(suggestive of an infectious or malignant process), and a dermatologic examination for evidence of petechiae, purpura, or ecchymoses Children with ITP generally have a normal physical examination except for petechial rash, ecchymoses, and other signs of bleeding Management/Diagnostic Testing Initial Evaluation and Diagnosis The diagnosis of ITP should be considered in all patients with isolated thrombocytopenia with a platelet count less than 100,000/μL Initial lab tests include CBC, reticulocyte count, blood smear for review, and type and screen Direct antibody test (Coombs), coagulation panel, uric acid, and other tests should be performed based on clinical presentation Atypical features should prompt consideration of other diagnoses and further evaluation The well-appearing child with a normal physical examination, isolated thrombocytopenia, characteristic findings on peripheral blood smear, an unremarkable personal and family history, and absence of history or examination findings suggestive of an alternate diagnosis may be diagnosed with ITP Although some controversy exists, bone marrow biopsy and aspiration is generally unnecessary in children older than 12 months with a typical presentation Any historical or physical examination features raising concern for an oncologic process should prompt bone marrow evaluation before the initiation treatment If a patient with acute leukemia is mistakenly diagnosed as having ITP and treated with steroids, the correct diagnosis of leukemia may be delayed and long-term outcome could be adversely affected Treatment Increasingly, the management of ITP is guided by bleeding symptoms rather than the platelet count Management of an acute episode for a patient with persistent or chronic ITP should be based on past successful therapy and in conjunction with the primary hematologist There is practice heterogeneity for when and how to treat pediatric patients with acute ITP Here we provide an approach based on the recent American Society of Hematology guidelines Many patients with acute ITP with absent or mild bleeding may be managed with observation Indications for pharmacologic intervention include moderate bleeding symptoms ( Table 93.8 ), inability to keep patients safe from significant head trauma, or the need for surgery Most, though not all, of these patients will have platelet counts below 30,000/μL For patients with moderate–severe bleeding symptoms, several initial medications and dosing regimens are cited in the literature Table 93.9 presents a few examples of regimens used IVIG and steroids are the two most common first-line treatments Anti-D is relatively contraindicated if hematocrit is low due to bleeding or if there is evidence of autoimmune hemolysis, and now carries an FDA black box warning due to risk of severe hemolysis For life-threatening bleeding, which is fortunately rare in this population, platelet transfusion and in some cases emergent splenectomy are required in addition to initiating pharmacotherapy Avoid