Guía para la Atención Integral de Tumores del Sistema Nervioso en Población Infantil

Objectives

Provide nationally standardised, comprehensive care for children and adolescents under 18 years with nervous-system tumours, from early recognition and referral through diagnosis, treatment, rehabilitation, survivorship, palliative care and family bereavement support. The guidance seeks timely intervention, better diagnostic precision, appropriate risk-based treatment, improved quality of life and reduced treatment-related harm in a setting with constrained diagnostic and specialist capacity, particularly outside urban referral centres.[1][2][3][4]

• Recognise persistent or progressive neurological warning signs early and refer suspected cases promptly to paediatric and paediatric haematology-oncology services without waiting for imaging or other investigations.[5][6][7]
• Classify tumours using histological, molecular and genetic information, aligned with the 2021 World Health Organization classification, to improve diagnosis, risk stratification and treatment planning.[8][9]
• Deliver multimodal treatment, combining maximal safe surgery, radiotherapy and tumour-specific chemotherapy according to tumour type, location, age, resection status, dissemination and clinical condition.[10][11][12][13]
• Preserve neurological function while seeking total or maximal feasible tumour excision, managing hydrocephalus and mass effect, and limiting injury to healthy tissue during radiotherapy.[10][14][11]
• Provide continuous nutritional care to detect and manage malnutrition, overweight and obesity; support growth, functional recovery and treatment tolerance; and prevent metabolic and gastrointestinal complications.[15][16][17]
• Provide developmentally appropriate psychological, social, spiritual and palliative support for children and families throughout treatment, remission, relapse, advanced disease and bereavement.[18][3][4]

Implementation

Implement the guideline as a national instrument approved under Resolution No. 02-DGN-2026, using a tiered pathway that starts at first-level care and progresses through general, regional and specialist hospitals according to clinical need and available services. Care is multidisciplinary, with referral hospitals providing advanced imaging, pathology, surgery, oncology treatment and follow-up, while first-level facilities identify warning signs, stabilise urgent conditions and arrange safe, documented referral.[19][1][5][6][20][21]

• Identify children through active and passive detection of persistent or worsening neurological symptoms, then undertake history-taking, vital-sign measurement, anthropometry, general and neurological examination, and rapid Paediatric Assessment Triangle and ABCDE assessment where urgent illness is suspected.[5][22][6]
• Stabilise life-threatening conditions using basic life-support and emergency measures, including management pathways for intracranial hypertension, cerebral oedema and seizures, before or during transfer as clinically necessary.[5][23][24]
• Refer suspected cases with written clinical information, multidisciplinary coordination and safe transport to facilities with paediatric services, then to specialist paediatric haematology-oncology hospitals where indicated. Named referral sites include Hospital Escuela, Hospital Mario Catarino Rivas and Hospital Regional de Atlántida.[5][6][10][11]
• Establish multidisciplinary committees in treating facilities to define each child’s diagnostic and treatment route. Potential members include paediatric oncology, neurosurgery, neurology, intensive care, radiology, pathology, anaesthesiology, nursing, psychology, rehabilitation and palliative-care personnel, adapted to installed capacity.[2][25][10]
• Use computed tomography as initial imaging where available and magnetic resonance imaging, preferably 1.5 tesla or higher, for characterisation and treatment planning; use spinal or advanced imaging, functional magnetic resonance imaging, angiographic imaging or other techniques when clinically indicated and available.[25][26]
• Confirm diagnosis through biopsy where required, with histopathology, immunohistochemistry and appropriate molecular or genetic testing; use the findings to establish tumour type, grade, prognosis and treatment selection.[26][9]
• Provide specialist neurosurgery with an operating microscope, descriptive operative records and documentation of the percentage of tumour resected; use intraoperative imaging and neuromonitoring where available to support precision and protect function.[10][14][11]
• Plan radiotherapy through multidisciplinary review and refer patients to facilities able to deliver the required modality. Adapt chemotherapy regimens and surveillance to tumour characteristics and the child’s clinical circumstances.[12][13][27]
• Monitor treatment and survivorship through clinical review, neurological assessment, imaging schedules adjusted to follow-up stage and clinical condition, and surveillance for recurrence, treatment effects, endocrine deficits, organ dysfunction, developmental impacts and psychosocial difficulties.[13][27][15]
• Assess nutritional status early and repeatedly, using anthropometric, clinical, biochemical and dietary measures; select oral, enteral, parenteral or mixed support according to intake, gastrointestinal function and clinical status.[15][16][17][18]
• Support implementation through paediatric psycho-oncology programmes, staff education, family counselling and the Sistema de Información Integral en Salud for health-information management.[6][4][28][29]

Monitoring & Evaluation

Monitoring is principally clinical and pathway-based rather than a formal programme-performance framework. The guidance requires assessment, documentation, follow-up imaging, multidisciplinary review and monitoring of treatment effects, but does not establish consolidated national indicators, targets, reporting schedules, surveillance processes, evaluation methods or accountability arrangements.[6][25][26][14][29]

• Document initial clinical history, vital signs, weight, height, head circumference for children under five years, body mass index for those over five years, and findings from general and neurological examination.[5]
• Monitor vital signs and neurological status during assessment and management, confirm referral information at second-level care, and undertake complete physical and neurological reassessment.[6][25]
• Use neuroimaging to characterise tumours, assess treatment response, identify complications and investigate clinical deterioration; computed tomography is also indicated following surgery.[25][26][27]
• Record operative findings descriptively, including the percentage of tumour resected, and use intraoperative imaging and neuromonitoring where available to identify residual tumour and reduce injury to motor, sensory and speech functions.[10][14][11]
• Assess pathology through tumour type, tissue architecture, grade and relevant molecular markers to support diagnosis, prognosis and treatment selection.[9]
• Review patients through paediatric haematology-oncology, neurosurgical and other specialist follow-up, with frequency adjusted to the follow-up year, complications and clinical condition.[27][15]
• Schedule magnetic resonance imaging every six months during the first two years of follow-up, annually in the third year, according to clinical judgement in the fourth year, and generally omit routine imaging in the fifth year where the patient’s condition permits.[27][15]
• Monitor nutritional status from within 48 hours of hospital admission or at the first paediatric oncology consultation, repeating assessment weekly during admission and every two to four weeks in ambulatory care.[15]
• Measure nutritional progress using weight change, height or length, body-mass-index Z-scores, mid-upper-arm circumference, triceps skinfold and, where feasible, fat-free and fat mass. A 5% weight change in one month or 10% in six months indicates malnutrition risk.[15]
• Monitor hospital nutritional support through daily weight and fluid balance, biochemical reassessment every 48 to 72 hours, adjustment of energy and protein provision, and recording of metabolic or infectious complications.[18]
• Assess nutritional adequacy against estimated requirements, classifying intake of at least 75% as adequate, 50% to 74% as moderate risk, and below 50% as high risk.[16]
• Provide periodic psychological follow-up during remission and survivorship, while monitoring relevant neurological and physiological parameters during anaesthesia and perioperative care.[3][4][28]
• Use the Sistema de Información Integral en Salud as the identified information-management mechanism; its cancer data fields, reporting frequency, governance and performance-monitoring use are not specified.[28][29]

Costing & Financing

No explicit costing, budget, financing source, allocation, funding gap, resource-mobilisation mechanism or economic assumption is provided for the guideline, its clinical pathways, hospital services or supportive-care components.[1][13][18][20][30]

• Prioritise acquisition and maintenance of computed tomography and magnetic resonance imaging equipment in referral hospitals, although no associated cost or funding mechanism is specified.[26]
• Recognise positron emission tomography-computed tomography as constrained by the unavailability and difficult procurement of required radiopharmaceuticals in the country; no funding gap or procurement budget is quantified.[25]
• Require specialist diagnostic, surgical, radiotherapy, chemotherapy, nutritional, psychological, anaesthetic, rehabilitation and palliative-care capacity, but the source does not cost these workforce, equipment or service requirements.[10][12][15][4]