Beyond the ANC..

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Beyond the ANC..
Other Aspects of Neutropenia
Mary Ann Bonilla, MD St. Josephs Childrens
Hospital
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Neutropenia

• Decrease in the the absolute neutrophil count
• ANC WBC x ( segs bands)
• Total WBC 5000 cells/mm3
• Band Neutrophils 5
• Segmented Neutrophils 55
• ANC 3000 cells/mm3

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Severity Infection

• Mild 1000-1500 cells/mm3 commonly
  asymptomatic
• Moderate 500-1000 cells/mm3 gingivitis,
  impetigo, otitis
• Severe lt 500 cells/mm3 bacteremia,
  peritonitis, pneumonia

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Human Immune System
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Infection Prevention

• Maintaining Surface Barriers
• Skin
• Mucous Membranes
• Pulmonary
• GI Tract

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Wash your hands

• Basic Hygiene
• Before food handling
• Teach children good habits early
• Hand Sanitizers or wipes

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Practice Good Hand Nail Care
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• Clean and treat cuts with antibacterial cleanser
  (Betadaine)
• Apply antibacterial ointment
• -Neosporin, Bacitracin
• -Bactroban-prescribed

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Infants

• Good care of diaper area
• Prompt attention to rashes
• May need anti-fungal cream, Nystatin

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Mouth Care
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• Peridontal Disease
• Mouth sores
• -Apthous Ulcers

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Mouth Care

• Dental Cleanings-2 to 4 times/year
• Regular Brushings
• Flossing
• Mouth Wash
• -Biotene
• -Peroxide based cleanser
• -Fluoride Rinses

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What is else is in her mouth?
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Cleaning vs. Sterilization ?
Yes Not necessary
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Gastrointestinal

• Proper care and handling of food
• Cook poultry and meats thoroughly
• Bottled Water if unsure of safety
• Pateurized milk and juice

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Pulmonary

• Avoid sick or coughing individuals
• Mask if necessary
• Immunizations including Flu vaccine if medically
  indicated

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Just Warm or Fever ?
Take the Temperature!
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Proper Techniques
No Rectal Temperatures !!!
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Fever Episodes

• Seek medical attention for tempgt 101O
• CBC, Cultures
• Antibiotics

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Osteoporosis

• Disease marked by low bone mass and deterioration
  of bone tissue
• Leads to bone fragility
• Increased susceptibility to fractures of the hip,
  spine and wrist
• "silent disease"

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Osteoporosis
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Osteoporosis
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• 9 Children SCN
• -3 osteoporosis, 6 osteopenia, 4 vertebral
  fractures
• Age at Dx 1 mo to 9 yrs
• G-CSF 3 mo to 5.1 yrs
• Rx Biphosphantes (alendronate), Calcium/ Vit D,
  Exercise. No side effects- 7 mo to 3.5 yrs

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Risk Factors

• Poor diet and low calcium intake
• Vitamin D deficiency
• Use of certain medications (corticosteroids,
  chemotherapy, anticonvulsants and others)
• Chronic medical conditions
• An inactive lifestyle-immobilization
• Race

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Bone Mineral Density (BMD) Tests

• Determine rate of bone loss and/or monitor the
  effects of treatment if a DXA BMD test is
  conducted at intervals of one year or more 
• Detect osteoporosis before a fracture occurs

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Bone Mineral Density Scan
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Osteoporosis Prevention Calcium Intake

• Dairy and Calcium Rich Foods
• Calcium supplements
• -1000 and 1300 mg a day
• Vitamin D
• -400 and 800 IU per day

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Weight Bearing Exercises
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Osteoporosis Prevention

• Maintain a healthy weight
• Dont smoke
• Limit alcohol and carbonated soda consumption

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Medications

• Bisphosphonates
• -Alendronate ( Fosamax)
• -Ibandronate (Boniva)
• -Risedronate (Actonel)
• Estrogen/Hormone Therapy

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Barriers to Communication

• My child is sick but not sick enough!
• Its not cancer.
• My doctor has never had a patient with

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Barriers to Communication

• Finding a physician
• Trained Specialist
• Do they have an interest in your disease?
• Are they open to receiving advice?
• Professionals do not take things personally

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Barriers Language

• What I heard
• D.C. N.G.
• Check I.N.O.
• Start P.O.
• Translation
• Remove the nose tube. Check the fluid status.
  Feed the patient.

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Physician Responsibility

• Stay informed of Medical Research
• Stay interested
• Communicate in a clear compassionate manner
• Provide education- written verbal
• Have adequate Support Staff

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Patient Responsibility

• Keep Records
• Be Compliant
• Be An AdvocateNot An Adversary
• Ask Questions and Ask Again!
• Schedule Family Conferences
• Seek Valid Sources of Information
• Be Realistic

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Barriers Stress

• Reduce Pain and Anxiety
• EMLA
• -Blood tests
• -IV catheters
• -G-CSF injections

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• Intravenous Conscious Sedation for Painful
  Procedures

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Reducing Stress-Therapy

• Child Life Specialist
• Psychologist/ Social Work
• -Individual, Family
• Support Groups
• Relaxation Techniques
• -Yoga, Meditation

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And the Best Medicine.

• .

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Hugs !!!
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Helpful Vocabulary

• ANC,absolute neutrophil count
• Anemia, too few red blood cells.
• Antibodies, proteins made by a subgroup of white
  blood cells, the lymphocytes that are responsible
  for the body's defense
• Bands, young neutrophils.
• Bone marrow, the spongy material located in the
  centre of our bones. It is the home of our stem
  cells, which reproduce to create our blood,
  including white blood cells, red blood cells,
  platelets, B- and T lymphocytes and macrophages

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• CBC (Complete blood count), a summary of the
  numbers of various types of cells present in the
  blood at the time of the blood draws.
• Cytogenetics, a method by which chromosomes can
  be analysed down the microscope.
• Erythrocytes, red blood cells.
• Fever, temperature above 101o
• G-CSF, granulocyte-colony stimulating factor.
  Leukocytes, white blood cells consisting of
  granulocytes, monocytes and lymphocytes. 
•  

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• Hemoglobin (Hb)- reflectscapacity of red blood
  cells to transport oxygen and nutrition to the
  tissues
• Hematopoiesis, the formation of blood
• Lymphocytes, subgroup of leukocytes, which are
  responsible for the body's defence against
  viruses (T lymphocytes) and the production of
  antibodies (B lymphocytes). Neutrophils, a
  subgroup of granulocytes defending the body
  against bacterias.
• Neutrophils are also known as segs, polys or
  segmented neutrophils.

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• Osteopenia, mildly demineralized bone substance.
• Osteoporosis, severely demineralized bone
  substance.
• Platelets, a subgroup of blood cells responsible
  for clotting, which are also called thrombocytes.
• RBC-Red blood cells (RBC)
• Retic-Reticulocyte. Young RBCs.
• Splenomegaly, the enlargement of the spleen. 

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• Stem cells, the most immature cell in the bone
  marrow, which are able to reproduce themselves
  and develop into different types of blood cells.
• Subcutaneous (SQ), under the skin.
• Thrombocytopenia, the decreased number of
  platelets in the blood
• White blood cells, a subgroup of blood cells
  consisting of monocytes, granulocytes and
  lymphocytes, which together build the immune
  system and defend the body against infection.