Leukaemia in children

Overview & Definition

A child is brought in pale, covered in bruises, with a fever that will not settle, and the blood film shows blasts. This is leukaemia until the bone marrow proves otherwise, and the first task at the bedside is to recognise the emergency and to move the child from an elective workup into a resuscitation. Leukaemia is the commonest malignancy of childhood, and the acuity of the presentation, with its threat of bleeding, sepsis and the metabolic disaster of tumour lysis, is what makes the first hours decisive. A delay of days can change the outcome, which is why every paediatrician must hold the diagnosis actively in mind. [9]

Leukaemia is a clonal malignancy of the haematopoietic precursor cell in which the normal maturation of a single lineage is arrested and the immature blast accumulates in the bone marrow. The accumulation crowds out the normal red cell, white cell and platelet precursors, producing the trilineage failure that explains almost every symptom, and the blasts spill into the peripheral blood. The disease is defined by the lineage of the arrested cell, and the separation into the lymphoid and the myeloid forms is the single most important early distinction because it determines the chemotherapy, the prognosis and the supportive care. [1]

The acute leukaemias dominate childhood, and of these acute lymphoblastic leukaemia is by far the commonest, accounting for roughly three quarters to four fifths of all childhood leukaemia. Acute myeloid leukaemia is less common but more evenly spread across the paediatric age range, and it carries a distinctive neonatal presentation in the infant with Down syndrome. The chronic leukaemias are rare in children and fall outside the everyday paediatric encounter, which is why this topic is built around the two acute forms and the emergencies they bring. [1]

The gravity of the diagnosis, and the remarkable improvement in its outlook, are why the topic sits at the centre of the fellowship examination. A candidate who can recognise the presentation, read the count and the film, chart the urgent diagnostic pathway, anticipate and prevent the oncologic emergencies, and explain the risk-adapted therapy to a family is demonstrating exactly the reasoning the boards reward. The contemporary survival of childhood acute lymphoblastic leukaemia now exceeds ninety percent in the best protocols, and the candidate who carries that number, alongside the humility of the emergencies, has the framework for the whole topic. [1][5]

References10Show ledgerHide ledger

1. [1]Hunger SP, Mullighan CG Acute Lymphoblastic Leukemia in Children N Engl J Med, 2015.PMID 26465987
2. [2]Rubnitz JE, Kaspers GJL How I treat pediatric acute myeloid leukemia Blood, 2021.PMID 34115839
3. [3]Howard SC, Avagyan A, Workeneh B Tumour lysis syndrome Nat Rev Dis Primers, 2024.PMID 39174582
4. [4]Perissinotti AJ, Bishop MR, Bubalo J Expert consensus guidelines for the prophylaxis and management of tumor lysis syndrome in the United States: Results of a modified Delphi panel Cancer Treat Rev, 2023.PMID 37579533
5. [5]Cooper SL, Brown PA Treatment of pediatric acute lymphoblastic leukemia Pediatr Clin North Am, 2015.PMID 25435112
6. [6]Verma A, Lupo PJ, Shah NN Management of Down Syndrome-Associated Leukemias: A Review JAMA Oncol, 2023.PMID 37440251
7. [7]Prusakowski MK, Cannone D Pediatric Oncologic Emergencies Hematol Oncol Clin North Am, 2017.PMID 29078932
8. [8]Sas V, Blag C, Zaharie G Transient leukemia of Down syndrome Crit Rev Clin Lab Sci, 2019.PMID 31043105
9. [9]Fragkandrea I, Nixon JA, Panagopoulou P Signs and symptoms of childhood cancer: a guide for early recognition Am Fam Physician, 2013.PMID 23939697
10. [10]Bhojwani D, Pui CH Relapsed childhood acute lymphoblastic leukaemia Lancet Oncol, 2013.PMID 23639321