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Childhood Cancer 2nd edition,
Childhood Cancer


Insist on frequent, thorough hand washing for every member of the family.


Your child should not be vaccinated while on chemotherapy.


Never give aspirin, Motrin, or ibuprofen for fever.


If an immunosuppressed child is exposed to chicken pox, call the doctor immediately.

Chemotherapy-Related Low Blood Counts


The following excerpt is taken from Chapter 16 of Childhood Cancer: A Parent's Guide to Solid Tumor Cancers, 2nd Edition by Honna Janes-Hodder & Nancy Keene, copyright 2002 by O'Reilly & Associates, Inc. For book orders/information, call (800) 998-9938. Permission is granted to print and distribute this excerpt for noncommercial use as long as the above source is included. The information in this article is meant to educate and should not be used as an alternative for professional medical care.

Bone marrow, the spongy material that fills the inside of the bones, produces red cells, white cells, and platelets. Chemotherapy drugs destroy the cells inside the bone marrow and dramatically lower the number of cells circulating in the blood. Frequent blood tests are crucial in determining whether the child needs transfusions. Many children treated for cancer require transfusions of red cells and platelets. Consequently, when the number of infection-fighting white cells is low, the child is in danger of developing serious infections.

What is an ANC? (also called AGC)

The activities of families of children with cancer revolve around the sick child's white count, specifically the absolute neutrophil count (ANC). This is sometimes called an absolute granulocyte count (AGC). The ANC (or AGC) provides an indication of the child's ability to fight infection.

When a child has blood drawn for a complete blood count (CBC), one section of the lab report will state the total white blood cell (WBC) count and a "differential," in which each type of white blood cell is listed as a percentage of the total. For example, if the total WBC count is 1500 mm3, the differential might appear as in the following table:

White blood cell type

Percentage of total WBCs

Segmented neutrophils (also called polys or segs)

49%

Band neutrophils (also called bands)

1%

Basophils (also called basos)

1%

Eosinophils (also called eos)

1%

Lymphocytes (also called lymphs)

38%

Monocytes (also called monos)

10%

To calculate the ANC, add the percentages of neutrophils and bands, and multiply by the total WBC. Using the example above, the ANC is 49% + 1% = 50%. 50% of 1500 (.50×1500) = 750. The ANC is 750.

Erica ran a fever whenever her counts were low, but nothing ever grew in her cultures. They would hospitalize her for 48 hours as a precaution. She was never on a full dose of medicine because of her chronically low counts. She's five years off treatment now and doing great.

How to protect the child with a low ANC

Generally, an ANC of 500 to 1,000 provides children enough protective neutrophils to fight off exposure to infection due to bacteria and fungi. With an ANC this high, you can usually allow your child to attend all normal functions such as school, athletics, and parties. However, it is wise to keep close track of the pattern of the rise and fall of your child's ANC. If you know that the ANC is 1,000, but is on the way down, this will affect your decision about what activities are appropriate. Each hospital has its own guidelines concerning activities for children with low ANCs.

The following are parents' suggestions for detecting and preventing infections:

  • Insist on frequent, thorough hand washing for every member of the family. Use soap and warm water, lather well, and rub all portions of the hands. Children and parents need to wash before preparing meals, before eating, after playing outdoors, and after using the bathroom.
  • Make sure that all medical personnel at the hospital or doctor's office wash their hands before touching your child.
Nurses and doctors frequently come into the room and don't wash their hands. I make them wash their hands, change their gloves, or squirt Purell on them. I always had a bottle of Purell with me. They would say that they washed their hands before they came into the room. Well, you just touched the doorknob and you have to wash them again.

I had a situation like this with our oncologist. He washed his hands, and then right before starting Zoe's spinal, his cell phone rang and he answered it. He started to proceed, and I stopped him and told him to wash his hands again because he touched the cell phone. He was taken aback for a second, and then agreed. Fortunately, he is a great guy and has fun ribbing me about my overprotective nature and attention to detail (I doubt these are the exact words he uses to describe me).

  • Keep your child's diaper area and skin creases clean and dry.
  • When your child's ANC is low, make arrangements with your pediatrician to use a back entrance to the office to avoid exposure to sick kids in the waiting room. It sometimes helps to make all appointments for early morning so that your child can be seen in a room that hasn't had several sick children in it.
  • Whenever your child needs a needle stick, make sure that the technician cleans your child's skin thoroughly with both betadine and alcohol.
  • Protect your child if she has a low ANC.
When my son's ANC was low, we took extra care to avoid situations that increased his risk of infection. We kept him home from school and restricted the number of visitors to our home. Little things that many people take for granted were dependent upon whether his ANC was high enough. For example, we wouldn't take him to see a movie if his ANC was low. Sitting in an enclosed theater with so many people would have definitely been a bad idea without enough neutrophils.
  • If your child gets a small cut, wash it with soap and water, rinse with hydrogen peroxide, and cover with a clean Band-Aid.
  • When your child is ill, take his temperature every two to three hours. Do not permit anyone to take the temperature rectally (in the anus) or use rectal suppositories, as this may cause anal tears and increase the risk of infection and bleeding.
Believe it or not, we once stopped the nursing assistant from doing a rectal temp during an inpatient admission. When we had a room on the pediatric oncology side, this never happened, but for that admission those rooms were full, and we were on the other side of the floor.

  • Do not use a humidifier as the stagnant water can become a reservoir for contamination.
  • Apply sunscreen whenever your child plays outdoors. Children taking certain chemotherapy drugs, such as methotrexate, or who have received radiation, are sun sensitive, and a bad sunburn can easily become a site for infection.

  • Your child should not receive routine immunizations while on chemotherapy. Your physician or nurse can prepare medical exemption cards for your child's school.

  • Siblings should not be vaccinated with the live polio virus (OPV). They should get the killed polio virus (IPV). Verify that your pediatrician is using the appropriate vaccine for the siblings.
  • If your child's ANC is low, an infected site may not become red or painful.
My daughter kept getting ear infections while on chemo. They would find them during routine exams. I felt guilty because she never told me her ears were hurting. I told her doctor that I was worried because she didn't complain of pain, and he reassured me by telling me that she probably felt no pain because she didn't have enough white cells to cause swelling inside her ear.
  • Never give aspirin for fever. Aspirin or aspirin-containing drugs interfere with blood clotting. Ibuprofen may be given if approved by your child's oncologist. If your child has a fever, call the doctor before giving any medication.
  • Ask your child's oncologist about using a stool softener if your child has problems with constipation. Stool softeners can help prevent anal tears.
  • Call the doctor if any of the following symptoms appear: fever above 101ºF (38.5ºC), chills, cough, shortness of breath, sore throat, severe diarrhea, bloody urine or stool, or pain or burning while urinating.
Whenever my daughter (diagnosed when one year old) was on antibiotics ( frequently), she developed a vaginal yeast infection. It was very painful for her and a nightmare for me.

•  •  •   •  •  

My son's big toes became large and red from ingrown toenails while on treatment. He had several surgeries to remove the corners of each nail to prevent infection. That was several years ago, and his toes look bad but are not painful.

Two serious infections that plague children during treatment for cancer are pneumonia and chicken pox.

Pneumonia

Pneumonia is inflammation of the lungs caused primarily by bacteria or viruses. The symptoms of pneumonia are rapid breathing, chills, fever, chest pain, cough, and bloody sputum. Children with low blood counts can rapidly develop a fatal infection, and must be treated quickly and aggressively. Most cancer centers recommend an annual influenza shot to help prevent this cause of pneumonia.

My son received chemotherapy just days before he was scheduled to go to the American Cancer Society's camp. His ANC was 1200 and he looked so sick, but he begged to go and I let him. It was early in his treatment and I didn't realize the pattern of his blood counts. They called me from camp on Friday to say he had a temperature of 103ºF (39.5ºC) and needed to go to the hospital. He was very weak and feverish; his WBC was 140, and his ANC was 0. Both lungs were full of pneumonia. I was furious at the doctor for giving him permission to go to camp and at myself for not paying closer attention to how quickly his counts dropped. I'm sure he had the pneumonia before he even went to camp. They started him on five different antibiotics, and his fever went up to 106ºF (41.1ºC) that night. We didn't know if he would live or die. He started to gradually improve the next morning and was completely recovered in a week.

Chicken pox

Chicken pox is a common childhood disease caused by a virus called varicella zoster. The symptoms are headache, fever, and malaise, followed by eruptions of pimple-like red bumps. The bumps typically start on the stomach, chest, or back. They rapidly develop into blister-like sores that break open, then scab over in three to five days. Any contact with the sores can spread the disease. Children are contagious up to 48 hours before breaking out.

Chicken pox can be a fatal disease for immunosuppressed children, so extreme care must be taken to prevent exposure. It will be necessary to educate all teachers and friends to be vigilant in reporting any outbreaks. The child can be kept home from school or preschool until the outbreak is over.

Chicken pox can be transmitted through the air or by touch. Exposure is considered to have occurred if a child is in direct contact or in a room for as little as ten minutes with an infected person. If your child has never had chicken pox, it is better to take him to beaches or parks rather than indoor play areas.

If an immunosuppressed child is exposed to chicken pox, call the doctor immediately. If the doctor is able to administer a shot called VZIG (Varicella Zoster Immune Globin) within 72 hours of exposure, it may prevent the disease from occurring or minimize its effects.

We knew when Jeremy was exposed, so he was able to get VZIG. He did get chicken pox, but only developed a few spots. He didn't get sick; he got bored. He spent two weeks in the hospital in isolation. We asked for a pass, and we were able to go outside for some fresh air each day.

If a child develops chicken pox while on chemotherapy, the current treatment is hospitalization or, if possible, home therapy for IV administration of acyclovir, a potent antiviral medication. This drug has dramatically lowered the complication rate of chicken pox.

Kristin broke out with chicken pox on the Fourth of July weekend. Our hospital room was the best seat in the house for watching the city fireworks. She did get covered with pox, though, from the soles of her feet to the very top of her scalp. We'd just give her gauze pads soaked in calamine lotion and let her hermetically seal herself. They kept her in the hospital for six days of IV acyclovir, then she was at home on the pump (a small computerized machine that administers the drug in small amounts for several hours) for four more days of acyclovir. She had no complications.

A child who has already had chicken pox may develop herpes zoster (shingles). If your child develops eruptions of vesicles similar to chicken pox which are in lines (along nerves), call the doctor. The treatment for shingles is identical to that of chicken pox.

An immunization for chicken pox has been developed and is likely to be given to children with cancer in the future. Currently, there is insufficient data to indicate its usefulness or safety in these children.

Pets

It is very unlikely that your child will be harmed from living with a household pet, but several common sense precautions are needed to protect a child with a low ANC from disease, worms, or infection:

  • Make sure that the animal is vaccinated against all possible diseases.
  • Have pets checked for worms as soon as possible after your child is diagnosed, and then every year thereafter (more often for puppies).
  • Do not let pets eat off plates, or lick your child's face.
  • Keep children away from the cat litter box and any animal feces outdoors.
  • Have children wash hands after playing with the pet.
  • Make sure that your pet has no ticks or fleas.
  • If you have a pet that bites or scratches, consider finding another home for it. On the other hand, if you have a gentle, well-loved pet, do not give it up.
I think parents should know that you should not automatically get rid of your dog because your child has a low ANC. We went through a small crisis trying to decide whether to give away our large but beloved mongrel. The doctors wouldn't really give us a straight answer, but a parent in the support group said, "DO NOT get rid of your dog. Your son will need that dog's love and company in the years ahead." She was right. The dog was a tremendous comfort to our son.

If your child wants to buy a pet while undergoing treatment for cancer, here are some suggestions:

  • Do not get a puppy. All puppies bite while teething, increasing the chance that your child may contract an infection.
  • Do not get a parrot or parakeet as these species can transmit psittacosis.
  • Do not get a turtle or other reptile (snake, iguana) as they sometimes carry salmonella.
  • Avoid buying any animal that is likely to bite or scratch.

If you have any concerns or questions about pets you already own or are thinking of purchasing, ask your oncologist for advice.

We had an odd situation when Christopher (age three) was diagnosed with neuroblastoma. Our oncologist told us about not letting Christopher around any birds or animals with a lot of fur. The problem was I am a farmer. Not just cattle, but I also raise turkeys. When the houses are full, we hold about 60,000 at a time.

Even before Christopher could walk he would go to work with me. He especially enjoyed helping me feed baby birds. Christopher had a huge plastic dump truck he would put feed in and push around while I fed with a wheelbarrow. We would take our shirts off and be silly together--a very special time. When Christopher was diagnosed, I told the doctors I had no problem selling or shutting the farm down if it gave Christopher a better chance of surviving or would reduce the chance of infection. They told us to keep Christopher away from the animals and especially the turkeys and to keep him inside when his ANC was low, which we did. Every time I got baby turkeys in, I would move his truck to that house. Sometimes I would cry, sometimes I wouldn't. But I absolutely hated taking care of the little birds.

In late June when Christopher was declared in remission, again we happened to get a house full of baby turkeys in. This time, Christopher didn't want his truck, but he pushed my wheelbarrow and we got silly again. I really missed that.


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