Family history – thrombocytopaenia or other haematological or immunological disorders
Co-morbid conditions that may increase the risk of bleeding
Lifestyle factors that may pose a risk for trauma and bleeding
Possible systemic lupus erythematosis (SLE) – can get isolated thrombocytopaenia. Suspect in older children from a higher risk ethnic background eg: Aboriginal, Asian, African, Maori. Family history of SLE or rheumatoid arthritis. Ask about a photosensitive rash, arthritis, mglagia, oral ulcers, hair loss, dry eyes or mouth, fatigue, weight loss, fever.
Possible malignancy – chronic pain, fevers, weight loss, pallor
Usually a well looking child with normal observations
Bleeding signs – document location and size of pupura, areas of petechiae. Look for mucosal bleeding, check for retinal haemorrhages
Dysmorphic features – suggestive of a congenital syndrome e.g. Fanconi syndrome, Thrombocyopaenic-Absent Radius (TAR) syndrome
Urinalysis – haematuria
Full Blood Count (FBC) – shows thrombocytopaenia, normal haemoglobin, normal white cell count, and normal blood film aside from large (left shifted – megakaryocytic) platelets and occasionally some atypical lymphocytes.
The platelet count may be as low as < 20 x 109/L
The blood film must be reviewed by a Laboratory Haematologist (preferably Paediatric) to confirm the diagnosis of ITP
A bone marrow aspirate is rarely required, and is only considered when the diagnosis is uncertain and a haematological malignancy needs to be excluded
Systemic Lupus Erythematosis (e.g. SLE)
Haematological malignancies (e.g. leukemia)
Infections – viruses, meningococcal disease
Drug induced thrombocytopaenia
Haemolytic uraemic syndrome
Other coagulation disorders (e.g. disseminated intravascular coagulation (DIC))
ITP will spontaneously remit without any treatment within 6 months and most children can be followed up as outpatients
Children should be admitted if they have significant bleeding
No treatment is necessary unless there is significant bleeding
Treatment (must be decided by a General Paediatric Team) may include oral steroids and intravenous gamma globulin. Platelet transfusions are not generally given.
The natural history of ITP is that most patients will spontaneously remit within 6 months and many within 1-2 months
Most patients will not require any treatment and can be managed as outpatients
No treatment is necessary unless there is significant bleeding or occasionally in other exceptional circumstances
The decision whether to treat or not must be made by the General Paediatric Team. Treatment can include steroids and intravenous immunoglobulin. These drugs do not influence the natural history of the disorder but can acutely raise the platelet count.
Any internal haemorrhage (including intracranial haemorrhage)
Discuss the management of these patients immediately with the on call General Paediatric Consultant and Paediatric Clinical Haematologist (and the General Surgical Team, Neurosurgical Team, ENT Surgical Team if required).
Exceptional circumstances to consider treatment may be imminent overseas travel, an adolescent with self image issues, menorrhagia or a high risk of trauma. In this group, oral steroids can be considered – prednisolone 4mg/kg once daily for 4 days.
Platelet transfusions are only given in exceptional circumstances – such as life threatening bleeding, and only with Paediatric Clinical Haematologist approval.
The platelet count should be monitored no more frequently than weekly
In chronic ITP, splenectomy and rituximab (an anti CD20 monoclonal antibody) can be considered
Discuss the diagnosis and management with the nearest local Paediatrician (if available)
If unavailable, discuss with the General Paediatric Team at PMH – they can be phoned through switchboard on (08) 9340 8222, 24 hours a day, 7 days a week
Most patients can be managed at home, without the need to transfer to PMH
See the links below for the GP letter and Health Fact Sheet for parents
Significant bleeding, irrespective of the platelet count
Any suspicion of intracranial haemorrhage – needs urgent diagnosis and management
If unsure after hours, consider admission to the ED Observation Ward (4E) and discussion with the Paediatric Emergency Department Senior Doctor in the morning.
Patients can be sent home from the Emergency Department when:
The diagnosis is definite and there is no active bleeding
The child is well and the social situation is such that there is good parental supervision and safety in the home (with respect to the risk of trauma)
There is the opportunity reassure and educate the parents in the Emergency Department
There is appropriate follow up arranged with the General Paediatric Team within the next 1-2 weeks
Referrals and follow-up
Discuss the management of all ITP cases with the on call General Paediatric Team
The General Paediatric Team must review the patient within 2 weeks in ACDF or Outpatient Clinic
Give the parent a form for a repeat FBP (to be done within 2 weeks prior to the appointment)
Referral to the Paediatric Haematology Outpatient Clinic can be done by the General Paediatric Team if the diagnosis remains uncertain, the white cell count is abnormal, the blood film is atypical, there is failure to respond to treatment or in chronic ITP
Health information (for carers)
The patient should avoid trauma – specifically no bicycles or trampolines
The patient should not take any non steroidal anti-inflammatory medications eg: ibuprofen