Peds - Ch. 46: Alteration in Cellular Regulation, Hematologic/Neoplastic Disorder

The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of:

Ewing sarcoma. Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors. Osteosarcoma is the most common type of bone malignancy in children. It occurs primarily in the long bones. Ewing sarcoma is a highly malignant bone cancer. It occurs in the pelvis, chest wall, vertebrae, and midshaft of the long bones. Neuroblastomas are seen in children younger than 5 years old and arise from immature nerve cells and the adrenal glands. Hodgkin disease develops from the immune system. Non-Hodgkin lymphoma is a blood cancer.

The nurse is caring for a child admitted to the hospital for an open fracture of the femur following a motor vehicle accident. The nurse notes the following lab values: white blood cells 10,000/mm3, hemoglobin 7.9 g/dl (79 g/L), hematocrit 28%, platelets 151,000/mm3. Which nursing action is priority?

Transfuse 1 unit of packed red blood cells. In a situation where the child exhibits signs of anemia related to acute hemorrhage, the nurse should anticipate administering a transfusion of packed red blood cells to improve oxygenation and circulation. Administration of antibiotics, pain assessment, and family education can be performed after the beginning the blood transfusion.

The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning?

"I mix ferrous sulfate with milk in a bottle." Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining.

A 15-year-old client diagnosed with von Willebrand disease has reached menarche. Based on this fact, what information is most important for the nurse to convey to the client?

Expect menstrual bleeding to be heavy. Females diagnosed with von Willebrand disease are at risk for menorrhagia. Bruising in the perineal area is not a risk unless there is some sort of trauma at the site. Von Willebrand disease does not cause intermittent periods or shorten the duration of menses.

Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse?

"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usually methotrexate, to be administered immediately following lumbar puncture as treatment for potential infiltration.

Parents tell the nurse who is admitting their infant for a well-child exam that they recently saw a "white glow" in their child's left pupil. What is the nurse's best response?

"I will report this to the pediatrician." The "white glow" may indicate retinoblastoma; immediate investigation is needed. The red reflex is indicative of eye health. Eye rubbing and a plugged tear duct are unrelated to the symptom described.

The nurse is educating the parents of a school-aged child with acute lymphoblastic leukemia (ALL). What statement by the parents indicates the parents need further education?

"My child will have increased urination because the immature white cells affect the kidneys." The child's kidneys are not directly effected by the proliferation of abnormal white blood cells. The parents are correct about joint pain, chemotherapy and bone pain.

A nurse is reviewing the laboratory test results of a 3-year-old child. Which absolute neutrophil count would the nurse identify as indicating neutropenia?

1.0 The normal absolute neutrophil count (ANC) ranges from 1.5 to 8.0 (1500 to 8000/mm3). An ANC less than 1.5 (1500/mm3) in children over age 1 indicates neutropenia.

When reviewing information about the incidence of the various types of childhood cancer, nursing students demonstrate understanding of the information when they identify which type as having the highest incidence?

Acute lymphoblastic leukemia (ALL) Acute lymphoblastic leukemia accounts for approximately 32% of all childhood cancers. Neuroblastomas account for 8%; non-Hodgkin lymphoma accounts for 6%; osteogenic sarcoma accounts for 3%.

The nurse is preparing to send a child with cancer for a radiation treatment. Which medication should the nurse provide to premedicate the child for this procedure?

Antiemetic Radiation has systemic effects. Radiation sickness that includes nausea and vomiting is the most frequently encountered systemic effect. It also occurs to some extent as a result of the release of toxic substances from destroyed tumor cells. To counteract this, a child is prescribed an antiemetic before each procedure. The child does not need an analgesic, antipyretic, or antineoplastic agent prior to receiving a radiation treatment.

A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify what location as an unlikely site for childhood cancer?

Bladder The most common sites for childhood cancer include the blood, lymph, brain, bone, kidney, and muscle. Bladder is a common site for adult cancer.

The father of an 8-year-old boy who is receiving radiation therapy is upset that his son has to go through 6 weeks of treatments. He doesn't understand why it takes so long. In explaining the need for radiation over such a long time, what should the nurse mention?

Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Radiation is not effective on cells that have a low oxygen content (a proportion of cells in every tumor), nor is it effective at the time of cell division (mitosis). Therefore, radiation schedules are designed so that therapy occurs over a period of 1 to 6 weeks and includes time intervals when cells will be in a susceptible stage.

A nurse is providing care to a toddler with nephroblastoma and is being evaluated. Which nursing action would be most important?

Placing a "no abdominal palpation" sign above the child's bed Nephroblastoma (Wilms tumor) metastasizes rapidly, so it is important that the child's abdomen not be palpated any more than necessary for diagnosis, because handling appears to aid metastasis. There is no need to restrict the child's visitors. Ensuring nothing by mouth would be appropriate prior to surgery. Preventing weight-bearing activities would be appropriate for a child with Ewing sarcoma.

What is the priority action the nurse should take when caring for a child newly diagnosed with Wilms tumor (nephroblastoma)?

Protect the abdomen from manipulation. Manipulation can release malignant cells into the abdominal cavity. Constipation may be a problem following surgical intervention. Pain is uncommon; obtaining a urine specimen is not a priority.

A 9-month-old infant with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help the nurse determine that the infant is actually taking it daily?

The stools will appear black. Oral iron supplements are dark in color because the iron is pigmented. As a result of digestion of this pigment, the stools of an infant taking iron will be dark to black. Taking iron supplements will cause constipation, not diarrhea. After treatment with iron, the reticulocyte count should be increased, not decreased. Children with iron deficiency are tired and many times irritable. With correction of the deficiency, the infant should be less irritable and have more energy.

A school nurse is teaching a group of parents about signs and symptoms of cancer in children. Which symptom is an early sign of a brain tumor?

headache, vision changes, and vomiting Children with any form of brain tumor develop symptoms of increased intracranial pressure: headache, vision changes, vomiting, an enlarging head circumference, or papilledema. Lethargy, projectile vomiting, and coma are late signs. Epistaxis is not usually related to a brain tumor. A growing tumor produces specific localized signs, such as nystagmus (constant horizontal movement of the eye) or visual field defects. As tumor growth continues, symptoms of ataxia, personality change (e.g., emotional lability, irritability), and seizures may occur. These would be later symptoms.

The nurse is reviewing the medical record of a child diagnosed with Hodgkin lymphoma at the asymptomatic stage. Which would the nurse identify as typically the first sign reported by the child?

painless, enlarged lymph node Children with Hodgkin lymphoma typically present with swollen, painless, and rubbery-feeling lymph nodes in the cervical or supraclavicular region. Depending on the extent of the disease at diagnosis, other symptoms may be present. However, this child was diagnosed in stage I (asymptomatic). If the lymph nodes of the chest are involved, the child has moved to the symptomatic stages and may experience dyspnea and cough. Chest pain may result from the pressure exerted by the enlarged nodes. General symptoms can also include fever, drenching night sweats, and weight loss.

The oncology nurse is alert for clients displaying signs and symptoms of disseminated intravascular coagulation (DIC). Which symptom would alert the nurse to this emergency condition?

uncontrolled bleeding DIC is a complex condition that is secondary to other problems such as sepsis. It is life-threatening. Symptoms of DIC include uncontrolled bleeding, petechiae, ecchymosis, purpuric rash, prolonged prothrombin time and partial thromboplastin time, an increased D-dimer assay, decreased antithrombin III levels, below-normal fibrinogen levels, and increased fibrin-degradation products. The platelet count is decreased in DIC. In moderate to severe cases it is less than 50,000/mm3 (50 ×109/L). The symptom the nurse would see first is uncontrolled bleeding. The remainder are laboratory results that would be used to make the diagnosis.

While assessing an adolescent, the nurse notes pallor and a beefy red tongue. Upon questioning, the adolescent reports eating a vegetarian diet to help with weight loss. Which health care provider prescription will the nurse anticipate?

vitamin B12 injections Children with pernicious anemia have a vitamin B12 deficiency and have symptoms such as pallor, irritability, beefy red tongue, and diarrhea. Children with iron-deficiency anemia require ferrous sulfate. Folic acid is needed for children with macrocytic anemia. Hydroxyurea could be prescribed for a child with sickle cell anemia.

A mother asks the nurse why her infant who was born at 34 weeks' gestation is being prescribed ferrous sulfate. Which response by the nurse is most appropriate?

"Preterm infants are at risk for iron-deficiency anemia." Infants born prematurely are at risk for iron-deficiency anemia because iron stores are built during the last few weeks of gestation. Although some infants with pyloric stenosis may require an iron supplement, such as ferrous sulfate, not all infants will. Infants with excessive diarrhea may develop iron-deficiency anemia, and ferrous sulfate helps improve red blood cell formation, but this does not explain why a preterm infant is being prescribed an iron supplement.

The nurse is caring for a 14-year-old client scheduled for magnetic resonance imaging (MRI). The nurse explains the test to the child and family. Which information would be most appropriate to include in the explanation?

"The MRI uses radio waves and magnets to produce a computerized image of the body." The MRI uses radio waves and magnets to produce a computerized image of the body. The bone scan is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement. The ultrasound uses sound waves to create images that visualize body structures and locate masses. Radiography uses radiation to examine soft tissue and bony structures of the body.

The nurse is caring for a child with aplastic anemia. The nurse is reviewing the child's blood work and notes the granulocyte count is about 500, platelet count is over 20,000, and the reticulocyte count is over 1%. The parents ask if these values have any significance. Which response by the nurse is appropriate?

"These values will help us monitor the disease." This response answers the parent's questions. In the nonsevere form, the granulocyte count remains about 500, the platelets are over 20,000, and the reticulocyte count is over 1%. The other responses do not address what the parents are asking and would block therapeutic communication.

The child has been diagnosed with leukemia. Rank the following medications used to treat leukemia in order based on the stage of treatment.

-oral steroids and vincristine through an intravenous line -high-dose methotrexate and 6-mercaptopurine -low doses of 6-mercaptopurine and methotrexate -chemotherapy through an intrathecal catheter During induction, the child receives oral steroids and IV vincristine. During consolidation, the child receives high doses of methotrexate and 6-mercaptopurine. During maintenance, the child receives low doses of methotrexate and 6-mercaptopurine. During central nervous system prophylaxis, the child receives intrathecal chemotherapy.

Antiemetics are ordered to control nausea and vomiting in the child undergoing chemotherapy. How can the nurse most effectively use these medications?

Administer the antiemetic before starting chemotherapy Antiemetics are most effective when given before chemotherapy begins and then on a regular schedule to prevent nausea and vomiting throughout administration of chemotherapy. Nonpharmacologic measures can be used in conjunction with antiemetics but not in place of them.

The nurse is caring for a 6-year-old boy with an abdominal neuroblastoma prior to having a magnetic resonance imaging (MRI) scan without contrast done. Which intervention would the nurse expect to perform?

Administering a sedative as ordered to keep the child still. The nurse would expect to administer a sedative as ordered to keep the child still because the machine makes a loud thumping noise that could frighten the child. The child must lie without moving while the MRI is being done. Encouraging fluid intake to increase radionuclide uptake is necessary for a bone scan. Advising the physician that the child is allergic to shellfish is an intervention for a computed tomograph (CT) scan with contrast. If the child did not have an IV prior to the MRI and contrast was going to be used, then an IV would need to be inserted for the contrast after the noncontrast MRI was finished. Applying EMLA to an injection site prior to inserting an IV would be appropriate for both the CT and bone scans.

The toddler with a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude?

Administering the measles, mumps, rubella (MMR) vaccine Live vaccines (viral or bacterial) should not be administered to an immunosuppressed child because of the risk of causing disease. The other health maintenance activities are important for the health maintenance of the toddler and should be included during the well-child visit.

What is one advantage of an implanted port (central venous access device) that the nurse will explain to an adolescent?

Body appearance changes very little. An implanted port has nothing extending through the skin and may be obvious only as a slight protrusion at the insertion site. Some tunneling from the port to a central vein is needed. Removal of the port requires a surgical procedure. Flushing of the port is necessary when used and on a regular basis.

The nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia (ALL)." What will confirm this diagnosis?

Bone marrow aspiration Bone marrow aspiration and biopsy are diagnostic. An abnormal white blood count and symptoms of lethargy, bruising, and pallor only create suspicion of leukemia; a twin may or may not be affected.

A nurse is administering a blood transfusion to a child. About 35 minutes after beginning the transfusion, the child develops pruritus and urticaria. Some wheezing is noted. Which action would the nurse take first?

Discontinue the transfusion. The child is experiencing a transfusion reaction; the first step with any transfusion reaction is to discontinue the transfusion. Oxygen should be given, and the nurse should anticipate the need for an antihistamine to reduce the child's symptoms. An iron-chelating agent would be given for hemosiderosis after repeated transfusions. A blood culture would be obtained if the child developed a fever.

Which diagnosis would be most appropriate for an infant with a large retinoblastoma after surgery?

Disturbed sensory perception related to enucleation Retinoblastoma is a congenital highly malignant tumor. When there is early detection the goal is to treat the tumor and preserve as much vision as possible. If there is advanced disease, enucleation is necessary. It may be difficult for an infant or young child to learn to see the world with only one eye and adapt to this sensation. Pain may be present but it is not related to retinal removal. The entire eye structure is removed. If the eye needs to be removed the child has not experienced normal vision for some time previous to surgery so there would not be fear relating to the loss of normal vision. Anticipatory grieving would occur more from the parents than the infant.

A child with hemophilia A is scheduled for surgery. Which precautions would the nurse institute with this client?

Handle the child gently when transferring to a stretcher. Hemophilia is a group of X-linked recessive disorders that prevent clot formation. The best care for the child is to prevent any bruising or bleeding so gentle handling when moving the child from the stretcher is necessary. Because the child is having surgery, infusion of clotting agents will be necessary. Analgesia will be needed postoperatively as will surgical dressings. IM injections are contraindicated because of potential bleeding. Brushing the teeth is part of normal daily hygiene.

The pediatric nurse is explaining to a new graduate nurse the differences in planning well-child maintenance for a child with cancer. Which statement by the new nurse demonstrates understanding of the teaching?

No routine live vaccines are administered while on chemotherapy. Children with cancer need much of the same well-child maintenance care that all children do, with one exception. While they are undergoing chemotherapy, which causes a decreased immune response, they should not receive "routine" vaccines, especially live vaccines. The siblings in the home can receive all nonlive vaccines, and the entire family (including the child undergoing treatment) is encouraged to receive a yearly flu vaccine. Growth and development are monitored during well-child visits, but it is not necessarily true that growth and development may be stunted. It is always a good idea to eliminate second-hand smoke for all children, not just for children with cancer. Childhood cancers do not seem to be related to environmental contaminants.

The nurse is planning care for a child with idiopathic thrombocytopenic purpura. Which client education should be included?

Not to pick or irritate the nose Idiopathic thrombocytopenic purpura (ITP) occurs as an immune response following a viral infection. It produces antiplatelet antibodies that destroy platelets. This leads to the classic symptoms of petechiae, purpura, and excessive bruising. Without adequate platelets, children bleed easily from lesions. If the child "picks" the nose, an area could be opened and bleeding could occur. Folic acid will have no effect on the disease process. The lesions are not itchy and are open or draining, so cold water washing and soothing lotions are not required.

A 5-year-old client has been diagnosed with leukemia and is currently on chemotherapy and radiation. The child is having difficulty due to mucositis. Which is the most appropriate nursing diagnosis for this child?

Risk for imbalanced nutrition, less than body requirements, related to inflammation Mucositis is inflammation of the oral mucosa, which puts this child at risk for risk for imbalanced nutrition. The client may have pain due to neoplastic process in the bone, but that is not mentioned in the scenario. The client may have lost hair, but that is not mentioned. The client's family coping is also not mentioned.

A pediatric client is diagnosed with an infratentorial tumor of the brain. The nurse would identify which as a possible site for this type of tumor?

brain stem Infratentorial tumors are located in the brain stem, fourth ventricle, and cerebellum. Supratentorial tumors are located in the cerebrum.

The nurse will select which meal as the best choice for a child with iron-deficiency anemia?

cheeseburger, broccoli, and fresh strawberries Children with iron-deficiency anemia require diets rich in iron and vitamin C (vitamin C enhances iron absorption). Meats are excellent sources of iron. Broccoli is a good source of iron, and strawberries are a good source of vitamin C. To help the body absorb the most iron from the meal, tea and foods rich in calcium (such as milk and cheese) should be avoided.

A hospice nurse is providing at-home care to a child with end-stage cancer. The nurse is developing a plan of care to manage the child's pain. Which medications will the nurse likely include?

opioids Chronic or terminal pain may be managed in the home with continuous administration of opioids, orally or intravenously, as a bolus injection or infusion. Both pharmacologic and nonpharmacologic interventions are important in managing pediatric pain. Mild analgesics, topical anesthetics, and opioids can be used to treat pain. Sedatives such as midazolam or anesthetic medications such as ketamine or propofol may be used to assist children undergoing painful procedures that are required routinely during their cancer treatment.

The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myeloid leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately?

temperature of 101°F (38.3°C) or greater The parents should seek medical care immediately if the child has a temperature of 101°F (38.3° C) or greater. This is because many chemotherapeutic drugs cause bone marrow suppression; the parents must be directed to take action at the first sign of infection in order to prevent overwhelming sepsis. The appearance of earache, stiff neck, sore throat, blisters, ulcers, or rashes (or difficulty/pain when swallowing) are reasons to seek medical care, but are not as grave as the risk of infection.

A child with cancer is dying and in hospice care. When developing the plan of care, which intervention should the nurse include as the primary focus?

keeping the child pain-free Children die from cancer. They may die at home or in the hospital, and hospice care can be provided in either setting. Children with terminal cancer often experience a great deal of pain, particularly when death is imminent. The primary goal of caring for a dying child is the prevention and alleviation of pain. The nurse would work with the parents to determine the pharmacologic and nonpharmacologic methods which work best. Many times, dyspnea and agitation can occur as a result of pain. These symptoms are reduced with pain management. Any care to the child, even in hospice care, should be developmentally appropriate. Emotional support is a necessity, both for the child and the parents, but pain relief is the priority.

A nurse is teaching parents of a child with iron-deficiency anemia how to administer ferrous sulfate. The nurse determines that the teaching was successful when they make which statements? Select all that apply.

-"We'll give him the medicine before he eats his meals." -"He has to make sure that he brushes his teeth well." -"He might get constipated, so we'll try to get him to eat some more fiber." -"We'll have him take the liquid medicine with some orange or pineapple juice." Ferrous sulfate should be given on an empty stomach with water to enhance absorption. If the child develops gastrointestinal distress, then it can be given after meals. Iron can stain the teeth; therefore, thorough brushing is needed. Ferrous sulfate causes constipation, so the parents should encourage high-fiber foods to reduce the risk. Iron is best absorbed in an acidic environment, so giving the drug with a citrus juice is appropriate. The drug should not be given with milk, eggs, coffee, or tea. The liquid form should be mixed with water or juice to mask the taste and prevent staining of the teeth.

The nurse identifies that the client is at risk for an infection related to chemotherapy-induced immunosuppression. What would the nurse include in the teaching plan for the child and parents about reducing the child's risk? Select all that apply.

-Encouraging frequent, thorough handwashing -Having the child sleep in a single bed and room To reduce the risk of infection, the nurse should teach the child and parents about minimizing the child's exposure to potentially infectious situations. The nurse should encourage the parents to arrange for the child to sleep in a single bed and room and, if possible, avoid close contact with other family members who may be developing upper respiratory tract infections. Thorough and frequent handwashing, especially after using the bathroom and before eating, is essential. A high-calorie, high-protein diet helps to rebuild white blood cells and should be encouraged. If possible, the child's exposure to large crowds and visitors should be limited because of the increased risk of infection from these individuals. Fresh flowers and plants should be avoided because they could harbor mold spores.

A school-aged child with cancer is receiving chemotherapy. Which nursing action would best promote the oral comfort of a child receiving chemotherapy?

Keeping the child's lips moist with petroleum jelly to prohibit cracking The mouth of a child receiving chemotherapy can become very inflamed and painful. It is important for the nurse to assess the oral cavity for redness, lesions, and plaques frequently. If the child is NPO, ice chips can be used to provide hydration to the mucosa. It is important to use a soft-bristle toothbrush when brushing the teeth. Excessive pressure on the gums will cause bleeding. If the gums are very inflamed, the child may use a saltwater solution or commercial mouthwash to keep the mouth clean. Instruct the child that this may cause burning. If burning or stinging occurs then discontinue the practice and provide solutions with pain medication. Using a petroleum product on the lips will provide hydration to the lips and keep them from being irritated or cracking. Drinking cold or hot foods will cause more pain in the mouth and may cause further irritation. Acidic fruit juices will cause increased pain and irritation in the mouth and may cause more inflammation.

The health care provider has just informed the parents of a 3-year-old that their child has leukemia. The mother begins crying and tells the nurse she does not want her baby to die. What is the nurse's best response?

"I know this is scary, but leukemia has a high cure rate in children these days." Because of the tremendous advances in cancer research and treatment over the past 20 years, the prognosis for children and the chances for a cure improve daily. Up to 95% of children with the most common form of leukemia, for example, can expect to be cured. Praising the health care provider is not therapeutic because it denies the mother's fears. Acknowledging her fears is therapeutic, but informing her of the high cure rate is more helpful. It is doubtful that any parent feels "lucky" when hearing a diagnosis of cancer, and hearing this will not make the treatment any easier.

A 4-month-old infant is found to be anemic. Which is the most likely cause of anemia in this child?

Inadequate intake of dietary iron in the mother during late gestation A newborn usually has enough iron in reserve to last for the first 6 months of life. After that, the infant needs iron incorporated into the diet. Because iron stores are laid down near the end of gestation, women with iron deficiency during pregnancy tend to give birth to iron-deficient babies because the babies do not receive iron stores. At birth, hemoglobin is largely of the infant type (hemoglobin F), which is composed of two alpha and two gamma polypeptide chains. During the first 6 months of life, this infant type is gradually replaced by adult hemoglobin (hemoglobin A), which is composed of two alpha and two beta chains. For this reason, diseases such as sickle-cell anemia or the thalassemias, which are disorders of the beta chains, do not become apparent clinically until this hemoglobin change has occurred (at approximately 6 months of age).

A 3-year-old boy has been brought to the doctor's office with symptoms of anorexia and abdominal pain. A blood test reveals a lead level of 20 μg/100 mL. The child is prescribed an oral chelating agent. On discharge, the nurse should counsel the parents regarding:

removal or covering of flaking paint on the walls of the home. The usual sources of ingested lead are paint chips or paint dust, home-glazed pottery, or fumes from burning or swallowed batteries. A child with a blood lead level over 5 μg/dl needs to be rescreened to confirm the level and then active interventions begun to prevent further lead exposure, such as removal of the child from the environment containing the lead source or removal of the source of lead from the child's environment. Removal of the lead source is not an easy task in homes because simple repainting or wallpapering does not necessarily remove the source of peeling paint adequately. After some months, the new paint will begin to peel because of the defective paint underneath. The walls must therefore be covered by paneling or drywall or other solid protective material.

To prevent further sickle cell crisis, the nurse would advise the parents of a child with sickle cell anemia to:

notify a health care provider if the child develops an upper respiratory infection. Infections caused by the Streptococcus pneumoniae can be lethal to a child with sickle cell, because they can cause overwhelming sepsis or meningitis. By 2 months of age the child should be started on Penicillin V as prophylaxis against pneumococcal infections. The child should receive the 7 valent pneumococcal series in infancy. After 2 years of age the child should receive the 23 valent pneumococcal vaccine. He or she should also be immunized against meningitis. Participating in strenuous activities such as running and limiting the amount of fluids leads to a reduction of oxygen and dehydration. This can lead to the increased sickling of cells. The anemia of sickle cell disease is not the result of iron deficiency. It is the result of the abnormal shape of the red blood cell. Administering iron will not correct the anemia.