CPHON common mistakes
CPHON · Understand the traps and how to avoid them.
Waiting for a returned absolute neutrophil count (or for repeat cultures) before giving the first dose of empiric broad-spectrum antibiotics to a child on chemotherapy who spikes a fever.
Candidates carry a med-surg habit of 'confirm the lab before acting,' and they worry that antibiotics will blunt culture yield, so they sequence the workup ahead of the drug.
What to do instead
Drill the rule that fever in a child expected to be neutropenic is a medical emergency: draw cultures and give empiric antipseudomonal coverage within 60 minutes, never delaying for the ANC result. Practice recognizing the single-temperature threshold (≥38.3 °C once, or ≥38.0 °C sustained over an hour) rather than waiting for a 'high' fever.
Judging risk for tumor lysis syndrome from one set of electrolytes drawn after chemotherapy has started, and clearing a child as low risk because potassium and creatinine look normal on that single draw.
TLS is mentally filed as a potassium problem, so a normal potassium reads as 'safe,' and candidates anchor on a single time point instead of a trajectory across the 24–72 hours after induction.
What to do instead
Practice interpreting serial panels against Cairo-Bishop–style criteria (potassium, phosphorus, uric acid, corrected calcium, creatinine), including the percentage-change-from-baseline component, and rehearsing the prevention bundle: vigorous hydration, allopurinol or rasburicase by risk category, and frequent monitoring during the first days of induction.
Selecting 'give vincristine intrathecally' as part of triple intrathecal prophylaxis, or accepting vincristine delivered by a route/setup other than a short IV administration.
Vincristine is grouped mentally with methotrexate and cytarabine as 'a chemo we put in the spinal fluid,' and the drug's name familiarity masks its unique fatal-if-intrathecal status.
What to do instead
Memorize the short list of agents that are fatal when given intrathecally and the safe administration standard (IV push or short infusion, minibag, never a spinal needle), then rehearse the independent double-check of drug, dose, and route at the bedside for every intrathecal and every vinca-alkaloid order.
Recommending chlorhexidine or a compounded 'magic mouthwash' as the primary intervention for chemotherapy-induced oral mucositis, and reaching for an NSAID for the pain.
Adult wound-care and general pain heuristics transfer in automatically, and the compounded rinse is a familiar ritual on many units, so it feels like the expected answer.
What to do instead
Anchor on the guideline-based oral care bundle (saline or sodium bicarbonate rinses, soft toothbrush, bland diet) plus systemic opioid for significant mucositis pain, and learn that chlorhexidine and unproven compounded rinses are not recommended. Avoid NSAIDs in thrombocytopenic patients.
Planning antiemetics as PRN-only after emetogenic chemotherapy, or giving a single 5-HT3 antagonist as the whole regimen for a highly emetogenic protocol.
Candidates equate 'as needed' with safe and think one modern antiemetic is sufficient; they also forget that pediatric prophylaxis is scheduled, not reactive.
What to do instead
Learn prophylaxis as a scheduled, guideline-matched combination (5-HT3 antagonist plus dexamethasone, with an NK1 antagonist added for eligible ages on highly emetogenic regimens, plus consideration of olanzapine), given before the first dose and continued on a schedule through the expected emetogenic window, with breakthrough agents planned in advance.
Treating a child with sickle cell disease and new fever, chest pain, and hypoxemia by giving a large crystalloid bolus while deferring transfusion, or transfusing toward a normal hemoglobin.
Fever-plus-hypoxemia reads as sepsis and the fluid bolus is reflexive; separately, candidates assume 'more hemoglobin is better' and push toward 12 g/dL without considering hyperviscosity.
What to do instead
Recognize acute chest syndrome as its own emergency: antibiotics plus prompt simple transfusion targeting a hemoglobin around 10 g/dL (exchange transfusion if severe), cautious fluids, and analgesia that does not suppress ventilation. Memorize that overshooting the hemoglobin in sickle cell raises viscosity and worsens the crisis.
Giving a rapid IV fluid bolus to a newly diagnosed child with a very high white count and respiratory distress, and/or transfusing red cells before cytoreduction.
Both actions are the default responses to 'sick child with distress and anemia,' and the white count is treated as a lab curiosity rather than the cause of the pulmonary and neurologic findings.
What to do instead
Link extreme leukocytosis to leukostasis and treat it as a cytoreduction emergency (urgent leukapheresis or hydroxyurea per protocol, oxygen, cautious fluid management, avoiding red cell transfusion until the white count is reduced because anemia is protective against hyperviscosity).
Choosing 'refer to palliative care' only when curative options are exhausted or when a do-not-resuscitate order is being discussed.
Palliative care is mentally fused with hospice care from adult generalist exposure, so it feels like giving up rather than adding a layer of support.
What to do instead
Learn the definitional split: palliative care is symptom management plus goals-of-life communication layered in from diagnosis alongside curative therapy, and hospice is a terminal-phase designation. Rehearse phrasing that explains concurrent palliative involvement to families without implying abandonment.
Reading a preschooler's regression, magical thinking, or belief that the illness is punishment as maladaptive coping or as a behavioral problem needing a psych referral, and explaining the diagnosis to a young child in abstract adult terms.
Adult coping frameworks (insight, verbal processing) are applied to a child who is cognitively not there yet, and candidates underestimate how egocentrism drives self-blame.
What to do instead
Map explanations and interventions to developmental stage: literal, concrete language with play and medical play for preschoolers; explicit reassurance that the child did not cause the illness; normalization of regression; and peer/teen groups that address autonomy and body image for adolescents.
Selecting codeine or tramadol as the opioid for a young child's pain, or continuing an asparaginase infusion after a mild hypersensitivity reaction.
These are common adult and older-pediatric analgesics, and a 'mild' reaction feels tolerable enough to finish the dose rather than waste it.
What to do instead
Memorize the pediatric hard stops: codeine and tramadol are contraindicated in young children (and after tonsillectomy in older children) because of CYP2D6 ultrarapid metabolism, and meperidine is avoided. For asparaginase, stop the infusion at the first sign of hypersensitivity, treat, and know the erwinia or PEG-asparaginase alternatives for re-exposure.