Background: To show the initial presenting features the children of acute lymphoblastic leukemia presented till the diagnosis at oncology Center/ Diyala/ Iraq.Methods: A retrospective study, carried out during 2016-2017. The data include constitutional, hematological, and infiltrative features with laboratory findings registered at patient’s files until the diagnosis. Data were analyzed by Statistical Package of Social Sciences v. 20.Results: The total patients were 55, distributed into: T- cell (10.9%) and B- cell leukemia (89.1%), FAB classification include L1 (11%), L 2 (89%) and L3 (0%). Most of patients presented at 1- 10 years of age (p value= 0.000); M: F= 1.3:1 (p value= 0.345). Fever and pallor were the most common features, 81.8% (p value=0.000) and 67.3% (p value=0.010), respectively. Other features were bone pain (40%), anorexia (36.4%), fatigability (30.9%), muco-cutaneous bleeding (27.3%), hepatosplenomegaly (56.4%), lymphadenopathy (49.1%), and facial palsy (1.8%). Hemoglobin was < 8 gm/ dl in 70.9 %, white cell count was < 50×109 cells/L in 70.9 %; 12.3% has severe leukocytosis, and platelets' count was between 20- 100 × 109 cells/L in 49%. Mediastinal infiltration (7.2%), pleural effusion (1.8%), pericardial effusion (1.8%), and positive cytospin (5.4%).Conclusions: L2 subtype was the dominant subtype; this contrary to all other studies and may be related to the prognosis. Most of the initial features were general and may indicate more common illnesses, but their constellation with complete blood picture should rise the possibility of leukemia. A rare complication, pleural effusion, was detected as initial feature.