Immune Thrombocytopenic Purpura in Children

What is immune thrombocytopenic purpura (ITP) in children?

ITP is a blood disorder that causes a decrease in the number of platelets in the blood. Platelets help stop bleeding. So a decrease in platelets can result in easy bruising, bleeding gums, and bleeding inside the body. The lower the platelet count, the greater the risk of bleeding. 

ITP may be acute or chronic:

• Acute thrombocytopenic purpura. This type is most common in young children (2 to 6 years old). The symptoms may follow common viral illnesses. Acute ITP usually starts very suddenly. Symptoms often go away in less than 6 months (often within a few weeks). Treatment is not usually needed. The disorder typically does not recur. Acute ITP is the most common form of the disorder.

• Chronic thrombocytopenic purpura. This disorder can start at any age. The symptoms last at least 12 months. Adults have this form more often than children, but it does affect teens. Females have it 2 times to 3 times more often than males. Chronic ITP can recur often.

What causes ITP in a child?

In most cases, the cause of ITP in children is unknown. Known causes include:

• Immune system problems

• Viral infections

• Some medicines or vaccines

What are the symptoms of ITP in a child?

The symptoms of ITP are related to increased bleeding. Some children have very mild symptoms or none at all. Symptoms may include:

• Purpura. This is the purple color of the skin after blood has "leaked" under it.

• Bruising. A bruise is blood under the skin. Children with ITP may have large bruises from no known injury. Bruises can appear on the elbows and knees just from movement.

• Petechiae. Tiny red dots under the skin that are a result of very small bleeds.

• Nosebleeds

• Bleeding in the mouth or in and around the gums

• Blood in urine or stool

• Heavy menstrual bleeding (period) that is unusual

• Vomiting with blood

• Bleeding with a head injury. This may be life-threatening in a child with ITP.

• Internal bleeding. If the platelet count is very low, there is a risk for internal bleeding, such as in the brain or the abdomen.

The symptoms of ITP may look like other health problems. Always check with your child's healthcare provider for a diagnosis.

How is ITP diagnosed in a child?

Your child's healthcare provider will ask questions about your child's medical history and do a physical exam. Other tests may include:

• Complete blood count (CBC). A complete blood count checks the red and white blood cells, blood-clotting cells (platelets), and sometimes, young red blood cells (reticulocytes). It also includes more details about the red blood cells.

  • Normal platelet count is between 150,000 per microliter to 450,000per microliter. With ITP, the platelet count is less than 100,000 per microliter. Children with ITP often have a platelet count of less than 10,000per microliter. 

• Peripheral smear. A small sample of blood is examined under a microscope. Blood cells are checked to see if they look normal or not.

• Bone marrow aspiration. This test is very rarely needed. It looks at the production of platelets and rules out any abnormal cells the marrow may be making that could lower platelet counts.

How is ITP treated in a child?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Your child's provider will likely refer you to a hematologist, an expert in blood disorders. Not all children with ITP require treatment. Most children recover without treatment. Blood tests to monitor platelet levels and protection from bleeding may be all that is needed.

When treatment is needed, the 2 most common forms of treatment are steroids and immune globulin:

• Corticosteroids.Brief treatment with steroid medicine helps prevent bleeding by decreasing platelet destruction. Steroids can increase the platelet count in 2 to 3 weeks.

• Intravenous immune globulin (IVIg).  A single dose of IVIg helps slow the destruction of platelets. It works more quickly than steroids (within 24 to 48 hours).

• Anti-D or Rh immune globulin. This medicine temporarily stops the spleen from destroying platelets. It's used very carefully because it may actually destroy red blood cells.

Other treatments for ITP may include:

• Medicines that promote platelet production

• Rituximab. This is a type of antibody that helps to increase platelets by preventing their destruction.

• High-dose dexamethasone. This is a type of steroid.

• Splenectomy. This is surgery to remove the spleen. This treatment may be done because the spleen is where most platelets are destroyed.

What are possible complications of ITP in a child?

Complications of ITP in children include:

• Serious bleeding

• Complications from medicines used to treat ITP. Ask your child's healthcare provider about medicine side effects.

How can I help my child live with ITP?

To prevent bleeding, consider the following:

• Talk with your child's healthcare provider about which activities are safe when your child's platelet count is low.

• Make sure your child wears a helmet and other protective pads when bike riding, skating, or skateboarding.

• Don't let your child take part in contact sports like soccer, football, rugby, and wrestling, as well as other high-injury activities.

• Don't give your child aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs) that increase the chance of bleeding.

Talk with your child's provider about other ways to prevent injuries.

When should I call my child's healthcare provider?

Call your child's healthcare provider if your child has worsening symptoms of bleeding.

Key points about ITP in children

• ITP is a blood disorder with decreased blood platelets. It may result in easy bruising, bleeding gums, and internal bleeding.

• The cause is usually unknown, but it may be an autoimmune disorder or follow a viral illness. It can also occur with certain medicines or vaccines.

• Treatment may not be needed. Observation alone is a very common approach. The most common treatments are immune globulin or corticosteroids.

Next steps

Tips to help you get the most from a visit to your child’s healthcare provider:

• Know the reason for the visit and what you want to happen.

• Before your visit, write down questions you want answered.

• At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

• Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

• Ask if your child’s condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if your child does not take the medicine or have the test or procedure.

• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.