Your child will be allowed to have visitors during transplant. Sometimes visitors are limited during the respiratory seasons. Your transplant team will provide information related to this. It is important to never allow anyone that is ill to visit your child.
The days before transplant during the conditioning are counted as minus days. The day of stem cell infusion is considered day 0. Engraftment and recovery following the transplant are counted as plus days. For example, a child may enter the hospital on day -8 to begin the conditioning treatment for preparative regimen. Days +1, +2, etc. will follow the day after the stem cell infusion. There are specific events, complications, and risks associated with each day before, during, and after transplant.
The type of conditioning regimen that is given to your child is based on your child’s disease and the type of transplant. The preparative regimen may consist of several types of chemotherapy and/or total body irradiation (TBI). The chemotherapy and radiation is given in the 5 to 10 days prior to the stem cell or bone marrow infusion. The purpose of giving this chemotherapy/radiation is to (1) destroy any cancer cells that may still be present in the body and (2) make room in the bone space for the new marrow to grow and make new cells.
Infusion of the Stem Cells or Bone Marrow
After the preparative regimen is complete, the bone marrow or stem cells are given through the central venous catheter into the bloodstream. It is not a surgical procedure to place the marrow into the bone, but is similar to receiving a blood transfusion. Over the next 2 to 3 weeks the cells find their way to the bone marrow where they begin to reproduce and establish new, healthy blood cells.
What to expect during the infusion
Several safety measures will take place prior to the infusion to prevent a reaction and to be prepared if a reaction occurs. Your child may receive medications such as Tylenol and Benadryl before the infusion begins. Vital signs will be taken frequently during and after the infusion. Your child will be monitored with a cardiac monitor. Medication and safety equipment will be available in case a reaction occurs.
During the infusion your child may experience any, or all of the following symptoms:
Shortness of breath
Infusion of Autologous Stem Cells
An autologous stem cell transplant is when stem cells are harvested from the child and then given back to the child after intensive treatment. This is sometimes called a stem cell “rescue” rather than “transplant.” Since the stem cells are not needed right after they are collected, they are preserved with a chemical called DMSO and stored in a very cold freezer. Immediately before they are infused they are thawed in a warm water bath, usually at bedside. DMSO may produce a bad taste in the child’s mouth at the time of infusion. It is a good idea to have candy available, such as suckers or hard candy to cover up the bad taste. Parents and others in the room at the time of the infusion may notice a different odor. This odor is also caused by the DMSO as it is excreted from the patient’s body. Some people think it smells like rotten eggs or creamed corn. Because it is a sulfa-based chemical patients with allergies to Sulfa may have allergic reactions to DMSO.
Graft vs. Host Disease Prophylaxis (Allogeneic transplant only)
Graft vs. Host Disease (GVHD) occurs when the donor’s immune system reacts against the recipient’s tissue. The new cells do not recognize the tissues and organs of the recipient’s body.
Medications will be giving before and during the transplant to help reduce the risk of this complication. These medications may include:
Cyclosporine (Neoral, Sandimmune)
Tacrolimus (Prograf, FK506)
Mycophenolate (Cellcept, MMF)
Sirolimus (Rapamune, rapamycin)
Visit informational sections on GVHD here.
The Period Before Counts Recover
Typically, from the time the cells are infused until engraftment is the time when your child will be the most sick. This is the time when your child’s blood counts (white cells, hemoglobin, and platelets) and absolute neutrophil count (ANC) are very low. Therefore, your child is at greater risk for fevers, infections, and bleeding. Most of the side effects that your child is experiencing at this time are due the effects of the preparative regimen.
Your child may experience:
Fevers requiring a number of antibiotics and/or antifungal medications.
Mouth sores/ mouth and throat pain requiring narcotic pain medication, typically given as a continuous infusion.
Frequent blood and platelet transfusions.
Total Parenteral Nutrition (TPN) or NG (nasogastric) feeds are often needed due to decrease in appetite and difficulty eating due to mouth sores.
Nausea, vomiting, diarrhea
Engraftment is when the infused stem cells make their way to the marrow and begin reproducing new blood cells.
Depending on the type of transplant and disease being treated, engraftment usually occurs around day +15 through day +30. Blood counts will be performed frequently during the days following transplant to evaluate initiation and progress of engraftment. Platelets are generally the last blood cell to recover.
Engraftment can be delayed because of infection, medications, low donated stem cell count, or graft failure. Although the new bone marrow may begin making cells in the first 30 days following transplant, it usually takes 1 year or more for the immune system to fully recover.
In an allogeneic transplant, when the ANC begins to increase, a blood test will be sent to see if the cells in the blood are from the donor or patient. This test is called chimerism testing. The results are described as a percentage, such as “all cells seen were 100% donor.” Chimerism will be sent periodically after the transplant, usually at the time of engraftment, day +100, one year after transplant and then yearly.
Potential Complications after Transplant
Veno-occlusive Disease(VOD)/Sinusoidal Obstruction Syndrome (SOS)
SOS or VOD is a potentially serious liver problem caused by high dose chemotherapy and/or radiation. The blood vessels that carry blood through the liver become inflamed and blocked. Without a supply of blood, the liver cannot remove toxins, drugs, and other products from the blood stream. Pressure and fluids build up in the liver area.
Symptoms of VOD/SOS include:
rapid weight gain
pain or tenderness in the area of the liver
enlarged abdomen (fluid accumulates in the abdomen)
jaundice (yellow coloring of the skin and eyes) as a result of increased bilirubin
Mild cases may resolve on their own. Treatments are available for more serious forms of VOD/SOS
Graft vs. Host Disease
Please see the following sections on Graft Versus Host Disease:
The information on the website is intended to introduce you to some of the medical procedures and treatments which you/your child may receive when undergoing a hematopoietic progenitor cell transplant. The information on the website provides general guidelines but cannot replace the recommendations of your primary medical team. Specific patient care treatment options and procedures are the prerogative of each patient and their medical care team. You are encouraged to discuss any concerns or questions you have with your medical care team. Although every attempt has been made to post information that is clear and accurate, no guarantee is made to the reliability, completeness, relevancy, accuracy, or timeliness of the content. No liability is assumed by the Pediatric Blood and Marrow Transplant Consortium for any damages resulting from use or access to information posted on this website.