ITP BleedingCase Powerpoint Presentation

1. Pediatrics ITP,
Bleeding, and
Child abuse

2. Immune Thrombocytopenia
(ITP)
01

3. Definition of
Thrombocytopenia
• Platelet count <150,000/μL
• Often found incidentally or during bleeding/bruising work-
up
• Immune-mediated processes are the most common causes
in children

4. ITP
• Most common cause of isolated thrombocytopenia in
children
• Peak age: 2–5 years
• Sudden bruising, petechiae, or mucosal bleeding
• Often post-viral or post-vaccine, but many cases idiopathic
• Primary ITP: No associated systemic disease
• Secondary ITP: Associated with SLE, HIV, CVID, ALPS, drugs
• By Duration:
• Newly diagnosed: <3 months
• Persistent: 3–12 months
• Chronic: >12 months

6. Pathogenesis
• Autoantibodies (IgG) against GP IIb/IIIa, Ib/IX, etc.
• Antibody-coated platelets macrophage clearance (mainly
→
spleen)
• Antibodies may also impair megakaryocyte function
• Involvement of T-cell cytotoxicity and immune
dysregulation (Tregs/B-cells)

7. Epidemiology
• Annual incidence: 1–6.4/100,000 children
• Underdiagnosed due to asymptomatic or mild cases
• Peak: 2–5 years, minor secondary peak in adolescence

8. Clinical Presentation
• Healthy-appearing child with:
• Sudden petechiae, purpura, bruising
• ± mucosal bleeding (epistaxis, oral, GU, GI)
• Often preceded by viral illness or MMR vaccination
• Systemic signs absent (no fever, bone pain, hepatosplenomegaly)

10. Bleeding Severity
• Most have mild mucocutaneous bleeding
• 40% have mucosal bleeding
• Serious bleeding: ~3%
• Intracranial hemorrhage (ICH): <1%
• High risk if platelets <10,000/μL

11. Diagnostic
evaluation
• CBC with differential
• Peripheral blood smear
• Reticulocyte count
• Direct antiglobulin test
• Immunoglobulin levels
Further tests if atypical findings

12. Diagnostic Criteria
• Platelets <100,000/μL
• Normal CBC, normal smear
• No systemic symptoms
• Diagnosis of exclusion
Note: Antiplatelet antibody testing not helpful (low
sensitivity/specificity)

13. Differential Diagnosis
• Malignancies (ALL, lymphoma)
• Infections (EBV, HIV, CMV)
• Autoimmune diseases (SLE)
• Bone marrow failure syndromes
• DIC, TTP, HUS
• Drug-induced thrombocytopenia
• Inherited thrombocytopenia

14. Management
• Observation for mild/no bleeding
• Treat if:
• Platelets <10,000/μL
• Mucosal or life-threatening bleeding
• First-line: IVIG, anti-D (if Rh+), or steroids
• Reserve platelet transfusions for emergencies

16. Severe Bleeding
Management
• Platelet transfusions: 10–30 mL/kg bolus
• IVIG + Steroids ± anti-D
• Add TPO-RA (romiplostim) to sustain counts
• Consider ICU admission for ICH or GI hemorrhage

18. Disease Course
• 80–90% recover in 3–6 months
• 10–20% chronic ITP (>12 months)
→
• Risk factors for chronicity:
• Older age
• No preceding infection
• Less severe thrombocytopenia at diagnosis
• Insidious onset

19. Chronic ITP:
Management
• Avoid contact sports, NSAIDs
• Monitor labs and menstrual bleeding
• First-line: IVIG, steroids
• If recurrent/severe:
• TPO-RAs preferred
• Rituximab if autoimmune-associated
• Splenectomy rare (reserved, due to lifelong risks)

20. Prognosis
• 30% spontaneous remission by 2 years
• 50% remission by 5 years
• Severe bleeding <10% over 5 years
• Younger age = better prognosis

21. Bleeding in Children
02

22. Approach to Pediatric Bleeding
● Begin with a focused history
● Follow with targeted physical exam
● Order baseline labs based on findings
● Use structured tools like bleeding assessment scores

23. Focused History
● Onset and frequency of bleeding
● Triggering events (trauma, surgery, dental work)
● Type of bleeding: mucosal vs deep tissue
● Past medical history, meds, supplements
● Family history of bleeding disorders
● Possible child abuse in unexplained bruising

24. Bleeding Assessment Tools
● ISTH Bleeding Assessment Tool (BAT)
○ Score 3 further evaluation needed
≥ →
● Helps quantify symptoms and guide testing
● Use when the history is unclear or symptoms vague

26. Child Abuse Considerations
● Pattern and location of bruises inconsistent with history
● Multiple stages of healing
● Delay in seeking care
● Consider abuse in any atypical bruising without coagulopathy

27. Initial Lab Work-Up
● CBC + Platelet count
● Peripheral smear
● Prothrombin time (PT)
● Activated partial thromboplastin time (aPTT)
● Fibrinogen
● Von Willebrand panel:
○ VWF antigen
○ VWF activity
○ Factor VIII level

28. Diagnostic Approach
● Use initial lab results to narrow causes
● Algorithm-based evaluation is recommended
● Examples:
○ ↓ Platelets: consider ITP, leukemia, DIC
○ Normal platelets + PT/aPTT: consider factor
↑
deficiencies
○ Normal PT/aPTT + mucosal bleeding: think VWD

29. Further Testing
● Based on initial findings, consider:
● Coagulation factor assays (VIII, IX, XI, XIII)
● Platelet function testing (e.g., aggregation studies)
● Antiphospholipid antibodies
● Thrombin time (TT), factor XIII activity
● Fibrinolysis evaluation (e.g., D-dimer, euglobulin clot lysis time)

31. Child Abuse
03

32. Definition
● Injury inflicted upon a child by a caregiver or parent
● Legal and cultural definitions may vary
● Key: Inflicted, not accidental trauma

33. Epidemiology
● Thousands of injuries and deaths annually worldwide
● High risk of repeated harm if not intervened
● Early recognition = lifesaving
● Most common in children under 5 years

34. Approach to Suspected Abuse
● Keep abuse in differential diagnosis of any unexplained
injury
● Carefully assess:
○ History: inconsistency, delay in care
○ Physical exam: patterned injuries, fractures
● Involve child protection teams when possible
● Report any suspicion to child services

35. Risk Factors
(Contextual, Not Diagnostic)
● Young age
● Household history of abuse
● Family stress, poverty, isolation
● Caregiver mental illness or substance use
● Race or socioeconomic status should NOT be used to guide
suspicion

36. Red Flag History for Abuse
● Injury inconsistent with developmental stage
● Vague or changing history
● Delay in seeking medical attention
● Recurrent injuries with no clear cause
● Explanation not matching injury severity

37. Red Flag History for Abuse

39. Red Flag Physical Exam Findings
● Bruises in non-mobile infants
● Patterned or clustered bruises
● Burns (e.g., immersion, cigarette)
● Retinal hemorrhages
● Multiple fractures in various healing stages
● Genital or perianal injuries

41. When to Pursue Full Work-Up
● Presence of any red flag history or exam finding
● Use institutional abuse protocol (lab + imaging)
● Refer to child protection team or abuse specialist
● Transfer if specialized services are not available

42. Screening
Recommendations
• ED/urgent care: Routine screening for <5 years recommended
• Increases detection
• Reduces missed cases
• Use validated tools
• Requires institutional commitment and team collaboration

43. Primary Care
Limitations
• Universal screening not yet supported by evidence
• Rely on clinical vigilance + family dynamics assessment
• Incorporate abuse awareness into developmental visits

44. Thank
You!