Management of the Child with a Non-Blanching Rash (NBR): (i.e. Petechiae, Purpura & Ecchymoses)

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Objectives

Guidance for the diagnosis and management of children presenting with a non-blanching rash. It includes a management algorithm and photos to aid the clinician. 

Scope

Children presenting with a non-blanching rash.

Audience

Medical and nursing staff in the Emergency Department and Acute Care Environments. 

Management of the Child with a Non-Blanching Rash Algorithm go straight to algorithm if patient unwell.

It is not uncommon for children to present to the Emergency Department with a non-blanching rash (accounting for approx. 2% of all attendances) +/- fever and other systemic features of illness. 1, 2

The minority of children with invasive bacterial infections, such as meningococcal disease (MCD), must be distinguished from the majority of individuals presenting with a non-blanching rash secondary to a benign self-limiting illness (90% of paediatric hospital presentations with NBR  do not have MCD; furthermore petechiae can be found in up to 3% of well infants). 3, 4, 5

Meningococcal disease remains the leading infectious cause of death amongst the paediatric population within both the UK and the developed world. The highest rates of invasive infection are in children < 5yrs (particularly those under 1yr of age); a second peak occurs amongst 11 – 22yr olds. Early recognition & treatment has been shown to improve outcome. 6, 7

  • Petechiae: pinpoint-sized capillary haemorrhages (< 2mm in diameter)
  • Purpura: essentially coalesced petechiae measuring > 2mm
  • Ecchymoses: lesions of a similar appearance to purpura, but > 1cm in size (i.e. bruises) 8

If in any doubt – Treat as Meningococcal disease

 

Differential Diagnoses:

  1. Invasive Meningococcal Disease
  2. Sepsis with other Bacteria
  3. Trauma / Non-Accidental Injury
  4. Thrombocytopenia
  5. Viral Illness
  6. Mechanical (secondary to transient increases in vascular pressure e.g. straining, coughing or vomiting; manifestation of petechiae in the distribution of the superior vena cava – i.e. above the patient’s nipple line)

  7. The following groups are distinct diagnoses and often have specific signs and symptoms:
    1. ITP: Idiopathic Thrombocytopenia
    2. HSP: Henoch-Schönlein Purpura
    3. Acute Leukaemia
    4. HUS: Haemolytic Uraemic Syndrome 5, 8, 9

Once the above differentials have been excluded, this leaves us with a further group of children in whom we need to distinguish invasive meningococcal disease and other underlying bacterial sepsis from self- limiting viral illness or a traumatic / mechanical cause.

The algorithm in this guideline is based on observation & investigation of these children and acts as a guide to their initial assessment and management.



Management of the Child with a Non-Blanching Rash:
6, 7, 15, 16

* Children who have received pre-hospital IM / IV Benzylpenicillin:

  • Follow the NBR guideline as above on initial ED presentation
  • Regardless of clinical condition → these children will require hospital admission for an observation period of a minimum of 6 – 8hrs post-antibiotic administration

**The “ILL” Criteria:

Children should be considered unwell when they have the following features:

  • Abnormal Vital Signs:
  • Tachycardia
  • Tachypnoea +/- oxygen desaturation in air
  • Increasing systolic to diastolic difference in blood pressure
    (i.e. a widening pulse pressure)

  • Poor Peripheral Perfusion:
  • Cold Extremities
  • Prolonged Capillary Refill Time > 2 secs

  • Altered Conscious State:
  • Irritability (inconsolable crying or screaming)
  • Lethargy (as reported by family or other medical / nursing staff) 5, 15

***ESSENTIAL PROCESS PRIOR TO DISCHARGE FROM RHC:

Ensure clear & appropriate indications for return advice given to child’s parent / guardian.

See this parent information leaflet for additional guidance on return advice

Important Points:

Indicators of meningococcal disease (or other serious bacterial infection) include:

  • The unwell child (see above NBR treatment algorithm + ILL criteria)
  • Purpura > 2mm diameter (unless clinical picture suggestive of HSP)
  • Abnormal blood indices (of which WCC & CRP are most often appraised)

Evidence is based on both retrospective and prospective observational studies; the salient points include:

  • It is highly unlikely significant bacteraemia is present if the non-blanching rash is localised to an SVC distribution and is not spreading
  • No single serological factor (i.e. FBC or CRP) can rule-out significant bacterial illness on its own
  • If observation is required → a period of 4hrs is recommended
  • The presence of purpura make meningococcal disease more likely 4, 5, 6, 7

 

Idiopathic Thrombocytopenia: 


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  • Most common haematological cause of a non-blanching rash
  • Affected children are typically well (with an absence of fever / other signs of infection)
  • Majority present between the ages of 2 – 5yrs
  • 60% have a preceding viral infection                     
  • Petechiae, purpura and bruising are often present in sites of frequent mild trauma
  • Physical examination is usually otherwise unremarkable (i.e. no hepatosplenomegaly)
  • Caused by destruction of circulating platelets by IgG-based platelet antibodies
  • The platelet level at which petechiae appear spontaneously is usually ≤20 x 109/L
  • Suspicion of ITP always necessitates taking a FBC + Blood Film (demonstrating isolated thrombocytopenia with an otherwise normal blood film appearance)
  • A self-limiting disorder overall; > 80% spontaneously resolve within 6 – 8 weeks 8, 10

Henoch-Schönlein Purpura:


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  • An IgA-mediated systemic small vessel vasculitis
  • Classical symmetrical distribution of palpable purpura - predominantly over the child’s buttocks, lower limbs and ankles
  • Often associated with arthritis, peripheral oedema and colicky abdominal pain
  • May have associated renal involvement (with haematuria +/- proteinuria)
  • Diagnosis is uncommon < 2yrs of age; usually manifests between 3 – 10yrs
  • Incidence peaks throughout the winter months; often preceded by an URTI
  • Take blood for: FBC (platelet levels should be within normal range), Coagulation Screen, U&Es and Bone Profile (to monitor renal profile)
  • Blood Pressure measurement (determine BP centile based on child’s sex, age + height)
  • Urinalysis; plus send urine samples to quantify protein : creatinine ratio and for microscopy, culture & sensitivity
  • Most cases have a benign course with remission occurring within ~ 6 weeks 8, 10, 11

See RHC Clinical Guidelines for further information regarding initial assessment and management

Acute Leukaemia:

  • Most common paediatric malignancy → accounts for 1/3rd of all childhood cancers
  • Typically short history (manifesting over days-to-weeks)
  • Consider in children with: hepatosplenomegaly, lymphadenopathy, easy bruising, petechiae (in absence of trauma), pallor, fatigue, weight loss, bone + / - joint pain etc.
  • Diagnostic tests: Baseline Bloods (including: FBC, Blood Film, U&Es, Bone Profile, LFTs, LDH); CXR (to exclude mediastinal mass)
  • Discuss any suspected new diagnoses with on-call consultant haematologist 9, 10

Haemolytic Uraemic Syndrome:  

  • Rarely causes petechiae or purpura
  • Commonest cause of acute renal failure in Scotland
  • Usually follows a diarrhoeal prodrome (often bloody)
  • Most cases due to verotoxin-producing Escherchiae coli
    (0157:H7 most prevalent subtype)       
  • A triad of:
    1. Microangiopathic Haemolytic Anaemia
    2. Thrombocytopenia                                                                  
    3. Acute Renal Failure
  • Mainstay of management involves acute assessment of patient’s intravascular status with subsequent fluid resuscitation as appropriate
  • Correction of electrolyte abnormalities thereafter
  • Avoidance of NSAIDS e.g. Ibuprofen
  • See link to HUS guideline below for preliminary tests and further management 10, 12

See RHC Clinical Guidelines for additional information

 

Further Considerations:

Viral Cause:

  • Petechial rash may be associated with viral illnesses (of which, enterovirus & adenovirus are the most prevalent causes)
  • Presentation is often with an URTI +/ - ‘flu-like symptoms or gastroenteritis
  • In a study of 69 children with a petechial rash in Germany: Schneider et al. (2013) found that petechial rashes restricted to an SVC distribution + a CRP value within normal parameters (quantified as < 6mg/L) did not have Invasive Meningococcal Disease 5, 8, 9, 13

Trauma:  

Where there are concerns that a NBR may be due to non-accidental injury:

  • Address safeguarding concerns & discuss with Senior Medic / Consultant
  • See existing Child Protection Guideline for further details regarding appropriate management: 4, 5, 8, 14
References
  1. Wells LC, Smith JC, Weston VC, et al. The child with a non-blanching rash: how likely is meningococcal disease? Arch Dis Child 2001; 85 : 218 – 22.
  2. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr 1997; 131 : 398 – 404.
  3. Brogan P, Raffles A. The management of fever and petechiae: making sense of rash decisionsArch Dis Child2000; 83: 506 - 507.
  4. Riordan F.A. et al. Non-Blanching Rash Audit Group. Validation of two algorithms for managing children with a non-blanching rash. Archives of Disease in Childhood 2016:101(8): 709 - 713.
  5. Barnetson L et al. Petechial rash in children: a clinical dilemma.Emergency Nurse: The Journal Of The RCN Accident And Emergency Nursing Association 2016: 24(2): 27 - 35.
  6. NICE Clinical Guideline [Internet]. Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. National Institute for Health and Clinical Excellence; 2010: CG102. [updated Feb. 2015; cited 2018 March 28th 2018]. 
  7. SIGN National Clinical Guideline [Internet]. Management of invasive meningococcal disease in children and young people. Scottish Intercollegiate Guidelines Network; 2008: CG102. [cited March 28th 2018]. 
  8. May N. Don’t Be Rash: Petechiae in well kids at St. Elmyn’s [Internet]. Manchester; 2003. [cited March 28th 2018]. 
  9. Waterfield T, Dyer E.M, Lyttle M. D. Fifteen-minute consultation: the child with a non-blanching rash. Archives of Disease in Childhood - Education and Practice
  10. Tasker R.C, McClure R.J, Acerini C.L, editors. Oxford handbook of paediatrics. 2nd Oxford (UK): Oxford University Press; 2013.
  11. Royal Hospital for Children. Clinical Guideline on: Henoch-Schonlein Purpura (HSP); renal management on presentation with. [Internet] GG&C Guidelines [updated Feb. 2017; cited March 28th 2018]. 
  12. Royal Hospital for Children. Clinical Guideline on: Haemolytic Uraemic Syndrome; investigation and management of. [Internet] GG&C Guidelines [updated Oct. 2016; cited March 28th 2018]. 
  13. Schneider H, Adams O, Weiss C et al. Clinical characteristics of children with viral single and co-infections and a petechial rash. The Pediatric Infectious Disease Journal 2013; 32 (5): 186 - 191.
  14. Royal Hospital for Children. Clinical Guideline on: Child Protection Protocol. [Internet] GG&C Guidelines [updated Oct. 2016; cited March 28th 2018]. 
  15. Royal Children's Hospital. Clinical Practice Guideline on: Fever and petechiae – purpura. [Internet] Melbourne, Australia. [cited March 28th 2018]. 
  16. Thomas A.E, Baird S.F, Anderson J. Purpuric and petechial rashes in children: initial assessment. [Internet] BMJ Best Practice [cited March 28th 2018]. 
Editorial Information

Last reviewed: 23 November 2020

Next review: 30 November 2023

Author(s): Dr Aoife Ryan (Paediatric Medicine Trainee, RHCG)

Co-Author(s): Link clinician for general paediatrics: Dr Ruth Bland (Consultant in General Paediatrics, RHCG) on behalf of Department of Paediatrics, RHCG; Correspondence author: Dr Steve Foster (Consultant in Paediatric Emergency Medicine) on behalf of Department of Paediatric Emergency Medicine, RHCG.

Approved By: Paediatric Emergency Medicine & Acute Paediatric Medicine Clinical Governance Groups

Reviewer Name(s): Paediatric Clinical Effectiveness & Risk Committee