ABP Pediatric Hematology-Oncology common mistakes
ABP Pediatric Hematology-Oncology · Understand the traps and how to avoid them.
When a child has microcytic anemia and a normal or high ferritin, selects iron deficiency and starts iron without checking CRP or obtaining hemoglobin electrophoresis.
Ferritin rises as an acute-phase reactant, and thalassemia trait also produces a low MCV; pattern-matching to 'low MCV equals iron deficiency' overrides the effect of inflammation.
What to do instead
Interpret ferritin alongside CRP and the blood smear/Mentzer index; obtain hemoglobin electrophoresis before committing to long-term iron and reassess after an iron trial.
In sickle cell disease with acute chest syndrome, orders simple packed red cell transfusion to raise hemoglobin to 12 g/dL rather than targeting about 9–10 g/dL or using exchange transfusion.
Equates severe anemia and hypoxia with a need to normalize hemoglobin, but raising hemoglobin increases blood viscosity and can worsen vaso-occlusion.
What to do instead
Transfuse to a target hemoglobin near 9–10 g/dL, or use exchange transfusion for severe hypoxemia, and avoid exceeding 10–11 g/dL unless exchange is planned.
Starts corticosteroids for presumed immune thrombocytopenia in a child with petechiae before reviewing the blood smear or examining for hepatosplenomegaly and lymphadenopathy.
Immune thrombocytopenia is common and steroids are familiar, but early steroids can obscure a diagnosis of leukemia and increase risk when marrow involvement is present.
What to do instead
Confirm isolated thrombocytopenia on smear, document absence of atypical features, and obtain a bone marrow aspirate before steroids when any feature is atypical.
Withholds factor VIII replacement in a child with hemophilia A and an acute hemarthrosis until ultrasound or other imaging confirms the bleed.
Concern about unnecessary factor and reliance on imaging to confirm a bleed; however, early factor prevents cartilage damage and imaging may be normal early.
What to do instead
Give factor VIII immediately on clinical suspicion of hemarthrosis, then use imaging and analgesia; avoid NSAIDs and avoid desmopressin for severe hemophilia.
In a child with suspected new acute lymphoblastic leukemia and fever, gives systemic corticosteroids before obtaining a diagnostic bone marrow and cerebrospinal fluid sample.
Steroids rapidly reduce fever and lymphoblasts, but they can clear marrow blasts and alter cerebrospinal fluid, making diagnosis and central nervous system staging unreliable.
What to do instead
Obtain marrow and lumbar puncture first unless the child is unstable; if steroids are unavoidable, document this and plan to repeat staging.
In a child with sickle cell disease and a falling hemoglobin after transfusion, attributes pain and anemia to vaso-occlusive crisis and orders another transfusion without checking DAT or eluate.
Delayed hemolytic transfusion reaction and hyperhemolysis can present with pain and hemoglobin below the pretransfusion level, and another transfusion can worsen hemolysis.
What to do instead
Check DAT, eluate, reticulocyte count, LDH, and bilirubin; avoid further transfusion unless life-threatening and consider exchange transfusion or immunosuppression.
In febrile neutropenia, obtains blood cultures and waits for results before giving empiric antibiotics, or chooses a regimen without antipseudomonal coverage.
Desire for culture-directed therapy and discomfort with broad antibiotics, but Pseudomonas sepsis can progress within hours.
What to do instead
Give an antipseudomonal beta-lactam within 60 minutes of presentation, after cultures are drawn, and adjust later based on results.
In tumor lysis syndrome, monitors only uric acid and misses hyperkalemia, hyperphosphatemia, and hypocalcemia; or repeats uric acid after rasburicase and interprets the result as true.
Uric acid is the most discussed marker, but potassium and phosphate rise first and cause arrhythmia and renal failure; rasburicase degrades uric acid ex vivo unless the sample is cooled.
What to do instead
Monitor potassium, phosphate, calcium, creatinine, urine output, and ECG; use rasburicase for high-risk disease and collect uric acid on ice or interpret post-rasburicase values with caution.
In a survivor of childhood Hodgkin lymphoma treated with chest radiation, screens only for recurrence and does not order breast imaging, thyroid function testing, or echocardiography.
Focus on oncology follow-up and underestimation of late effects; radiation-related breast cancer risk begins about 8 years after exposure, and cardiac and thyroid risks persist.
What to do instead
Create a risk-based survivorship care plan with breast MRI/mammography starting at age 25 or 8 years after radiation (whichever is later), annual thyroid examination/TSH, and echocardiography per anthracycline and radiation dose.
When a child with relapsed leukemia has worsening symptoms, avoids introducing palliative care because the family or team equates it with stopping cancer treatment.
Palliative care is conflated with end-of-life care; clinicians fear it signals abandonment and delay symptom control and goals-of-care discussions.
What to do instead
Frame palliative care as concurrent symptom management and goals support; refer early for pain, dyspnea, and psychosocial needs while continuing disease-directed therapy.