Pediatric ITP and Critical Bleeding

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Source: Sirotich E, Chowdhury SR, Modi D, et al. Critical bleeding in adults and children with immune thrombocytopenia: a multicenter cohort study. Blood Adv. 2025;9(13):3238-3248; doi: 10.1182/bloodadvances.2024015494.Investigators from multiple institutions conducted a retrospective study to describe the frequency, treatments, and outcomes of critical bleeds in children and adults with immune thrombocytopenia (ITP). Study participants were patients with ITP and a platelet count <20 x 109/L who presented to 1 of 7 emergency departments (EDs) in the US and Canada between 2010 and 2019. Four of the participating sites were pediatric EDs. The medical records of study patients were reviewed and demographic and clinical information abstracted. Critical bleeding was defined as bleeding in a critical anatomic location and/or an ongoing bleed that resulted in hemodynamic instability or respiratory compromise. Separate analyses were conducted on data from adult and pediatric patients; data on the pediatric patients are summarized here. The main outcomes were rate of critical bleeds among eligible participants, frequency of different treatments, hospital length of stay (LOS), and mortality.Data were analyzed on 1,226 patients who presented to the ED with ITP and a platelet count <20 x 109/L, including 296 adults and 930 children. Among the pediatric patients, 918 (98.7%) presented with bleeding. There were 13 (1.4%) children who met criteria for a critical bleed. The median age of pediatric patients with critical bleeding was 11 years, and the median lowest platelet count in these children was 3 x 109/L. Overall, 6/200 (3.0%) children with critical bleeds were ≥12 years old, and 7/725 (1.0%) were <12. Of the 13 children with critical bleeds, 6 (42.2%) had intracranial hemorrhage (ICH), 3 had epistaxis, 3 gynecological bleeds, and 1 had both epistaxis and gastrointestinal hemorrhage. In 4 pediatric patients, the critical bleed was the initial presentation of ITP, and in the remaining 9, the median time since diagnosis was 10 months. Treatments included intravenous immune globulin (IVIG) in 10 (76.9%) pediatric patients, corticosteroids in 8 (61.5%), platelet transfusions in 8 (61.5%), red blood cell transfusions in 6 (46.2%), thrombopoietin receptor agonists in 4 (30.8%), and antifibrinolytic agents in 4 (30.8%). One 20-year-old patient had an urgent splenectomy. Median hospital LOS was 3 days. The mortality rate in pediatric patients with critical bleeds was 15.4% (2/13). Both of these children had ICH, and both were ≥12 years old.The authors conclude that critical bleeding in children with ITP presenting to the ED is rare but associated with a significant mortality rate.Dr Hogan has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Pediatric ITP is an acquired, usually self-resolving, disorder defined as an isolated platelet count <100,000 cell/uL in children ages 1–18 years old.1 Although treatment decisions and outcomes often are based on platelet counts <10,000 cells/uL, the severity of bleeding clinically impacts management, quality of life, morbidity, and mortality.2 Reporting of anatomical sites and definitions of bleeding severity vary among publications.3 A previous systemic review reported a weighted proportion of ICH of 0.4% and severe (non-ICH, with extensive mucosal bleeding as minimum criterion) bleeding of 20.2% in children with acute or chronic ITP.2Other factors increasing bleeding risks unrelated to or not resulting in 'secondary' thrombocytopenia include comorbidities, drug use, inherited disorders of hemostasis, and anatomic malformations.1,2 Social concerns or certain behaviors in toddlers and adolescents may also increase traumatic bleeding risks.4 American Society of Hematology Guidelines suggest observation for no bleeding or minor bleeding,5 yet consider treatment based on above bleeding risks, distance from hospital, timing of menstruation, or surgical intervention.4,5The current study of a large, contemporary US and Canadian cohort describes rare, life-threatening bleeding in children with ITP. Selection bias arises from missing children with bleeding directly admitted to a hospital, lacking data from non-urban, smaller hospitals, and comorbidities in 2 of the children. Based on a small number of critical bleeds, it is difficult to determine risk factors and how the timing or types of treatments may have impacted mortality. (See AAP Grand Rounds. 2010;23[2]:19.)6Although rare, critical bleeding in children with ITP could be fatal despite combination therapies.With an incidence of about 2–5 per 100,000, it is likely that most pediatricians will encounter patient(s) with ITP. (See AAP Grand Rounds. 2025;53[1]:9.)7 It is well to remember that the majority of affected children will have petechiae, bruising, or minor bleeding, necessitating outpatient treatment only7—in sharp contrast to the current study cohort with critical bleeding.