Suspected Cancer in Children & Young People (NG12)

Safety

The NG12 Action Levels — Know the Exact Timeframes

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NG12 attaches a specific timeframe to each action. Learn these four levels — every feature below maps to one of them.

Immediate

Specialist assessment within hours (acute referral / same-day admission) — for the child who may have acute leukaemia.

Very urgent

Appointment or test within 48 hours — the workhorse level: very urgent FBC, very urgent paediatric appointment, or very urgent direct-access X-ray/USS.

Urgent

Appointment within 2 weeks (2-week-wait) — e.g. absent red reflex → ophthalmology.

Other action

A specific test or routine paediatric appointment, with safety-netting and review.

Unexplained petechiae → Immediate Immediate specialist assessment for leukaemia (non-blanching spots).

Unexplained hepatosplenomegaly → Immediate Immediate specialist assessment for leukaemia.

Systemically unwell child Toxic, septic-looking, reduced consciousness, severe pain → emergency admission (999/A&E), not an outpatient pathway.

The whole value of NG12 in children is the timeframe attached to each action — "refer" without "within 48 hours" is too slow for diseases that can progress in days. Petechiae or hepatosplenomegaly carry a high enough leukaemia risk that NG12 escalates them past the 48-hour FBC straight to immediate assessment.

Assess

Focused History & Examination of the Worrying Child

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History

Duration & progression; persistent / unexplained features (the NG12 keywords) — morning vomiting or headache, bone pain waking at night, weight loss, night sweats, fatigue, recurrent infection, easy bruising/bleeding; parental concern and the number of prior presentations.

Examination — always

Plot growth & (under-2s) head circumference; temperature; full skin (petechiae, bruising, pallor); lymph nodes (site, size, generalised?); abdomen (mass, hepatosplenomegaly — do not repeatedly palpate a mass); eyes (red reflex, squint, proptosis); neuro (cerebellar signs, gait, fundi).

“Unexplained” = act

NG12 hinges on unexplained and persistent — a feature with no clear benign cause triggers the relevant action level, not reassurance.

Systemically unwell

A toxic, septic-looking child or one with reduced consciousness needs emergency admission, not an outpatient pathway.

Childhood cancers hide behind common, non-specific symptoms, so the protective step is a complete, structured examination of every worrying child — skin, nodes, abdomen, eyes and neurology — because the discriminating sign (petechiae, an abdominal mass, an absent red reflex, cerebellar signs) is often found only when specifically sought. The words “unexplained” and “persistent” are the NG12 triggers: a feature without a clear benign explanation is what converts a routine review into a timed referral.

Leukaemia

Leukaemia — Immediate vs Very Urgent FBC (48h)

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Leukaemia is the commonest childhood cancer (~30%). Split features into immediate referral vs a very urgent FBC within 48 hours.

Immediate referral

Unexplained petechiae or hepatosplenomegaly → immediate specialist assessment (don't wait for the FBC).

FBC ≤48h Pallor

Unexplained → very urgent FBC within 48 hours.

FBC ≤48h Persistent fatigue

Unexplained, persistent → FBC within 48h.

FBC ≤48h Unexplained fever

→ FBC within 48h.

FBC ≤48h Persistent infection

Unexplained & persistent → FBC within 48h.

FBC ≤48h Generalised lymphadenopathy

→ FBC within 48h.

FBC ≤48h Unexplained bruising / bleeding

→ FBC within 48h.

FBC ≤48h Persistent / unexplained bone pain

→ FBC within 48h (± X-ray, Step 5).

Acting on the result

Abnormal FBC (cytopenias, blasts, very high/low WCC) or a clinical concern despite a normal count → discuss with paediatrics the same day. A normal FBC does not fully exclude leukaemia if concern persists.

The FBC with film is fast, accessible and high-yield, so NG12 uses it as the 48-hour gate for most leukaemia features. Many of these symptoms overlap with viral illness — the trigger is being unexplained or persistent. Petechiae/hepatosplenomegaly skip the test because their predictive value is high enough to warrant immediate assessment.

Brain / CNS

Brain & CNS Tumours — Very Urgent (48h) · HeadSmart

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CNS tumours are the commonest solid childhood cancer. NG12: very urgent referral (appointment within 48 hours) for a newly abnormal cerebellar or other central neurological function.

Refer ≤48h Newly abnormal neuro exam

New cerebellar signs (ataxia, nystagmus, intention tremor) or other new central neurological abnormality → very urgent paediatric/neuro referral within 48 hours.

HeadSmart red flags

Persistent/recurrent morning vomiting; new persistent headache (esp. waking the child); new squint/diplopia or papilloedema; deteriorating vision; abnormal balance/gait/coordination; behaviour or developmental change/regression.

By age

Infants: rising head circumference, developmental regression. School-age: headache, visual problems. Always plot head circumference in the under-2s.

Action

Low threshold — discuss/refer urgently; many present with evolving, subtle signs over weeks.

Childhood brain tumours are notoriously slow to diagnose because early signs are subtle and intermittent. The HeadSmart campaign and NG12's 48-hour referral exist precisely to compress that delay — a newly abnormal cerebellar/CNS exam is never "wait and see".

Abdominal

Neuroblastoma, Wilms' & Retinoblastoma

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Refer ≤48h Abdominal mass / enlarged organ

Palpable abdominal mass or unexplained enlarged abdominal organ → very urgent referral within 48 hours (neuroblastoma, Wilms' tumour). Do not repeatedly palpate.

Refer ≤48h Visible haematuria

Visible and unexplained → very urgent referral within 48h (Wilms'/renal).

Refer ≤48h Other neuroblastoma features

Unexplained proptosis, periorbital bruising, bone pain, pallor, irritability in a young child → very urgent assessment.

Refer ≤2wk Absent red reflex

Absent red reflex / white reflex (leucocoria), or a new squint → urgent ophthalmology referral within 2 weeks (retinoblastoma).

An abdominal mass in a child is a Wilms' tumour or neuroblastoma until proven otherwise; repeated palpation of a Wilms' is avoided because of (a small) rupture/seeding concern. Retinoblastoma is the classic absent-red-reflex diagnosis — sight- and life-threatening but highly curable when caught early, hence a firm 2-week ophthalmology route.

Lymphoma / Sarcoma

Lymphoma & Bone / Soft-Tissue Sarcoma

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Refer ≤48h Lymphoma

Unexplained lymphadenopathy with any of: fever, night sweats, weight loss, pruritus, breathlessness, or hepatosplenomegaly → very urgent referral within 48 hours.

X-ray ≤48h Bone sarcoma

Unexplained bone swelling or bone pain → very urgent direct-access X-ray within 48 hours (osteosarcoma, Ewing's).

Refer ≤48h If X-ray abnormal

X-ray suggests possible bone sarcoma → very urgent referral within 48 hours.

USS ≤48h Soft-tissue sarcoma

Unexplained lump increasing in size → very urgent direct-access ultrasound within 48 hours; refer very urgently (≤48h) if USS suggests sarcoma or is uncertain with ongoing concern.

"Growing pains" and minor trauma are the traps for bone sarcoma — unexplained or persistent bone pain/swelling earns a 48-hour X-ray, not reassurance. An enlarging unexplained soft-tissue lump warrants ultrasound within 48 hours; persistent clinical concern overrides a reassuring scan.

Investigate

Direct-Access Investigations & Acting on Results

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FBC ≤48h

Pallor, fatigue, fever, persistent infection, bruising/bleeding, generalised lymphadenopathy or persistent bone pain → very urgent FBC (with film) within 48 hours for leukaemia.

X-ray ≤48h

Unexplained bone pain/swelling → very urgent direct-access X-ray within 48 hours (osteosarcoma, Ewing's).

USS ≤48h

Unexplained lump increasing in size → very urgent direct-access ultrasound within 48 hours (soft-tissue sarcoma).

Acting on results

Abnormal FBC (cytopenias, blasts, very high/low WCC) → discuss with paediatrics the same day. X-ray/USS suggesting sarcoma → very urgent referral ≤48h. A normal test does not exclude cancer if concern persists — refer anyway.

Don't delay referral

For immediate features (petechiae, hepatosplenomegaly) refer without waiting for any test.

NG12 gives primary care direct, fast access to the few tests that matter in children — the FBC with film, and direct-access X-ray/USS — precisely so a child can be triaged within 48 hours without first waiting for a clinic appointment. The governing safety principle is that a normal result never overrides ongoing clinical or parental concern: the test informs urgency, it does not licence reassurance, and the immediate features bypass testing altogether.

Refer / Safety-net

Parental Concern, Communication & Safety-Netting

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Persistent parental concern

NG12: take account of the insight/knowledge of parents and carers — consider referral if a parent or carer has persistent concern, even when your assessment is reassuring.

Repeat presentations

≥3 presentations with the same problem (or repeated attendances) is a recognised trigger to lower the referral threshold and review.

Safety-net actively

Continue to investigate until symptoms are explained or resolved; give specific verbal + written advice on which symptoms warrant urgent re-attendance and the expected timescale.

What "very urgent" means

Explain a 48-hour referral/test to the family, what will happen, and that it is precautionary; document red flags, the action taken, the timeframe, and the follow-up/review plan.

Make the timeframe explicit on the referral

State "immediate", "very urgent (within 48 hours)" or "urgent (within 2 weeks)" on the referral so it is triaged correctly — and phone for the immediate/48-hour ones.

Parents detect serious illness early; NG12 explicitly elevates persistent parental concern and repeated attendance to referable triggers. Stating the exact NG12 timeframe on the referral (and phoning for the urgent ones) is what ensures the child is actually seen inside the window — the safety-net that catches the cancers that don't read the textbook.

Reference

Complete NG12 Children & Young People Table — Symptom · Action · Timeframe

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The full NICE NG12 table (updated May 2025), reproduced by symptom group. Each row gives the exact action and timeframe. Immediate = acute referral/admission within a few hours. ≤48h = very urgent appointment or test within 48 hours. ≤2 weeks = urgent (2-week-wait). Other = consider referral / clinical judgement.

Abdominal

Hepatosplenomegaly (unexplained)

Immediate Referral to paediatrician

Abdominal mass / enlarged abdominal organ (unexplained)

≤48h Paediatrician appointment

Splenomegaly (unexplained)

≤48h Paediatrician appointment

Bleeding / bruising / rashes · Skin / surface

Petechiae (unexplained)

Immediate Referral to paediatrician

Bruising / bleeding (unexplained)

≤48h FBC

Pallor

≤48h FBC

Lumps / masses

Lymphadenopathy (unexplained)

≤48h Paediatrician appointment

Lymphadenopathy (generalised)

≤48h FBC

Lump (unexplained) increasing in size

≤48h USS

Neurological

New abnormality of cerebellar or other central neurological function

≤48h Paediatrician appointment

Non-specific

Fatigue (persistent, unexplained)

≤48h FBC

Fever (unexplained)

≤48h FBC

Infection (unexplained & persistent)

≤48h FBC

Fever with lymphadenopathy / splenomegaly (unexplained)

≤48h Paediatrician appointment

Night sweats with lymphadenopathy / splenomegaly

≤48h Paediatrician appointment

Pruritus with lymphadenopathy / splenomegaly

≤48h Paediatrician appointment

Weight loss with lymphadenopathy / splenomegaly

≤48h Paediatrician appointment

Persistent parental concern

Other Consider referral to paediatrician

Respiratory

SOB with lymphadenopathy / splenomegaly (unexplained)

≤48h Paediatrician appointment

Skeletal

Bone pain (persistent or unexplained)

≤48h FBC

Bone pain / swelling (unexplained)

≤48h X-ray

Urological

Haematuria (visible & unexplained)

≤48h Paediatrician appointment

Primary-care investigations / eye

USS / X-ray suggests sarcoma

≤48h Paediatrician appointment

Absent red reflex

≤2 weeks Referral to ophthalmologist

Almost every NG12 childhood-cancer feature funnels into one of two fast routes — immediate (petechiae, hepatosplenomegaly) or very urgent within 48 hours (everything else bar the 2-week ophthalmology route for an absent red reflex). Holding the whole table in view shows how tight the children's timeframes are compared with adults, and that "very urgent FBC within 48 hours" is by far the commonest action.