Bone marrow—the spongy material that fills the inside of the bones—produces red blood cells (RBCs), white blood cells (WBCs), and platelets. Chemotherapy drugs can damage or destroy the cells inside the bone marrow and can dramatically lower the number of cells circulating in the blood. Frequent blood tests will be done to determine whether your child needs a transfusion. Many children treated for leukemia require transfusions of RBCs and sometimes platelets. When the number of infection-fighting WBCs is low, your child is in danger of developing serious infections.

Absolute neutrophil count (ANC)

The ANC provides an indication of a child’s ability to fight infection. Generally, an ANC of 500 to 1,000 provides children with enough protective neutrophils to fight off infection caused by bacteria and viruses. When your child’s ANC is this high, you can usually allow her to attend all normal functions such as school, athletic events, 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 the ANC is 1,000, but is on the way down, it will affect which activities are appropriate for your child. The activities of families of children with cancer usually revolve around the sick child’s WBC count and, specifically, the ANC.

When your child has an abnormally low level of neutrophils (WBCs) in the blood, it is called neutropenia. Your child will be deemed neutropenic when he has a low ANC (below 500).

When a child has blood drawn for a complete blood count (CBC), one section of the lab report will state the total WBC count and a “differential.” The differential lists each type of WBC as a percentage of the total. For example, if the total WBC count is 1500 mm³, the differential might look like this:

The ANC is calculated by adding the percentages of segmented and band neutrophils, and then multiplying by the total WBC. Using the example above, the ANC is 49% + 1% = 50%; 50% of 1,500 (.50 x 1500) = 750; so 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 two years off treatment now and doing great.

How to protect a child with a low ANC

Every hospital has different guidelines concerning activities for children with low ANCs, but here are parents’ suggestions for ways to prevent and detect infections:

• Insist on frequent, lengthy (at least 1 to 2 minutes), and thorough hand washing for every member of the family. Use plenty of soap and warm water, lather well, and rub all portions of the hands, including between all the fingers and under the fingernails. Children and parents need to wash before preparing meals, before eating, after playing outdoors, after petting an animal, and after using the bathroom.

We always had antibacterial baby wipes in our car. We washed Justin’s hands, and our own, after going to any public places such as parks, museums, or restaurants. They can also be used to wipe off tables or high chairs at restaurants.

• Make sure all medical personnel at the hospital or doctor’s office thoroughly 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. I tell them, “Well, you just touched the door-knob 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 my daughter’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.

• Whenever your child needs a needle stick, make sure the technician washes his hands and then cleans your child’s skin thoroughly with both betadine and alcohol.
• If your child gets a small cut, wash it with soap and water, rinse it with hydrogen peroxide, and cover it with a small bandage.
• When your child is ill, take her temperature every two to three hours. Call the doctor if your child’s temperature is 101° F (38.5° C) or above.
• Do not permit anyone to take your child’s temperature rectally (in the anus) or use rectal suppositories, as these 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 bacteria.
• Apply sunscreen whenever your child plays outdoors. The skin of children taking certain chemotherapy drugs or who have recently received radiation therapy is sensitive to the sun, and a bad sunburn can easily become infected.
• Your child should not receive routine immunizations while on chemotherapy. Your child’s doctor or nurse can complete medical exemption forms for your child’s school. Siblings should not be given 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.

Christine was diagnosed just a week after her younger sister, Alison, had been given the live polio vaccine. Because there was a small risk that Alison could infect any immunosuppressed child with polio, she was not allowed to visit the oncology floor of the hospital.

• If your child’s ANC is low, an infected site may not become red or painful.

My daughter kept getting ear infections while on chemotherapy. 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, because aspirin and drugs containing aspirin 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.
• Call the clinic if any of the following symptoms appear: fever above 101° F (38.5° C), chills, cough, shortness of breath, sore throat, severe diarrhea, bloody urine or stool, and pain or burning while urinating.

Some people choose to keep their kids away from everything and everyone during treatment, while others restrict their activities when they’re neutropenic or receiving a particularly heavy dose of chemo. You will learn how to trust your instincts and your doctor’s advice, and also learn how to take your cues from your child. For us, we try to walk a fine line between keeping Hunter’s life as normal and stimulating as possible, while not taking any foolish risks with his health. When he’s neutropenic (ANC below 500), when he’s in a particularly heavy round of chemo, or when there’re illnesses going around we keep him at home. When he’s doing well then we take him out a bit more, but sensibly: no shopping malls on Saturdays, no contact with anyone who’s sick, and limited contact with other kids. During the week, I will take him with me to the grocery store, or to see his grandparents or cousins, provided everyone is healthy. When he’s feeling well we also go to the park, ride our bikes, and do normal kid stuff. I carry around antibacterial hand wipes with me so I can keep him clean after visiting playgrounds.