Parents/carers are advised to telephone the unit if their child’s temperature is 38oC or above on one occasion, even if they appear well. They are also instructed to contact the hospital if their child appears unwell, regardless of fever, and community professionals should note that low temperature may be a later sign of sepsis.
Families / carers will be given advice over the phone as to what action to take following a Paediatric Haematology/Oncology Telephone Triage Assessment.
All families are advised to have a digital thermometer at home.
Definition of neutropenia
A child or young person is classed as neutropenic when their neutrophil count is less than 1.0 x109/L
Definition of febrile neutropenia
Febrile neutropenia is defined as having a neutrophil count of less than 1.0 x109/L and a temperature of 38°C or above on one occasion.
Low temperatures < 36.0C may also indicate sepsis and the same guidelines should be followed as for febrile neutropenia.
Any unwell child or young person who is receiving chemotherapy or radiotherapy should be considered at risk of infection even if afebrile and not neutropenic.
Background
Febrile neutropenia is common in children and young people receiving cytotoxic chemotherapy for malignancy. Any child or adolescent presenting with febrile neutropenia is at risk of neutropenic sepsis which is a serious life threatening condition. Therefore prompt and appropriate treatment must be started within one hour of temperature (if an inpatient) or one hour of arriving in hospital. Time of travel to hospital from onset of fever must be considered in giving advised about attending for review. Families must be made aware that children with fever who are unwell and immunocompromised may deteriorate rapidly and they can call 999 for assistance at any point on the journey.
The risk and pattern of infection in patients with malignancy or other immunosuppressing condition depends on the primary diagnosis and the type, duration and intensity of the treatment. The signs of infection may be minimal or absent in the presence of neutropenia or when patients are on steroids. Since there is no certain way of telling which febrile neutropenic patients have a potentially life-threatening infection, all such patients require investigation and empiric antibiotic therapy. Some or all of the following factors may be important:
General risk factors
- Duration and severity of neutropenia - neutrophils <0.5x109/L and predicted to continue for > 7 days or rapidly falling neutrophil count
- Mucositis and gut toxicity due to chemotherapy or radiotherapy
- Radiotherapy
- Previously documented Pseudomonas aeruginosa
- Evidence of serious sepsis - hypotension, shock
- Aplastic anaemia with neutrophils < 0.5 x 109/L
- Autologous, allogeneic or unrelated donor bone marrow or stem cell transplant recipients
- Chronic graft versus host disease
- Long term immunosuppressive treatment
- In-dwelling Central Venous Access Device or CSF access device or other ‘foreign body.’
Diseases linked to protocols which predispose to high risk febrile neutropenia
- Acute myeloid leukaemia (AML)
- Acute lymphoblastic leukaemia (ALL) in the first six months after diagnosis
- Relapsed AML or ALL.
- Stage 4 neuroblastoma
- B cell non-Hodgkin lymphoma / Burkitt lymphoma
- Osteosarcoma
- Ewing sarcoma.
Initial treatment
Treatment is started immediately - as soon as a full blood count and blood cultures have been taken. We do not wait for the results of the blood count or blood cultures.
Important information
Treatment should be started without delay even if the child or young person is apyrexial on presentation. Parental report of a pyrexia initiates treatment.
Do not perform rectal examination or administer rectal medications.