Initial Management of Febrile Neutropenia in CHILDREN

Initial Management of Febrile Neutropenia in CHILDREN


Febrile neutropenia is a medical emergency; complete the assessment and initiate antibiotics within 60 minutes

Contact the on-call pediatric oncologist within 60 minutes of the patient’s arrival

Reminder: DO NOT take temperature rectally

  • Oral/tympanic temperature greater than or equal to 38.3°C OR at least 38°C lasting 1 hour
  • Axillary temperature greater than or equal to 37.8°C OR at least 37.5°C lasting 1 hour (oral/tympanic temperature preferred)

Absolute neutrophil count (ANC) less than 0.5 x 10⁹ cells/L OR expected to fall to less than 0.5 x 10⁹ cells/L within the next 72 hours.

  • fever (may be masked by steroids, especially dexamethasone)
  • irritability
  • hot or cold shivers (rigors), sweating
  • warm forehead with flushed or pale face
  • rapid heart rate
  • new rash
  • vomiting
  • a sore which does not heal
  • sores in the mouth or throat and/or drooling
  • pain on swallowing (food/saliva)
  • coughing
  • pain with a bowel movement
  • diarrhea
  • change in level of consciousness
  • painful or frequent urination
  • abdominal pain
  • rarely, fever may not be present despite a significant infection; unwell neutropenic children should always be managed with infection in mind, even in the absence of fever.

Initial Evaluation and Management

Complete history, including:

  • Past exposures
  • History of infection
  • Expected period of neutropenia
  • Drug allergies
  • Ask parents for child’s “Treat Promptly” febrile neutropenia card (if available)
  • Initial physical examination should include, without being limited to: sinuses, oral mucosa, eyes, skin/IV access sites, genital region, perianal region (without digital rectal exam), feet.
  • Examine to determine whether there are signs and symptoms of meningitis (sometimes very difficult to detect).
  • CBC with differential, Na, K, Cl, urea, creatinine, liver function tests daily x 3 days
  • Lactate (WITHOUT tourniquet if via peripheral site)
  • Blood cultures x 2 sets simultaneously (before administering antibiotics). DO NOT withhold antibiotics more than one hour. If central catheter present, obtain 1 set via peripheral site and 1 set via each lumen of the central catheter.
  • Urinalysis and culture

May also consider:

  • Influenza assay
  • Respiratory virus panel (e.g. RSV, adenovirus, etc.)
  • +/- other laboratory tests according to clinical judgment
  • Chest radiography (PA + LAT)

  • +/- other imaging according to clinical judgment

  • Protective (neutropenic) isolation
  • +/- other measures, according to isolated/suspected organisms (e.g. influenza, C. difficile, etc.)
  • Vital signs (BP, HR, RR, SaO2, T°) q1h until patient is stable, then q4h (or more frequently according to the patient's condition)
  • Reminder: Do NOT take temperature rectally or perform a digital rectal examination.

IV: D5W + NaCl 0.9% at 1.5 x maintenance; maximum of 150 mL/h OR Equivalent oral hydration

Clinical Considerations

Possibility of “afebrile” febrile neutropenia in patients taking corticosteroids; who may present with hypothermia or unexplained clinical deterioration.

Contact the pediatric oncologist or a medical microbiologist/infectious diseases specialist for treatment alternatives if first line agents cannot be used.

  • Always take into consideration previous microbiological culture results and recent antibiotic use to guide the choice of antibiotic therapy.
  • If history of AmpC or ESBL beta-lactamases, use meropenem empirically rather than piperacillin+tazobactam or ceFEPIME

If meningitis is suspected, use meropenem (DO NOT use piperacillin+tazobactam)

Additional Information

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