Vincristine is a core chemotherapeutic drug administered to pediatric acute lymphoblastic leukemia patients. Despite its efficacy in treating leukemia, it can lead to severe peripheral neuropathy in a subgroup of the patients. Peripheral neuropathy is a debilitating and painful side-effect that can severely impact an individual's quality of life. currently, there are no established predictors of peripheral neuropathy incidence during the early stage of chemotherapeutic treatment. As a result, patients who are not susceptible to peripheral neuropathy may receive sub-therapeutic treatment due to an empirical upper cap on the dose, while others may experience severe neuropathy at the same dose. contrary to previous genomics based approaches, we employed a metabolomics approach to identify small sets of metabolites that can be used to predict a patient's susceptibility to peripheral neuropathy at different time points during the treatment. Using those identified metabolites, we developed a novel strategy to predict peripheral neuropathy and subsequently adjust the vincristine dose accordingly. in accordance with this novel strategy, we created a free user-friendly tool, VIPNp, for physicians to easily implement our prediction strategy. our results showed that focusing on metabolites, which encompasses both genotypic and phenotypic variations, can enable early prediction of peripheral neuropathy in pediatric leukemia patients. Acute lymphoblastic leukemia (ALL) is the most common cancer among children, accounting for approximately 26% of all pediatric cancers in the USA 1. Although the 5-year survival rate of pediatric leukemia patients is as high as 86%, the side-effects of the treatment can severely impact the quality of life of survivors 2. In particular, vincristine, a core chemotherapeutic drug administrated as part of the ALL therapy that has been in use for more than 50 years, has a dose-limiting toxicity: peripheral neuropathy. Vincristine-induced peripheral neuropathy (VIPN) is characterized primarily by numbness, tingling, and a painful sensation felt in the hands and feet, muscle weakness, and constipation due to its effect on the sensory, motor, and autonomic nerves 3-5. In some instances, VIPN can be prolonged and may last even after discontinuation of the treatment, impairing patients' motor skills 6-9 which results in limitation of their daily life activities for many years after completion of therapy 10. While VIPN is severe in a subpopulation of patients, another subpopulation experiences negligible neuropathy. Currently, there are neither established ways of predicting susceptibility to VIPN in patients, nor ways to treat it effectively, resulting in a suboptimal management for both the cohorts. Predicting VIPN susceptibility in patients will enable better dosage decision making tools for physicians and in turn may improve the quality of life of these patients. Several researchers have studied the association between genomics and VIPN incidence; however, the majority of the results have been controve...