Infections, low blood counts, and iron overload in children and teens

Infections

Children with blood cancer, especially those undergoing chemotherapy, are more likely to get infections because of their weakened immune systems. Cancer and certain cancer therapies can damage the immune system by reducing the number of infection-fighting white blood cells. Children with a low white blood cell count are at a higher risk of developing infections, and these infections can be more serious and harder to treat. In severe cases, infections can lead to death.  

Blood cancer treatment can destroy cancer cells as well as healthy, infection-fighting white cells. If your child's white cell counts decrease moderately, you won't need special precautions, especially if the cells return to normal within a short period. However, if they have a severe or prolonged low white cell count, especially after intensive drug therapy, they may be at greater risk for infection.  

To prevent or manage infection, their healthcare team may:  

• Prescribe antibiotics to prevent or treat infection
• Prescribe growth factors to improve white cell counts, such as filgrastim (Neupogen®), pegfilgrastim (Neulasta®), and sargramostim (Leukine®). These medications can cause serious side effects in some people. Discuss the risks and benefits with your doctor. 
• Stop or delay treatment to allow blood cell counts to rise 

Signs and symptoms of infection

If your child experiences any signs of infection, don't delay seeking medical attention. If they have even one of the following symptoms, contact their doctor immediately:  

• A temperature of 100.4° F or higher
• Chills
• Persistent coughing
• Redness, swelling, or tenderness, especially around a wound or IV site
• A sore throat
• Pain when urinating
• Frequent diarrhea or loose bowel movements
• Bleeding gums or white patches in the mouth   

The hand-washing experiment

Your child should be taught how to keep their hands clean to prevent infections. Let them know that washing their hands the right way can prevent infections from spreading. Visit The Centers for Disease Control and Prevention website to learn how to make hand hygiene a family activity. 

Teach your child to wash their hands:  

• Before and after making or eating meals or snacks
• Before and after changing diapers
• After coughing, sneezing, or blowing their nose
• Before and after using the bathroom  

12 ways to reduce infection risk

1. Make sure your healthcare team takes steps to avoid exposing you and your family to bacteria, viruses, and other infection-causing agents: They should practice frequent and vigorous hand washing or, in some cases, wear masks, gowns, and/or gloves.
2. Discuss how to avoid infection with members of your healthcare team if your child is receiving outpatient treatment. Caregivers need to be meticulous in cleaning catheters to reduce the risk of bacteria entering the body.
3. Wash your hands thoroughly, especially before eating and before and after using the bathroom. This applies to everyone—people in treatment and those around them.
4. Avoid crowds and individuals with contagious diseases such as colds, flu, measles, or chicken pox.
5. Check with your doctor about getting vaccinations. Find out whether you should avoid people who've recently been immunized with live, weakened forms of organisms or viruses that cause the disease, such as measles, and how long you should stay away.
6. Clean your child's rectal area gently but thoroughly after each bowel movement. Ask your doctor for advice if irritation or hemorrhoids are a problem. Check with your healthcare team before using enemas or suppositories.
7. Don't cut or tear your fingernails' or toenails' cuticles.
8. Avoid cuts or nicks when using scissors, needles, or knives.
9. Use an electric razor to avoid cuts.
10. Use an extra soft toothbrush that won't hurt the gums.
11. Don't squeeze, pick, or scratch at wounds or blemishes.
12. Clean cuts and scrapes immediately. Rinse the wound under running water. Wash the skin around the wound with soap. To avoid irritation, don't use soap on the wound.
13. Take a warm (not hot) bath, shower, or sponge bath every day. Don't rub skin to dry it; use a light touch to pat skin dry. Use lotion or oil to soften and heal skin if it becomes dry and cracked.
14. Wear protective gloves when gardening or cleaning up after animals, young children, or others.
15. Follow food safety guidelines.  

Low blood counts

Cancer therapy can lower a child's blood cell counts and chemotherapy can especially affect rapidly dividing bone marrow cells. This hinders the marrow's ability to supply new cells to the blood during treatment and for some time after. Children receiving treatment for blood cancer can experience the following side effects from low red blood cells, platelets, and/or white blood cells:  

Low red cell counts (Anemia)   

Red blood cells contain hemoglobin which carries oxygen around the body. Side effects of anemia include:  

• Fatigue or shortness of breath, especially with physical activity
• Pale skin, gums, or nails
• Light-headedness or dizziness
• A tendency to feel cold  

Most people with a mild or moderate decrease in red cells don't realize they're anemic. However, anemia can become severe if your child continues to produce too few red cells. Their doctor may prescribe a red cell growth factor or a blood transfusion for severe anemia to help restore their red cell count.  

Erythropoiesis-stimulating agents (ESAs) are a class of drugs your child's doctor may use to improve your anemia. ESAs such as epoetin alfa (Epogen®, Procrit®) and darbepoetin alfa (Aranesp®) are synthetic versions of erythropoietin, a hormone produced in the kidneys that stimulates the body to produce red blood cells. ESAs are injected under your skin.   

Some studies suggest that ESAs may increase the risk for blood clots because they correct anemia too vigorously. Also, in some forms of cancer, the use of an ESA may be associated with a worse outcome. If your doctor prescribes an ESA, you'll be given information and guidelines from the FDA about the drug. Talk with your doctor about the risks and benefits of this therapy.   

Your child's doctor may also recommend blood transfusions to raise your blood cell count and alleviate symptoms. If they're given blood transfusions, they are more susceptible to developing iron overload. 

Low platelet counts (Thrombocytopenia)

Platelets are tiny blood cells that help form blood clots to slow or stop bleeding. A mild or moderate decrease in platelet counts usually doesn't cause bleeding. However, people with a severely low platelet count may experience:  

• Excessive bleeding from cuts or bruises
• Pinhead-sized bleeding points in the skin, called petechiae, especially on the lower legs and ankles
• Black-and-blue spots on the skin from minor bumps without any apparent injury
• Reddish or pinkish urine
• Black or bloody bowel movements
• Bleeding from the gums or nose
• Headaches
• Dizziness
• Weakness
• Pain in joints and muscles  

Once therapy is completed and the platelet count is restored to a sufficient level, these side effects rapidly fade. However, if additional treatments are necessary and your child's platelet count remains low, they may need a platelet transfusion. Certain medications can weaken the platelets and worsen bleeding problems as well.

How to avoid problems

Follow these tips to help prevent or lessen the effects of low platelet counts:  

• Ask your doctor whether it's safe to take aspirin, acetaminophen, ibuprofen, or other over-the-counter or prescribed medicines
• Use an extra soft toothbrush and care for teeth and gums
• Blow gently into a soft tissue to clean the nose
• Avoid cuts or nicks from scissors, needles, knives, or tools.
• Avoid burns
• Avoid contact sports and other activities that might result in injury

Low white cell counts (Neutropenia)

White blood cells help fight infection. A severe or prolonged low white cell count puts you at an increased risk for infection; therefore, your doctor may prescribe growth factors that can stimulate your marrow to make new white cells to prevent or reduce infections. Growth factors can also be used to help the marrow recover after marrow transplantation and stem cell transplantation.   

Colony-stimulating growth factors may cause mild bone pain, usually in the lower back or pelvis, around the time the white cells start to return to the marrow. This mild pain lasts only a few days and your doctor can prescribe a painkiller. Be aware, however, that doctors are cautious when prescribing these medications for people with cancer that involves the bone marrow because growth factors might stimulate cancer cell growth.

Iron overload

Some people may need periodic red cell or platelet transfusions to improve blood cell counts and help alleviate symptoms. Children who have ongoing transfusions may be at risk for "iron overload"—the term for a condition that, if untreated, can damage the heart and liver.   

Red cells contain iron, and patients who have regular transfusions that range from less than two units to four or more units of blood a month can accumulate too much iron in their bodies as a result.   

Your child’s doctor's decision to give you red cell transfusions is based on a combination of factors, including:  

• The level of hemoglobin (the protein in red blood cells that carries oxygen) in your blood
• Whether your child has symptoms such as fatigue or shortness of breath
• Any other health conditions they may have

If your child is receiving transfusions, their doctor may monitor them for iron overload with a blood test called a serum ferritin level, which measures the body's iron store. A drug called an iron chelator may be administered to remove excess iron from the body because of transfusion-dependent anemias. Be sure to talk with your child's doctor about the potential benefits and risks of using these drugs.