported that 8 percent of males had participated in some form of sexual activity with animals and that 40-50 percent of boys growing up on a farm had sex with an animal at least once. Kinsey also reported that 1.5 percent of females had contact with animals before adolescence….”

Some limited data has found zoophilia/zoophilic disorder among people who were sexually abused, or are violent or sex offenders. One 2016 case report discusses an adolescent male who was illiterate, who had experienced childhood sexual abuse and lived near a farm. A meta-analysis by Seto and Lalumiere found a 14% rate of bestality among juvenile sex offenders (JSOs). In another study of JSOs, rates for bestiality was 3.9-38% for JSO in the literature the authors reviewed. Their own data showed 37.5% self-reported bestiality which increased to 81.3% when the JSOs underwent polygraph examination.

Questions for Further Discussion
1. What are treatment options for paraphilic disorders?
2. What are special health needs of incarcerated youth?
3. How common is teen violence?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Health and Teen Sexual Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Kinsey A, Wardell C, Pomeroy B, Martin CE. Philadelphia: W.B. Saunders; 1948. Sexual Behavior in the Human Male.

Hensley C, Tallichet SE, Dutkiewicz EL. Childhood bestiality: a potential precursor to adult interpersonal violence. J Interpers Violence. 2010 Mar;25(3):557-67.

Seto MC, Lalumiere ML. What is so special about male adolescent sexual offending? A review and test of explanations through meta-analysis. Psychol Bull. 2010 Jul;136(4):526-75.

Holoyda B, Newman W. Zoophilia and the law: legal responses to a rare paraphilia. J Am Acad Psychiatry Law. 2014;42(4):412-20.

Ranger R, Fedoroff P. Commentary: Zoophilia and the law. J Am Acad Psychiatry Law. 2014;42(4):421-6.

Schenk AM, Cooper-Lehki C, Keelan CM, Fremouw WJ. Underreporting of bestiality among juvenile sex offenders: polygraph versus self-report. J Forensic Sci. 2014 Mar;59(2):540-2.

Satapathy S, Swain R, Pandey V, Behera C. An Adolescent with Bestiality Behaviour: Psychological Evaluation and Community Health Concerns. Indian J Community Med. 2016 Jan-Mar;41(1):23-6.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital