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\begin{document}

\title{Comment on: Secondary impacts of constipation in acute lymphoblastic
leukemia in U.S. children's hospitals}



\author[1]{Rameez Naqvi}%
\author[2]{Saif Abbas Chatoo}%
\author[3]{Zayn Ahmad}%
\affil[1]{UCL}%
\affil[2]{Cardiff University School of Medicine}%
\affil[3]{Queen Mary University of London Barts and The London School of Medicine and Dentistry}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\emph{Comment on: Secondary impacts of constipation in acute
lymphoblastic leukemia in U.S. children's hospitals}

Rameez Naqvi\textsuperscript{1}, Saif Abbas Chatoo\textsuperscript{2},
Zayn Ahmad\textsuperscript{3}

\textsuperscript{1} UCL Medical School

\textsuperscript{2} Cardiff School of Medicine

\textsuperscript{3} Barts and The London School of Medicine and
Dentistry

\textsuperscript{*} Correspondence to:

Rameez Naqvi, UCL Medical School, 74 Huntley St, London WC1E 6DE, Tel.:
07851081725, Email: zchanaq@ucl.ac.uk

Text word count 493;

Abstract word count: N/A;

Brief running title: Letter to the Editor

Key words: Chemotherapy, ALL, Pediatric oncology

Tables: 0

Figures: 0

We read, with great interest, the article by Belsky et al. on the
effects of constipation in pediatric oncology patients, particularly
looking at children who had undergone induction therapy for Acute
Lymphoblastic Leukemia (ALL)\textsuperscript{1}. As medical students who
have recently had pediatric and oncology placements, we would like to
share our thoughts on what we found to be a fascinating topic.

The process of diagnosing and treating a child with cancer is an
extremely distressing period for the patient and parent/carer of the
patient. The majority of parents of pediatric oncology patients are said
to be either mildly or severely distressed\textsuperscript{2}. There is
also the challenge that lies with the side effects of chemotherapy along
with the struggle in communicating with some young children. Due to side
effects, patients can present distressed and require hospital admission,
under the guise that it is due to their original condition rather than
the treatment. We applaud Belsky et al. for including patients who were
readmitted in order to seek psychological support for the side effects
of their treatment, as this is a factor often overlooked when looking at
readmission data.

On our placements, the diagnosis of constipation secondary to
chemotherapy was difficult to navigate. We found that the side effects
of the medication, such as constipation or fatigue, can cause some
patient families to feel an incongruency with their agenda and the
healthcare providers, as some find it difficult to perceive that the
treatment can also cause the child pain. This can cause strain on an
already difficult relationship to manage\textsuperscript{3}. Although it
was beyond the stated scope of this study, this would be an interesting
secondary impact of chemotherapy side effects that can be explored in
the same demographic of patients.

As mentioned by Belsky et al., it can be difficult to attribute the
constipation solely to the medication being used. There are a variety of
confounding factors that can arise during induction therapy that can
also cause constipation -- dietary changes due to hospital admission,
lack of water intake due to fatigue and lack of energy to exercise, to
name a few. To further expand the study, looking into these factors and
their magnitude of effect would provide a clearer understanding of the
secondary effects of constipation.

The study defined constipation by the presence of a diagnosis code or a
patient who is receiving two constipation medications. The author
recognizes that patients can receive these medications prophylactically,
so ideally there should be a method of investigating the indication in
these patients. It must also be said that diagnosis coding means that
there is an element of human error which can cause inaccuracies in the
data collected. This can be seen in some international
studies\textsuperscript{4}.

Future retrospective studies should consider investigating the
confounding factors and authenticating diagnoses in order to provide a
more robust causality. Research into the true effects of chemotherapy in
Pediatrics is crucial and we hope to see more research within this
field.

References:

Belsky, J., Batra, S., Stanek, J. and O'Brien, S., 2021. Secondary
impacts of constipation in acute lymphoblastic leukemia in U.S.
children's hospitals.~\emph{Pediatric Blood \& Cancer} ,.

Boyden, J., Hill, D., Nye, R., Bona, K., Johnston, E., Hinds, P.,
Friebert, S., Kang, T., Hays, R., Hall, M., Wolfe, J. and Feudtner, C.,
2021. Pediatric palliative care parents' distress, financial difficulty,
and child symptoms.~\emph{Journal of Pain and Symptom Management} ,.

Zarkowski, P. and Aksu, M., 2021. Legal and Ethical Issues in Treating
Adolescent Patients.~\emph{Dental Clinics of North America} , 65(4),
pp.815-826.

Farhan, J., Al-Jummaa, S., Al-Rajhi, A., Al-Rayes, H. and Al-Nasser, A.,
2005. Documentation and coding of medical records in a tertiary care
center: a pilot study.~\emph{Annals of Saudi Medicine} , 25(1),
pp.46-49.

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