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Neutropenic Fever (Children)

What Is Neutropenic Fever

Neutropenic fever is identified by a single oral temperature reading above 38.3°C or a body temperature greater than 38.0°C sustained for over an hour in a child with neutropenia1. Neutropenia commonly occurs following chemotherapy, as the count of neutrophils (a type of white blood cell) in the bloodstream decreases after a child post-chemotherapy. A child is considered neutropenic when their absolute neutrophil count (ANC) falls below 1500/mm3.

Neutropenic fever is a prevalent side effect of cancer treatment. It is imperative to treat fever in a neutropenic child as a medical emergency, as they are at risk of bacterial sepsis (infection) if left untreated. Children with any form of immunodeficiency or recent received chemotherapy are susceptible to neutropenic fever, requiring an urgent full blood count (FBC) at the onset of fever.

Source: 1Infectious Diseases Society of America

Causes Of Neutropenic Fever

White blood cells defend of our body against invaders such as bacteria, fungi and viruses, with neutrophils playing a crucial role.

Chemotherapy and radiation therapy can impair bone marrow function. Certain cancers that invade the bone marrow also reduce blood cell counts.

When the impact of cancer or therapeutic agents significantly diminishes the number of neutrophils, children become more vulnerable to infections. The risk of serious infection in children undergoing cancer treatment correlates with the severity and duration of neutropenia.

A normal ANC is above 1500/mm
3. Children with brief periods of neutropenia (ANC between 200/mm3 to 500/mm3) and less than seven days of fever tend to respond better than those with severe neutropenia (ANC less than or equal to 200/mm3) lasting over seven days. Lung, skin and blood infections are more common when the ANC falls below 500/mm3, with the risk of life-threatening infections increasing further as the ANC falls below 200/mm3.

Neutropenia and its nadir often occur between seven to 14 days post-chemotherapy. This duration varies depending on the underlying condition and the chemotherapy regimen. For example, patients with acute myeloid leukaemia may experience severe neutropenia for up to four weeks, compared to patients with standard-risk acute lymphoblastic leukaemia, where neutrophil counts usually recover by day 10.
Signs And Symptoms Of Neutropenic Fever

It is advisable keep a reliable axillary or tympanic (ear) thermometer at home.

A child with neutropenic fever may display one or more of these infection warning signs:

  • Fever (temperature over 38°C)
  • Chills or shaking
  • Burning sensation during urination; increased frequency of urination
  • Redness, warmth, swelling or drainage from a wound
  • Cough and shortness of breath
  • Sore throat accompanied by fever
  • Mouth ulcers
  • Vomiting and/or diarrhoea with fever
  • Skin rashes, particularly round blisters
Diagnosis And Treatment Options For Neutropenic Fever

The doctor will conduct a detailed history and complete physical examination to identify the cause of the fever and its source. Common sites of infections include:

  • Upper respiratory tract (Otitis Media or Sinusitis)
  • Oropharynx (Dental Abscess or Mucositis)
  • Lower respiratory tract (Pneumonia, including Pneumocystis Jirovecii Pneumonia)
  • Gastrointestinal tract (Clostridium Difficile Colitis or Typhlitis)
  • Skin (Cellulitis, Chicken Pox or Herpes Virus Infection)
  • Perineum and perianal area (Anal Fissure or Abscess)
  • Central catheter sites (Tunnel or Exit Site Infection)

For a child with neutropenic fever, the following tests and imaging studies may be performed:

  • Full blood count
  • Tests to assess the degree of inflammation indicating a serious bacterial infection
  • Blood cultures from central venous lines, if present
  • Samples from potential infection sites (urine, sputum, wound, stool and others) for testing
  • Chest X-ray for symptomatic cases (e.g., cough, breathlessness, low oxygen saturations)
  • Respiratory viral immunofluorescence or multiplex polymerase chain reaction for upper respiratory tract infection symptoms
  • Imaging studies (CT scan, ultrasound, 2D-echo, etc.) as indicated by physical findings

Educating patients and caregivers about signs, symptoms and risks of neutropenic fever is crucial for successful treatment outcomes. This empowers them to seek timely treatment and prepare for potential complications.
Broad-spectrum antibiotics are promptly initiated after appropriate investigations. If a specific viral infection such as Herpes Simplex Virus or Cytomegalovirus, is evident, antiviral drugs may also be started. In cases of prolonged neutropenic fever, antifungal treatment may be considered for children at risk.

A child's discharge depends on the type of infecting organism, the source of infection and the child's recovery status. Discharge criteria include:

  • Evidence of marrow recovery (ANC over 500/mm3 and rising)
  • Absence of fever for at least 24 hours
  • Low probability of bacterial or fungal blood infection after 48 hours
  • Clinical well-being (haemodynamically stability with normal blood pressure, heart rate, oxygen saturation and respiratory rate)
  • Provision of adequate care and monitoring at home
  • Sufficient oral intake
Tips For Taking Care Of Children With Neutropenic Fever

If your child has a neutropenic fever or infection, bring them to the nearest Children's Emergency.

While completely preventing neutropenic fever is challenging, certain measures can reduce infection risk:

  • Maintain frequent hand hygiene
  • Avoid crowded places and public transportation, or use it during off-peak hours if necessary
  • Avoid contact with sick individuals
  • Refrain from sharing food, drinks, cups or personal items such as toothbrushes
  • Shower daily
  • Cook meat and eggs thoroughly to eliminate germs
  • Wash raw fruits and vegetables carefully
  • Avoid eating raw food
  • Regularly clean teeth and gums with a soft toothbrush
  • Keep household surfaces clean
  • If possible, vaccinate all household members against varicella and influenza 
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