In managing ECMO, preventing thrombus formation and hemolysis is crucial. While centrifugal pumps are increasingly used in pediatric ECMO, pumps designed for low flow range are not approved in Japan. Thus, centrifugal pumps for adults are used in pediatric ECMO cases. This increases the risk of thrombus formation in the enlarged flow paths before and after the centrifugal pump. To prevent thrombus formation in the ECMO circuit, it is necessary not only to appropriately optimize the dosage of anticoagulants but also to pay meticulous attention to circuit configuration. Furthermore, using centrifugal pumps at low flow rates increases shear stress on the blood, making hemolysis significantly more likely to occur in pediatric cases compared to adult cases. To reduce the incidence of hemolysis, it is necessary to use centrifugal pumps designed for low flow range. However, given the current situation where such centrifugal pumps are not approved in Japan, we must proceed with the understanding that hemolysis is more likely to occur in pediatric ECMO cases using centrifugal pumps. Moving forward, to reduce complications and improve outcomes in pediatric ECMO, the development of pediatric ECMO systems, including centrifugal pumps optimized for low-flow range, is required.