Stem Cell (Bone Marrow Transplant)

What is a stem cell transplant?

A stem cell transplant is a medical procedure to replace missing or damaged blood-forming stem (hematopoietic or progenitor) cells with healthy stem cells. The procedure is also known as a bone marrow transplant (BMT) or hematopoietic cell transplant (HCT). 

The main source of stem cells is the bone marrow. Bone marrow is a soft, spongy material that is in the center of most of the body’s bones. The bone marrow works like a blood cell factory, constantly making new blood-forming stem cells. These cells then mature into cells that become:

• Red blood cells (which carry oxygen)
  
• Platelets (which help the blood clot)
  
• White blood cells (which fight infection)
  

A stem cell transplant may be used to treat certain childhood cancers, sickle cell disease, and some other blood or immune system disorders. The transplant process is complex. It is a major medical procedure and can cause serious side effects. Your care team will let you know if a stem cell transplant might be an option for your child.    

How a stem cell transplant works

There are 2 types of stem cell transplants:

• Allogeneic transplant uses stem cells from a donor. 
  
• Autologous transplant uses the patient’s own cells.

General steps of a stem cell transplant process include:

• Finding a suitable donor (if allogeneic transplant)
  
• Collection of stem cells from a donor (allogeneic) or your child (autologous)
  
• Pre-transplant testing and evaluation to make sure your child is a good candidate for a transplant
  
• Conditioning or pre-transplant treatment using chemotherapy and/or radiation therapy 
  
• Infusion of stem cells through a vein, much like a blood transfusion
  
• Infused stem cells travel to bone marrow to divide and make healthy blood cells (engraftment)
  
• Care to manage side effects and prevent infection
  

Before the stem cell transplant

Not every patient is a candidate for transplant. The medical team will consider factors such as your child’s:

• Age
  
• General health
  
• Diagnosis
  
• Treatment history
  
• Genetic markers for donor matching (if allogeneic transplant)

Lab tests will measure blood counts, kidney function, liver function, and exposure to infectious diseases. Your child will also have tests to examine the heart, lungs, kidneys, and other vital organs.

Your child will need a central line if one is not already in place.

You will also meet with care team members such as a social worker or psychologist to discuss emotional and mental health. A financial counselor can help with insurance approvals and financial issues.

What to expect during the stem cell transplant 

Transplant patients usually stay in the hospital 4–6 weeks or longer. Your child will stay in a special part of the hospital for transplant patients and other patients who have little or no immune system function. Infection control guidelines are different in the transplant unit than in other areas of the hospital.

Infusion of stem cells

The transplant process is challenging. But receiving the stem cells is relatively simple. It is much like a blood transfusion. Stem cells are in a bag or syringe connected through a tube to your child’s central line. It takes a few minutes to a few hours. It is not painful.

Engraftment

After entering the bloodstream, the stem cells travel to the bone marrow. Here they begin to divide. Stem cells become white blood cells, red blood cells, and platelets. This process is called engraftment. Engraftment usually begins 2–4 weeks after you receive the cells. White blood cells are the first to engraft, followed by red blood cells and then platelets. Your child may need transfusions of red blood cells and platelets to keep counts in a safe range while waiting for engraftment.

Doctors use blood tests to confirm that new blood cells are being made. After the transplant, your child will have daily blood draws for testing. Your care team will monitor your child’s red blood cells, white blood cells, and platelets to track the progress. 

Bone marrow aspiration can also help doctors see how well the new stem cells are growing. This procedure involves the removal of a small sample of bone marrow through a needle for examination under a microscope.

Caring for your child

A parent or other adult family member will need to stay with your child in the hospital. The transplant process is physically and emotionally draining for caregivers. It is best to have more than 1 family caregiver who can care for your child. Each caregiver must be trained, so it is important to plan ahead.

Preventing infection

During the first part of the hospital stay, your child will have high-dose chemotherapy with or without radiation. The treatment makes room for the healthy stem cells and helps prevent rejection of donor cells. It also weakens the immune system, so your child will be at high-risk of getting an infection.

Patients and family caregivers must take many precautions to prevent infections, such as wearing a mask and washing hands often.

All visitors must be screened for possible infections and contagious illnesses. Every transplant center is different. Be aware of hospital rules for visitors.

General transplant unit guidelines include:

• All caregivers and visitors must meet certain screening criteria before entering the transplant unit and must follow infection control guidelines.
  
• Only the patient and family caregiver can stay overnight.
  
• Visiting hours are limited. The primary caregiver is not considered a visitor.
  
• The number of caregivers and visitors allowed in the room is usually limited. 
  
• There may be age requirements for siblings and visitors.
  
• All caregivers and visitors must wash their hands when entering and leaving the patient’s room. 

Supporting your child during transplant

Being away from family, friends, and normal activities can be hard. Your child’s care team will help your child be as comfortable as possible. Child life specialists can provide fun activities such as games and crafts. Rehabilitation therapists will create an exercise plan for your child and give ideas about how to stay active.

You can bring toys and other items to help your child feel more at home. Encourage your child to connect with others through texts, social media, video chats, e-mails, phone calls, and letters. 

Keeping up with school

Your child will not be able to attend school during transplant and until their immune system has recovered. Your child can keep up with some schoolwork. Talk to your child’s school and connect with your hospital’s school services.

Tips for care at home

When you leave the transplant unit, your child will still have a very weak immune system. They will be less able to fight infections. Some infections can be life-threatening. Your child will need to stay with a family caregiver at home until their immune system returns to normal. This can take from a few months to a year. Please discuss with your care team what is best for your child. 

Return for clinic visits

After leaving the hospital, your child will have frequent clinic appointments for the first few weeks. If you live near the hospital, you can return home. If not, you will need to stay in a special housing facility near the hospital.

Be prepared to stay all day at these appointments. Your child will have a physical exam and may need tests and treatments. Over time, you will not need to return to the hospital as often unless problems or complications occur. Bring all medications to every clinic visit.

Prevent illness and infections

Even after going home, you will need to take extra care to reduce the risk of infections.

• Your child will not be able to return to school right away. You will need to set up a way to complete schoolwork from home, either through an arrangement with the school or using homebound services from your local school system.
  
• Your child should not go to public places such as grocery stores, malls, movies, restaurants, or houses of worship for a while.
  
• People who are sick or who have been exposed to contagious illnesses should not visit your home.
  
• Your care team will tell you when it is safe for your child to begin normal activities. Please ask them if you have questions about the safety of a specific activity. 
  

Give medicines correctly

Your child may need many medicines after a stem cell transplant. Be sure to give all medicines as prescribed. Contact your doctor or pharmacist if you don’t understand how to give a medicine, have trouble giving the medicines on time, or if your child has trouble taking the medicine. If your child doesn’t take medicines on schedule or at the correct dose, it could make their condition worse or lead to life-threatening infections or side effects.

When to call your care team 

Call your health care provider or seek medical care right away if your child has any of these symptoms:

• Fever
• Rash or itching that is severe, worsens, or does not go away
  
• Increase in bruising, pale skin, bleeding, or petechiae (pinpoint purple-red spots on the skin)
  
• Mouth sores
  
• Shortness of breath or trouble breathing
  
• Earache, sore throat, or other symptoms of cold or flu
  
• Nausea, vomiting, diarrhea, and/or weight loss
  
• Constant headache
  
• Fainting
  
• Difficulty waking from sleep
  
• Major change in condition

Let your care team know if your child has been exposed to chickenpox, shingles, measles, rubella (German measles), or hepatitis.

Questions to ask your care team

• What are the benefits and risks of a stem cell transplant for my child?
  
• What other treatment options are available?
  
• How will the transplant work and what should we expect during each stage?
  
• How long will my child need to be in the hospital?
  
• When can my child return to normal activities after the transplant?
  
• What follow up care will my child need?
  
• What are the possible long-term effects of a stem cell transplant?
  

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