Public health diplomacy in an era of complexity, uncertainty, and unpredictability: perspectives from a YFG-ASPHER workshop.

Oral mucositis (OM) is a common complication of hematopoietic stem cell transplantation (HSCT), occurring in up to 80% of pediatric recipients and often peaking during neutropenia (). Severe OM (WHO grade ≥3) may cause uncontrolled pain, interruption of oral intake, and infection, thereby prolonging hospitalization and complicating post-transplant recovery (). The mucosal injury arises from conditioning regimen cytotoxicity, which disrupts epithelial renewal and compromises local immune defenses (). Basic oral care, photobiomodulation, and cryotherapy are supported as preventive strategies () but are often insufficient once severe OM is established, particularly in pediatric patients who have lower pain thresholds, reduced treatment cooperation, and heightened anxiety (, ). We report a 13-year-old girl with transfusion-dependent -thalassemia who developed WHO grade 4 OM after unrelated-donor HSCT, complicated by profound neutropenia, refractory alloimmune thrombocytopenia, gastrointestinal bleeding, nutritional vulnerability, swallowing dysfunction, and anxiety. This case presents a staged multidisciplinary nursing pathway that kept essential oral and supportive care feasible and safe when these complications occurred together, with explicit reasoning for why each intervention was chosen, when it was introduced, and how it was adjusted. A 13-year-old girl had intermediate -thalassemia at 9 months with 12 years of regular transfusions and iron chelation therapy. Both parents were carriers of the -thalassemia trait. She had no known drug allergies, and her growth and development were age appropriate. On admission (day −14): height 155 cm, weight 41.0 kg, body mass index 17.1 kg/m (healthy-weight range, ∼25th–50th percentile for age). Baseline oral health showed suboptimal hygiene with plaque and multiple caries but no recurrent ulceration or oral infection. A pre-transplant dental program (October 27–31, 2023) was provided including restorations, pit-and-fissure sealing, supragingival scaling, fluoride varnish, and oral hygiene education, and pre-transplant examination confirmed intact mucosa without active caries or periodontal disease. The conditioning regimen combined anti-thymocyte globulin (5 mg/kg total), busulfan (3.2 mg/kg/day ×3), fludarabine (40 mg/m/day ×5), thiotepa (410 mg total), and cyclophosphamide (15 mg/kg/day on days −8/−7 and 50 mg/kg/day on days +3/+4). Stem cells were infused on January 8, 2024 (day 0; 20 × 10⁸/kg, CD34 + 2.072 × 10⁶/kg) and again on day +1 (7.0 × 10⁸/kg, CD34 + 0.65 × 10⁶/kg) for a low CD34 + count. On day +6, the patient developed gingival erythema, small oral ulcers, sore throat, and mild diarrhea. OM then progressed and by day +14–16 there was hemorrhagic crusting of the lower lip, diffuse erosions of palate, gingiva, and tongue, pseudomembrane formation, and spontaneous bleeding from ulcer surfaces. Mouth opening was limited to two fingerbreadths. On day +17, she was unable to tolerate oral intake and developed hematemesis; oral intake was withheld (water allowance) and anticoagulation was discontinued. Pain intensity peaked at Numeric Rating Scale (NRS) 8. The patient exhibited fear of pain and bleeding, with difficulty sleeping (SAS 56).