Pediatric ITP
Idiopathic Thrombocytopenic Purpura
Comprehensive Nursing Notes
Overview
Idiopathic Thrombocytopenic Purpura (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia (low platelet count) without a clear cause. In pediatric patients, it is typically an acute, self-limiting condition that often resolves spontaneously within 6 months.
Quick Facts
- Most common in children 2-10 years old
- Slightly more common in boys than girls
- Often follows viral illness (1-4 weeks after)
- 80-85% of pediatric cases resolve within 6 months
- Platelet count typically < 20,000/μL
Also Known As
- Immune Thrombocytopenic Purpura
- Primary Immune Thrombocytopenia
- Autoimmune Thrombocytopenic Purpura
- Childhood ITP
Pathophysiology
Triggering Event
Viral illness or immune stimulation
↓
Immune Response
Production of antiplatelet antibodies
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Platelet Destruction
Antibody-coated platelets removed by spleen
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Thrombocytopenia
Increased bleeding risk
Key Mechanism: In ITP, the immune system produces antibodies against platelet antigens. These antibody-coated platelets are recognized by macrophages in the spleen and removed from circulation, resulting in thrombocytopenia.
ITP in children differs from adults in several important ways:
| Feature | Pediatric ITP | Adult ITP |
|---|---|---|
| Onset | Usually acute | Often insidious |
| Prior infection | Common (50-65%) | Less common |
| Gender distribution | Slight male predominance | Female predominance |
| Spontaneous remission | 80-85% within 6 months | 10-20% within 6 months |
| Chronic ITP rate | 10-20% | 70-80% |
Clinical Presentation
Common Signs & Symptoms
- Petechiae: Small, pinpoint red spots on skin
- Purpura: Larger purple/red bruises
- Ecchymoses: Larger bruises from minor trauma
- Mucosal bleeding: Gums, nose (epistaxis)
- Easy bruising: Often first sign noticed
Less Common Manifestations
- Hematuria: Blood in urine
- GI bleeding: Melena or hematemesis
- Menorrhagia: In adolescent females
- Fatigue: General weakness
Red Flag
Intracranial hemorrhage is rare (<0.5%) but is the most serious complication
Children with ITP typically appear well aside from their bleeding manifestations. The presence of systemic symptoms like fever, weight loss, bone pain, or lymphadenopathy should raise suspicion for alternative diagnoses such as leukemia or other bone marrow disorders.
Distribution Pattern of Bleeding Manifestations
80-90%
Cutaneous manifestations
(petechiae, purpura, bruising)
(petechiae, purpura, bruising)
15-30%
Mucosal bleeding
(epistaxis, gum bleeding)
(epistaxis, gum bleeding)
< 5%
Serious internal bleeding
(GI, urinary tract)
(GI, urinary tract)
< 0.5%
Intracranial hemorrhage
(life-threatening)
(life-threatening)
Nursing Assessment
Mnemonic: “PLATELETS”
Use this mnemonic to guide your nursing assessment for pediatric ITP:
- P – Petechiae and Purpura: Location, extent, timing of appearance
- L – Laboratory values: Platelet count, CBC, peripheral smear
- A – Active bleeding: Current bleeding sites and severity
- T – Trauma history: Recent injuries or unusual bruising
- E – Epistaxis: Frequency, duration, and severity of nosebleeds
- L – Lifestyle limitations: Impact on activity and quality of life
- E – Environmental safety: Home evaluation for bleeding risks
- T – Treatment history: Previous medications or interventions
- S – Symptoms neurological: Headache, vision changes, altered mental status
Physical Assessment Focus
- Skin: Document location, size, and number of petechiae/purpura
- Oral mucosa: Check for gum bleeding, buccal petechiae
- ENT: Assess for epistaxis, pharyngeal bleeding
- Abdomen: Evaluate for splenomegaly (unusual in ITP)
- Neurological: Assess for signs of intracranial pressure
- Vital signs: Monitor for tachycardia, hypotension indicating blood loss
History Collection
- Recent illnesses: Viral infections within past 4-6 weeks
- Medication history: Especially those affecting platelet function
- Bleeding pattern: Onset, progression, precipitating factors
- Family history: Bleeding disorders, autoimmune conditions
- Immunization history: Recent vaccinations
- Activity level: Limitations due to fear of bleeding
Diagnostic Evaluation
| Diagnostic Test | Typical Findings in ITP | Nursing Considerations |
|---|---|---|
| Complete Blood Count (CBC) |
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| Peripheral Blood Smear |
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| Bone Marrow Aspiration (Not routine, performed in atypical cases) |
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| Antiplatelet Antibody Testing |
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| Coagulation Studies (PT, PTT, fibrinogen) |
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ITP is largely a diagnosis of exclusion. The typical triad includes: 1) isolated thrombocytopenia, 2) otherwise normal blood counts, and 3) absence of other causes of thrombocytopenia. Bone marrow aspiration is generally reserved for atypical presentations, patients with additional cytopenias, or when considering malignancy.
Differential Diagnosis
Differential Diagnosis Mind Map
Pediatric Thrombocytopenia
↓
Decreased Production
- • Leukemia/malignancies
- • Aplastic anemia
- • Bone marrow infiltration
- • Viral suppression (CMV, EBV)
- • Nutritional deficiencies
- • Congenital disorders
Increased Destruction
- • ITP (primary)
- • Hemolytic uremic syndrome
- • Disseminated intravascular coagulation
- • Thrombotic thrombocytopenic purpura
- • Drug-induced thrombocytopenia
- • Post-transfusion purpura
Sequestration/Other
- • Hypersplenism
- • von Willebrand disease
- • Platelet function disorders
- • Infection (e.g., sepsis)
- • Secondary ITP (lupus, HIV)
- • Hemangiomas (Kasabach-Merritt)
Management & Treatment
Management Principles: Treatment decisions are based on platelet count, bleeding symptoms, and patient factors rather than diagnosis alone. Many children with ITP and minimal bleeding can be managed with observation only, regardless of platelet count.
| Treatment Approach | Indications & Medications | Nursing Considerations |
|---|---|---|
| Observation (“Watch and Wait”) |
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| First-Line Therapies |
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| Second-Line Therapies (For chronic/refractory ITP) |
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| Surgical Management |
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| Emergency Management |
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Mnemonic: “SAFE CHILD”
Key principles in managing pediatric ITP:
- S – Severity assessment: Evaluate bleeding risk and symptoms
- A – Activity restrictions: Appropriate limitations based on platelet count
- F – Follow-up regularly: Monitor platelet counts and symptoms
- E – Educate family: Signs of bleeding and when to seek care
- C – Conservative approach: “Watch and wait” when appropriate
- H – Head trauma prevention: Critical safety measure
- I – Individualize therapy: Based on symptoms, not just platelet count
- L – Limit invasive procedures: Avoid unnecessary platelet trauma
- D – Document response: Track treatment efficacy and disease course
Nursing Care & Interventions
Bleeding Precautions
- Implement appropriate activity restrictions based on platelet count
- Pad crib/bed rails for young children
- Use soft toothbrush or sponge for oral care
- Avoid IM injections and rectal temperatures
- Apply pressure to venipuncture sites for at least 5 minutes
- Minimize invasive procedures
Medication Administration & Monitoring
- Administer corticosteroids with food to minimize GI upset
- Monitor for steroid side effects (mood changes, increased appetite, facial fullness)
- Premedicate before IVIG infusion (acetaminophen, diphenhydramine)
- Monitor vital signs during infusion therapies
- Assess for headache after IVIG (common side effect)
- Check platelet count response to therapy
Assessment & Monitoring
- Perform frequent skin assessments for new petechiae or bruising
- Monitor for mucosal bleeding (oral, nasal, gingival)
- Assess for signs of internal bleeding (abdominal pain, headache)
- Regular neurological assessments with severe thrombocytopenia
- Check urine and stool for occult blood
- Monitor vital signs for tachycardia or hypotension
Psychosocial Support
- Address anxiety regarding appearance (bruising, petechiae)
- Provide age-appropriate explanation of condition
- Support school re-entry with appropriate activity modifications
- Connect family with support resources
- Assist with navigating activity restrictions
- Address parental anxiety regarding bleeding risk
When caring for children with ITP, help parents understand that restricting activities must be balanced with allowing normal childhood development. For most children with platelet counts >10,000/μL and no significant mucosal bleeding, reasonable activity with some precautions (avoiding contact sports, trampolines, etc.) is usually appropriate. Individualize recommendations based on the child’s age, developmental level, and bleeding history.
| Platelet Count | Activity Recommendations |
|---|---|
| <20,000/μL |
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| 20,000-50,000/μL |
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| >50,000/μL |
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Family & Patient Education
Essential Education Topics
Disease Understanding
- Basic pathophysiology in simple terms
- Expected disease course and prognosis
- Self-limiting nature of pediatric ITP
- Relationship between platelet count and bleeding risk
- Importance of follow-up care
Medication Teaching
- Purpose of prescribed medications
- Proper administration techniques
- Expected side effects and management
- Importance of completing full course
- Medication interactions to avoid
Bleeding Precautions
- Age-appropriate activity modifications
- Home safety measures to prevent injury
- Proper techniques for controlling epistaxis
- Oral hygiene with soft toothbrush
- Avoiding medications that affect platelet function (aspirin, NSAIDs)
When to Seek Medical Attention
- Persistent or severe headache
- Vision changes or neurological symptoms
- Blood in urine or stool
- Uncontrolled bleeding from any site
- Significant head injury (seek care immediately)
Important Medication Warning
Instruct families to avoid medications that affect platelet function, including:
- • Aspirin and aspirin-containing products
- • Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen
- • Some herbal supplements (ginkgo biloba, garlic supplements, ginseng)
Acetaminophen (Tylenol) is the preferred analgesic/antipyretic for children with ITP.
Teaching Tool: “BLEED ALERT”
Teach families to seek immediate medical attention for:
- B – Blood in urine or stool
- L – Large or rapidly expanding bruises
- E – Extreme fatigue or pallor
- E – Excessive bleeding that doesn’t stop with pressure
- D – Dizziness or fainting
- A – Altered mental status or behavior
- L – Lasting headache or neck pain
- E – Eye problems (vision changes, eye pain)
- R – Respiratory difficulties
- T – Trauma to head (any head injury)
Expected Outcomes & Prognosis
Acute ITP
- • 80-85% resolve within 6 months
- • Most recover without treatment
- • Minimal long-term sequelae
- • Low risk of recurrence
- • Excellent overall prognosis
Chronic ITP
- • 15-20% persist beyond 12 months
- • More common in older children
- • May require long-term therapy
- • Spontaneous remission possible over years
- • Generally good quality of life with management
Complications
- • Intracranial hemorrhage (<0.5%)
- • Severe bleeding requiring hospitalization (3-5%)
- • Treatment-related complications
- • Impact on academic/social development
- • Anxiety/emotional impact on child and family
Quality of Life Considerations
Children with ITP may face several quality of life challenges that nurses should address:
Physical Impact
- • Activity restrictions limiting normal play
- • Visible bruising causing self-consciousness
- • Fatigue from repeated medical visits
- • Side effects from medications
- • School absences for treatment/monitoring
Psychosocial Impact
- • Anxiety about bleeding or injury
- • Social isolation from activity restrictions
- • Questions from peers about visible bruising
- • Parental overprotection
- • Stress from unpredictable disease course
Nursing Interventions to Improve Quality of Life
- • Provide school resources to educate teachers and classmates
- • Help develop modified physical education plans
- • Connect families with support groups or other ITP families
- • Teach coping strategies for visible symptoms
- • Guide parents in balancing safety with normal development
- • Address misconceptions about the disease
Case Study Example
Clinical Case: Emily, 6-year-old with ITP
Patient Presentation
Emily, a 6-year-old female, is brought to the pediatrician by her mother who noticed multiple “strange bruises” on Emily’s legs and arms over the past 3 days. Her mother reports that Emily had a cold with fever and runny nose about 2 weeks ago that resolved without complications. Emily has no significant past medical history and is up-to-date on immunizations.
Physical Examination
- • Multiple petechiae on extremities and trunk
- • Several ecchymoses on shins and forearms
- • Small areas of gingival bleeding
- • No hepatosplenomegaly
- • No lymphadenopathy
- • Otherwise healthy-appearing child
Laboratory Results
- • Platelet count: 8,000/μL
- • Hemoglobin: 12.5 g/dL
- • WBC: 7,500/μL with normal differential
- • Peripheral smear: Decreased platelets, normal RBC and WBC morphology
- • PT/PTT: Normal
Nursing Assessment & Interventions
- Complete physical assessment, focusing on skin and mucous membranes
- Assess for signs of intracranial hemorrhage (headache, vomiting, altered mental status)
- Implement bleeding precautions
- Provide family education about ITP
- Teach parents how to monitor for bleeding
- Discuss activity restrictions appropriate for platelet count
- Collaborate with healthcare team on treatment plan
Treatment Plan & Outcome
After diagnosis of ITP, Emily was started on oral prednisone (2 mg/kg/day) due to her very low platelet count and mucosal bleeding. Her platelet count rose to 35,000/μL after 3 days and 125,000/μL after 10 days of treatment.
Prednisone was tapered over 4 weeks. Emily was maintained on activity restrictions during treatment, with gradual return to normal activities as her platelet count improved.
At 3-month follow-up, Emily’s platelet count was 230,000/μL without treatment, indicating complete remission of her acute ITP.
Nursing Care Plan
| Nursing Diagnosis | Goals/Outcomes | Interventions | Evaluation |
|---|---|---|---|
| Risk for Bleeding related to decreased platelet count |
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| Risk for Injury related to bleeding tendency and activity level |
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| Knowledge Deficit regarding ITP disease process and management |
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| Anxiety related to diagnosis, visible symptoms, and safety concerns |
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Key Takeaways
Pediatric ITP: Core Concepts
Disease Characteristics
- • Autoimmune platelet destruction
- • Often post-viral in children
- • 80-85% spontaneous resolution
- • Diagnosis of exclusion
- • Isolated thrombocytopenia
Nursing Priorities
- • Bleeding prevention and detection
- • Safe medication administration
- • Family education and support
- • Balance safety with development
- • Monitor for treatment response
Key Interventions
- • Bleeding precautions
- • Activity modifications
- • Medication management
- • Family teaching
- • Psychosocial support
Remember that ITP in children is typically a self-limiting condition with an excellent prognosis. The nursing approach should focus on preventing complications while minimizing the impact on the child’s normal development and quality of life. Parents often need significant support to manage their anxiety about bleeding risk while still allowing their child to engage in modified but developmentally appropriate activities.
Resources for Families
Organizations & Support
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Platelet Disorder Support Association
Information, support, and advocacy for ITP patients
www.pdsa.org -
ITP Support Association
Resources for families and patients
www.itpsupport.org.uk -
American Society of Hematology
Patient resources on ITP
www.hematology.org
Educational Materials
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Books for Children
“Petit Purpura” – Children’s book explaining ITP
“My Immune System Needs Glasses” – Explaining autoimmunity to kids -
School Resources
ITP School Alert Cards
Teacher Information Packets (available from PDSA) -
Medical ID Information
MedicAlert Foundation
www.medicalert.org