Infection Precautions for Children During Cancer Treatment

This page is for parents and caregivers of a child getting cancer treatment. It starts with the emergencies, fever and central line problems, then covers everyday habits that lower the risk of infection.

A fever in a child on cancer treatment is not a wait-and-see problem. It can be the only sign of a bloodstream infection, and it can turn serious in hours.

CDC says to call the doctor immediately for a temperature of 100.4 °F (38 °C) or higher. If you cannot reach the team right away, go to the emergency room. Some centers use a different number. Write your team's exact number on the refrigerator, and if it is lower than 100.4 °F, use theirs.

NCI lists other signs of infection to call about. They include chills, cough, sore throat, diarrhea, ear or sinus pain, a skin rash, mouth sores, swelling or redness around a catheter, and changes in urine. Call about anything new that worries you, too.

This is the instruction families most often get wrong, and it matters.

NCI says to talk with the doctor or nurse before giving any medicine for fever, including aspirin, acetaminophen such as Tylenol, and ibuprofen. Those drugs can mask a serious problem. A child who looks fine because the fever was knocked down is still a child with a possible bloodstream infection, and now nobody can see it.

If your team has already told you not to give fever medicine before being seen, follow that. If nobody has told you either way, ask at the next visit and write the answer down.

The route matters more than parents expect.

Ask your team which way to take your child's temperature and which thermometer to use.

Ask before using a rectal thermometer, suppository or enema. Your team may say to avoid them while counts are low.

Neutrophils are the white blood cells that fight bacteria. The absolute neutrophil count, or ANC, is calculated as part of a complete blood count.

MedlinePlus defines neutropenia as fewer than 1,000 neutrophils per microliter, and severe neutropenia as fewer than 500.

The lower the ANC, the higher the risk. When counts are low, the American Cancer Society advises staying away from large crowds and sick people. Wear a mask if you go out.

Ask for your child's ANC at every visit, and ask what number changes the plan. That single question converts a vague warning into a rule you can follow.

These two deserve their own plan because both have a treatment window that closes.

Chickenpox and shingles. CDC lists children with leukemia or lymphoma, and people on immune-suppressing medicines, among those at highest risk of severe varicella. The virus is very contagious. CDC puts the secondary attack rate among susceptible household contacts between 61% and 100%. That is the share of people without immunity at home who catch it. CDC says a person is contagious from 1 to 2 days before the rash appears until every blister has crusted over. Incubation runs 14 to 16 days, with a range of 10 to 21.

For an exposed immunocompromised child without evidence of immunity, CDC recommends VariZIG, a varicella-zoster immune globulin. It should be given as soon as possible after exposure, and can be given within 10 days.

Measles. CDC's post-exposure options are MMR vaccine within 72 hours of exposure, or immune globulin within 6 days. Live MMR is not given during chemotherapy, so immune globulin is the route the team will consider for a child in treatment.

Practical version: if your child is in the same room as someone with chickenpox, shingles, or measles, call the oncology line that day. Do not wait for symptoms. Tell the school and daycare that you must be called the same day for these three, not sent a newsletter next week.

CDC's guidance on altered immunocompetence is clear on both halves.

The child. Live vaccines are not given during chemotherapy. They should also wait at least 3 months after the treatment that weakens the immune system ends. The live list includes MMR, varicella, MMRV, live attenuated influenza vaccine, rotavirus, yellow fever, oral typhoid, and BCG. CDC says to avoid giving vaccines during chemotherapy or radiation if possible. The body may not respond well to them then. Some children get a shot within 14 days before treatment or during it. They are treated as not vaccinated. They get repeat doses at least 3 months after treatment ends. Ask which of your child's shots will need redoing.

The household. CDC states that MMR, varicella, and rotavirus vaccines should be given to susceptible household and close contacts when indicated. Vaccinating siblings protects the patient. One precaution: if a household member develops a rash after varicella vaccine, keep them away from the patient until the rash clears. NCI's general advice for people with neutropenia also mentions avoiding people who recently received a live vaccine, so confirm the household plan, including flu vaccine choice, with your team.

A central line is a catheter placed in a large vein, and CDC notes it can stay for weeks or months. It is also a direct route into the bloodstream for germs.

Follow the care steps your team taught you exactly. Only people trained by hospital staff should handle the line. Visitors do not touch it.

Call right away for redness, pain, warmth, or swelling at the site, a temperature of 100.4 °F or above, fluid, blood, or pus leaking, or a line that is blocked, leaking, will not flush, or has moved.

NCI's prevention list is short and boring, which is a sign it works:

• Wash hands often with soap and warm water, especially before eating.
• Keep catheter sites clean.
• Stay away from sick people and crowds.
• Handle food safely by cooking meat, fish, and eggs thoroughly and washing or peeling produce.

Call the oncology line immediately, or go to the emergency department if you cannot get through, and say the child is on chemotherapy, for:

• A temperature of 100.4 °F (38 °C) or higher, or a lower number if your team gave you one.
• Shaking chills, even without fever.
• Redness, swelling, or drainage at a central line site.
• Trouble breathing, a stiff neck, confusion, or a new rash of blisters.

If your child is struggling to breathe, is confused, or is hard to wake, call 911 or your local emergency number.

Do not give fever medicine first unless your team has told you to. Bring the medicine list and the date of the last chemotherapy dose.

See Neutropenic Fever During Cancer Treatment for what happens after you arrive, and Childhood Cancer Overview for the wider picture. Also useful: Helping a Child Take Medicine During Cancer Treatment, School 504 Plans During Childhood Cancer, Transition to Adult Follow-Up After Childhood Cancer, and Childhood Cancer Scans and Scanxiety.

• Infection and Neutropenia during Cancer Treatment, National Cancer Institute
• Fever During Chemotherapy, Centers for Disease Control and Prevention
• Low White Blood Cell Count and Cancer, MedlinePlus
• Neutropenia, American Cancer Society
• About Central Line-associated Bloodstream Infections, Centers for Disease Control and Prevention
• Altered Immunocompetence, Vaccines and Immunizations, Centers for Disease Control and Prevention
• Clinical Guidance for People at Risk for Severe Varicella, Centers for Disease Control and Prevention
• Pink Book Chapter 22: Varicella, Centers for Disease Control and Prevention
• Measles Vaccine Recommendations, Centers for Disease Control and Prevention
• Food Safety for Older Adults and People with Cancer, U.S. Food and Drug Administration