What is the best course of action for a 15-year-old (yo) patient with thrombocytopenia (low platelets)?

Management of a 15-Year-Old with Thrombocytopenia

For a 15-year-old with low platelets, the initial approach depends critically on the platelet count and bleeding symptoms: if the count is >30,000/μL with no or minor bleeding (skin manifestations only), observation without treatment is recommended; if there is non-life-threatening mucosal bleeding (epistaxis, gum bleeding) or the count is <30,000/μL, a short course of corticosteroids (≤7 days) is preferred over other treatments. 1

Initial Assessment and Risk Stratification

The first priority is determining the actual platelet count and bleeding severity, as these drive all management decisions 1:

• Platelet count ≥20,000/μL with no or minor bleeding (petechiae, bruising only): Manage as outpatient with observation 1
• Platelet count <20,000/μL with no or minor bleeding: Still manage as outpatient but ensure hematology follow-up within 24-72 hours 1
• Any mucosal bleeding (epistaxis, gum bleeding, menorrhagia): Treatment indicated regardless of platelet count 1
• Severe bleeding or platelet count <10,000/μL: Consider hospitalization 1, 2

Critical pitfall: Adolescents (>10 years) have a 47% risk of developing chronic ITP compared to 23% in younger children, but they should still be managed according to pediatric guidelines, not adult protocols 1

Observation Strategy (No or Minor Bleeding)

For patients with only skin manifestations (bruising, petechiae), observation is strongly recommended over any pharmacologic treatment 1:

• Strong recommendation against IVIG (moderate certainty evidence) 1
• Strong recommendation against anti-D immunoglobulin (moderate certainty evidence) 1
• Conditional recommendation against corticosteroids (very low certainty evidence) 1

The rationale: 75-80% of children achieve spontaneous remission by 6 months, and treatment at presentation does not prevent severe bleeding episodes 1. Natural history studies of >2,500 children showed only 0.17-0.2% developed intracranial hemorrhage, and most occurred despite treatment 1.

Treatment Indications and First-Line Therapy

Treatment is indicated for 1:

• Non-life-threatening mucosal bleeding (epistaxis >15 minutes, gum bleeding, menorrhagia)
• Diminished health-related quality of life
• Platelet count <10,000/μL with high-risk activities or poor follow-up access

First-Line Treatment Options

If treatment is needed, corticosteroids are preferred over IVIG or anti-D for non-life-threatening mucosal bleeding 1:

Corticosteroid dosing 1:

• Prednisone 1-2 mg/kg/day for maximum 7 days (strong recommendation against courses >7 days) 1
• Alternative: High-dose dexamethasone (though less studied in pediatrics) 1
• Expected response: Platelet increase within 2-7 days in 50-80% of patients 3

IVIG (if corticosteroids contraindicated or more rapid response needed) 1:

• Dose: 0.8-1 g/kg as single dose 1, 3
• Response time: 1-7 days 3
• More expensive and requires IV access 1

Anti-D immunoglobulin 1:

• Conditional recommendation against use for non-major mucosal bleeding 1
• Should be avoided if patient has decreased hemoglobin from bleeding 3

Emergency Management (Life-Threatening Bleeding)

For severe bleeding (CNS, GI, or life-threatening hemorrhage) 3:

• Immediate corticosteroids (methylprednisolone 30 mg/kg IV or prednisone 2 mg/kg) 3
• PLUS IVIG 0.8-1 g/kg immediately 3
• PLUS platelet transfusion (target >50,000/μL) 3, 4
• Consider emergency splenectomy for refractory cases 3

Essential Diagnostic Workup

Before assuming immune thrombocytopenia (ITP), exclude secondary causes 1, 3:

Mandatory testing 1, 3:

• HIV and Hepatitis C serology 1, 3
• Antiphospholipid antibody panel (lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I) 3
• Review medication history (especially recent antibiotics, NSAIDs, anticonvulsants) 2

Bone marrow examination is NOT necessary for typical ITP presentation (isolated thrombocytopenia, otherwise well-appearing) 1. Consider bone marrow only if 1, 3:

• Abnormalities beyond thrombocytopenia on CBC or blood smear
• Atypical features (fever, weight loss, organomegaly)
• No response to treatment after 6-12 months

Activity Restrictions and Monitoring

Activity restrictions based on platelet count 2:

• >50,000/μL: No restrictions necessary 3, 2
• 20,000-50,000/μL: Avoid contact sports, high-risk activities 2
• <20,000/μL: Strict avoidance of trauma-risk activities 2

Monitoring frequency 1, 3:

• Weekly platelet counts during first 2-4 weeks 3
• If stable on observation: Monthly monitoring acceptable 3
• After treatment changes: Weekly for at least 2 weeks 3

Second-Line Therapies (Chronic ITP >12 Months)

If ITP persists beyond 12 months with ongoing bleeding or treatment dependence 1:

Thrombopoietin receptor agonists (TPO-RAs) 1, 5, 6:

• Eltrombopag: Starting dose 50 mg daily (≥27 kg) or 37.5 mg daily (<27 kg); 25 mg daily for East/Southeast Asian patients 5
• Romiplostim: Starting dose 1 mcg/kg weekly subcutaneous, titrate by 1 mcg/kg increments (max 10 mcg/kg) 6
• Response rate: 62-75% achieve platelet count ≥50,000/μL 5
• Critical warning: Monitor platelets weekly for 2 weeks after discontinuation due to rebound thrombocytopenia risk 3

Rituximab 1, 3:

• Dose: 375 mg/m² weekly × 4 weeks 3
• Response rate: 60% overall, 40% complete response 7
• Onset: 1-8 weeks 3

Splenectomy 1:

• Should be delayed at least 12 months from diagnosis due to potential for spontaneous remission 1
• Response rate: 80-85% initial, 66% sustained at 5 years 1, 7
• Mandatory pre-splenectomy: Vaccinations (pneumococcal, meningococcal, Haemophilus influenzae type b) and counseling on antibiotic prophylaxis 1

Platelet Transfusion Thresholds for Procedures

If invasive procedures are needed 3, 4:

• Central venous catheter: ≥20,000/μL 4
• Lumbar puncture: ≥40,000/μL 4
• Major surgery: ≥50,000/μL 4
• Neurosurgery: ≥100,000/μL 3

Common Pitfalls to Avoid

• Do NOT treat based solely on platelet number—bleeding symptoms and clinical context are essential 1, 3
• Do NOT use corticosteroids for >7 days in newly diagnosed pediatric ITP due to side effects without proven benefit 1
• Do NOT normalize platelet counts as a treatment goal—target is ≥50,000/μL to reduce bleeding risk 3
• Do NOT assume adult ITP management applies to adolescents—use pediatric guidelines through age 17 1
• Do NOT forget to ensure hematology follow-up within 24-72 hours for newly diagnosed patients managed as outpatients 1