Acute lymphoblastic leukaemia (ALL) in children
Acute lymphoblastic leukaemia (ALL) is a cancer of the white blood cells.
More children than ever are surviving childhood cancer. There are new and better drugs and treatments. But it remains devastating to hear that your child has cancer, and at times it can feel overwhelming. There are many healthcare professionals and support organisations to help you through this difficult time.
Understanding more about the cancer your child has and the treatments that may be used can often help parents to cope. We hope you find the information here helpful. Your child's specialist will give you more detailed information. If you have any questions it’s important to ask the specialist doctor or nurse who knows your child’s individual situation.
We hope this information answers your questions. If you have any further questions, you can ask a nurse or doctor involved in your child's treatment.
We have more information about acute lymphoblastic leukaemia that's been written specifically for teens and young adults.
One-third of all childhood cancers are leukaemia, with approximately 400 new cases in the UK each year. Approximately three out of four of these cases are acute lymphoblastic leukaemia (ALL). ALL can affect children of any age, but is more common in children aged 1-4. It is more common in boys than in girls.
Acute lymphoblastic leukaemia (ALL)
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Leukaemia is a cancer of the white blood cells. All blood cells are made in the bone marrow. Bone marrow contains:
red blood cells, which carry oxygen around the body
platelets, which help the blood to clot and control bleeding
white blood cells, which help fight infection.
There are two different types of white blood cells: lymphocytes and myeloid cells (including neutrophils). These white blood cells work together to fight infection. Normally, white blood cells develop, repair and reproduce themselves in an orderly and controlled way. In leukaemia, however, the process gets out of control and the cells continue to divide in the bone marrow, but do not mature.
These immature dividing cells fill up the bone marrow and stop it from making healthy blood cells. As the leukaemia cells are not mature, they cannot work properly. This leads to an increased risk of infection. Because the bone marrow cannot make enough healthy red blood cells and platelets, symptoms such as anaemia and bruising can occur.
There are four main types of leukaemia: acute lymphoblastic (ALL), acute myeloid (AML), chronic lymphocytic (CLL) and chronic myeloid (CML). Chronic leukaemias usually affect adults and are extremely rare in children and young people. Each type of leukaemia has its own characteristics and treatment. Acute lymphoblastic leukaemia is a cancer of immature lymphocytes, called lymphoblasts or blast cells.
There are two different types of lymphocytes - T-cells and B-cells. Often, leukaemia occurs at a very early stage in the immature lymphocytes, before they have developed into either T-cells or B‑cells. However, if the cells have developed this far before becoming leukaemic, the type of leukaemia may be known as T-cell or B-cell leukaemia.
This information is about acute lymphoblastic leukemia. If your child's cancer is one of the other types listed above, our cancer support specialists can give you further information about it.
The exact cause of ALL is unknown. Research is going on all the time into possible causes of this disease. Children with certain genetic disorders, such as Down’s syndrome, are known to have a higher risk of developing leukaemia. Brothers and sisters of a child with ALL (particularly identical twins) have a slightly increased risk of developing ALL themselves, although this risk is still small.
Like all cancers, ALL is not infectious and cannot be passed on to other people.
Signs and symptoms of ALL
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As the leukaemia cells multiply in the bone marrow, the production of normal blood cells is reduced. Children may therefore become tired and lethargic because of anaemia, which is caused by a lack of red blood cells. Children may develop bruises, and bleeding may take longer to stop because of the low number of platelets present in their blood (which help blood to clot). Sometimes, children suffer from infections because of low numbers of normal white blood cells.
A child is likely to feel generally unwell and may complain of aches and pains in the limbs or may have swollen lymph glands.
At first, the symptoms are just like those of a viral infection, but when they continue for more than a week or two, the diagnosis usually becomes clear.
A blood test usually shows low numbers of normal white blood cells and the presence of the abnormal leukaemia cells. A sample of bone marrow is usually needed to confirm the diagnosis. A sample is also sent to the genetics department to look for any abnormal chromosomes, and for a test called MRD (minimal residual disease) analysis.
A test called a lumbar puncture is done to see if the spinal fluid contains any leukaemia cells. A chest x-ray is also done, which will show if there are any enlarged glands in the chest. Other tests may be necessary, depending on your child’s symptoms.
These tests will help to identify the precise type of leukaemia and help doctors decide on the best treatment. Our page on tests for children’s cancers explains these tests in more detail.
The aim of treatment for ALL is to destroy the leukaemia cells and enable the bone marrow to work normally again. Chemotherapy is the main treatment for ALL. Usually, a combination of chemotherapy drugs and steroids is given according to a treatment plan (often called a protocol or regimen).
The treatment is given in several phases, or 'blocks', which are explained below.
This phase involves intensive treatment, aimed at destroying as many leukaemia cells as possible. The induction phase lasts 4-6 weeks. A bone marrow test is taken at the end of induction treatment to confirm whether or not the child still has leukaemia. The sample that is taken is looked at under a microscope and when there is no evidence of leukaemia, the child's condition is referred to as being in 'remission'.
Consolidation and central nervous system (CNS) treatment
The next phase of treatment is aimed at maintaining the remission and preventing the spread of leukaemia cells into the brain and spinal cord (the central nervous system, or CNS). CNS treatment involves injecting a drug, usually methotrexate, directly into the spinal fluid (intrathecally) during a lumbar puncture. Occasionally, radiotherapy to the brain is also necessary.
After this consolidation treatment there is a recovery period which is called interim maintenance. This is when more drugs will be given to try to keep the leukaemia in remission.
Further doses of chemotherapy treatment, called delayed intensification, are given to kill off any remaining leukaemia cells. Between two and four blocks of treatment may be needed, depending on your child's particular treatment plan.
This phase of treatment lasts for up to two years from diagnosis for girls and up to three years for boys. It involves the child taking daily and weekly tablets, and having monthly injections of chemotherapy.
Children will be able to take part in their normal daily activities as soon as they feel able to. Most children return to school before beginning maintenance treatment.
Bone marrow transplantation
Bone marrow treatment is only used for children with ALL that's likely to come back following standard chemotherapy. It can also be used for children whose leukaemia has come back (recurred) following standard treatment.
In some situations it may be necessary for boys to have radiotherapy to their testicles. This is because leukaemia cells can survive in the testicles despite chemotherapy.
Central nervous system (CNS) radiotherapy
Children who have leukaemia cells in their CNS when they’re first diagnosed with ALL may need to have radiotherapy to their brain (cranial radiotherapy). Your child's specialist will discuss with you which treatment and how much of it your child needs, and will answer any questions you have. If your child is younger than 2 years old they will not be given this treatment.
Side effects of treatment for ALL
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Many cancer treatments will cause side effects. This is because while the treatments are killing the cancer cells, they can also damage some normal cells.
Some of the main side effects of chemotherapy are:
reduction in the number of blood cells produced by the bone marrow, which can cause anaemia (an increased risk of bruising, bleeding and infection)
loss of appetite and weight
feeling sick (nausea) and being sick (vomiting).
Steroid medicines can also cause side effects such as:
mood changes and irritability
muscle weakness (especially in the legs).
Most side effects are temporary, and there are ways of reducing them and supporting your child through them. Your child’s doctor or nurse will talk to you about any possible side effects. It is important to discuss any side effects your child is having with the team treating them, so that they know how your child is feeling.
Late side effects of treatment for ALL
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A small number of children may develop late side effects, sometimes many years later. These include possible problems with puberty and fertility, a change in the way their heart works and a small increase in the risk of developing another cancer later in life. Your child’s doctor or nurse will talk to you about any possible late side effects.
Many children have their treatment as part of a clinical research trial. Trials aim to improve our understanding of the best way to treat an illness, usually by comparing the standard treatment with a new or modified version. Specialist doctors carry out trials for ALL.
If appropriate, your child's medical team will talk to you about taking part in a clinical trial and will answer any questions you have. Written information is provided to help explain things.
Taking part in a research trial is completely voluntary, and you'll be given enough time to decide if it's right for your child.
Most children with ALL are cured. If the leukaemia recurs after initial treatment, it usually does so within the first three years. Further treatment can then be given.
Long-term side effects (late side effects) are rare, and most children with ALL grow and develop normally.
If you have specific concerns about your child’s condition and treatment, it's best to discuss them with your child’s doctor, who knows the situation in detail.
As a parent, the fact that your child has cancer is one of the worst situations you can be faced with. You may have many different emotions, such as fear, guilt, sadness, anger and uncertainty. These are all normal reactions and are part of the process that many parents go through at such a difficult time.
Your teams of doctors and nurses are there to help support your child and family as well as carry out treatments. It is important to discuss any difficulties you may be having with your treatment team.
The section on children’s cancers talks about the emotional impact of caring for an unwell child and suggests sources of help and support. It also discusses the range of powerful emotions your child may experience throughout their illness, including how you can support your child.
Our booklet Katie’s Garden is a storybook for primary school-age children about a girl's experience of cancer)
Children's Cancer and Leukaemia Group (CCLG)
CCLG coordinates research and care for children and their parents. There are 21 CCLG specialist centres for the treatment of childhood cancer and leukaemia, covering all areas of the UK and Ireland (there's a map of the centres on the website). The website has information about the CCLG, childhood cancer and leukaemia.
CLIC Sargent offers practical support to children and young people with cancer or
Leukaemia CARE is a national charity that provides care and support to patients, their families and carers, through the diagnosis and treatment of leukaemia or an allied blood disorder.
This section has been compiled using information from a number of reliable sources, including:
Voute PA, et al. Cancer in Children: Clinical Management. 5th edition. 2005. Oxford University Press.
Pinkerton, et al. Evidence-based paediatric oncology. 2nd edition. 2007. Blackwell Publishing.
CYPALL. Guidelines for treatment of children and young persons with acute lymphoblastic leukaemia and lymphoblastic lymphoma (Interim Guidelines 3). 2011.
Eds. Greer JP, et al. Wintrobe’s clinical hematology. Volume 2. 12th edition. 2009. Lippincott Williams and Wilkins.
With thanks to: Dr Jenny Welch, Consultant Haematologist; and the people affected by cancer who reviewed this edition. Reviewing information is just one way of the ways you could help when you join our Cancer Voices network.
We worked with the Children's Cancer and Leukaemia Group (CCLG) to write our information about children's cancer.