Background: Unlike other pediatric cancers, acute lymphoblastic leukemia (ALL) treatment includes a prolonged maintenance phase during which children typically resume regular activities. As COVID-19 transmission persists despite the end of the public health emergency declaration, physicians need data regarding the impact of COVID-19 in this population to guide families in managing risk. Procedure: The Pediatric Oncology COVID-19 Case Report (POCC) collected de-identified clinical and sociodemographic data on children with cancer and COVID-19. This subset analysis compares 481 children (≤21yo at COVID-19 infection) with ALL in maintenance (ALL-MTN) to other children with cancer and COVID-19 (n=1,190). Results: Children in ALL-MTN had fewer hospitalizations, (23% vs 29%, p=0.01), intensive care unit admissions (ICU: 3% vs 5%, p=0.01), and were less likely to die (0% vs 2%, p=<0.01). However, they more often had cancer therapy changed (50% vs 33%, p=<0.01). Lower odds of hospitalization and ICU admission persisted in multivariable analyses adjusting for age, race/ethnicity, insurance, ANC, and comorbidities. There were independent associations among children in ALL-MTN with sociodemographic factors (Hispanic ethnicity, public insurance) and clinical characteristics (comorbid conditions, neutropenia) and both hospitalization and ICU admission. Vaccination decreased odds of hospitalization. Conclusions: Children in ALL-MTN continue to have significant COVID-19 risks, with less hospitalization and ICU admission but more therapy changes than other children with cancer. These risks should be addressed when discussing participation in activities (school, camp, sports, etc.), prevention (COVID-19 vaccination) and mitigation (masking) strategies. The high level of therapy modifications could have long-term consequences and should continue to be followed.

Background: Sedation for lumbar punctures (LPs) in pediatric acute lymphoblastic leukemia (ALL) patients has been the standard for decades to reduce pain and anxiety. Recent studies on the potential long-term neurocognitive effects of cumulative propofol exposure has raised concerns about this practice. The recent pandemic introduced additional burdens to patients, with the requirement of a negative COVID-19 test prior to each sedated procedure. Procedure: These factors prompted a quality improvement intervention at our institution where we aimed to reduce post-Induction sedated lumbar punctures (LPs) by 50%. Our intervention included patient and family education followed by a simulation of the procedure for selected patients. Those converted to unsedated LPs were queried for their preference. Comparative cost, clinical time and LP success rates were collected for sedated and unsedated LPs. Results: Following the intervention, the percentage of LPs performed with sedation dropped from 100% to 48.1%. All LPs were successful using both techniques. Most patients who experienced the unsedated LP technique, and their guardians, strongly preferred this approach. Unsedated LPs significantly reduced clinical time (169 vs 83 minutes) for families, decreased expenditures ($5,736.16 reduction per procedure) and improved institutional opportunity cost due to a decrease in last-minute cancellations. Conclusion: We have shown that it is feasible to significantly reduce the use of sedation for LPs in patients with ALL, which has the potential to improve health and patient experience at a lower cost.