What to Expect When Thrombocytopenic Children Present With Domestic Head Injury?

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To the Editors:
I read with interest the recent articles entitled “Head trauma and intracranial hemorrhage in children with idiopathic thrombocytopenic purpura (ITP)” by Alterkait et al1 and Poddighe.2 I share with the latter about the concerns of serious head injury in the active, ambulatory toddler, but the evidence to date does not support the usefulness of medical interventions in the prevention of serious bleeding in children diagnosed with ITP.3 The 114 cases of intracranial hemorrhage occurring in children with ITP noted by Alterkait et al are largely recovered cases from retrospective studies and thus are extreme examples of head injury among thrombocytopenic patients. Details about the mechanism of injury are often insufficient, and there is a lack of information on the consequences of the day-to-day head trauma in real life. Thus, when thrombocytopenic children present with domestic head injury, there are no sufficient evidence-based data to inform practice.
Four children with preexisting thrombocytopenia were seen in our hospital after an apparently “minor” head injury. A 7-year-old boy with chronic ITP bumped on to a door while playing in his friend's party when his platelet was 20 × 109/L. Besides an obvious hematoma on his forehead, he was otherwise well. He was discharged home with tranexamic acid. A 3-year-old boy with neuroblastoma accidentally fell from his bed when his platelet was 10 × 109/L. Another 3-year-old boy with neuroblastoma slipped and fell when his platelet count was 10 × 109/L. The distance of fall was estimated to be 0.9 m in both cases. Both children presented with a hematoma over the occiput. They were sent home after a platelet transfusion. In all 3 children, normal skull radiographs were obtained before discharge.
A fourth child, an 18-month-old girl with neuroblastoma, struggled and fell from her mother's arms while she was carried around. She fell an estimated distance of 1.7 m and landed on the left side of her head. By the time she reached hospital, her crying stopped and the result of her general and neurological examination was normal. A hematoma was noted at the site of impact. Her platelet was 22 × 109/L. She was sent home after skull radiographs were obtained. Two days later, when she was seen in the hematology clinic, a cephalhematoma was noted of the left parietal bone. A linear fracture was noted when the skull radiographs were reviewed (Fig. 1A). A later computed tomography found a small epidural hematoma under the left parietal bone (Fig. 1B). No treatment was needed because she remained well and the thrombocytopenia resolved. She went on to receive further chemotherapy including high-dose chemotherapy with autologous peripheral blood stem cell transplantation without any bleeding issues.
This experience indicates that thrombocytopenic children presenting with unintentional domestic head injury from linear deceleration generally have favorable outcomes. Additional studies are required to inform proper management under such circumstances.
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