When to Get Professional Help

The first question is whether you need help from medical professionals. You should take a temperature and call the doctor or nurse immediately if any of the following are true:

• A temperature of 101 degrees by mouth at any time. It is very important to have a reliable thermometer that can be easily read. A digital thermometer is the easiest to use. When it is finished recording the temperature, it lights up and shows you the exact number. Ask the pharmacist or store clerk to help you pick out a digital thermometer. If you use a glass thermometer, then keep it in the mouth for 3 minutes or under the arm for 5 minutes. Don't place the thermometer in the rectum. Rectal temperatures may cause infection or bleeding in young people receiving chemotherapy.
  
• A temperature of 101 degrees under the arm at any time. It is very common to take children's temperatures under their arms. This is called an auxiliary temperature. The number recorded by a thermometer under the arm can be slightly lower than one recorded by mouth, but it is still accepted. If you use a glass thermometer, leave it under the arm for 5 minutes.
  
• A temperature greater than 100 under the arm or orally for 4-6 hours or longer.
  
• Any severe shaking chills, especially after flushing a central IV line. Chills warn you that a fever will probably happen. They often come before a fever. If the young person chills, take a temperature and call the doctor immediately. Chills that happen after flushing a central IV line may indicate that bacteria in the line were released when it was flushed. Take the temperature immediately and when the chills are over, and be sure to report that the central line was flushed before the chills.

Any of these symptoms (even if they occur without a fever). They all indicate an infection even if a fever is not present. All are easy to watch for, particularly the last one, when the younger person is "just not him- or herself." All are reasons to call.

• Too weak to drink fluids
• Frequent, painful urination
• No urine output for 8 hours for 2 years old and younger or 12 hours for over 2 years old.
• Any new redness or swelling
• New cough, shortness of breath, or rapid breathing
• Cold symptoms or sore throat
• New abdominal pain
• Diarrhea
• Increased sleepiness
• Irritability
• Too weak to play
• Just not him- or herself

Know the following facts when you call the doctor or nurse.

1. What were the temperatures and what times did you take them? If you don't know exactly how long the fever has been high, report the time that you took the temperature and the time that you first noticed any other changes, such as redder skin, sweating, or the young person complaining about feeling hot or feverish.
   
2. How much fluid did the person with fever drink since the fever began or in the past 8 hours? Report fluid intake as cups or glasses or bottles drunk over the past day or two. Reporting the amount of fluids drunk and the amount of urine passed helps the doctor or nurse determine if he or she is becoming dehydrated. Be sure to say if the amount of fluids, such as water, soda, juice, or soup, is less than he or she usually drinks in a normal day.
   
3. Has urine output been normal or is it less than normal?
   
4. When was the last chemotherapy and what drugs were given? Have fevers followed these drugs before?
   
5. What were the last blood counts? When and where were they drawn?
6. What is the young person's weight?

Always call the oncology staff treating your child! We will use your local doctor as much as possible, but we want to know what is happening.

Here is an example of what someone might say when calling.

"I am Joan Smith, Michael Smith's mother. My son is Dr. Harvey's patient. He's 3 years old and has leukemia. The homecare plan for fever says that I should call if shaking chills started. They did and when I took his temperature at 1 o'clock it was 101.4. He had chemo five days ago."

What You Can Do To Help

After you've called in, here are some things you can do at home.

1. Reduce any high temperatures
2. Prevent infections caught from others or the environment
3. Prevent infections caught from normal bacteria on the skin, mouth, urine, or stools

Reduce any high temperatures

Fever is lowered by acetaminophen, such as Tylenol and other brands, by helping the body get rid of heat, and by correcting or preventing dehydration. The drugs and other measures listed below will not take care of what is causing the fever, but they will help to lower a temperature and make the person more comfortable.

• Do not give acetaminophen unless you have been told to give it by your oncology physician or nurse. Acetaminophen (Tylenol and other brands) lowers high temperatures and makes the person with cancer feel less discomfort. Acetaminophen will not make the infection disappear. Give the right amount of acetaminophen by checking the child's weight and finding the dose (number of tablets or right amount of liquid) on the bottle that matches that weight. Acetaminophen should be given by mouth, not rectally.
  
• Do not give aspirin or ibuprofen. These drugs promote bleeding, especially in the gastrointestinal (GI) tract. When your child is receiving or recovering from chemotherapy, he or she is at a higher risk than normal of bleeding. Therefore, aspirin, ibuprofen (Motrin, Advil, Nuprin and other ibuprofen products) are not to be given.
  
• Give any other medications prescribed for fever or infection by your doctor. If an antibiotic has been prescribed, continue to give it as ordered.
  
• If chilly or shaking, keep the person warm and covered up with a blanket. Shaking chills generate more heat so the young person should be covered just enough to keep them from shaking. When he or she stops shivering, begin to remove layers of covers one at a time.
  
• If hot, remove heavy clothing, cover lightly with a sheet and put cool washcloths on the forehead. Cooling the forehead brings some relief to the discomfort of feeling very hot. In addition, the cool cloths also cools the blood that flows through the head close to the surface of the skin.
  
• Place in slightly warm water if the temperature is very high (over 103 degrees) and the child is not shivering. Place the young person in water that is slightly warmer than room temperature and let them play or enjoy the water. Avoid the extremes of a hot bath or cold water. Do not bathe in rubbing alcohol. This can be toxic to young persons if they inhale it. It is also absorbed through the skin. Stop any actions which cause shivering, dress the child, and wrap in a light sheet or blanket.
  
• Offer cool fluids every hour. Check the amount of fluid necessary for your child in the fluid chart (see Fluid Chart). The body needs more fluid when feverish. That's because more fluids than usual are being lost through the skin and through the lungs. The risk of dehydration when the fever is high.
  
• Dress the young person in light clothing. Light fabrics allow air to pass through to the skin and do not trap body heat under the clothes.
  
• Change damp clothing and bed linens. If the child with fever sweats, the moisture dries on the skin, and he or she can get chills from the moisture. This adds to discomfort and also can make the body cool down too rapidly.

Prevent infection caught from others or the environment

Infections caught from others or from the environment can be prevented by a combination of strategies.

• Caregivers should wash hands with soap and water before contact with the child. The most common way that bacteria and viruses are passed from person to person is on the hands. This can be prevented very effectively by thorough hand-washing with soap and water before contact with the young person or their belongings.
  
• Don't share a thermometer or toothbrush with anyone else. Anything that goes in the mouth should not be shared because it's easy to pass germs from one person to another this way.
  
• Avoid people who may have infectious and transmissable diseases like colds, flu, chicken pox, and cold sores. Asking others to wait to visit until a cold is over will lower the risk of catching it.
  
• Report if the child is exposed to chicken pox, measles, or shingles immediately. The viruses that cause chicken pox, measles, and shingles can seriously affect the young person receiving chemotherapy. When any exposure occurs, a dose of antibody is usually prescribed, which can temporarily increase immunity and possibly prevent development of an infection.
  
• Avoid unpasteurized raw milk, raw shellfish, and raw eggs. Uncooked eggs, unbaked cookie dough, and unpasteurized milk carry many bacteria that can cause severe gastrointestinal diseases, such as those caused by salmonella. These diseases are associated with nausea, vomiting, diarrhea, and extreme weakness.
  
• Don't swim in ponds or rivers. Water can collect a lot of bacteria and the young person is more likely to get an infection from swimming in non-chlorinated waters.
  
• Wear shoes to prevent cuts and bruises. Even small cuts on the feet can let bacteria into the body.
  
• Wash any cuts right away with soap and water and bandage them for the first few hours. Cuts and scrapes need to be washed with soap and water and covered with a Band-Aid or gauze patch. These openings on the skin can easily get infected if dirt stays inside the cut.
  
• Avoid sunburn. Use a sunscreen lotion, wear hats or scarves, and stay out of the sun. Sunburn leads to blisters and open skin. Once the skin is open, it's easier to infect.
  
• Arrange for someone else to groom the pet, empty cat litter boxes, and clean pet cages. Pet feces contain high levels of bacteria and fungi which are easily transferred to humans. Get someone other than the young person to groom the pet, clean cages, clean fish tanks, or change litter boxes. Don't give pets away for this reason. Their love and company are very helpful for the young person, and it is fine for the young person to play with the pet.
  
• Give Bactrim if prescribed during chemotherapy. Bactrim is an antibiotic which is given to prevent a serious kind of pneumonia called Pneumocystis pneumonia. If prescribed, it is to prevent this problem.

Prevent infection caught from the body's normal bacteria in the skin, mouth, urine, or stool

Young people with cancer can also catch infections from themselves, from their skin, mouth, urine, or stool. The following tips describe ways to prevent infection from these sources.

• Wash the skin every day with a shower, sponge bath, or full bath. Good hygiene is very important. Daily bathing will decrease the amount of bacteria on the skin and decrease the chance of them causing infection.
  
• Wash hands frequently with soap and water, especially after using the bathroom and before eating.
  
• Use lotions and moisturizers on the skin to prevent drying, chapping and cracking. Lotions boost the ability of the skin to stay intact. There is less risk of cuts and openings where bacteria can break in and cause infection.
  
• Thoroughly cleanse the rectal area after bowel movements. Look for any sores or breaks in the skin after each cleansing. Girls should be taught to wipe from front to back after a bowel movement.
  
• Make sure the young person is resting during the day, eating well balanced meals, drinking plenty of fluids, and getting mild exercise.
  
• Avoid rectal temperatures and suppositories. Taking a rectal temperature or administering suppositories adds to the risk of infection because bacteria which normally live inside the intestine and rectum may be introduced into the bloodstream through tiny tears in the lining of the rectum.
  
• Encourage good dental hygiene four times each day (after meals and at bedtime). Check all surfaces in the mouth for sores each day. Brushing the teeth at least four times a day will decrease the number of bacteria in the mouth. This helps prevent infections.
  
• Use Peridex two times per day if it is ordered during chemotherapy. Peridex is a special mouthwash that kills additional bacteria. Use as recommended by the doctor or nurse.
  
• Replace toothbrushes every three months. Toothbrushes harbor bacteria. They are wet most of the time and attract different types of organisms. Replacing them as frequently as every three months reduces the chances of infection in the mouth.
  
• Get a new toothbrush after treating a mouth infection (usually thrush infection). Even though the mouth infection was healed after using an antibiotic, the toothbrush has been contaminated and the mouth or thrush infection can continue to grow on the bristles of the brush. Discard it.
  
• Plan visits to the dentist when blood counts are normal. Many dentists will give the young person an antibiotic to take before they clean or work in the mouth. Any child with a central IV line must have an antibiotic with any dental exam or work. The dentist will check with the child's doctor to find out what the blood counts are and whether or not dental work should be done at that time.

  The mouth has many kinds of normal bacteria in it and regular cleaning or drilling by a dentist can cut the gums. The young person with low white cells is at risk of an infection or abscess when these bacteria enter a small cut.
  

• Visit the dentist regularly. Care of the mouth and teeth is very important for the young person with cancer. If dental visits are not covered by insurance or the cost of a visit is too expensive and prevents you from making regular dental appointments, talk this over with the doctor, nurse, or social worker. Financial help can be arranged. For example, some rural counties have a free dental clinic that visits school districts once or twice a year. Some large hospitals have dental schools in them and dentists there see patients who use that hospital. Find out about your options.

Prevent infection from school, daycare, or siblings

Check with the doctor before any brothers or sisters get immunizations or vaccinations such as oral polio. General, "killed" vaccines, such as DPT, HIB, Pneumovax, hepatitis, and flu can be safely given. Check with your doctor before a sibling receives a "live" vaccine, such as oral polio.

Find a contact person such as a teacher or school nurse who will tell you about any outbreaks of infectious disease in your child's classrooms, daycare settings, or babysitters. You cannot always learn about outbreaks of infections, such as measles or chicken pox, quickly enough to know that your other children are potential carriers of these diseases and can bring them home. Ask the school nurse and teacher to call you about these outbreaks as soon as they know about them. If you don't have a phone, then have the nurse and teacher tell another adult who will find you and tell you in person. Although your other children may be good sources of information about what is happening at school, it's best to be sure that you'll get this important information and then tell your child's doctor about the problem. Sometimes, preventive medicines are given or special precautions are advised.

It is important to know if the young person receiving chemotherapy has been exposed to illnesses. Ask the school nurse and teacher to call you about any outbreaks as soon as they know about them. Sometimes preventive medicines are given to the young person with cancer, usually within 72 hours after exposure. Other special precautions may also be advised.

Prevent infection when counts are low

It is very important to follow all the previous suggestions to prevent infections when the white blood cell counts are low. An additional suggestion should also be followed to prevent infection and fever.

Make sure the young person avoids large indoor crowds. Think of alternatives to large indoor crowds when counts are low because the risk of catching an infection or cold is higher in this environment. You also will be advised if it is necessary to keep your child home from school. Don't restrict the young person from indoor crowds when counts are normal because the child wants to return to events that are fun and familiar.

Possible Obstacles

Think about what will stop you from carrying out your plan and how you will overcome the obstacle.

Here are some obstacles that other people have faced.

1. "The fever came down after I gave him acetaminophen, so I don't need to call."
   Response: Whatever started the fever in the first place will not be fixed by one dose of acetaminophen. It is very important to find out if the young person needs to be treated for an infection.
   
   
2. "My son just doesn't look sick, but his temp is 102."
   Response: People handle high temperatures differently. Some get very sleepy and weak, others take longer to show signs of not feeling well. Follow the guidelines for reporting temperatures.
   
   
3. "My daughter believes that if she brushes her teeth a lot, her gums will bleed from all of the scrubbing."
   Response: The gums will bleed during and after tooth-brushing if she doesn't brush regularly. Bacteria cake onto the gums and break the tissues down, making them weaker. Sometimes they'll bleed after chewing or biting into a piece of food. Gentle regular brushing removes the bacteria and toughens up the skin that covers the gums and mouth.

Carrying Out and Adjusting Your Plan

Prepare in advance. Practice in your mind how you will carry out your plan and arrange transportation ahead of time just in case you need it quickly. When the time comes to act to stop a fever or infection, carry out your plan and make changes to fit each situation. Use this homecare plan as a reference and make sure that others who are involved with helping read this plan.

Checking on results

If fevers occur, do you know when to call for help and what to do to lower the temperature and make the young person more comfortable? Are fevers occurring less often? Answers to these types of questions will tell you that you have learned how to watch for and handle this problem.

If your plan doesn't work

If fever remains a problem, your plan does not seem to be working, or fevers are happening more often, there are two things you can do. Consider them in this order.

1. Check the When To Get Professional Help section of this care plan. If you answer yes to any symptoms on that list, call the doctor or nurse immediately.
2. If fever problems continue or you are not sure how to prevent them or spot them, ask the doctor or nurse during office hours for help. Tell them what you have done and what the results have been.

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