Immune Thrombocytopaenic Purpura (ITP)
Description Diagnostic criteria General and supportive measures Medicine treatment Surgical treatment Referral ICD-10 code: D69.3 DESCRIPTION A common bleeding disorder of childhood due to the immune-mediated destruction of platelets. It occurs most frequently in children aged 2 to 5 years and often follows infection with viruses (including HIV) and medications. Chronic ITP (more than 6 months du
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Surgical treatment
Referral
ICD-10 code: D69.3
DESCRIPTION
A common bleeding disorder of childhood due to the immune-mediated destruction of platelets.
It occurs most frequently in children aged 2 to 5 years and often follows infection with viruses (including HIV) and medications. Chronic ITP (more than 6 months duration) occurs in 10 to 20% of children with ITP.
Complications are rare, but include severe haemorrhage and bleeding into vital organs.
DIAGNOSTIC CRITERIA
Clinical
- Sudden onset of bruising and bleeding, either spontaneously or after minor trauma, into the skin and mucous membranes and rarely elsewhere in an otherwise well child.
- The lesions may range from pinpoint petechial bleedings to large ecchymoses, and are often increased on pressure points.
- Epistaxis is common.
- Exclude child abuse.
- The presence of the following makes the diagnosis of ITP unlikely:
- splenomegaly,
- masses,
- hepatomegaly,
- joint swelling,
- lymphadenopathy,
- bone pain,
- rashes present other than petechiae or ecchymoses.
Investigations
- Thrombocytopenia with normal white cell count and differential, and normal haemoglobin and red cell morphology, other than the effects of blood loss. Mean Platelet Volume (MPV) is often increased.
- Normal INR (PT) and partial thromboplastin time (PTT).
- Abundant megakaryocytes on bone marrow aspiration with normal erythroid and myeloid cellularity.
- A normal LDH and uric acid help to rule out leukaemia.
- Indications for bone marrow biopsy/aspiration: Prior to starting steroids, or any other abnormality on FBC or any atypical cells on differential count.
- Test all newly diagnosed cases for HIV.
Follow up patients with a diagnosis of ITP not confirmed with bone marrow aspiration for development of new clinical signs and abnormalities on laboratory investigations.
GENERAL AND SUPPORTIVE MEASURES
- Avoid:
- platelet transfusions unless bleeds are life-threatening,
- contact sport, injury and trauma, and
- dental procedures in the acute phase.
- Re-assure patient and family that resolution usually occurs.
MEDICINE TREATMENT
Avoid medication that affects platelet function, e.g. NSAIDs, and aspirin.
Acute ITP
Most cases are self-limiting and will resolve without treatment. Consider such conservative management for mild cases (in discussion with relevant specialist/subspecialist).
Active bleeding:
- Prednisone, oral, 4 mg/kg/dose as a single daily dose for 4 days.
- Stop after 4 days without tapering dose.
Chronic ITP
Intermittent treatment if platelets < 10 x 109/L and significant bleeding episodes:
- Prednisone, oral, 4 mg/kg/dose as a single daily dose for 4 days.
- Stop after 4 days without tapering dose.
Acute life-threatening bleeds (e.g. intracranial bleeding): (acute or chronic ITP)
- Methylprednisolone, IV, 30 mg/kg/dose administered over 30–60 minutes as a single daily dose for 3 days.
- Maximum dose: 1 g.
- Beware of arrhythmias, hypertension, etc.
- Check BP daily.
AND
After administration of methylprednisolone:
- Paediatric platelet concentrate, leucodepleted, 5–10 mL/kg over 20 minutes.
Refer to specialist for advice on further management.
SURGICAL TREATMENT
Consider splenectomy in children 5 years and older with chronic ITP for more than one year plus significant bleeding or substantial limitation in activities as a result of the ITP.
Pre-splenectomy
- 2 weeks prior to surgery:
- PCV-13, IM, 0.5 mL, followed by PPV-23, IM, 0.5 mL 8 weeks later.
- Hib booster, IM, 0.5 mL.
- Meningococcal vaccine, IM, 0.5 mL.
Post splenectomy
- Phenoxymethylpenicillin, oral, 12 hourly.
- If < 5 years of age: 125 mg.
- If > 5 years of age: 250 mg.
- Give indefinitely until at least 18 years.
- Pneumococcal polysaccharide vaccine. Repeat vaccination as a booster 5 years after the initial dose.
- Annual influenza vaccine.
- Hib and MCV boosters every 5–10 years.
- Catch up conjugate pneumococcal vaccine:
- If < 12 months of age: 3-dose series.
- 12 months of age and older: 2 doses, 8 weeks apart.
REFERRAL
- Suspected ITP with unusual features such as splenomegaly or lymphadenopathy.
- ITP complicated by severe haemorrhage, bleeding into vital organs or an intracranial haemorrhage.
- ITP needing surgery
- ITP that fails to resolve in 6–12 months on adequate treatment (chronic ITP).
- If there is no local capacity to fully investigate the condition.
Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital_2023 edition_ Updated February 2025
Chapter 3: Blood and Blood Forming Organs, 3.9 Immune Thrombocytopaenic Purpura (ITP)