Dear Editor

The review article on neonatal thrombocytopenia highlighted practical aspects in the management of a common yet often overlooked problem in neonatal practice. Three important factors were correctly highlighted by the authors – that thrombocytopenia exists in more than a fifth of the babies in any neonatal intensive care unit (and in a severe form in a sizeable minority), that it often is multifactorial in origin and guidelines for platelet transfusion are now more conservative. I would, however, like to bring out some difficulties that are faced in managing this problem, especially in developing countries.

1. The first manifestation of thrombocytopenia may well be a baby bleeding from nose, mouth and venepuncture sites and massive pulmonary hemorrhage is a common component of this. Once pulmonary hemorrhage has taken place, the outcome is usually poor. We, therefore, assess adequacy of platelets in common high-risk situations such as prematurity, sepsis, placental insufficiency and necrotizing enterocolitis.

2. Adequacy of platelets as seen in a well-prepared peripheral blood smear seen by an experienced pathologist is felt to be the best indicator of platelet counts. It also helps in diagnosis of specific platelet anomalies (e.g. May-Hegglin and Wiskott Aldrich anomalies); and provides corroborative evidence of sepsis while utilizing very little blood. A need possibly exists to incorporate this investigation into NICU protocols and to carry it out on a daily basis till platelets are consistently adequate.

3. In many centers, well-equipped blood banks are not available, and platelets as a component are always difficult to procure. If random donor platelets are not available, time taken to bleed donors and prepare platelet concentrates may be too long and sick neonates may not survive this period. Use of fresh whole blood in this situation, while far from ideal, is the only option available in these situations.

4. Tests for HPA are not routinely available even in many tertiary care centers of our country. Indeed, the diagnosis as well as management of NAITP is difficult in this situation.

5. Use of rhTpo as well as rhIL-11 is not likely to be the standard of care in most centers. One wonders whether systemic EACA can help tide over crises where blood or its components are not available for the bleeding neonate.

References

(1) I Roberts, NA Murray. Neonatal thrombocytopenia: causes and management. Arch Dis Child Fetal Neonatal Ed 2003; 88: F359-364.

Dear Editor

Robert's and Murray has given an excellent review on the above topic and shared their experiences in the management of neonatal thrombocytopenia. Truely it is very controversial when to transfuse platelets in babies with thrombocytopenia. It is a well known fact that platelet transfusions do not save babies but give enough time for the antibiotic to act if the underlying cause is sepsis. We had experienced situautions where platelets have gone down to <_10000 but="but" later="later" recovered="recovered" without="without" sequelae="sequelae" eventhough="eventhough" no="no" platelets="platelets" were="were" transfused.="transfused." p="p"> Authors have not mentioned about the benign thrombocytopenia of pregnancy and its effects in the newborn. In 1996 I have conducted a study in Sultanate of Oman among pregnant mothers with gestational thrombocytopenia and their newborns (unpublished data). 1.8%(11/600) of mothers had thrombocytopenia without any underlying cause. Among the babies born to these mothers with gestational thrombocytopenia the incidence of thrombocytopenia was 27%(3/11). One baby had platelet count below 30,000 and was asymptomatic. Baby spontaneously recovered over a period of 5 days. Others had counts above 50,000 and spontaneous recovery was recorded over a period of 3-4 days.

A knowledge of this type of benign thrombocytopenia is useful for Obstetricians as well as to Pediatricians when confronted with a newborn having thrombocytopenia but clinically well.