Check neurological status before each blinatumomab cycle

Blinatumomab trades chemotherapy's infection risk for neurotoxicity — tremor, confusion, speech disturbance, and rarely seizures — which in the paediatric ALL trial was about four times more frequent than with chemotherapy. Before each cycle and daily during infusion, do a brief neurological check, including handwriting or a simple writing test in older children, which often changes before other signs. Know your unit's cytokine release syndrome and neurotoxicity grading and the thresholds for interrupting the infusion or giving steroids, and teach families what to look for at home if continuous infusion runs outside hospital.

• Perform a brief neurological check before and daily during blinatumomab infusion.
• Use a handwriting test in children old enough to write — it changes early.
• Teach families to report tremor, confusion or speech changes immediately.
• Keep a written plan for interrupting infusion and giving steroids.

Why it matters

The switch from chemotherapy to immunotherapy changes which toxicity the team must watch for.

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