Inclusion Criteria:

- Age: 0-21 years (and at least 5 kg body weight), with a minimum of 80% of
participants under 18 years of age.

- Diagnosis: KMT2A-r, NPM1-m, or NUP98-r acute leukemia in first or greater relapse or
refractory to standard (re-) induction treatment (including HSCT). Please note that
genetic alteration must be confirmed by the central laboratory, or the participant
will discontinue protocol therapy.

- Eligible participants also must fulfill one of the following conditions:

1. Bone marrow relapse is defined as:

1. A single bone marrow sample showing ≥ 5% leukemic blasts by flow
cytometry, fluorescence in situ hybridization (FISH) testing, or other
molecular method.

- a single bone marrow sample with at least two tests showing ≥ 1%
leukemic blasts, examples of tests (confirmed by central lab)
include: Flow cytometry showing leukemia ≥ 1% by multiparameter flow
cytometry (MFC) confirmed by central lab.

- Karyotypic abnormality as confirmed by central cytogenetic review.

- FISH abnormality identical to one present at diagnosis (must be above
level of sensitivity of specific FISH probe; central cytogenetic
review required).

- Polymerase chain reaction (PCR) or next generation sequencing
(NGS)-based demonstration of validated leukemogenic lesion (e.g.,
fusion, mutation) in a Clinical Laboratory Improvement Amendments
(CLIA)-approved laboratory that matches initial diagnosis and is
quantifiable as ≥1% confirmed by central lab.

2. Participants with combined extramedullary and bone marrow relapse (defined
as above) are eligible.

3. Participants with isolated extramedullary disease (EMD) are not eligible.
EMD relapse is defined as biopsy-proven extramedullary disease without
bone marrow disease after documented complete response (CR) following
initial therapy. Participants with isolated central nervous system (CNS)
relapse are not eligible. Participants with a combined
medullary/extramedullary relapse, including CNS disease, are eligible.

4. Participants with asymptomatic CNS3 disease are eligible if they do not
have isolated CNS3 extramedullary relapse.

5. For participants unable to undergo bone marrow assessment, a peripheral
blood absolute blast count ≥ 1,000 cell/microliter is sufficient to
diagnose relapsed or refractory disease and facilitate confirmation of
required genetic alterations for protocol therapy.

2. Refractory disease/induction failure:

1. Acute myeloid leukemia (AML): The bone marrow contains ≥ 1% leukemic
blasts by MFC at the end of 2 cycles of induction therapy.

2. Acute lymphoblastic leukemia (ALL)/mixed-phenotype acute leukemia
(MPAL)/acute undifferentiated leukemia (AUL): The bone marrow contains ≥
1% leukemic blasts by MFC at the end of induction and consolidation, or
persistent MRD prior HSCT (defined as > 0.01%).

3. For participants unable to have bone marrow assessed, a peripheral blood
absolute blast count ≥ 1,000 cell/microliter is sufficient to diagnose
relapsed or refractory disease.

3. Molecular refractory disease in infant ALL, defined as MRD >0.05% after primary
induction and consolidation therapy measured by MFC or PCR.

- Performance status: Participants must have a performance status corresponding to
Eastern Cooperative Oncology Group (ECOG) scores of 0, 1 or 2 (≥ 50% Lansky or
Karnofsky score). Use ECOG for adult participants (≥18 to 21 years), Karnofsky for
participants ≥16 to 18 years of age, and Lansky for participants < 16 years of age.
Participants who are unable to walk because of paralysis, but who are up in a
wheelchair, will be considered ambulatory for the purpose of assessing the
performance score.

- Adequate organ function:

1. Renal function defined as: Creatinine clearance (CrCl) ≥60 mL/min (as measured
by a nuclear glomerular filtration rate [GFR] scan or calculated by the
Schwartz formula and normalized to a body surface area of 1.73 m^2).

2. Liver function defined as:

1. Direct bilirubin < 3 x upper limit of normal (ULN) and Serum glutamic
pyruvic transaminase (SGPT) (alanine transaminase [ALT]) ≤ 5 x ULN.

2. If liver abnormality is due to radiographically identifiable leukemia
infiltrate, the participant will remain eligible.

3. Cardiac function defined as: Pre-treatment left ventricular function on
echocardiography: Fractional shortening (FS) ≥ 25% or ejection fraction (EF) ≥
40%, and no signs of congestive heart failure within 4 weeks before start of
screening.

- Prior therapy: Participants must have recovered from the acute toxic effects of all
prior anti-cancer therapy (excluding Grade 2 toxicities that are not considered a
safety risk or medically significant toxicity deemed irreversible by the
Investigator) and must meet the following minimum duration from prior anti-cancer
directed therapy prior to enrollment.

1. Cytotoxic chemotherapy: Must not have received within 14 days or within 5 drug
half-lives (whichever is longer), of entry onto this study, except for
hydroxyurea or corticosteroids. Use of steroids and hydroxyurea for other
purposes such as differentiation syndrome, or to premedication to prevent
allergic reaction or during anesthesia is allowed.

2. Intrathecal cytotoxic therapy: No washout or waiting period is required for
participants having received any combination of intrathecal cytarabine,
methotrexate, and/or hydrocortisone.

3. Antibodies: ≥ 21 days must have elapsed from infusion of last dose of an
antibody-drug conjugate. For unmodified antibodies or T cell engaging
antibodies, 2 half-lives must have elapsed before enrollment. Any toxicity
related to prior antibody therapy must be recovered back to baseline.

4. Interleukins, interferons and cytokines (other than hematopoietic growth
factors): ≥ 21 days after the completion of interleukins, interferon or
cytokines (other than hematopoietic growth factors).

5. Hematopoietic growth factors: ≥ 14 days after the last dose of a long-acting
growth factor (e.g., peg-filgrastim) or 7 days for short-acting growth factor.

6. Radiation therapy (RT): 14 days have elapsed for local palliative RT (small
port); ≥ 84 days must have elapsed if prior craniospinal RT or if ≥ 50%
radiation of pelvis; ≥ 42 days must have elapsed if other substantial bone
marrow (BM) radiation.

7. Stem cell infusions:

1. Participants who have relapsed after allogeneic (non-autologous) BM or
stem cell transplant (with or without total body irradiation [TBI]) or
boost infusion (any stem cell product; not including donor lymphocyte
infusion [DLI]) must be at least 84 days post HSCT and without evidence of
graft versus host disease (GVHD) of any severity except: the use of
topical steroids for cutaneous GVHD is allowed and stable steroid doses
less than or equal to 10 mg of prednisone daily is permitted. Prednisone
dose must be adjusted for body surface area (BSA) in young children.
Physiologic doses of hydrocortisone for participants with adrenal
insufficiency is allowed.

2. Participants who after relapse and continue to receive cyclosporine,
tacrolimus or other agents to treat or prevent either GVHD post BM
transplant or organ rejection post-transplant are not eligible for this
trial. In the relapse setting, participants must be off medications to
treat or prevent either GVHD post BM transplant or organ rejection
post-transplant for at least 14 days prior to enrollment. A stable steroid
dose as mentioned above is allowed.

8. Cellular therapy: ≥ 30 days after the completion of DLI or any type of cellular
Therapy (e.g., modified T cells, NK cells, dendritic cells, etc.).

9. Prior exposure to a different menin inhibitor: Participants who received
previous treatment with a different menin inhibitor are allowed to enrol in the
study with the exception of those who experienced a severe adverse event
attributable to the strong anti-proliferative/pro-differentiation effects of
other menin inhibitors (such as severe differentiation syndrome). Participants
who experienced a severe adverse event, which can directly be attributed to
specific effects (e.g., long QT syndrome) observed with other menin inhibitors
can participate in the study if they fulfill the inclusion criteria.

- Informed consent: Written, signed and dated informed consent and pediatric assent
(if applicable) according to local law and legislation should be collected before
start of any study procedures.

- Female participants of childbearing potential must have a negative urine or serum
pregnancy test confirmed prior to enrollment.

- Female participants with infants must agree not to breastfeed their infants while on
this study.

- Contraception:

1. Participants of reproductive potential, starting from menarche and onwards, may
not participate unless they have agreed to use a highly effective contraceptive
method per Clinical Trial Facilitation Group (CTFG) guidelines for the duration
of study therapy and for 6 months after the completion of all study therapy.
For further guidance please review the CTFG website.

2. Male participants must use a condom during intercourse and agree not to father
a child or donate sperm during therapy and for the duration of study therapy
and for 4 months after the completion of all study therapy.

- Enrollment APAL2020SC trial (US and Canada only): Participants in the US and Canada
must have enrolled in the APAL2020SC trial prior to enrollment in the APAL2020K
trial.

Exclusion Criteria:

- Participants who in the opinion of the investigator may not be able to comply with
the study requirements of the study.

- Participants with Down syndrome.

- Participants with EMD are not eligible. EMD relapse is defined as biopsy proven
extramedullary disease without bone marrow disease after documented CR following
initial therapy.

- Participants with isolated CNS relapse are not eligible, as well as symptomatic CNS3
disease.

- Participants with acute promyelocytic leukemia (APL) or juvenile myelomonocytic
leukemia (JMML).

- Participants with malabsorption syndrome or any other condition that precludes
enteral administration of a menin inhibitor.

- Concomitant therapy: Gastric pH has great influence on absorption of ziftomenib;
therefore, the use of proton pump inhibitors is prohibited, if necessary H2 Blockers
may provide an alternative treatment option.

- Participants who are currently receiving another investigational drug.

- Participants with any known congenital bone marrow failure syndrome.

- Participants with known prior allergy to any of the medications used in protocol
therapy.

- Participants with documented active, uncontrolled infection at the time of study
entry.

- Active/uncontrolled known human immunodeficiency virus (HIV) infection, hepatitis B
virus (HBV) and hepatitis C virus (HCV). Note: HIV testing does not need to be
conducted at screening unless it is required per local guidelines or institutional
standard.

- Post menarche female participants with positive pregnancy test, and a lactating
female participant.

- Participant has a pre-existing disorder predisposing the participant to a serious or
life-threatening infection (e.g., cystic fibrosis, congenital or acquired
immunodeficiency, bleeding disorder, or cytopenia not related to the leukemia or its
treatment).

- Participants must not be receiving other investigational medications (defined as
medicinal products not yet approved for any indications, including
alternative/herbal therapies) within 30 days of first dose of study drug or while on
study.

- Significant congenital cardiovascular disease including, but not limited to
conditions such as long QT syndrome, fundamental uncorrected cardiac defect (e.g.,
coarctation of the aorta) that poses a significant risk to the participant
(ventricular septal defect or atrial septal defect are considered non-significant).

- Underlying medical condition that, in the Principal Investigator's opinion, will
make the administration of study treatment hazardous or obscure the interpretation
of toxicity determination or AEs.

- For fludarabine and cytarabine: Hypersensitivity to the active substance or to any
of the excipients.

- Recent live vaccinations for at least 6 months.