Cytostatic treatment for children is provided by hospitals with paediatric haemato-oncologists or oncologically trained paediatricians. Therefore, families have been advised to contact directly the hospital responsible for the treatment of their child.
Signs of septicaemia
Fever (> 38°C) in a neutropenic child is always a serious sign: the child should be immediately referred to the nearest paediatric hospital. If the blood neutrophil count is below 0.5 × 109 /l, fever is always an indication to start broad-spectrum antimicrobial treatment at hospital after the blood culture samples have been taken.
Abdominal pain and diarrhoea can be the first signs of septicaemia.
Focal infections without fever (otitis, sinusitis) can be treated normally if the general condition of the patient is good. Suspect septicaemia also in a non-febrile patient with deteriorated general condition.
Viral infections
If a child undergoing chemotherapy for malignancy (especially leukaemias and lymphomas) comes into contact with a person with chickenpox, prophylactic antiviral medication is indicated. It is advisable to treat symptomatic chickenpox or herpes zoster in such a child at hospital with acyclovir.
The prophylaxis is started 7 to 9 days from the exposure and it lasts for 7 days. In deep immunosuppression the medication may at discretion be continued for up to day 21 counted from the time of exposure.
Drug alternatives:
valacyclovir 60 mg/kg/24 h p.o. divided into 3 doses, maximum dose 3 000 mg/24 h (250 mg and 500 mg tablet strengths) or
acyclovir 80 mg/kg/24 h p.o. divided into 4 doses, maximum dose 3 200 mg/24 h.
Zoster hyperimmunoglobulin (2 ml i.m. if the child weighs less than 20 kg and 4 ml i.m. if the weight is more) may also be given at discretion if the patient has not had chickenpox Chickenpox. It is advisable to administer the prophylaxis within 48 hours from the exposure.
Oseltamivir medication started within 48 hours from symptom onset is recommended for influenza infection.
Concerning the treatment of other viral infections presenting as respiratory infections or with gastrointestinal symptoms, the specialist unit responsible for the treatment of the immunocompromised person should be consulted. The treatment of a non-febrile viral infection is principally based on symptomatic supportive therapy.
Fungal infections
A fungal infection should be suspected and empirical treatment started if fever persists in a neutropenic patient despite broad-spectrum antimicrobial treatment.
Children who are the most severely immunosuppressed, e.g. those who have received stem cell transplantation, have prophylactic antifungal medication.
Pneumocystis jirovecii
Most children with cancer chemotherapy have trimethoprim-sulphamethoxazole prophylaxis to prevent P. jirovecii pneumonia. A patient with rapid and shallow breathing, even if with only a low-grade fever, should be admitted without delay to a hospital for chest x-ray and arterial blood oxygen measurement. The diagnosis is confirmed by a lung biopsy.
Splenectomized children
Splenectomized children are usually vaccinated against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae already before the operation. Depending on the vaccine, the patient's age and national immunization programme, revaccinations may be needed. Consult local guidance for further details.Vaccination against influenza is also recommended.
High fever in a splenectomized child is always a severe symptom and requires prompt taking of blood culture and usually intravenous treatment with an antimicrobial that is effective also against haemophilus.