Anaemia in pediatric oncology patients is a critical condition where there is a reduction in red blood cells or hemoglobin, impairing oxygen delivery to tissues. It can result from the cancer itself (e.g., bone marrow infiltration), chemotherapy, or other factors like bleeding or hemolysis. Severe anaemia in these children requires urgent evaluation and management due to the risk of life-threatening hypoxia, fatigue, and cardiac strain.

Common in children being treated for cancer. Usually well tolerated. Most often as a result of suppression of normal hematopoiesis by chemotherapy. Other causes are chronic blood loss, infection, hemolysis, nutritional deficiencies, bone marrow infiltration.

Treatment

• Blood transfusion at a Hb of 7-10g/dl not advisable unless there is decompensation or blood loss is continuous.

• Blood products should be transfused preferably and leukodepletion filters should be used.

• Recombinant erythropoietin may be useful.

This is defined as total platelets of <150,000/cmm. They are classified into: mild 101-149/cmm, moderate 51-100/cmm, severe 21-50/cmm, Profound ≤20/cmm. Thrombocytopaenia is often caused by chemotherapy, Radiation therapy, Bone marrow metastasis, DIC, infection.

• Avoid all NSAIDs
• Spontaneous bleeds can occur if platelets < 10,000
• Platelet transfusion indications:
  • count < 10000/microL
  • Any CNS bleed (even if count > 10000)
  • Bone marrow aspiration, lumbar puncture, surgery.

This defined as a total leukocyte count of >50,000/microL in acute myeloid leukaemia (AML) or >100,000/microL in other malignancies. Hyperleucocytosis is found in 9-13% cases with acute leukaemic leukaemia in 5-22% cases of acute myeloid leukaemia, and bone marrow metastasis. This is due to high metabolic activity of the dividing blasts along with the production of various cytokines causes endothelial damage and hemorrhage. Which lead to adhesive interactions between damaged endothelium and the leukaemic blasts cause leukostasis. Leukostasis leads to local hypoxemia. The release of procoagulants from blasts and decreased platelets exacerbate local hemorrhage dilated intravascular coagulopathy.

• Central nervous system (CNS): blurred vision, altered mental status, dizziness, coma, cranial nerve palsy, intra cerebral haemorrhage, 
• Pulmonary: tachypnoea, dysnoea, hypoxia from pulmonary haemorrhage, alveolar damage.
• Renal: renal vein thrombosis, oliguria, priapism
• Tumour lysis syndrome (TLS)

1. Leukapheresis is done in patients with hypoxic or CNS Signs and severe renal or metabolic abnormalities. Which may decrease early death rate. Challenges with leukapheresis are the need for anticoagulation, difficulty with access in small children, and not widely available in many hospitals. 
2. Exchange Blood Transfusion
3. Hyperhydration 
4. Allopurinol (10mg/kg/day), Rasburicase (0.2mg/kg IV)
5. Avoid red blood cell over-transfusion if hemodynamically stable because this increases viscosity
6. With rapid Chemotherapy treat with hydroxyurea, cyclophosphamide and steroid.

Clinically significant neutropenia is defined as an absolute neutrophil count (ANC) <500cells/microL or expected to decline due to recent chemotherapy administration. Single temperature > 38.5°C (101° F) or two consecutive temperatures > 38.0°C (100.4°F) taken orally in a 12-hour period and lasting at least 1 hour. There may still be infection in the absence of fever. 80 % of all patients develop fever at least once during treatment. Infectious source identified in 30%. 80% infection believed to arise from patient’s endogenous flora.

• Mild- 1000-1500cells/microL
• Moderate- 500-1000cells/microL
• Severe- 200-500cells/microL
• Profound-<200cells/microL

• Degree of neutropenia
• Rapid decline in ANC
• Prolonged duration neutropenia (> 7 to 10 days)
• Cancer not in remission
• Comorbid illness
• Peripheral lines and central venous catheters.

Patients should be pan (blood, urine, stools, sputum, discharges) cultured including from central line as well as chest x-ray.

1. Single agents e.g. ceftriaxone, cefepime, imipenem, piperacillin-tazobactam ± amikacin
2. Consider vancomycin in MRSA
3. Fluconazole 6mg/kg stat, then 3mg/kg/day to cover for fungi
4. Acyclovir @10mg/kg/dose 8hrly to cover for viruses
5. Antimalarials if malaria parasite is positive
6. Deworming with anthelminthics
7. Consider removing all indwelling devices.
8. Counsel on reverse isolation.
9. Neutropenic diet.
10. Use of G-CSF e.g. Filgrastim.

Hematological emergencies, including severe anemia, bleeding, hyperleukocytosis, and febrile neutropenia, are particularly dangerous in children with blood cancers (like leukemia) or those receiving chemotherapy. Severe anemia is exacerbated by conditions such as malaria or nutritional deficiencies, which are prevalent in this region.

Challenges in managing these emergencies in sub-Saharan Africa include limited access to specialized healthcare, diagnostic tools, and timely treatments like chemotherapy or blood transfusions. Recognizing symptoms early, ensuring rapid referral to tertiary centers, and integrating community awareness are critical to improving outcomes. Expanding access to pediatric oncology services and improving health infrastructure are essential steps toward saving children's lives from these life-threatening conditions.