Assessment and Management of Acute Idiopathic Thrombocytopenia Purpura (ITP)
Scope and Purpose

​This guideline is designed to assist health care professionals in the assessment and management of children with suspected acute Immune Thrombocytopenia (ITP) aged 6 months to 16 years.
Presentation and Diagnosis
ITP presents with a petechial rash, bruising and/or bleeding. ​It often follows a self-limiting viral infection.
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Initial Investigations:
  • Full Blood Count (FBC) and blood film
  • Renal and Liver profiles, CRP
  • Coagulation Screen
  • Group & Save if active bleeding
  • Urine dipstick

A diagnosis of ITP can be made when ALL the following criteria are fulfilled: 
  • Isolated thrombocytopaenia with an otherwise normal FBC and other bloods normal
  • Blood film reviewed by haematology that is consistent with ITP – if not available, see Section 7 below
  • Child is otherwise well and examination normal except for petechial rash, bruising and/or bleeding

The following clinical features should make doctors consider an alternative diagnosis rather than ITP
  • Child under 12 months - please discuss with Paediatric Haematology
  • Unwell Child
  • Bone pain or limp
  • Abnormal Lymphadenopathy
  • Hepatosplenomegaly
  • Persistent Fever
  • Personal or strong family history of bleeding disorder/excessive bleeding
  • Abnormal blood results (except for thrombocytopenia)
Intracranial Haemorrhage
The most devastating complication of ITP is intracranial haemorrhage (ICH).  The risk of ICH is rare (< 1 %) .
Risk factors for ICH are:
  • Head trauma
  • Haematuria
  • Other bleeding beyond bruising and petechial rash
Acute Management of ITP
Once diagnosis of ITP is made, management is based on clinical symptoms, not platelet count. 
Symptoms/Signs
Management
Petechiae and bruises only
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Epistaxis that stops within 30 minutes
Can usually be discharged home and no treatment required unless there is uncertainty about diagnosis.

Reassure parents – give advice and information leaflet (see below)
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Safety Net advice - return to hospital for following:
  • Epistaxis > 30 minutes
  • Haematuria
  • Bleeding PR
  • Bleeding from mouth
  • Any significant neurological symptoms
Epistaxis requiring nasal packing and/or ENT treatment.

Painful oral purpura and/or significant gingival bleeding
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Haematuria, passing blood PR, haematemesis, significant menorrhagia with Hb > 80g/L.
​Admit to hospital
Discuss management with a haematologist in local hospital prior to treatment if possible

Treatment 
  • Oral tranexamic acid (TXA)25mg/kg (max 1.5g) TDS for 3-5 days – do not use with haematuria.  
  • TXA liquid may not be immediately available – tablets can be crushed/dispersed in water or the injection can be given orally (should be diluted with some WFI)
  • Dose reduction of TXA required in renal impairment, if Creatinine Clearance(CrCl) = 25-50 ml/min/17.73m2, use 25mg/kg same dose BD. If CrCl = 15-25, use 25mg/kg OD,  If CrCl <15 or on PD, use 12.5mg/kg OD(Evelina formulary)
  • Use in caution with known epileptic patients as can precipitate further seizures.

If further treatment besides TXA is required, consider the use of IVIg and/or oral prednisolone as below in discussion with local haematologist:
  • Either IVIG 0.8-1.0g/kg stat and repeat if required after 24-48 hours if still significant bleeding
  • Or oral prednisolone 2mg/kg (max 80mg) for 4-7 days 
  • NB, can use IVIG and prednisolone in combination
Suspected internal haemorrhage
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Significant external haemorrhage with Hb < 80g/L
Admit to hospital and consider HDU or PICU care
Urgent consultation with haematologist in local hospital and with tertiary paediatric haematologist
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Treatment
  • IV tranexamic acid 10 mg/kg tds (or oral as above if IV not available) – see considerations as above for TXA
  • Combination of IVIG 0.8-1.0 g/kg one dose stat and pulse IV methylprednisolone 30 mg/kg (max 1g) daily for 3 days
  • Consider Platelet transfusion
Advice on discharging a patient home
  • If blood film result not available prior to discharge, the blood film result must be reviewed within 24 hours.
  • Avoid aspirin and NSAIDs.
  • Avoid intramuscular injections.
  • Can return to school if platelet count > 20x109/L or after first week if well regardless of platelet count, but avoid should sports and other activities where there is a risk of head injury if platelet count < 50x109/L.
  • Provide patient information leaflet.
  • Inform families of ITP Support Association.
Follow Up
Children under 12 months of age should be discussed with a Paediatric Haematologist

Children who are not admitted to hospital
  • A Full Blood Count should be repeated at 1/52 and again at 3/12.  Bloods can be checked at other times, but acute management does not depend on platelet count.
  • A child can return to full activity and sports if platelets > 50x109/L
  • In 75% of children, platelet count will normalise (> 150x109/L)  by 3/12 – then patient can be discharged
  • If platelet count has not normalised by 3/12, repeat FBC at 6/12 and at 12/12.  
  • If platelet count has not normalised by 12/12, this would be considered as chronic ITP.  Discuss follow up with tertiary paediatric haematology

Children who require admission to hospital
  • Discuss follow up with tertiary paediatric haematology
Patient Information Sheet
Process for Monitoring Compliance
The PIER network will review problems associated with this guideline through governance process.

Guideline to be reviewed after three years or sooner as a result of audit findings or as any changes to practice occurs.
References​
Document Version: 
1.0

Lead Authors: 
Dr Michael Roe, Consultant Paediatrician with an interest in non-oncological haematology, UHS
Approving Network:
Wessex Paediatric Haematology Network
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Date of Approval: 


Review Due: