Colony-stimulating factors (CSFs) are not generally used for children with ALL, unless they suffer persistent and drastically reduced blood counts. They are sometimes used for children with acute myeloid leukemia (AML) or for those who have stem cell transplants. High-dose chemotherapy reduces the number of white blood cells used by the body to fight infections. The administration of CSFs, such as granulocyte colony-stimulating factor (G-CSF, also known by the brand name Neupogen®) and granulocyte-macrophage colony-stimulating factor (GM-CSF, also known as sargramostim, or by the brand name Leukine®), can reduce the severity and duration of low white blood counts, lessening the chance of infection. G-CSF may be given by IV or by subcutaneous injection. GM-CSF must be administered by subcutaneous injection.

Kenny was only two years old when he was receiving G-CSF, so he was too young to understand why he needed the shots. He would cry and beg us not to hurt him—that he was sorry. My heart would break, but I would have to give him the shot. We finally developed a really good system. Right before being discharged after a round of chemo, we would put EMLA® on Kenny’s arm and then have the nurse place an insulflon. It was a small catheter that Kenny didn’t even notice was in his arm. It was good for 7 to 10 days, which was the duration of his G-CSF for the entire month. We would draw up the amount needed for injection, then place it in the insulflon and inject it very slowly. Kenny never felt it and no longer begged us not to do the G-CSF. Oh, how I wished we had done this from the beginning! Kenny’s counts would usually start to decline about four days after his chemo. At about Day 10 the G-CSF would kick in, and his counts would skyrocket.

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Katie had G-CSF (brand name is Neupogen®) after each high-dose cytarabine. But it is in her protocol to give it to her after her other chemotherapy if low counts caused a delay of over seven days in treatment—and we were pretty close a few times. She’s had no side effects from Neupogen® that I can recall. The worst thing about it for us was giving the shots at home. They’re subcutaneous, so the needle is short, but Katie still said they hurt, even with EMLA®.