Hematology and Coagulation | Immune Thrombocytopenia in Children - Pediatric - Inpatient/Ambulatory/Emergency Department
Management of Immune Thrombocytopenia in Children - Pediatric -
Inpatient/Ambulatory/Emergency Department Guideline Summary
Objective: To provide standardized, evidence-based guidelines for the acute management of primary ITP in children.
Target Population: Children (1-17 yrs) with suspected primary ITP
Link to Full Guideline: Management of Immune Thrombocytopenia (ITP) in Children - Pediatric -
Inpatient/Ambulatory/Emergency Department
Summary of Key Points
• Immune thrombocytopenia (ITP) is an acquired autoimmune disorder in which a low platelet count (<100 x 109/L)
results from destruction of existing platelets and impaired production of new platelets.
• In most pediatric cases, ITP is mild and resolution often occurs without intervention; approximately three-
quarters will respond to 1st line therapies.
• ITP can be primary (no other apparent causes of thrombocytopenia) or secondary (there is an identifiable
associated condition) in nature
• ITP is also categorized based on the duration of thrombocytopenia as follows1:
o Newly diagnosed ITP (<3 months duration)
o Persistent ITP (3-12 months duration)
o Chronic ITP (>12 months duration)
Evaluation and Management
• A diagnosis of primary ITP is established on a clinical basis through a patient history, physical examination,
complete blood count and peripheral smear1-6. A diagnosis of ITP is made when these examinations yield:
o isolated thrombocytopenia (<100 x 109/L) on the CBC
o no abnormal findings on peripheral smear
o an absence of findings that would raise concern for other causes of thrombocytopenia
* If atypical features are present or there is concern for other conditions associated with thrombocytopenia
(i.e. systemic illness, infection, malignancy, autoimmune illness), consider pediatric hematology consultation
and additional referrals to help guide further work up
• UW Health endorses the recommendations pertaining to children (#10-21) within the American Society of
Hematology (ASH) 2019 guidelines1 for immune thrombocytopenia and also the carried over recommendations
from 2011 ASH guideline3 that were not changed/updated in 2019.
o The endorsed recommendations are summarized in Table 1 of the full guideline
o Appendix A outlines our internal guidance for the management of ITP in children
o Appendix B provides a summary of key points for recommended 1st and 2nd line medications for ITP
References
1. Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv.
Dec 10 2019;3(23):3829-3866. doi:10.1182/bloodadvances.2019000966
2. Gafter-Gvili A. Current approaches for the diagnosis and management of immune thrombocytopenia. Eur J Intern Med. Feb
2023;108:18-24. doi:10.1016/j.ejim.2022.11.022
3. Neunert C, Lim W, Crowther M, et al. The American Society of Hematology 2011 evidence-based practice guideline for immune
thrombocytopenia. Blood. Apr 21 2011;117(16):4190-207. doi:10.1182/blood-2010-08-302984
4. Russo G, Parodi E, Farruggia P, et al. Recommendations for the management of acute immune thrombocytopenia in children. A
Consensus Conference from the Italian Association of Pediatric Hematology and Oncology. Blood Transfus. Jul 27
2023;doi:10.2450/BloodTransfus.501
5. Singh G, Bansal D, Wright NAM. Immune Thrombocytopenia in Children: Consensus and Controversies. Indian J Pediatr. Feb
2020;87(2):150-157. doi:10.1007/s12098-019-03155-4
6. Verissimo V, Carter T, Wright H, et al. Australian and New Zealand consensus guideline for paediatric newly diagnosed immune
thrombocytopaenia endorsed by Australian New Zealand Children's Haematology and Oncology Group. J Paediatr Child Health. May
2023;59(5):711-717. doi:10.1111/jpc.16395
7. Provan D, Arnold DM, Bussel JB, et al. Updated international consensus report on the investigation and management of primary
immune thrombocytopenia. Blood Adv. Nov 26 2019;3(22):3780-3817. doi:10.1182/bloodadvances.2019000812
8. Liang Y, Zhang L, Gao J, Hu D, Ai Y. Rituximab for children with immune thrombocytopenia: a systematic review. PLoS One.
2012;7(5):e36698. doi:10.1371/journal.pone.0036698
Copyright © 2024 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 04/2024
Effective 3/28/2024. Contact CCKM@uwhealth.org for previous versions.
Appendix A. Management of Immune Thrombocytopenia in Children
Copyright © 2024 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 04/2024
Effective 3/28/2024. Contact CCKM@uwhealth.org for previous versions.
Appendix B. Summary of Key Points for 1st and 2nd Line Medications for ITP in Children
* Medication information obtained from Lexi-comp® drug monographs except where cited otherwise. Clinical Pearls are based on expert opinions from UW Health subject matter experts.
Drug Dosing Information
(Assumes normal organ function)
Contraindications,
Warnings /
Precautions, Drug
Interactions
Adverse Effects
(Select common and significant toxicities
reported here; refer to Lexi-comp® for
complete list)
Clinical Pearls
(Pearls are based on expert opinions from internal subject matter experts
regarding drug selection, patient monitoring)
First-line Acute Therapies
Prednisone 2-4 mg/kg/day orally (max 120 mg daily) in 3-4
divided doses, for 5-7 days
Review in Lexi-comp® Gastritis
Insomnia
Mood/behavior changes
Increased appetite, weight gain
Hypertension
Hyperglycemia
Time to response: 2-7 days
Prolonged durations are not recommended and tapers are not needed
with short durations.
Prednisone is preferred over dexamethasone.
IVIG 0.8–1 g/kg IV for 1-2 days2,4,5,7
Alternative Dosing: 400 mg/kg IV for 5 days
See UW Health IVIG Guideline for further
details regarding pre-medication, infusion rates,
monitoring.
Review in Lexi-comp® Headache
Fever, chills
Nausea, vomiting
Infusion reactions
Hypersensitivity reaction
Rare (<1%) possibilities include:
Thrombosis, renal failure, hemolytic
anemia, and aseptic meningitis
Time to response: 1-2 days (usually within 24 hrs)
May be preferred when a rapid rise in platelet count is needed and can be
used in combination with corticosteroids for more severe cases
Anti-D Ig
50–75 mcg/kg over slow IV push (3-5 min) Review in Lexi-comp® Fever, chills
Headache
Infusion reactions
Severe intravascular hemolysis is a rare
possibility –monitor for 8h post-infusion
Time to response: 1-2 days
May be considered as an alternative to IVIG in select patients;
Patient must be Rh-positive, DAT-negative, and not splenectomized
Second-line Therapies
Eltrombopag
(TPO receptor
agonist)
1–6 y: 25 mg/day orally
>6-yrs: 50 mg/day orally (Reduce initial dose to
25 mg once daily if East/Southeast Asian
ancestry (e.g., Chinese, Japanese, Korean,
Taiwanese)
Max dose 75 mg/day
Take without a meal or with a meal low in
calcium (=50 mg) and ≥ 2 hrs before and 4 hrs
after Ca-containing foods or
medications/supplements containing Ca, Fe, Al,
Mg, Se, or Zn.
Review in Lexi-comp® Abdominal pain
Diarrhea
Headache
Arthralgia, myalgia
Abnormal hepatic function tests
Re-evaluate platelet count in 2 weeks after initiation and use lowest dose
that achieves platelet count goal (i.e. >50k) to reduce bleeding.
• Eltrombopag: If below goal, increase in 12.5mg-25mg increments bi-
weekly to max dose
• Romiplostim: If below goal, increase by 1 mcg/kg weekly to max
dose
Discontinue if platelet count does not respond to a level that avoids
clinically important bleeding after 4 weeks at the max daily dose.
Thrombocytopenia is likely to recur following treatment cessation, but
some (10-30%) may experience sustained response after taper and
discontinuation
Romiplostim
(TPO receptor
agonist)
Initial 1 mcg/kg subcutaneously once weekly
(Dosing range 1-10 mcg/kg weekly)
Review in Lexi-comp® Rash
Abdominal pain
Diarrhea
Headache
Arthralgia, myalgia
Rituximab 375 mg/m2 IV infusion weekly × 4 doses5,8 Review in Lexi-comp® Headache
Fever, Chills
Urticaria
Serum sickness
Progressive multifocal
leukoencephalopathy (Rare)
Time to response: 3 weeks
Copyright © 2024 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 04/2024
Effective 3/28/2024. Contact CCKM@uwhealth.org for previous versions.