What is ITP?

“Thrombocytopenia” means low platelet count and “purpura” means purple in Latin. Purpura is the appearance of reddish-purple discolorations on the skin that do not blanch on applying pressure. Purpura is caused by bleeding underneath the skin and measures 0.3-1cm. They are called petechiae when the size are less than 0.3cm. “Immune” means the condition is caused by activation of the immune system by production of antibodies against one’s own platelet (autoantibodies). ITP can be primary or secondary. Secondary ITP is more common in adults than children and can be due to other conditions i.e. connective tissue disease like Systemic Lupus Erythematosus, malignancy or drugs.

ITP occurs in about 5 in 100,000 children. It equally affects girls and boys as in children it is mainly primary. In adults the incidence is higher in females than in males with a 2:1 ratio as connective tissues disease is nore common in women. In children, the peak age is 2 to 6 years old.

In children who have ITP, all of the blood cells are normal except for the platelets. Platelets are the cells that form blood clots and seal minor cuts and wounds. A person who has low platelets can bruise easily and can bleed for a long time even after minor injury.

What are the symptoms of ITP?

Most children do not have any symptoms while some have symptoms which range from superficial bleeds like:

• Easy / spontaneous bruising.
• Petechiae (tiny reddish-purple dots on the skin that are caused by bleeding under the surface of the skin) on the body, especially on the lower legs.
• Unexplained bleeding from the nose or gums.

or more serious bleeding like:

• Cuts or minor wounds that take a very long time to clot or stop bleeding.
• Blood in the urine or stool.
• Unusually heavy menstrual flow in teenage girl.

It usually appears quickly, over 1 to 2 days. The condition often occurs about 2 to 4 weeks following an infection (often a common viral infection). The symptoms disappear over 6 to 8 weeks in most cases. In children, it is usually an acute and self-limiting condition.

What causes ITP?

The cause of ITP is not known. People who have ITP form antibodies that destroy their blood platelets. Normally, antibody formation is a healthy response to bacterial or viral infection. In people who have ITP, however, the antibodies attack the body’s own platelets.

How is ITP diagnosed?

The doctor can begin to diagnose ITP by asking questions about your child’s health and doing a physical exam. He / she may take a blood sample for a test that counts blood cells and platelets (called full blood count or FBC) or look at it under a microscope (called a blood smear / picture). Sometimes the doctor may want to get a bone marrow (where platelets are produced) examination to rule out other possible causes of the low platelet count especially if the platelets are low enough and treatment with steroids is required.

How does ITP affect children?

ITP in children is usually mild and runs its course without the need for treatment. About 75% to 80% of children recover completely from ITP within about 6 months.

How is ITP treated in children?

Because most children recover with no treatment, many doctors recommend just watching them carefully and taking care of the bleeding symptoms. They are advised to avoid contact sports and physical activities that potentially expose the child to trauma and avoid medication that put them at risk of bleeding e.g.. aspirin which can cause gastric bleeding. If the platelet count falls to dangerously low levels, some doctors may recommend a short treatment with one of the 2 commonly used medications that is oral prednisolone or intravenous infusions (given through a vein) of immunoglobulin. Both medicines have some side-effects. The aim of treatment is to improve symptoms.

Treatment Options Include:

• Prednisolone. This is often the first type of treatment tried. It is a steroid medication and is taken as syrup or tablets. Prednisolone has been shown to increase the number of platelets quickly in children with ITP. Usually the doctor will perform a bone marrow examination first before starting steroids to ensure that there is no other cause for the low plaletet count such as in conditions like Acute Leukaemia which will be affected by steroids.
• Intravenous immunoglobulin (IVIg). This is an injection of a protein into the bloodstream and has been shown to work well in about 70% of children in increasing the number of platelets. It is not usually used as the first option because it involves an injection, can cause side-effect and is relatively expensive. It may be used as an emergency treatment if your child has severe bleeding or needs surgery and when there is insufficient time to wait for a bone marrow procedure.
• Anti-D immunoglobulin. This is a second-line therapy and usually given after consultation with a paediatric haematologist if the above 2 treatment modalities are not effective. However, it can only be given to children whose blood group is RhD positive.
• Platelet transfusions. Only in a life-threatening situation i.e. intracranial bleeding, the child may be given a transfusion of platelets at the same time as being treated with steroids and IVIg. This only helps to increase the number of platelets for a short time as the transfused platelets being used to form a blood clot at the bleeding site and also get attacked by the antibody that the body has produced before they are destroyed by the spleen. Platelets are given to help stop the bleeding in the acute phase of a life threatening situation.
• Surgery to remove the spleen (splenectomy). This is very rarely done in children with ITP. It is only really considered as an option if the child has life-threatening bleeding or severe chronic bleeding that is affecting or restricting a child’s day to day functioning / activities and where IVIg, pulsed steroids or anti-D Immunoglobulin have not been successful.

What can I do if my chiId has ITP?

If your child has ITP, you should avoid your child from taking medicines that increase risks for bleeding, such aspirin and ibuprofen (a non-steroidal anti-inflammatory drug). Your child also should avoid contact sports and physical activities such as soccer, hockey, going on a roller-coaster ride and unpressurised air travel.