Grading of hemorrhage in children with idiopathic thrombocytopenic purpura

Objective: To develop an instrument to allow semiquantitative assessment of hemorrhage in children with idiopathic thrombocytopenic purpura (ITP). Study design: Bleeding severity was graded on a scale of 0 to 4 in 4 different sites (overall, oral, epistaxis, and skin) on the basis of history during the previous 24 hours and physical examination. Results: Children with ITP (n = 54) were assessed on 109 different occasions by multiple observers, including 81 measurements by one of the authors. Grade of bleeding correlated inversely with platelet count. Grade 3 or 4 hemorrhage was infrequently encountered except involving the skin, where assessment was difficult. Grade 4 mucosal or internal hemorrhage was noted in 7 patients; none had life-threatening or fatal bleeding. Interrater agreement in grading of overall and mouth bleeding and epistaxis was acceptable. Conclusions: We conclude that scoring of hemorrhage is possible in children with ITP and that the grade of hemorrhage may represent a clinically meaningful end point in future studies.