ArticlesAssessment of UK practice for management of acute childhood idiopathic thrombocytopenic purpura against published guidelines
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.
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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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