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In children, the timing of thrombocytopenia, its extent, and associated clinical features dictate the investigation of pathophysiologic causes and management.

Thrombocytopenia is relatively common in critically ill children, and its presence may signify a benign transient condition to a serious condition. A review article published in Children summarizes the various clinical conditions with thrombocytopenia and their management in acutely ill children.

Paul Martinez, MD, and colleagues reviewed and compared the presentation, pathogenesis, and treatment of different clinical syndromes with thrombocytopenia, including thrombotic microangiopathic spectrum (TMA) and thrombocytopenia-associated multiorgan failure (TAMOF). They acknowledged that several new therapeutic interventions are being attempted for thrombotic thrombocytopenia, which may help patients with TAMOF. Further studies are warranted to determine their role in the management of TAMOF.

Associated Conditions

The authors cited several conditions associated with TMA (eg, transplantation, malignancy, and infections). Additionally, several drugs are linked to developing immune-mediated TMA and dose-dependent TMA. “Our understanding of TMA in acutely ill patients and the management strategies are rapidly evolving. A multidisciplinary team consisting of an intensive care physician, hematology/oncology, nephrology, and other specialties should be involved in their management,” the researchers stated.

Regarding future direction for clinical syndromes with thrombocytopenia, early identification of clinical phenotypes and their management still needs to be fleshed out. The authors recommended that prospectively collected registry data may help enhance identification and timely management of these conditions.

Another clinical condition with thrombocytopenia is disseminated intravascular coagulation (DIC). It is the most common mechanism attributed to thrombocytopenia in patients with sepsis. DIC can be classified as hyperfibrinolytic or hypofibrinolytic. The evidence for anti-thrombolytics in the management of DIC is mainly in adults. The researchers noted that additional research is needed to identify hyperfibrinolytic DIC in children and to use antifibrinolytics to understand the risks and benefits. Additionally, more research is necessary to assess the importance of thromboelastography in thrombocytopenic conditions in the pediatric population.

Advances & Directions for Future Research

Dr. Martinez and colleagues also analyzed platelet transfusions, the different thresholds, and complications. Current recommendations for the threshold for platelet transfusion are mainly based on consensus. Recommended areas for future research include reduced use of platelet transfusions and alternative strategies for thrombocytopenia management.

“The timing of occurrence of thrombocytopenia, the degree of thrombocytopenia, and associated clinical features in a given child will dictate the investigation of pathophysiologic causes and management,” the authors wrote. “There is an increasing understanding of the mechanisms of thrombocytopenia and new therapeutic approaches for the management of specific conditions with thrombocytopenia.”