Mediports and neutropenia

As pediatric surgeons, we are frequently faced with the the request for an "urgent" line to be placed in children with a newly diagnosed ALL. Having been involved in several situations where I am asked to place a mediport in a neutropenic child in order to start induction therapy, I decided to look at the available literature addressing the risk of line placement this patient population.

Understandably, the presence of a central line in any child increases the risk of infection. Rackoff et al (J Ped Heme Onc (1999) 21(4):260) in a study looking at the risk of infection in patients with ALL, showed that the presence of a line increases the risk of infection 4 fold.
Another study by Saul et al. (J Am Col Surg (1998) 186(6):654-8) looking at the risk of infection of line placement in children in general (most of whom had ALL), showed that the two main risk factors for line infection are neutropenia (ANC<1,000/mm) and failure to administer perioperative antibiotics.
Finally, as a direct answer my main question regarding whether we should place lines in neutropenic ALL patients or not, McLean et al (J Clin Onc (2005) 23(13):3024) looked at the risk of complications in lines placed early (<15 days) vs late (>15days) after initiation of induction therapy and noted that early placement was associated with a higher risk of positive blood cultures (OR 2.2) ,with the mean ANC being significantly lower in patients whose lines had to be removed (601/mm vs. 1,390/mm).

The way I see it, the best way to manage patients with newly diagnosed ALL (particularly if they are neutropenic), is to place a PICC line to start induction therapy then schedule an elective mediport placement at day 28 when these patients routinely get a repeat BM biopsy under general anesthesia as part of the protocol.