Background: Hyperleukocytosis in pediatric acute leukemia is associated with increased morbidity and mortality and using leukapheresis (LPH) as management is controversial. Procedure: At our tertiary referral center, pediatric patients with newly diagnosed acute leukemia and a leukocyte count of 100k/µL or greater were evaluated and compared based on the use of LPH or not in management. Results: At our institution, LPH was used in 8 of 62 (13%) patients with hyperleukocytosis with minimal complications. Mean leukocyte count in patients who received LPH versus those who did not was 498k/µL and 237k/µL, respectively. Patients who received LPH were more likely to have symptoms of neurologic or pulmonary leukostasis (63% vs 17%, 75% vs 17%, respectively). Conclusions: The addition of LPH did not alter time to chemotherapy or survival outcomes. Leukapheresis was safe and well tolerated at our institution.