Elsevier

The Lancet

Volume 350, Issue 9078, 30 August 1997, Pages 620-623
The Lancet

Articles
Assessment of UK practice for management of acute childhood idiopathic thrombocytopenic purpura against published guidelines

https://doi.org/10.1016/S0140-6736(97)04143-3Get rights and content

Summary

Background

Guidelines for management of acute immune thrombocytopenic purpura (ITP) in childhood were published in 1992. Regional audit in 1995 showed substantial variation in clinical practice not related to clinical differences in patient groups, which indicated a need for national audit.

Methods

Individuals aged from birth to their 16th birthday newly presenting with ITP were identified over 14 months by regular mailing of paediatricians and haematologists for case notification. Information was obtained from follow-up by a detailed questionnaire.

Findings

ITP was clinically mild and benign in 323 (76%) of 427 cases, including 181 (70%) of 260 cases with platelet counts below 10×109/L. There were no deaths or intracranial haemorrhages. There was a substantial discrepancy between clinical practice and published guidelines: many children were admitted to hospital and received treatment unnecessarily; there was overuse of intravenous immunoglobulin (IVIg) as first-line therapy (94 children); children received steroids without marrow examination; and there was inappropriate use of platelet transfusions (41 with mild or moderate disease).

Interpretation

Our results indicate a need for change in practice.

Introduction

Acute idiopathic thrombocytopenic purpura (ITP) in children is generally a short, self-limiting illness with a good prognosis. It has an equal sex incidence, and usually occurs in children aged 2 to 10 years, often after a viral infection. In a typical case, the child is well, but has a dramatic presentation with widespread cutaneous purpura, sometimes accompanied by mucosal haemorrhages and epistaxis; however, the child recovers quickly without serious morbidity. Despite this good outlook, fierce debate over the management of these children continues.1, 2, 3 Do they all need treatment, and, if so, with what? The extensive research features few adequate controlled randomised trials for the desired “evidence base” for therapy.4 Physicians tend to treat the platelet count (rather than the child), on the basis that it is a surrogate marker for the risk of serious bleeding. Treatment is not without hazard, and, because of these concerns, a group of UK paediatric haematologists published guidelines for the management of ITP.5

Retrospective local audit of the management of patients revealed major differences in management between hospitals,6 which did not result from differences between patient groups. ITP was thus an appropriate subject for a national audit against the published guidelines.

Section snippets

Methods

Paediatricians in the UK (members of the Royal College of Paediatrics and Child Health, formerly the British Paediatric Association) and paediatric haematologists (list supplied by the Paediatric Haematology Forum of the British Society for Haematology) were mailed roughly every 3 months (four occasions), to be asked whether or not they had seen a new patient (aged from birth to 16th birthday) presenting with ITP in the previous 3 months. Any case newly diagnosed from April 1, 1995, to May 31,

Results

Questionnaires were sent out in September, 1995, and in January, April, and July, 1996. The overall response rate (“have you seen a case”—yes/no) was 94%. The proportion of retrieved questionnaires was 76%.

427 analysable cases were reported over 14 months by 286 doctors; 339 (79%) of these cases were reported by paediatricians, and the remaining 87 by haematologists. 39 cases were excluded (prior to analysis) because the date of presentation was outside the study period or they were duplicates.

Discussion

The good response to the survey, clinical features, and outcome suggest that the cases reported in this survey represent current incidence of ITP and practice within the UK. The total population of children under age 16 years in the UK and Eire is approaching 13 million (population data from 1991 census obtained from Royal College of Paediatricians and Child Health and Institute of Obstetricians and Gynaecologists of Royal College of Physicians of Ireland), so the incidence of ITP over 14

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