See also
Fever and petechiae - purpura
Key points
- Immune thrombocytopenia (ITP) is an isolated low platelet count of <100 x109/L in a well child with an otherwise normal full blood evaluation (FBE) and film
- Alternative causes for petechiae and purpura need to be excluded
- The decision to treat a child should be based on clinical symptoms and not the platelet count; the majority do not require treatment
- The risk of intracranial haemorrhage in ITP is very low (<1%)
Background
ITP is an autoimmune bleeding disorder characterised by all three of:
- Isolated thrombocytopenia (platelet count of <100 x109/L, often <20 x109/L)
- Well child with no concerning features on clinical history or examination
- Otherwise normal FBE and film
ITP is the most common cause of symptomatic thrombocytopenia in children. It is a diagnosis of exclusion as there is no specific laboratory test to confirm the diagnosis
Newly diagnosed ITP is within 3 months of diagnosis. ITP often resolves within 3 months, and resolves in 75% of children by 6 months. Chronic ITP is longer than 12 months
Assessment
History and examination
- Sudden onset petechial rash or bruising
- Bleeding symptoms can also include:
- epistaxis, gum or gastrointestinal bleeding, haematuria or menorrhagia
- very rarely intracranial haemorrhage (ICH): headache, nausea, vomiting, lethargy, irritability, decreased consciousness or neurological symptoms
- Preceding viral infection or recent live virus immunisation eg MMR
- Well looking with normal clinical observations
Red flags for alternative diagnosis
- Bone pain, limp, anorexia, weight loss, jaundice, fever, sweats or infective symptoms
- Rash, arthritis, myalgias, dry eyes, mouth ulcers, recurrent infections or fever
- Family or personal history of bleeding disorders
- Recent medication use (NSAIDs, anticoagulants or other anti-platelet medications)
Differential diagnoses
- Leukaemia
- Bacterial or viral infection
- Non-accidental injury
- Aplastic anaemia
- Systemic lupus erythematosus
- Drug-induced thrombocytopaenia
- Thrombotic thrombocytopenic purpura or haemolytic uraemic syndrome
Investigations
- FBE and blood film is the only initial investigation required
- Film must be reviewed to exclude an alternative diagnosis
Management
The decision to treat a child should be based on the clinical symptoms and not the platelet count. Treatment decisions also need to take into consideration the presence of active bleeding, the risk of future bleeding (eg impending surgery) and psychosocial factors
Risk category |
Symptoms |
Management |
Low |
Many petechiae or large bruises
Painless oral/palatal petechiae or purpura
Blood crusting in nares |
Outpatient without medical treatment (unless significant psychosocial or safety concerns)
Repeat FBE and review in 1 week
Provide family education |
Moderate |
Epistaxis >5 mins
Haematuria
Haematochezia
Painful oral purpura
Significant menorrhagia |
Often require hospital admission
Film must be reviewed by a haematologist prior to starting treatment
Increase platelet count to stop bleeding (not to normal level)
First line: oral prednisolone 2 mg/kg (max 60 mg) for 4–7 days
Second line if poor response or rapid platelet rise is required (eg prior to surgery): IVIG 0.8–1 g/kg (discuss with haematology team)
Additional treatments:
|
Severe |
Suspected internal haemorrhage (brain, lung, muscle, joint, etc) OR mucosal bleeding that requires immediate intervention |
Urgent consultation with haematology team
Combination IVIG 0.8–1 g/kg and pulse IV methylprednisolone 15–30 mg/kg (max 1 g) daily for 3 days
Platelet transfusion 20 mL/kg, continuous if required
IV tranexamic acid 15 mg/kg
Urgent surgical intervention or referral depending on site of bleeding |
Life-threatening |
Documented ICH or life-threatening bleeding at any site |
Consult haematology team for:
- severe or life-threatening bleeding
- <1 year or >14 years of age
- any abnormality on blood film
- any concern for possible alternative diagnosis
- chronic ITP
- head injury or signs of ICH
Provide family education
- Provide written information and letter to document diagnosis
- Restrict activities to minimise the risk of head injury:
- avoid contact sports (eg footy, rugby, soccer, hockey and martial arts)
- limit activities that have a risk for traumatic injury (eg horse-riding, riding a scooter, skate-board or bike, climbing on play-ground equipment)
- Avoid anti-platelet, non-steroidal and anticoagulant medications. Avoid intramuscular injections
- Monitor for significant bleeding symptoms and go immediately to the emergency department if they occur
- Monitor for signs of ICH and go immediately to the emergency department if head injury or severe headache
Consider consultation with local paediatric team when
- Uncertainty about diagnosis, any red flags, or to arrange follow up
- Significant concern about the family’s ability to enact the management plan or attend follow-up
Consider transfer when
- Level of care exceeds the comfort of the local health service
- Severe or life-threatening haemorrhage
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when
Family understands the condition, management, activity restrictions, follow-up plan and when to go to the emergency department
Parent information
Idiopathic thrombocytopenic purpura
Last updated March 2020