Petechiae and purpura

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  • See also

    Sepsis – assessment and management
    Acute meningococcal disease
    Child abuse

    Key points

    • The majority of children with petechiae do not have a serious bacterial infection or meningococcal disease, and often will not have a specific cause identified
    • Seriously unwell children with petechiae/purpura require urgent management 


    • Serious bacterial infections including meningococcal disease can present with a non-blanching rash, with or without fever
    • The incidence of pneumococcal and meningococcal bacteraemia has decreased since the introduction of routine vaccination
    • There are many other infective and non-infective causes of petechiae and purpura (see table below)


    • Both petechiae and purpura do not blanch when pressure is applied - this is in contrast to other common rashes in children such as viral exanthems and urticaria
    • The 'glass test' can be used to assist with assessing whether a rash is blanching - a drinking glass can be applied firmly against a rash - if the rash does not disappear it is non-blanching

    Glass test
    Image: glass test

    • Petechiae are pinpoint non-blanching spots
    • Purpura are larger non-blanching spots (>2 mm)

    petechiae on the torso and legs of a child 
    Image: petechiae on the torso and legs of a child

    purpura on the torso and back/face of a child
    Image: purpura on the torso and back/face of a child


    All children with fever and petechiae/purpura should be reviewed promptly by a senior clinician


    • Immunisation status - children <6 months of age or with incomplete immunisation status 
    • Rapid onset and/or rapid progression of symptoms and rash
    • Medications: prior treatment with antibiotics may mask signs of a bacterial infection
    • High risk groups: immunosuppression, previous invasive bacterial infections
    • History of trauma/injury
    • Association with bleeding, abdominal pain, joint pain, difficulty mobilising  
    • Travel
    • Sick contacts


    Children are considered unwell when they have:

    • Abnormal vital signs: tachycardia, tachypnoea and/or desaturation in air
    • Cold shock: narrow pulse pressure, cold extremities, prolonged capillary refill
    • Warm shock: wide pulse pressure, bounding pulses, flushed skin with rapid capillary refill
    • Altered conscious state: irritability (inconsolable crying or screaming), lethargy (including as reported by family or other staff)
    • Limb tenderness or difficulty mobilising

    For more information on assessment of the unwell child see Resuscitation: Care of the seriously unwell child  

    For all children, also consider haematological causes and review for:

    • Hepatomegaly or splenomegaly
    • Lymphadenopathy
    • Swelling or erythema of joints

    Differential diagnoses

    Causes of petechiae and/or purpura







    Neisseria meningitidis  (meningococcal disease)

    Streptococcus pneumoniae 

    Haemophilus influenzae

    Group A streptococcus

    Staphylococcus aureus



    Vomiting or coughing - occurs in the distribution of the superior vena cava which is above the level of the nipples

    Local physical pressure eg holding child during procedure, tight tourniquet

    Non-accidental injury or accidental injury



    Immune thrombocytopenia (ITP)  

    Malignancy including acute leukaemia

    Aplastic anaemia

    Disseminated intravascular coagulation (DIC)

    Haemolytic uraemic syndrome (HUS)



    Henoch-Schönlein purpura (HSP)


    Drug-induced thrombocytopenia

    Note: There are additional causes of petechiae that should be considered in newborns (eg congenital cytomegalovirus, toxoplasmosis, neonatal lupus). Any newborn with petechiae should be promptly reviewed with a senior clinician



    purpura on the torso and back/face of a child

    * Senior clinician review may lead to decision making pathways outside of this flowchart, including the role of investigations. If a senior clinician is unavailable, the safest approach is to manage according to the flowchart.
    ** Film must be reviewed to exclude an alternative diagnosis   
    *** Antibiotics:

    • Cefotaxime: 50 mg/kg (2 g) IV 12H (week 1 of life), 6-8H (week 2-4 of life), 6H (>week 4 of life)
    • Ceftriaxone:
      • usual 50 mg/kg (2 g) IV daily
      • severe (including meningitis and brain abscess) 100 mg/kg (2 g) IV daily or 50 mg/kg (1 g) IV 12H
      • Where possible, ceftriaxone should be avoided in neonates <41 weeks gestation, particularly if jaundiced or receiving calcium containing solutions, including TPN
    • Flucloxacillin: 50 mg/kg (2 g) IV 6H

     Consider consultation with local paediatric team when

    • Assessing any unwell child, including any with suspected meningococcal disease
    • Uncertainty about diagnosis or to arrange follow-up
    • Advice regarding escalation of care

    Consider transfer when

    Child requiring care beyond the comfort level of the hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when

    • Serious cause of petechiae/purpura considered unlikely based on clinical assessment and/or investigations
    • Always advise parents to return for review if their child becomes more unwell or there is concern

    Parent information

    Fever in children

                                                                                                                    Last updated February 2021

  • Reference List

    1. Glass test image sourced from Kidspot: The simple home test that could save your child’s life, (accessed December 2020)
    2. Queensland Government Fact Sheet: Meningococcal disease, (viewed October 2020)
    3. Riordan, FAI. et al, Validation of two algorithms for managing children with a non-blanching rash, Archives of Disease in Childhood, 2016; 101:709-713.
    4. Waterfield, T. et al, Fifteen-minute consultation: the child with a non-blanching rash, Archives of Disease in Childhood - Education and Practice, 2018;103:236-240.
    5. Waterfield T. et al, Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet, 2020
    6. Wells, LC. et al, The child with a non-blanching rash: how likely is meningococcal disease?, Archives of Disease in Childhood, 2001;85(3):218-222.