Monday, June 26, 2017

Neutropenia... What?

It is recommended to screen for anemia (low red blood cell levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets - the main components of our blood.

One relatively frequent abnormal lab we see (especially during the winter months) is a low absolute neutrophil count (ANC). Neutrophils are a type of white blood cells that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections. While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection. A low ANC is called neutropenia.

Photo source: Wikimedia. Blausen.
The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.

Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders. The most common cause of neutropenia we see is after an infection. In most cases this type of neutropenia quickly resolves without any treatment. Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias. The drugs that can cause neutropenia are not commonly used medications and routine testing for neutropenia would be done when those medications are used. Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.

There are three levels of neutropenia:

  • Mild neutropenia: The ANC ranges between 1000-1500/μL
  • Moderate neutropenia: The ANC ranges between 500-1000/μL
  • Severe neutropenia: The ANC is less than 500/μL
    • Mild: ANC 1000-1500
    • Moderate: ANC 500-1000
    • Severe: ANC less than 500

  • Mild neutropenia: The ANC ranges between 1000-1500/μL
  • Moderate neutropenia: The ANC ranges between 500-1000/μL
  • Severe neutropenia: The ANC is less than 500/μL
  • Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about. I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection and they never got significantly sick. I have changed my personal protocol because if kids start getting sick, they will end up being rechecked and if they're healthy, there was no need to recheck.
    • If a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level -- though if your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
    • If the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, I will usually recommend a confirmation (repeat test) and possible further evaluation. 
    • If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
    • Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you'll have to talk to your child's doctor for a plan.

    What symptoms might happen if the ANC is low?

    Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment. Children with chronically low ANCs will have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers. A common cold or cough is NOT from a low ANC, since these are viral illnesses and a different type of white blood cell targets viruses.

  • Frequent infections
  • Serious respiratory infections, including pneumonia or sinus infections
  • Skin infections (e.g. cellulitis, abscesses)
  • Multiple serious infections (e.g. meningitis, bone infections)
  • Lymph node infections
  • Gum disease
  • Mouth sores/ulcers
  • Vaginal, urethral rectal ulcers
  • When do we worry?

    The level of ANC as well as the cause both determine the risk level of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy, they are at very high risk of bacterial infections. On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.

    We are concerned if the child has recurrent infections, poor growth, or a very low level. Each case must be evaluated by the person who ordered the test and who has recently seen your child.

    What treatment is done for a low ANC?

    Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn't grow well.

    Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.

    In children who have a chronically low ANC, I usually refer them to a hematologist (blood specialist) to evaluate why they have it and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.

    For more information:

    Benign familial leukopenia and neutropenia in different ethnic groups.
    Pediatric Autoimmune and Chronic Benign Neutropenia

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    Sunday, June 11, 2017

    Dry Drowning - What Parents Need To Know

    I thought about titling this one "We're drowning in dry drowning phone calls" because we are getting many worried calls about dry drowning, but that's overly dramatic and I hate headlines that make things seem like the sky is falling...

    drowning, dry drowning, water safety

    I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I've never seen it, I'd forgotten the term. Either way, it isn't very common at all, but it is an emergency when it happens, so it's good that we all know that it can happen. People also use the term secondary drowning and some experts differentiate the two by whether or not water actually gets into the lungs, causing swelling of the lung tissue, or if water irritates the vocal cords, causing them to spasm and close off. Either situation is potentially life threatening and they have similar symptoms. Note: Please see the addendum at the bottom. Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

    One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

    Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It's when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work - the air tubes are swollen, so air can't get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

    Symptoms you need to recognize and act upon by taking your child to an ER:

    • Cough: If your child has coughing for a minute or more after being in water, he's at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
    • Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
    • Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
    • Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn't the same thing as being tired after a long day. The medical definition is "Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction."
    • Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It's best to check it out in the ER.

    What will happen in the ER?

    Many parents don't want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don't have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child's symptoms and exam. There is no specific treatment for this, only supporting your child's airway and breathing as the swelling goes down.

    • If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling). 
    • An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well. 
    • Oxygen levels will be monitored and extra oxygen might be given. 
    • Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
    • Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.

    Prevention is important!

    As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds. 

    • Childproof your home when you have little ones who might play in a pet water bowl or the toilet. 
    • Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn't pretend they're drowning because it might distract a lifeguard from a true emergency. 
    • Learn infant and child CPR.
    • If you have a pool or pond at home, be sure there is a fence limiting access from your house.
    • Watch your kids closely and keep them within reach when they're in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present. 
    • Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they're okay, they probably are. Drowning victims can't ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue. From this site, signs of drowning:
    • Head low in the water, mouth at water level
    • Head tilted back with mouth open
    • Eyes glassy and empty, unable to focus
    • Eyes closed
    • Hair over forehead or eyes
    • Not using legs – Vertical
    • Hyperventilating or gasping
    • Trying to swim in a particular direction but not making headway
    • Trying to roll over on the back
    • Appear to be climbing an invisible ladder


    I just read this post that gives references regarding drowning definitions. It appears I didn't forget learning about dry drowning in medical school. It isn't really a thing. The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause. Check this out: On "Dry Drowning"

    Another: Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

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