Q: My 8-year-old niece has ITP. The doctors did the IVIG two weeks ago. It seems that her blood counts have dropped to 144,000. Five days after the procedure they were 350,000. We are waiting for the next count but the doctor says not to get our hopes high. What do you recommend as the next step? We are thinking that this is it and she will have to live a life of little physical activity and many possible complications.

A:Intravenous immune globulin (IVIG) has been the drug of second choice for many years. Some recent studies indicate that for Rh (D)-positive patients with ITP, intravenous Rho immune globulin (RhIG) is equally effective, less toxic, has greater ease of administration and is cheaper than IVIG. Children with platelet counts greater than 30,000/ml have a low risk of severe haemorrhage and require no specific treatment. In case the counts fall below 20,000/ml there is likelihood of purpura and mucosal bleeding. Oral prednisone is conservative treatment and the addition of intravenous RhIG for Rh(D)-positive patients or IVIG for Rh(D)-negative patients is a more aggressive treatment. Most children with ITP will become normal within 6 months. The treatment of children with continuing thrombocytopaenia is the same as for acute ITP. Many children settle with an adequate platelet count (i.e. more than 20,000/ml) and have no symptoms unless injured. In children under 10 years of age at diagnosis spontaneous remission is likely to occur eventually. Older children at diagnosis, and especially adolescent girls, are more likely follow a chronic course and particular problems may arise for girls at the onset of menstruation. Most children need no specific therapy to raise the count unless injured or requiring surgery or dental extraction.