Paediatric blood and cancer

Pediatric blood and cancer items turn on three maps: sickled pain and hydration, bleeding versus infection precautions after marrow suppression, and never kneading a Wilms mass.

Sickle cell disease and crisis

In sickle cell disease, abnormal hemoglobin polymerizes when the child is stressed by hypoxia, dehydration, cold, infection, or acidosis. Red cells stiffen into sickle shapes, jam small vessels, and create ischemic pain: a vaso-occlusive crisis (VOC). On the exam, that pain is the emergency. Treat it promptly with ordered analgesia, push hydration (IV or oral as ordered), give oxygen when sats fall, and rest the child. Withholding opioids because “kids exaggerate” or delaying fluids while you chase labs is the classic miss.

Teaching between crises aims at the triggers: steady fluids, warm clothing in cold weather, early evaluation of fever or infection, and adherence to ordered vaccines and disease-modifying plans. Splenic sequestration is a different emergency. Blood pools suddenly in an enlarging spleen, circulating volume drops, and the child looks pale, tachycardic, and shocked. That picture is not “another VOC you watch overnight.”

Hemophilia

Hemophilia is a clotting-factor deficiency (commonly factor VIII or IX). Without enough factor, minor trauma becomes a joint or muscle bleed. Early replacement of the missing factor stops the cascade from filling the joint; watching the knee “to see if it swells” is how target joints get damaged.

Why RICE alone is not enough: ice and elevation help comfort and swelling, but they do not replace the missing clotting protein. Desmopressin appears for some mild factor VIII patterns when ordered; do not invent that for every hemophilia stem. Teach families to treat early bleeds at home per their plan and to seek care for head, neck, or abdominal trauma.

• Joint bleed: factor first, then immobilize/compress/ice/elevate.
• Active range-of-motion during an acute hemarthrosis is the wrong “physical therapy” impulse.

von Willebrand, thalassemia, aplastic anemia

These three sit next to hemophilia and sickle cell on the same exam. von Willebrand disease is a platelet-adhesion problem more than a deep-joint problem. Expect mucocutaneous bleeding: nosebleeds, gums, heavy periods, bruising. Ordered desmopressin can release stored von Willebrand factor in many type 1 clients; it is not a universal hemophilia substitute. Still hold aspirin-type drugs unless cleared.

Thalassemia is defective hemoglobin production. Severe forms need chronic transfusion; the teaching overlay is iron overload and chelation as ordered, not “more iron syrup like the toddler with milk anemia.” That mix-up is the classic miss. Aplastic anemia is empty marrow: low WBC, low platelets, low RBC. Infection and bleeding precautions look like leukemia care. Avoid IM injections and raw-food bravado when neutrophils are gone. Fever is an emergency.

Iron-deficiency anemia

Toddlers who drink large volumes of cow’s milk fill up on low-iron calories and can irritate the gut enough to lose small amounts of blood. The child looks pale and tired; labs show microcytic anemia when the stem gives numbers. Adult iron teaching overlaps Anemias; the pediatric ask is milk limits plus liquid-iron technique.

The distractor mixes iron into a bottle of milk “so the child will take it.” That blocks absorption and stains the habit as much as the teeth. Give between meals when tolerated, and pair with the vitamin C teaching on the stem.

Leukemia, neutropenia, and bleeding precautions

Childhood leukemia crowds the marrow with immature blasts, so the child presents with infection risk (few working neutrophils), bleeding or bruising (few platelets), and fatigue or pallor (few red cells). Chemotherapy deepens that marrow suppression on purpose. Adult-style chemo safety, vesicants, and full neutropenia maps live in Oncology care. Here the pediatric ask is recognizing fever in a suppressed child as an emergency and pairing infection precautions with bleeding precautions on the same kid.

Fever at protocol thresholds (often about 38.0–38.3°C) with severe neutropenia is not “watch overnight with acetaminophen.” Culture and escalate on the febrile-neutropenia pathway because bacterial overgrowth can progress to septic shock in hours. Avoid rectal temps and IM injections when platelets or neutrophils are critically low unless specifically ordered. Live vaccines stay off the schedule until cleared.

Wilms tumor

Wilms tumor (nephroblastoma) is a flank or abdominal mass in a young child, often found by a caregiver who notices a firm belly asymmetry. The capsule can rupture with rough handling, spilling tumor cells. That is why repeated deep palpation is forbidden and why “feel it again to show the team” is the wrong instinct.

Preoperative teaching focuses on gentle care and NPO/surgical prep as ordered. Postoperative care follows nephrectomy and oncology plans. The single highest-yield exam rule remains: hands off the mass.

Neuroblastoma, osteosarcoma, Hodgkin lymphoma

Wilms is not the only mass. Neuroblastoma often sits in the adrenal or sympathetic chain; the abdomen can feel firm and may cross the midline (Wilms is more flank and stays more contained). Metastases to the orbits give “raccoon eyes” as tested. Catecholamine release can add diarrhea, hypertension, or flushing. Handle gently, but the “do not palpate” slogan still belongs first to Wilms capsules. Osteosarcoma hits adolescents at the metaphysis of long bones: persistent bone pain or a mass after a minor bump. Amputation or limb salvage plus chemo; phantom-limb pain is real, and stump care follows the surgical plan. Do not promise a sports timeline. Hodgkin lymphoma is painless rubbery cervical or supraclavicular nodes with B symptoms (night sweats, fever, weight loss) as the stem names them. Reed-Sternberg cells are the exam label. Neutropenia and fertility teaching follow the oncology chapter rules already above.

Priority map