Knowing what to expect will lay the foundation for months or years of tolerable tests. Because hospitals and practitioners have their own guidelines and preferences, the descriptions of procedures in the rest of this chapter may not exactly mirror your experience, but the fundamentals are the same everywhere. Reading the rest of this chapter may lessen your fears and help you to calm and prepare your child.

Questions to ask before procedures

You need information prior to procedures to prepare yourself and your child. Consider asking your doctor these questions:

•  Why is this procedure necessary and how will it affect my child’s treatment?

•  What information will the procedure provide?

•  Who will perform the procedure?

•  Will it be an inpatient or outpatient procedure?

•  Would you explain the procedure in detail?

•  Is there any literature available that describes it?

•  Is there a child life specialist on staff who will help prepare my child for the procedure? If not, are there nurses, social workers, or parents who can talk to me about how to prepare my child?

•  Is the procedure painful?

•  How long will it take?

•  What type of anesthetic or sedation is used?

•  What are the risks, if any?

•  What are the possible side effects?

•  When will we get the results?

Accessing catheters

The procedure that occurs most often during treatment is accessing your child’s central venous catheter. This procedure is described in detail in Chapter 13, Venous Catheters.

Audiogram

Some of the chemotherapy drugs that children receive for treatment of solid tumors can cause hearing loss. In addition, some children with these tumors experience hearing loss as a result of injury to nerves caused by the tumor itself, or from surgery or radiation. Your child’s doctor may order a hearing test, called an audiogram, to check for possible hearing problems.

During the audiogram, your child is tested in a soundproof room to prevent outside noises from interfering. You can remain with your child during this procedure. Earphones are placed on your child’s ears, through which sounds (such as beeps and tones) are relayed. Your child will be asked to signal when he hears a sound by either raising his hand or pressing a button. Each ear is tested separately. The results of the audiogram are usually displayed in the form of a graph, and the amount of hearing loss is measured in decibels.

Audiograms are repeated throughout therapy to monitor your child’s hearing if he is taking drugs that place him at risk.

A different type of hearing test, called a brainstem auditory evoked response, is described later in this chapter.

Blood draws

Frequent blood samples are a part of life during treatment for a solid tumor. Blood samples are primarily used for three purposes: to obtain a complete blood count (CBC), to evaluate blood chemistries, or to culture the blood to check for infection. A CBC measures the types and numbers of cells in the blood. Blood chemistries measure substances in the blood plasma to determine whether the liver and kidneys are functioning properly. Blood cultures help evaluate whether a child is developing a bacterial or fungal infection. For a list of normal blood counts, see Appendix A, Blood Tests and What They Mean.

A finger poke provides enough blood for a CBC, but blood chemistries or cultures require one or more vials of blood. Children with catheters usually have blood drawn from the catheter rather than the arm or finger. If the child does not have a catheter, blood is usually drawn from the large vein on the inside of the elbow. The procedures for a blood draw are similar to those for placing an IV, which are described later in this chapter. The only difference is that with a blood draw, the needle is removed as soon as the blood is obtained.

Bone growth test

A bone growth test is an x-ray of your child’s nondominant hand and wrist; for example, if your child is right-handed, the left hand and wrist will be x-rayed. It is performed to determine whether your child’s growth is appropriate for her age. Your child’s x-ray film will be compared with a series of photographs of wrist films of children of all ages so the radiologist can define your child’s “bone age” compared to her chronological age. The results help determine the need for endocrine testing. This test takes only a few moments to perform and is not painful.

Bone marrow aspiration

Bone marrow aspirations or biopsies are done as part of the diagnostic workup for several types of solid tumors to see whether the tumor has spread to the bone. They are also done prior to stem cell transplantation.

During a bone marrow aspiration, bone marrow is extracted from bones with a needle. Bone marrow biopsies remove a small piece of bone marrow with a special biopsy needle. Without sedation, bone marrow aspirations are very painful, so almost all hospitals anesthetize children for this procedure. Do not hesitate to advocate for this at your treatment center.

Doctors usually take a sample of the marrow from the iliac crest of the hip (the top of the hip bone in back or front). This bone is right under the skin and contains a large amount of marrow. The child lies face down on a table, sometimes on a pillow to elevate the hip. The doctor puts on sterile gloves, finds the site, and then wipes it several times with an antiseptic to eliminate any germs. The nurse places sterile paper around the site, then an anesthetic (usually xylocaine) may be injected into the skin and a small area of bone. The doctor then pushes a hollow needle (with a plug inside) through the skin into the bone, withdraws the plug, and attaches a syringe. She then aspirates (sucks out) the liquid marrow through the syringe. Finally, she removes the needle and bandages the area.

Bone scan

A bone scan is a test performed in the nuclear medicine department to assess the status of a particular bone or the entire skeletal system. It is often used when the oncologist suspects there is cancer present in the bones—either in the form of a primary bone sarcoma or metastatic disease.

Your child will be given an injection of a radioactive material, called technetium, which will travel through the blood to the bones. Approximately 2 hours later, the scan will be performed. You should be allowed to stay with your child during this procedure.

Brainstem auditory evoked response (BAER)

A brainstem auditory evoked response (BAER) test uses clicking sounds to evaluate a child’s hearing when a standard audiogram is not possible, either because of a child’s age or inability to respond. During the test, clicking noises or tone bursts are delivered through earphones. Your child’s brain waves are then measured by electrodes placed on the scalp and each earlobe. The test is not painful and takes about 30 minutes.

Computerized tomography (CT) scan

Computerized tomography (CT) is a complex, computer-enhanced procedure for obtaining x-ray images of the body. The machine looks like a big donut, and your child will be placed in the hole in the middle. Instead of having a fixed x-ray directed at one part of the body, the donut-shaped x-ray tube rotates around the body during the CT scan, generating hundreds of images as it moves. These images are called slices.

Before the procedure begins, your child may need to receive a liquid dye, called a contrast agent, which is given intravenously. If your child requires a CT scan of the abdomen, oral contrast will also be given. The technologist will position your child so the area being imaged is inside the opening of the CT machine. The technologist will not stay in the room while the images are taken.

If you plan to remain with your child, you will need to wear a lead apron to protect your body from unnecessary exposure to radiation. Sometimes, if the site being imaged is the chest area, your child may be asked to breathe in and hold her breath for several seconds. It is important that your child remain still during the CT scanning process. Small children who are unable to remain motionless for several minutes at a time are sedated before the procedure. You are usually asked to stay in the department until the images have been reviewed by the technologist to ensure they are adequate and do not need to be repeated.

Conventional x-ray

X-rays, a type of electromagnetic radiation, provide the doctor with a quick and simple way to view organs and structures inside your child’s body. X-rays are performed for many reasons during a child’s treatment for a solid tumor. Some of the most common reasons for taking x-rays are because they are:

•  Needed before operations.

•  Needed after your child’s central venous catheter is placed to confirm it is in the proper location.

•  Used to determine whether your feverish child has pneumonia.

For chest x-rays, your child may be asked to breathe in, hold his breath, and remain perfectly still for a few seconds. The technologist leaves the room during the time the x-rays are taken. If you are planning to stay with your child, you need to wear a lead apron to protect you from radiation. Your child may also have to wear a lead apron or lead shield to protect specific areas of his body. Pregnant women should not be in the room when x-rays are taken.

Echocardiogram

Several drugs used to fight cancer can damage the muscle of the heart, decreasing its ability to contract effectively. Many protocols require a baseline echocardiogram to measure the heart’s ability to pump before any chemotherapy drugs are given. Echocardiograms are then given periodically during and after treatment to check for heart muscle damage.

An echocardiogram uses ultrasound waves to measure the amount of blood that leaves the heart each time it contracts. The percentage of blood ejected during a contraction compared to blood in the heart when it is relaxed is called the ejection fraction.

The echocardiogram is performed by a technician, nurse, or doctor. The child or teen lies on a table and has conductive jelly applied to the chest. Then the technician puts a transducer (which emits the ultrasound waves) on the jelly and moves the device around on the chest to obtain different views of the heart. Pressure is applied on the transducer and can sometimes cause discomfort. The test results are displayed on a videotape and photographed for later interpretation.

Finger pokes

Finger pokes are different from blood draws because they only require a quick puncture of the skin to obtain a few drops of blood. The technician will hold the finger and quickly prick it with a small sharp instrument. Blood will be collected in narrow tubes or a small container. It is usually necessary for the technician to squeeze the fingertip to get enough blood. If a Buzzy^® or EMLA^® is not used, the squeezing part is uncomfortable and the finger may ache for a while.

One way to minimize the discomfort of a finger poke is to put a blob of EMLA^® on the tip of the middle finger, cover the fingertip with plastic cling wrap, and then use tape or a bandage to hold it in place. Another method is to buy long, thin balloons with a diameter a bit wider than your child’s finger. Cut off the open end, leaving only enough balloon to cover the finger up to the first knuckle. Fill the tip of the balloon with EMLA^® and slide it on the fingertip. EMLA^® needs to be applied an hour before a finger poke to be effective. When it is time for the poke, remove the plastic wrap or balloon, wipe off the EMLA^®, and ask for a warm pack. Wrapping this heated pack around the finger for a few minutes opens the capillaries to allow the blood to flow out more readily. Now your child is ready for a pain-free finger poke.

Some children are more anxious about the anticipation of a poke than the actual poke itself, so the use of EMLA^® may cause them to worry. As you try various methods, you and your child will learn what works best. Children who choose their own routines for pain control may feel more comfortable and secure.

Gallium scan

Gallium scans are performed in the nuclear medicine department and help doctors identify sites of tumors and infections. Prior to the scan, your child will be injected with a radiopharmaceutical, called gallium citrate, though the venous catheter or a IV. Usually, the scan is performed 24 to 48 hours after the injection. The procedure takes about 30 minutes. Your child needs to lie flat on an examination table while the machine scans above her. The machine makes noise but the procedure is not painful. You can stay with your child during this procedure.

Gastrostomy

A gastrostomy is the creation of an external opening in the abdominal wall through which a feeding tube (usually called a G-tube) is placed in the child’s stomach. This is appropriate for children who cannot eat normally because of chronic swallowing problems or long-term pain in the mouth or throat, or for children who have lost their appetite for a prolonged period because of disease or treatment. The stomach end of the feeding tube has a small balloon on it that prevents it from being accidentally pulled out.

A skilled gastroenterologist or surgeon can perform the procedure in about 10 minutes. Most children have general anesthesia for the procedure and remain in the hospital for 1 to 2 days after the operation to receive pain medication and make sure they can tolerate tube feedings. After 2 to 3 months, the tube may be replaced with an unobtrusive skin-level device called a button. After a short recovery, children may play, bathe, and swim normally.

The G-tube is used for liquid feedings and medications for as long as the child needs it. If a child no longer requires the tube, it is removed and a bandage is placed over the site. The wound closes spontaneously in a day or two.

Intravenous pyelogram (IVP)

Your child’s doctor may order an IVP if he feels there is an abnormality involving the urinary tract. Your child may need to fast before the procedure. Prior to the IVP, your child will have a contrast material injected into the bloodstream through an IV or venous catheter. X-rays are taken as the contrast material is collected and excreted by the kidneys. The process usually takes about an hour and you can stay with your child while the IVP is being performed. Children with an allergy to iodine should not have this test.

Magnetic resonance imaging (MRI)

MRI uses a magnetic field to create two-dimensional images of a cross section of an area of the body. Your child may need to receive a liquid dye, called a contrast agent, prior to or during the scan. The dye can be administered through your child’s central venous catheter or via a peripheral IV. For the MRI, your child lies on a platform that slides into a long tube. Inside the tube is a donut-shaped magnet. A special device, called a surface coil, is placed around the area of the body that is to be imaged.

The technologist does not stay in the room during the MRI. The MRI machine makes a loud knocking noise as the images are taken. Your child may need to wear special earplugs to help block out this sound. Young children, or any child with a fear of closed-in spaces (claustrophobia), may need to be sedated for the MRI procedure. MRI takes longer to perform than CT scans and requires that your child lie perfectly still. Although some centers now have open MRI scanners, they are not currently available in the majority of hospitals.

I-metaiodobenzylguanidine (mIBG) scan

Children who have neuroblastoma may require a special nuclear medicine scan called I-metaiodobenzylguanidine (mIBG) that can identify tumor cells in the bone or soft tissues. This procedure uses a radioactive substance—either iodine 123 metaiodobenzylguanidine or iodine 131 metaiodobenzylguanidine—that is injected in a vein 24, 48, or 72 hours prior to having the scan. The injected substance accumulates in neuroblastoma tumor cells, which then appear on the scan as a “hot spot.” Prior to the injection, and for 3 to 5 days after, your child will need to take an oral medication, called potassium iodide (also known by the brand name SSKI®), to protect the thyroid gland.

The scan takes place in a machine that is similar to a CT scanner. During the scan, the technician will place your child on a scanning bed, and two special cameras, one above and one below the bed, take images from head to foot. You should be permitted to stay with your child during this procedure. A mIBG scan usually takes much longer than other imaging techniques, and the child must remain very still during the procedure. Some young children will need to be sedated while the test is being done.

Parents often notice obvious hot spots during the mIBG scan. It is important to bear in mind that mIBG is excreted in the urine, and rare false positive results can appear in the groin area (for example, urine-soaked diapers or underwear). False positive results are also possible if the radioactive substance leaks around the central line or IV used for injection of the material.

Needle aspiration biopsy

Needle aspiration biopsies are sometimes used to obtain a sample of cells from a mass in an accessible area. Prior to the biopsy, children need to fast for several hours. The pediatric surgeon will first use ultrasound or CT images to determine the exact location of the mass. Once your child has been anesthetized, a needle is guided through the skin and into the mass; then a sample is removed. The sample is then sent to a pathologist, who will view the cells under a microscope. Your child will need to stay in bed for the next several hours with vital signs closely monitored to ensure there is no bleeding.

Using a thin, flexible tube called an endoscope, doctors can perform a needle aspiration biopsy in parts of the gastrointestinal (GI) tract. While your child is sedated, a gastroenterologist guides the endoscope through the mouth and into the stomach and duodenum. The tip of the endoscope contains a miniature ultrasound probe that creates visual images of the GI system. During the endoscopic ultrasound, a biopsy can be done of any tumor tissue seen via a needle that comes out of the end of the endoscope.

Positron emission tomography (PET) scan

Positron emission tomography (PET) is a type of imaging scan used to identify biochemical changes in the body’s tissues. MRI and CT scans provide information about structure and anatomy, but PET scans provide additional information about metabolism. This information helps more clearly identify location and extent of tumor and, after treatment, whether masses showing up on CT or MRI are scar tissue, dead tissue, or new growth of disease.

The PET scan involves injection of a radioactive drug (tracer) prior to scanning. The most common drug used is fluorine 18, also known as FDG-18, which is a radioactive version of glucose. The amount of radiation is very small, about the same as a conventional x-ray. After the injection, your child will wait for an hour or so until the tracer has spread throughout the body, and then the scan is done. No anesthesia is used and the entire procedure takes about 2 hours.

Usually, parents are told to not let their child consume any caffeine (e.g., soda, tea, chocolate) for 24 hours before the PET scan. Other than water, your child should not have any food or fluids for 4 hours before the scan. Your child should be told that the scan will not hurt and that he will have to remain very still while in the scanning machine.

Pulmonary function test

Some of the chemotherapy drugs children receive can damage the lungs. Your child’s doctor may order a pulmonary function test to evaluate your child’s respiratory status. The basic pulmonary function test is called a spirogram. Your child will blow into the machine to measure the amount of air she can inhale and exhale. The respiratory technician who administers the test will coach and instruct your child throughout the procedure to ensure she is giving her maximum effort. The test is administered at least three times to ensure the results are reliable. You can stay with your child while this test is done.

Your child cannot take this test if she is agitated, in pain, or too young to cooperate with the procedure. Your child should not take any bronchodilators or use an inhaler for 6 hours prior to the procedure. Also, be sure to have a list of medications your child is currently taking with you, because this is necessary for proper test interpretation.

Spinal tap (lumbar puncture or LP)

Due to the blood-brain barrier, systemic chemotherapy sometimes cannot destroy cancer cells present in the central nervous system (brain and spinal cord). Chemotherapy drugs may have to be directly injected into the cerebrospinal fluid (CSF) to kill any cancer cells present. For certain diseases, spinal taps are used to monitor a child’s response to treatment.

Most hospitals sedate children for spinal taps. If a child is not sedated, EMLA^® cream is usually prescribed to lessen the pain. Even with sedation, EMLA^® may be applied to minimize the sting of the topical anesthetic. To perform a spinal tap, the doctor or nurse practitioner first asks the child to lie on his side with his head tucked close to the chest and knees drawn up. A nurse usually helps hold the child in this position. The doctor, wearing sterile gloves, finds the designated spot in the lower back, swabs it with antiseptic several times, and administers one or two shots of an anesthetic (usually xylocaine) into the skin and deeper tissues. It is necessary to wait a few moments to ensure the area is fully anesthetized.

The doctor will push a needle between two vertebrae and into the space where CSF is found. The CSF will begin to drip out of the hollow needle into a container. After collecting a small amount of CSF, the doctor removes the needle, bandages the spot, and sends the CSF to the laboratory to see whether any cancer cells are present.

It is important to lie extremely flat for at least 30 minutes after a spinal tap to reduce pressure changes in the CSF. Sitting or standing up too soon can cause severe headaches. If your child develops a persistent severe headache following the procedure that lessens while he lies flat but throbs when he sits up, notify the doctor or nurse. The nurse will likely have your child lie flat and will offer him a high-caffeine beverage (such as Mountain Dew^®) to drink. If the headache persists, an anesthesiologist sometimes does a procedure called a “blood patch,” during which your child lies in the same position as for the spinal tap. The anesthesiologist will draw a small amount of blood from your child’s arm or central line. She will then inject the blood at the site of the prior spinal tap where CSF may be slowly leaking into the tissues. If this is the cause of the headache, the relief is immediate. You can stay with your child during the procedure.

Starting an intravenous (IV) drip

Most children with cancer have a permanent venous catheter implanted in their chest within a week of diagnosis to avoid the pain of multiple IV sticks (see Chapter 13, Venous Catheters). However, there may be instances when your child will need an IV line started, as well.

Most children’s hospitals have teams of technicians who specialize in starting IVs and drawing blood. The IV technician will generally use a vein in the lower arm or hand. First, a constricting band is put above the site to make the veins larger and easier to see and feel. The technician feels for the vein, cleans the area, and inserts the needle. Sometimes she leaves the needle in place and sometimes she withdraws it, leaving only a thin plastic tube in the vein. The technician will make sure the needle (or tube) is in the proper place, then will cover the site with a clear dressing and secure it with tape.

Here are a few ways to make this procedure a bit easier:

•  Stay calm. The body reacts to fear by constricting the blood vessels near the skin’s surface. Small children are usually more calm with a parent present, but teenagers may prefer privacy. Listening to music, visualizing a tranquil scene (such as floating in a pool or watching snow fall in the mountains), or using the same technician each time can help.

•  Use a topical anesthetic or a Buzzy^®. Using a topical anesthetic (e.g., EMLA^®) or a Buzzy^® (described earlier in the chapter) can be very helpful when starting an IV.

•  Keep warm. Cold temperatures cause the surface blood vessels to constrict. Wrapping the child in a blanket and putting a warm pack or heating pad on his arm can enlarge the veins.

•  Drink lots of fluids. Dehydration decreases fluid in the veins, making them harder to find.

•  Let gravity help. If your child is lying in bed, she can hang her arm down over the side to increase the size of the vessels in her arm and hand.

•  Let your child have control, as appropriate. If your child has a preference, let him pick the arm to be stuck. If he is a veteran of many IVs, let him point out the best vein.

•  Stop if problems develop. The art of treating children requires spending lots of time on preparation and not much time on procedures. If a conflict arises, take a time-out and regroup. Children can be remarkably cooperative if they feel you are respecting their needs and if they are given some control over the situation.

Traditionally, infants and young children have been restrained on their backs to insert IVs. This technique minimizes the risk of misplacing the IV, but it can cause significant fear and distress. Many treatment centers now allow parents to hold children upright in their laps to minimize stress. Child life specialists can teach parents ways to hold a young child to help him feel secure while undergoing procedures.

Subcutaneous injections

Some children require medications given by subcutaneous (under the skin) injection during their treatment. For example, Neupogen^® (filgrastim) is a granulocyte colony-stimulating factor (G-CSF) that is often used to boost the white blood cell count. It is usually given by subcutaneous injection. If you are required to give shots at home, make sure a nurse has trained you to do it and ask her to write down any tips she may have for making the shot as easy for your child as possible.

To minimize pain caused by subcutaneous injections, apply EMLA^® cream 1 to 2 hours before the shot, and then cover it with a Tegaderm^® patch or plastic cling wrap. Parents can also reduce pain by numbing the site prior to the injection by using a Buzzy^® device for 30 to 60 seconds or by rubbing ice over the skin.

Taking oral medications

As the parent of a child with a cancer, one of your most important jobs is to administer each dose of all oral medications to your child on time—every day. To accomplish this, it is essential to get off to a good start and establish cooperation early in the process. Pill swallowing is an essential skill for children and teens to master, and having a cancer diagnosis means they will need to learn how to do it in a short span of time. Many pills can be chewed or swallowed whole without leaving a bad taste in the mouth, but some medications should not be chewed because they have a bitter aftertaste and may cause your child to develop an aversion to all oral medications.

Children and teens can learn how to swallow pills by practicing with candy. One method, developed by the Child Study Center at New York University Langone Medical Center, starts with a child swallowing a tiny candy such as Nerds^®. When the child is able to easily do this five times, he practices swallowing a slightly larger candy. The size of the candies is gradually increased (e.g., mini M&Ms^®, Tic Tacs^®, and then full-sized M&Ms^®). This method allows your child or teen to practice swallowing in a relaxed setting at home with as much repetition as needed. With lots of encouragement from parents, the stress is minimal. If this method does not work for your child, a more gradual way to learn to swallow pills is described online at http://research4kids.ucalgary. ca/pill-study and listed in Appendix C, Books, Websites, and Support Groups.

For younger children who are not able to swallow pills, many parents crush the pills into a small amount of pudding, applesauce, jam, frozen juice concentrate, or another favorite food. However, your child may develop a lifelong aversion to these foods after treatment is over. Before mixing pills with food, check with the doctor or pharmacist, because some foods can negate the effects of medications.

Pharmacists can flavor oral medications with a product called FlavorX^®, allowing your child to choose from a variety of flavors such as banana, strawberry, mango, watermelon, and chocolate. The pharmacist can advise you about which flavors will work best to cover up the taste of each medication. You can find a local pharmacy that offers FlavorX^® by visiting the website www.flavorx.com.

Teens and medication

Teenagers usually have completely different issues around taking pills than do young children. Most problems with teens revolve around autonomy, control, and feelings of invulnerability. It is normal for teenagers to be noncompliant, and they cannot be forced to take pills if they choose not to cooperate. Trying to coerce teens fuels conflict and frustrates everyone. If you need help, ask the psychosocial team at the hospital to work out a plan for treatment adherence. Everyone will need to be flexible to reach a favorable outcome.

Taking a temperature

Fever is the enemy during treatment because it signals infection, and children on chemotherapy cannot fight infection effectively if their white blood cell counts are depressed. Parents take hundreds of temperatures, especially when their child is not feeling well. Temperatures can be taken under the tongue, under the arm, on the forehead, or in the ear using a special type of thermometer. Rectal temperatures are not recommended due to the risk of tears and infection. Here are a few suggestions that might help:

•  Use an infrared thermometer on the forehead.

•  Use a digital thermometer under the tongue or arm. Some have an alarm that beeps when it is time to remove the thermometer.

•  Tympanic (ear) thermometers are very easy to use.

Before you leave the hospital, you should know when to call the clinic because of fever. Usually, parents are told not to give any medication for fever and to call if the fever goes above 101° F (38.5° C). It is particularly important for parents of children with implanted catheters to know when to call the clinic, as an untreated infection can be life-threatening. It is also helpful to have a copy of your child’s most recent blood cell counts when you call to notify the doctor about fever.

Transfusions (blood)

Cancer treatment can cause severe anemia (a low number of oxygen-carrying red blood cells). This is because the normal lifespan of a red blood cell is 3 to 4 months, and as old cells die, the chemo-stressed marrow cannot replace them. Many children require transfusions of red blood cells when they are first admitted to the hospital and periodically throughout treatment.

One bag (called a “unit”) of red cells takes 2 to 4 hours to administer and is given through an IV or catheter. Mild allergic reactions are common. If your child is prone to allergies or experiences an allergic reaction, it may be necessary to premedicate her with an antihistamine such as Benadryl^® (diphenhydramine). Acute allergic reactions are rare, but they do happen. If your child develops chills and/or fever or any difficulty breathing during a transfusion, notify the nurse immediately so the transfusion can be stopped.

There are some risks of infection from red blood cell transfusions. Excellent tests are used to detect the most serious viruses in donated blood. The risk of exposure to the HIV virus from a blood transfusion is now less than 1 in 2 million. The risk of acquiring hepatitis B is 1 in 800,000, and hepatitis C is 1 in 1.6 million. Exposure to cytomegalovirus is also a small possibility. These very small risks are the reason transfusions are given only when absolutely necessary.

Transfusions (platelets)

Platelets are an important component of blood. They help form clots and stop bleeding by repairing breaks in the walls of blood vessels. A normal platelet count for a healthy child is 160,000 to 450,000/mm³. Chemotherapy can severely depress the platelet count. If a child’s platelet count is very low, it may be necessary to transfuse platelets so uncontrollable bleeding does not occur. Many centers require a transfusion when a child’s platelet count goes below 10,000 to 20,000/mm³, and sometimes repeat transfusions are required every 2 or 3 days until the marrow recovers. Platelet transfusions usually take less than an hour.

As with other blood products, an allergic reaction is possible and platelets are capable of transmitting infections such as hepatitis, cytomegalovirus, and HIV. Even though the chance of contracting these viruses is extremely low, platelets are transfused only when necessary.

Ultrasound imaging

Ultrasound provides the doctor with a quick and radiation-free tool for imaging internal organs. The ultrasound involves placing a small device called a transducer against the skin in the area that needs to be examined. The transducer sends inaudible sound waves into the body, which bounce off the internal organ and return to the transducer. The ultrasound machine uses these sound waves to form an image of the organ.

Before the procedure begins, your child may have to remove some items of clothing or jewelry that could interfere with the ultrasound. Sometimes your child will be asked to wear a hospital gown. The technologist will position your child on the examination table, and a clear gel will be applied to the area to be imaged. The technologist will move the transducer over the surface of the skin while the child remains still and relaxed. After the images have been taken, you may need to wait until they are reviewed before you can leave the department.

Urine specimens

Children taking chemotherapy often need to provide urine specimens. One way to help obtain a sample is to encourage your child to drink lots of liquids the hour before. If your child has an IV, you can also ask the nurse to increase the drip rate. Explain to the child why the test is necessary. Ask the nurse to show how the dip sticks work. (They change color, so they are quite popular with preschoolers.) You can use a shallow plastic bucket (called a hat) under the toilet seat to catch urine.

As all parents learn, eating and elimination are functions that the child controls. If she just can’t or won’t urinate in the hat, go out, buy her the largest drink you can find, and wait.

It may be necessary to obtain a sterile specimen of urine, or “clean catch,” if infection is suspected. You or your child will need to cleanse the perineal area with soap or an antiseptic towelette, and she will need to urinate into a small sterile container.

If your child is not yet toilet trained, if a clean catch is impossible, or if your child is unable to urinate, it may be necessary to insert a Foley catheter. This procedure can be quite stressful because it involves placing a sterile rubber tube up the urethra and into the bladder. It is definitely appropriate to ask that your child be given a mild sedative or muscle relaxant before the procedure if he is anxious, and to request that the most skilled person available perform the procedure. In skilled nursing hands, the procedure takes less than 5 minutes to perform.

Six-year-old Ethan’s introduction to procedures started the day he was diagnosed. The MRI that afternoon was no problem for him because he was nearly comatose. Getting through that scan was difficult only for my peace of mind. His next scan was a day later; he lay still, occasionally giggling, because he was watching Men in Black through special MRI-safe video goggles. Scans became a not-so-hard routine. Reminded to lie still, he often fell asleep through the jackhammer-like din of the MRI magnet.