Leukemia Missed in Children: When a Blood Count Is Indicated

A tired child, a fever, a bruise on the shin, a complaint that a leg hurts. Each of these is an ordinary part of childhood, and each can also be an early sign of leukemia, a cancer of the blood-forming cells. This article looks at how childhood leukemia can first appear, what published medical guidance says about when a blood count becomes indicated, and how Oregon law approaches a claim that the diagnosis came too late.

What childhood leukemia is

This article focuses on one form, acute lymphoblastic leukemia, or ALL. The National Cancer Institute (NCI) explains that "ALL occurs because too many stem cells become lymphoblasts that do not mature into B lymphocytes or T lymphocytes."¹ As those leukemia cells build up, the NCI explains, "there is less room for healthy red blood cells, platelets, and white blood cells."¹ The NCI also states that "ALL usually worsens quickly if it is not treated."¹

The symptoms, and why they are easy to explain away

The NCI states that "Symptoms of childhood ALL are caused by not having enough red blood cells and platelets and by having too many white blood cells that don't work well."¹ The symptoms it lists include fever, easy bruising or bleeding, weakness or fatigue, pale skin, bone or joint pain, painless swollen lymph nodes, and "frequent infections or infections that do not go away."¹ It also lists "flat, pinpoint, dark-red spots under the skin caused by bleeding (petechiae)."¹

The same NCI page adds a caution: "These symptoms may be caused by problems other than ALL."¹

When guidance says a blood count is indicated

Specific published criteria appear in the guidance of England's National Institute for Health and Care Excellence (NICE), in its guideline on suspected cancer, known as NG12. NICE is a UK body, and its guideline is not Oregon law. It does, however, set out in specific terms which findings it recommends should prompt a blood test.

For leukemia in children and young people, NG12 states: "Offer a very urgent full blood count to assess for leukaemia in children and young people with any of the following:"² The findings it lists are pallor, persistent fatigue, unexplained fever, unexplained persistent infection, generalised lymphadenopathy, persistent or unexplained bone pain, unexplained bruising, and unexplained bleeding.²

Two findings call for a faster response. NG12 states: "Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or hepatosplenomegaly."²

The guideline defines its own timing words. "Very urgent" means "To happen within 48 hours."³ "Immediate" means "An acute admission or referral occurring within a few hours, or even more quickly if necessary."³ The guideline defines "children" as "From birth to 15 years," and "children and young people" as "From birth to 24 years."³

NICE uses the term "full blood count." The test the NCI describes as a complete blood count, or CBC, "checks a sample of blood for" the number of red blood cells and platelets, the number and type of white blood cells, the amount of hemoglobin, and the amount of hematocrit.¹

What "unexplained" and "persistent" mean

Two words recur in the NICE list. The guideline defines "unexplained" as "Symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination and any primary care investigations)."³

It defines "persistent" as "The continuation of specified symptoms and/or signs beyond a period that would normally be associated with self-limiting problems."³ The guideline adds: "The precise period will vary depending on the severity of symptoms and associated features, as assessed by the health professional."³

So the guidance does not set a fixed number of days. It asks whether a symptom has outlasted what an ordinary, self-limiting illness would explain, as judged by the clinician seeing the child.

When bone and joint pain point somewhere else

Bone and joint pain deserve separate attention, because they can lead a clinician toward a different diagnosis. A 2020 study by Danish pediatricians compared children who had ALL and arthritis with children who had juvenile idiopathic arthritis (JIA), a chronic inflammatory joint disease. The authors wrote: "Acute lymphoblastic leukemia (ALL) may initially present with arthritis as part of a prodromal stage lasting for weeks or even months, without typical signs of leukemia."⁴ They continued: "Thus, ALL may be misdiagnosed as juvenile idiopathic arthritis (JIA), leading to a delay in proper treatment."⁴

Treatment for the wrong condition can matter too. The same authors noted that "Corticosteroids may, even when given intraarticularly, relieve symptoms, change the cytology of the bone marrow and reduce the subsequent response to chemotherapy."⁴ Their conclusion was practical: "A simple count of cell lines with low counts can serve as a basic diagnostic strategy."⁴

A 2022 study from Thailand of children with leukemia stated in its background section that "Childhood leukemia with musculoskeletal (MSK) involvement mimics various conditions, which consequently leads to diagnostic delays."⁵ Those authors also found that "hematologic abnormalities were significantly less frequent in the group with MSK involvement."⁵ In other words, in that study the children whose leukemia involved the bones and joints were less likely to have abnormal blood counts.

How Oregon law frames the question

In Oregon, a physician's care is measured by ORS 677.095(1). It provides that a physician licensed by the Oregon Medical Board "has the duty to use that degree of care, skill and diligence that is used by ordinarily careful physicians in the same or similar circumstances in the community of the physician or a similar community."⁶

Guidance like NG12 is medical literature, not Oregon law. In a case involving a child whose leukemia was diagnosed late, the factual questions a lawyer would evaluate include which symptoms were recorded at each visit and for how long; what explanation was given for them; whether a blood count was ordered, and when; whether its results were reviewed and acted on; and whether the explanation was revisited when the symptoms did not clear. Where a blood count was drawn but its results were never acted on, the issues overlap with those in our post on abnormal test results that never reached the patient.

Our posts on delayed cancer diagnosis and proving damages in a delayed-diagnosis case cover causation and damages in more detail, and our post on missed lymphoma symptoms covers a related blood cancer.

Time limits when the patient is a child

Oregon law puts time limits on when a claim can be filed, and cases involving children have their own wrinkles. For injuries from medical treatment, ORS 12.110(4) provides that the action "shall be commenced within two years from the date when the injury is first discovered or in the exercise of reasonable care should have been discovered."⁷ In Gaston v. Parsons, 318 Or 247 (1994), the Oregon Supreme Court held that "injury," as used in ORS 12.110(4), "consists of three elements: (1) harm; (2) causation; and (3) tortious conduct."⁸ The court held that the period "begins to run when the plaintiff knows or in the exercise of reasonable care should have known facts which would make a reasonable person aware of a substantial possibility that each of the three elements (harm, causation, and tortious conduct) exists."⁸ More on how discovery works is in our post on Oregon's medical malpractice statute of limitations.

Because the patient is a child, the clock works differently. ORS 12.160(1) tolls the statute of limitation while the person is younger than 18, if the person was a child when the cause of action accrued, and ORS 12.160(2) provides that the time may not be extended on that basis "for more than five years, or for more than one year after the person attains 18 years of age, whichever occurs first."⁹ That tolling does not reach the outer limit. ORS 12.110(4) provides that "notwithstanding the provisions of ORS 12.160, every such action shall be commenced within five years from the date of the treatment, omission or operation upon which the action is based …," with an exception for fraud, deceit or misleading representation.⁷ Minority alone does not push that five-year date back. The same interaction is discussed in our post on newborn sepsis and delayed recognition.

ORS 12.160 also addresses a parent's own claim for the child's medical bills. Subsection (5) provides: "If a child's cause of action is tolled under subsection (1) of this section, a cause of action for recovery of damages for medical expenses incurred by a parent, guardian or conservator of the child is tolled for the same period of time as the child's cause of action if the medical expenses resulted from the same wrongful conduct that is the basis of the child's cause of action."⁹

This article is educational

This article describes Oregon law in general terms. It is not legal advice and does not create an attorney-client relationship.

Time limits matter. Most Oregon personal-injury and auto-accident claims must be filed within two years of the injury or accident. Medical malpractice claims must be filed within two years of when you knew or reasonably should have known of the negligence, with an outer limit of five years from the act itself (with a fraud exception). Wrongful death claims must be filed within three years of the date of death. Claims against public bodies (cities, counties, state agencies, public hospitals) require a notice of claim within 180 days. Missing these deadlines typically ends a case.

If you think you may have a claim, call Huegli Law at 971-317-6436 for a free case review. Todd Huegli is licensed in Oregon and consults on cases in Oregon only.

Footnotes

1. PDQ Pediatric Treatment Editorial Board. Childhood Acute Lymphoblastic Leukemia (PDQ®)–Patient Version. National Cancer Institute. https://www.cancer.gov/types/leukemia/patient/child-all-treatment-pdq ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

2. NICE guideline NG12, Suspected cancer: recognition and referral — Recommendations organised by site of cancer (leukaemia in children and young people, 1.10.2–1.10.3). https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer ↩ ↩² ↩³

3. NICE guideline NG12, Suspected cancer: recognition and referral — Terms used in this guideline. https://www.nice.org.uk/guidance/ng12/chapter/Terms-used-in-this-guideline ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

4. Brix N, Rosthøj S, Glerup M, Hasle H, Herlin T. Identifying acute lymphoblastic leukemia mimicking juvenile idiopathic arthritis in children. PLoS One. 2020;15(8):e0237530. https://pmc.ncbi.nlm.nih.gov/articles/PMC7418991/ ↩ ↩² ↩³ ↩⁴

5. Kittivisuit S, Sripornsawan P, Songthawee N, et al. Musculoskeletal involvement in childhood leukemia: Characteristics and survival outcomes. Pediatr Rheumatol Online J. 2022;20:34. https://pmc.ncbi.nlm.nih.gov/articles/PMC9063147/ ↩ ↩²

6. ORS 677.095 — Duty of care. https://www.oregonlegislature.gov/bills_laws/ors/ors677.html ↩

7. ORS 12.110 (ORS chapter 12 — limitations of actions). https://www.oregonlegislature.gov/bills_laws/ors/ors012.html ↩ ↩²

8. Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994). https://static.case.law/or/318/cases/0247-01.json ↩ ↩²

9. ORS 12.160 — Suspension for minors and persons who have disabling mental condition. https://www.oregonlegislature.gov/bills_laws/ors/ors012.html ↩ ↩²