Synopsis
Recognise childhood leukaemia when common symptoms form an abnormal pattern, order and act on urgent first-line tests without false reassurance, stabilise oncological emergencies safely, and preserve definitive diagnosis by coordinating early paediatric oncology care.
- Childhood leukaemia often presents as a cluster: pallor and fatigue, bruising or petechiae, fever or infection, bone pain, lymphadenopathy and hepatosplenomegaly.
- Immediate specialist assessment is required for unexplained petechiae or hepatosplenomegaly; other key unexplained features warrant a very urgent FBC within 48 hours under NICE NG12.
- First-line tests are FBC with manual film, reticulocytes and urgent senior interpretation; one normal count or absence of circulating blasts does not exclude early leukaemia.
- Check renal and liver function, LDH, urate, potassium, phosphate, calcium, coagulation and group and save at urgent assessment to identify organ risk and tumour lysis.
- Reference-standard diagnosis is specialist bone-marrow morphology with flow cytometric immunophenotyping, cytogenetics and molecular testing.
- Do not start corticosteroids before diagnostic sampling unless the paediatric oncology team directs it; steroids can clear blasts, alter risk classification and complicate tissue diagnosis.
- Do not perform a lumbar puncture in unstable physiology, severe thrombocytopenia, raised intracranial pressure or before the oncology protocol and haemostatic plan is agreed.
- A mediastinal mass creates a positional and anaesthetic emergency: keep the child in the position of comfort and avoid sedation or lying flat until specialist airway planning.
- Hyperleucocytosis is managed in a principal treatment centre with controlled fluids, tumour-lysis prevention and protocol-specific cytoreduction; routine red-cell transfusion can worsen viscosity and needs specialist approval.
- Explain that urgent referral investigates serious possibilities and that many referred children will not have cancer; give families a named contact and clear next steps.
Key red flags
Unexplained petechiae or hepatosplenomegaly in a child or young person meets NICE criteria for immediate specialist assessment for leukaemia.
Pallor, persistent fatigue, unexplained fever, persistent infection, generalised lymphadenopathy, bone pain, bruising or bleeding requires a very urgent FBC within 48 hours.
Breathlessness, orthopnoea, facial or neck swelling, venous distension or stridor may indicate an anterior mediastinal mass and unsafe airway compression.
Severe headache, confusion, visual change, focal deficit or respiratory distress with marked leucocytosis suggests leukostasis and needs critical-care oncology input.
Hyperkalaemia, hyperphosphataemia, hypocalcaemia, hyperuricaemia, rising creatinine or oliguria signals spontaneous or treatment-related tumour lysis.
Fever or haemodynamic change with neutropenia or dysfunctional malignant white cells should be treated as possible sepsis, even when inflammatory signs are muted.
Investigation priorities
Detect cytopenias, leucocytosis and abnormal precursors and trigger same-day specialist action.
Management branches
Unexplained petechiae or hepatosplenomegaly is found.
- Contact paediatrics for immediate specialist assessment rather than waiting for a routine clinic.
- Obtain urgent FBC and film if this does not delay transfer and communicate the clinical concern to the laboratory.
- Assess and stabilise bleeding, infection, tumour lysis, breathing and neurological complications concurrently.