2.3 Health Promotion and Maintenance

Health maintenance does not pause for protocol

A 7-year-old in delayed intensification for ALL still needs a growth chart, a dental plan, a school infection plan, and a parent who knows that 38.2°C with an absolute neutrophil count (ANC) of 200/µL is an emergency. Domain I.B is not "wellness extras." It is how CPHON nurses keep children alive and developing while myelosuppression, radiation, and hospital time try to undo ordinary childhood.

Growth tracking and developmental screening

Plot height, weight, body-mass index, and—when age-appropriate—Tanner stage on every routine visit, not only at diagnosis. Red flags include crossing major percentile lines, poor linear growth after cranial or total-body radiation, obesity after prolonged corticosteroids, and failure to regain weight after mucositis. Refer to pediatric endocrinology for slowing height velocity after CNS-directed therapy rather than waiting for adult short stature.

Developmental screening continues with age-right tools and school reports. A toddler who loses words after months in isolation, a 9-year-old whose processing speed collapses after high-dose methotrexate and cranial radiation, and an infant with delayed motor skills after vincristine neuropathy all need evaluation, early-intervention or school services, and documentation—not a promise that "kids bounce back."

Anticipatory guidance by age

A 16-year-old on oral mercaptopurine who vapes with friends needs the same non-judgmental adherence talk you would give for missed doses—plus second-cancer and lung-injury counseling—not a lecture that ends the relationship.

Dental and oral health during chemotherapy

Mucositis, xerostomia, and radiation to salivary fields raise caries and infection risk. When counts allow, a dental evaluation before intensive therapy identifies loose teeth, abscesses, and appliances. During therapy:

• Soft toothbrush or toothettes; fluoride as advised; avoid alcohol rinses that dry mucosa.
• Examine the mouth daily for ulcers, herpes, candidiasis, or dental abscess.
• Defer elective dental surgery during neutropenia or thrombocytopenia; urgent dental infection is coordinated with oncology, often with platelet and antibiotic support.
• Head-and-neck radiation survivors need lifelong dental surveillance; "we will see a dentist when treatment is over" is too late if caries are already advancing.

Chlorhexidine, nystatin, or other mouth-care orders follow the protocol; the exam tests that oral care is scheduled nursing, not optional.

Sun protection after radiation

Irradiated skin burns more easily, may show recall with later drugs, and carries higher later skin-cancer risk in the field. Teach broad-spectrum sunscreen, clothing, hats, and no tanning beds. A 9-year-old after craniospinal radiation for medulloblastoma needs this at the beach and on the walk to school. Do not invent a percentage risk; teach the behavior.

Healthy activity and infection prevention

Activity is health promotion. Counts permitting, children should play, walk, and return to sport under orthopedic and team rules (endoprosthesis, amputation, steroid myopathy, thrombocytopenia). Prolonged bed rest worsens deconditioning and mood.

During severe neutropenia, teaching is specific:

• Avoid crowded indoor events, construction dust, and people with fever or varicella/zoster.
• School attendance follows the team's ANC and community-outbreak guidance, not a parent's wish to "keep life normal" during an ANC of 100/µL.
• Food safety: cook meats and eggs thoroughly; avoid unpasteurized dairy and juices; wash produce; no food from broken cold chain. Centers vary on strict "neutropenic diets"; the exam-stable teaching is food safety, not an invented banned-food trivia list.
• Central-line: clean dry dressing, no lake or bathtub soaking until cleared, report fever or exit-site redness the same day.

Immunizations and household contacts

Repeat the transition-of-care principle in the health-maintenance frame:

• Live-virus vaccines are generally deferred while the child is immunosuppressed (intensive chemotherapy, recent anti-B-cell antibody, early post-HSCT).
• Inactivated vaccines may be given in windows the oncology team chooses; response may be weak, so catch-up and titers are planned later.
• Household contacts should receive recommended inactivated vaccines and, in general, live vaccines so they do not infect the patient. Caution examples the nurse flags for the team: rotavirus-vaccine diapers in a household with a profoundly immunosuppressed infant, and never giving the patient a live vaccine at a sibling's well visit "while we are here."
• After immune recovery, the PCP and oncology team rebuild the schedule. Do not invent a month count as the only correct number; HSCT timelines are longer than standard chemotherapy and belong to the transplant team.

HPV vaccine, when age-eligible and immune status allows, is a second-primary-cancer prevention tool (cervix, oropharynx, anus, vulva, penis). Timing is coordinated with oncology. Do not quote invented effectiveness percentages. Tobacco and nicotine vaping counseling is the other high-yield risk-behavior talk, especially after alkylators, radiation, or HSCT.

Fever teaching: the item writers' favorite

Any fever in a neutropenic child is an emergency. Families leave with a written number—commonly 38.0°C (100.4°F) or the protocol's number—and a designated site (oncology clinic by day, the hospital the team names by night). They do not:

• Give acetaminophen or ibuprofen and wait until morning to see if it "breaks."
• Ask the school nurse to treat and return the child to class.
• Assume fever after vincristine or transfusion is automatically benign.

Antipyretics may be used after the team is notified and the child is on the way, if that is the written plan, but they never replace evaluation. Blood culture, broad antibiotics, and assessment for typhlitis, line infection, pneumonia, and septic shock are the clinical sequence; the family's job is to arrive, not to diagnose.

A parent who reports 38.2°C at home with ANC 200/µL has already met the threshold. The correct nursing response is immediate evaluation, not a teaching moment about "one isolated fever."

Health promotion on this exam is the ordinary pediatric checklist with neutropenia, radiation, and second-cancer risk written on top—and a fever rule that never becomes optional.