Cancer in children is rare. In developed countries, between 105 and 150 cases per 1 million children
are diagnosed every year. However, since it has a high mortality rate, it is the second-leading cause of
childhood mortality after injuries.

For parents, the news that their child has cancer can be devastating, so it is important to highlight that a significant percentage of these young patients can be effectively treated and cured. Overall, more than 75% of pediatric cancer patients become long-term survivors.

Unfortunately, early diagnosis that can be related to a better outcome is often delayed because childhood
cancer is rare and the presenting symptoms tend to be nonspecific and resemble those of benign conditions.

Studies have shown that the average delay in the diagnosis of leukemia is three weeks, of lymphoma
eight weeks, of brain tumors 12 weeks, and for various other solid tumors between 2.5 and 12 weeks.
The parental delay in seeking care was shorter than the health care system delay in making the diagnosis,
emphasizing that parents are usually the best observers of their children, and that physicians should listen to parents’ concerns.

This article addresses both frequent and rare presenting signs and symptoms of childhood cancer, with an emphasis on some “red flag” symptoms that should be brought to medical attention promptly.

The aim of this article is not to terrify parents and make them rush to the doctor every time their child
experiences one of the following signs or symptoms. They should, however, be aware of them and
consult their child’s health care provider if these symptoms persist or present repeatedly.

Cancer in children is different from adults, therefore symptoms that are suggestive of specific malignancies in adults are very rare in children. For example, symptoms like rectal bleeding and breast
lumps-that in adults could indicate colon or breast cancer respectively-are rare in children.

The most common types of cancer in children (approximately 70%) are acute leukemia (lymphoblastic
and myeloid), brain tumors, lymphoma (cancer or the lymph nodes) and neuroblastoma, whereas more
rare forms of cancer include bone and soft tissue tumors, as well as tumors of the kidneys, the liver and
the eyes.

Childhood cancer can present with a wide variety of symptoms, the following are symptoms which
should be evaluated by a doctor.

Pallor, Fatigue or Malaise
If a child appears to be persistently pale, tired and without energy, and especially if other worrying symptoms such as unexplained low-grade fevers, recurrent infections, bleeding manifestations (excessive
bruising, bleeding gums, recurrent nosebleeds, etc.) and/or lymphadenopathy (enlarged glands) are
present.

Prolonged or Recurrent Fever
Especially if it lasts for more than two weeks and if no cause has been identified, or if it is associated with
weight loss, loss of energy, night sweats, pallor, bruising, any palpable mass, bone pain, or lymphadenopathy (swollen glands).

Recurrent Infections
If a child has recently presented with infections that are recurrent or difficult to treat, especially if they are associated with other previously mentioned unexplained symptoms such as pallor, excessive bruising, weight loss, bone pain, enlarged lymph nodes or a palpable mass anywhere in the body.

Protracted and Unexplained Anorexia
New anorexia, especially if it is accompanied by significant weight loss or other suspicious symptoms
(recurrent infections, fever, pallor, lymphadenopathy, hepatosplenomegaly). These should not be
necessarily attributed to behavioural problems and warrant further investigation.

Lymphadenopathy
Swollen glands that are either localized or generalized are very common in children and parents often seek medical advice as they are aware of their potential significance. Most cases of lymphadenopathy,
however, are not malignant. Characteristics indicating a possibly sinister etiology include size larger than 2 cm, progression or persistence for more than four to six weeks, especially if a course of antibiotics has already been administered.

In addition to the above, any association with fever, night sweats, weight loss, abdominal masses, or orthopnea (difficulty to breath when lying down) should be reported to the doctor who might request some laboratory tests such as blood tests, X-rays or ultrasound.

Headaches
Common in children, they may be related to a variety of conditions including migraine, sinusitis, tension
headaches, and eye problems. Headaches, however, can be a worrying symptom if they have started recently, if they are persistent or present mainly in the morning, or awake the child from sleep.

Headaches should be further investigated especially if there is no history of migraine, if these headaches
are associated with vomiting, and if they are worse when the child lies down. Any neurologic signs (abnormal movements, gait disturbance, ataxia) or visual impairment (squint, blurred vision) warrant urgent medical attention.

School Performance Change
Any unexplained deterioration in school performance or any changes in the child’s personality and mood should be reported to the child’s doctor, especially if they appeared recently, are progressive and not otherwise explained.

Vomiting
Persistent or recurring, especially if it is associated with morning headaches or with an abdominal
mass.

Palpable Mass
Any palpable mass in the abdomen has a high probability of being malignant, especially if it is associated with vomiting, abdominal pain or constipation that has appeared recently. Any palpable mass or lump on the extremities, the head, neck or trunk that has appeared recently, is non-tender, hard, and larger than 2 cm in diameter, or is associated with regional lymphadenopathy, merits further investigation.

Limb Pain
Children often complain of limb pain. Such pains are often referred to as “growing pains” and can be
located to the bones or joints. If, however, such pains result in limping or refusal to walk, or if they are related to arthritis (redness and swelling of a joint), then parents should seek specialised advice, especially if the bone pain awakens the child at night, lasts more than two weeks, is localized, is associated with swelling of the limb, and does not improve with nonsteroidal anti-inflammatory drugs.

Back Pain
Back pain is uncommon in children. In older children it can sometimes be associated with carrying heavy
backpacks or with sports injuries. If, however, the child is younger than four years of age back pain
should always be assessed by a doctor. Features indicating a possibly malignant cause include worsening of the pain at night and association with fever. If the pain is not associated with recent trauma and if it is not relieved by nonsteroidal anti-inflammatory drugs (e.g., ibuprofen), the child should be evaluated by a doctor.

Posture Abnormalities
Any posture abnormality such as kyphoscoliosis (abnormal front-to-back curving of the upper spine),
lordosis (swayback) and especially torticollis (head tilt) should always be evaluated by a doctor as it may
indicate the existence of a brain or spinal tumor.

Urinary Problems
Urine retention or enuresis (bed wetting), especially if secondary associated with neurologic symptoms
or abdominal masses.

Testicular Swelling
Any new swelling or mass in the scrotum needs to be reported to the doctor who will evaluate it and
may request further tests such as an ultrasound (e.g., a varicocele that is a swelling of the veins in
the scrotum could be an indication of renal tumor).

Other Changes
More rare symptoms include persistent cough and dyspnea in a previously fit and healthy child, leucokoria (white eye pupils), protracted diarrhea or sudden constipation, and persistent eczema.

Parents should remember that cancer in children is rare and should not panic over every little change in their child. They need to be alert, however, for the changes described above and, if any occur, have them evaluated by their child’s doctor.

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From issue: 29/05-06