1. Evaluation of a child with thrombocytopenia
Platelet count< 150,000 cells/uL, age>3 mouths
CBC, blood smear evaluation
Anemia + thrombocytopenia
pancytopenia
Platelet clumps present pseudothrombocytopenia
Ill appearing?
No
Congenital anomalies?
Yes No
PMN hypersegmentation
RBC macroovalocytosis?
↓B12 or ↓RBC folate
B12 or folate deficiency
Medications
Immunizations
Irradiation
Toxins?
Yes No
Drug-induces Macrothrombocytes
Live immunization
Irradiation
Toxins Yes No
Other
morphologic
platelet
changes
No other
platelet
change
Bone marrow
Cyanotic heart disease
Fanconi anemia
Dyskeratosis congenita
Trisomy 13 or 18
Syndromes:
Kasabach-Merritt
TAR
Alport variants
ITP
Hereditary thrombocytopenia
Bernard-Soulier
Syndromes:
May-hegglin
Hermansky-Pudiak
Gray platelet
↑NI megakaryocytes
↓megakaryocytes
Leukemia
Aplastic anemia
Drug-induced
Amegakaryocytic
thrombocytopenia
Myelodysplasia
ITP is a diagnosis of exclusion
Response to therapy, if needed
(corticosteroid, IVIG, anti-D antibody),
confirms the diagnosis
Yes PTT, PT, TT prolonged DIC
R/O sepsis
See
Consumptional
coagulopathy
Normal
↑↑Spleen
Signs of portal
hypertension
platelet >
50,000
+/-pancytopenia
Male
Eczema
Recurrent
infection
Small platelets
Lymphadenopathy
Hepatosplenomegaly
Superior vena cava
syndrome
Abdominal mass
Chronically ill
appearing
Acute,
fibrile illness
WBC enzyme
assays
Ultrasonography
Thick smear
Biopsy of lymph node,
mass or bone marrow
consider tumor lysis
and superior vena
cava syndromes
HIV assay
ANA
U/A
Renal function
Blood culture
? antibiotics
Malaria
Gaucher disease
Portal hypertension
Hepatic
schistosomiasis
Cavernous
transformation of
the portal vein
Wiskott-Aldrich
syndrome
Lymphoma:
Hodgkin
Non-Hodkin
Neuroblastoma
leukemia
Myelodysplasia
R/O ADMAT-13
DAT
Auto/allo anti-platelet
antibody Sepsis
HIV
Autoimmune or
connective tissue
disease
HUS/TTP + other
microangiopathies
Prosthetic cardiac
valve
Varicella
EBV
CMV
Denque
hemorrhagic
fever
HIV
HUS
Hantavirus
Parvovirus
Other
viruses
TTP
Auto/all anti-platelet
antibodies
study
Heparin-induced thrombocytopenia Check
PF4
2. Thrombocytopenia in the well neonate
Platelet count < 150,000/uL
History, examination, CBC, blood smear evaluation, maternal platelet count
If there is on obvious etilogy
for the TP, bacterial sepsis
Congenital anomalies must be considered
Maternal history positive
Maternal TP
Neonatal TP in siblings
Maternal drug use
Mild TP no bleeding
Observe if no change
Maternal ITP
or SLE Mother
acutely ill
MASPAT or
Capture-P
for auto anti-platelet
antibodies
Preeclampsia
HELLP syndrome
DIC
Hyperthuroidism
Viral Illness
Platelet <50,000:
IVIG
?corticosteroids
Random donor platelet
transfusions if
bleeding( which is unusual )
Blueberry muffin lesions
congenital infection
hemangiomas
Kasabach-Merritt
syndrome
Purpura fulminans
Multiple malformations
Trisomy 21,13,18
45XO 11q23.3 deletion
TAR syndrome
Placenta
abnormal
Neonatal
autoimmune
TP
Drug
adsorption
MASPAT or
Capture-P
Drug-induced
TP
Placenta
infarcts
Chorangioma
Platelets <
50,000
IVIG < 20,000
Transfuse
maternal
platelet
Platelet Ag and
Ab studies on
parents and/or
baby ( MASPAT
or Capture-P
cross matching)
NAIT
Maternal history negative
Blood culture,
prophylactic
antibiotics
Abnormal
CBC/smear
Abnormal
Hb, WBC,
ANC, RBC
indiced or
RBC
fragments
Abnormal platelet
size +/- other
morphologic
changes
Bone marrow
infiltration
Aplastic anemia
Pearson syndrome
Congenital micro-angiopathic
anemia
Syndromes
Large platelets
Bernard-Soulier
May-Hegglin
Hermansky-Pudiak
Gray platelet
Small platelet
Wiskott-Aldrich
NI CBC and smear
Platelet > 20,000~30,000
no bleeding
Platelet <20,000~30,000
+/- clinical bleeding
Careful observation clinically
and follow platelet count
Count stable or
increasing
Transfuse random donor
platelets
Persistent platelets↑
No or transient
platelets ↑
Transfuse washed,
irradiated maternal
platelets
IVIG 1g/kg X 1~3 days
Persistent
platelets post-transfusion
↑
No or only transient
platelets↑
Neonatal
autoimmune TP
Kasabach-Merritt
syndrome
Early sepsis
Viral infection
Unknown etilolgy
Toxoplasmosis
NAIT
Drug-induced
Amegakaryocytosis
Macrothrombocytopenia
Familial TP
3. Thrombocytopenia in the ill neonate
Any etiology of thrombocytopenia
that occurs in the well child
History, examination, CBC, blood smear evaluation See Thrombocytopenia in the well neonate
Platelets 100,000~149,000/uL Platelets < 100,000/uL If platelets < 50,000? Cranial ultrasound to R/O intracranial
hemorrhage resulting from severe TP of any etology
Follow platelet count
>150,000/uL no
further evaluation
100,000~149,000
continue to fellow
PTT, PT, TT
High Hb Severe jaundice
and low Hb
Prolonged PTT, PT and/or
TT +/- microangiopathic
hemolytic anemia:
Consider D-dimer of FSP,
and/or fibrinogen +/- factors
II, V and VIII
Polycythemia
Cyanotic
congenital
heart disease
Erythroblastosis
fetalis
Exchange
transfusion p
phototherapy
DIC
Etologies
Acute infection
Asphyxia
RDS
Meconium aspiration
Obstetrical complications
Shock
Thrombosis
Severe hemolytic disease of
the newborn
Severe hepatic disease
TP usually mild enough not to
require transfusion except in DIC
due to erythroblastosis fetalis
Treat underlying disease
Maintain platelets > 50,000 with
transfusions
Maintain fibrinogen > 1.0g/L and
PT WNL with FFP +/-
cyrorecipitate
Normal PTT, PT, TT
RDS
Pulmonary hypertansion
Meconium aspiration
Mechanical ventilation
Perinatal
asphyxia
Infection
Viral
Bacterial
Fungal
No other specific
etiology identified
Unknown etiology
Ongoing re-evaluation
if
platelets <
50,000
Acutely ill
Usually premature
Abdominal signs
NEC
Acidosis
Emesis
Lethargy
+/- Central
venous
catheter
Hematuria
Pulseless
extremity
Drug use
Gancyclovir
Heparin
Vancomycin
Metabolic
defects
Thrombosis
Drug-induced
Stop drug
Remove catheter
when possible
LMWH
??Thrombolytic
therapy
Supportive care- Platelet transfusions to maintain count > 20,000 in stable
full term neonates, > 50,000 with hemorrhage, surgery, or more extremely
preterm infants
Observe for DIC