Fifteen minute consultation: Fever in children being treated for cancer

Abstract

Fever is a common symptom in children receiving treatment for cancer. Clinicians and families are most concerned about febrile neutropenia, though non-neutropenic fever often causes more challenging treatment dilemmas. This article provides a structured approach to the initial assessment, examination, investigation and risk assessment of children with fever during treatment for childhood cancer. Non-neutropenic fever in children with cancer is not well researched. There are no systematic reviews of its management and no National Institute for Health and Care Excellence (NICE) (or other international) guidance about what to do. Features to consider when managing non-neutropenic fever are discussed. Febrile neutropenia, meanwhile, is an oncological emergency and requires management using standard sepsis principles including administration of broad-spectrum antibiotics. Relevant NICE guidance provides a clear structure for treatment. Ongoing management depends on the response to initial treatment.

Nonneutropenic fever in children with cancer: A scoping review of management and outcome

“…A total of 646 titles and abstracts were reviewed, of which 83 full‐text articles were retrieved. From this, 16 relevant articles, describing 15 studies, were identified for inclusion in this review (Figure ) . No dedicated NNF treatment guidelines were identified in this search.…”

“…In this survey of practice, a number of different empiric antibiotic combinations were used and the presence of a CVC, or known source of infection, had variable impact on decision to start antibiotics. An overview of the treatment approach to NNF is available, which emphasizes adherence to local sepsis or possible CVC‐associated blood stream infection protocols, where relevant …”

“…The duration and depth of neutropenia further influences risk, with as many as 80% of patients developing a severe infection after three weeks of profound neutropenia in the preantibiotic era . Given the potential for severe infection and adverse outcome, much of the research has focused on the clinical syndrome of fever and neutropenia (FN), with very few studies addressing nonneutropenic fever (NNF) in this population . A detailed understanding of the causes, outcomes, and optimal treatment of NNF is increasingly important with the development of new generation cancer therapies that tend to cause less neutropenia but are still associated with a risk of infection …”

“…Results of a data linkage study from the United States suggest similarly high rates of NNF presentations to the emergency department . This burden of NNF has been previously http://unrecognized, as evidenced by the paucity of guidelines, care pathways, and dedicated research in this area . Furthermore, little is known about the cause of fever, frequency of bacteremia, and outcomes of these patients.…”

“…2 Given the potential for severe infection and adverse outcome, much of the research Abbreviations: ANC, absolute neutrophil count; ASPHO, American Society of Pediatric Hematology/Oncology; CDR, clinical decision rule; CVC, central venous catheter; FN, febrile neutropenia; NNF, nonneutropenic fever; OR, odds ratio has focused on the clinical syndrome of fever and neutropenia (FN), with very few studies addressing nonneutropenic fever (NNF) in this population. 3 A detailed understanding of the causes, outcomes, and optimal treatment of NNF is increasingly important with the development of new generation cancer therapies that tend to cause less neutropenia but are still associated with a risk of infection. 4,5 The frequency of NNF during pediatric cancer treatment is largely unknown but likely varies according to type of malignancy and treatment.…”