Bleeding is rarely severe in the newborn and is usually confined to first few days. Any baby with significant bleeding or very low platelet count less than 20,000/cmm should be given IVIgG 500-1000 mg/kg for 2 days. In contrast to the management of NAIT, platelet transfusion are seldom useful as transfused platelets are destroyed rapidly within few minutes and transfused platelets do not produce sustained rise in platelet counts. However, in life threatening hemorrhage 'random donor platelets may have role in tiding over the crisis and hence may be given. Maternally administered intravenous immunoglobulin (IVIgG) have been reported to be useful in preventing fetal thrombocytopenia. Caesarian section is usually recommended in all cases where the mother has active ITP to prevent severe bleeding in the baby due to trauma of delivery (38).

Neonatal thrombocytopenia associated with infection

With the recent advances in the management of neonates and premature babies particularly in intensive neonatal care unit and survival of more and more preterm babies and more and more prolonged hospitalization, systemic infection in neonates are seen more frequently. Thrombocytopenia commonly accompanies systemic infection in neonate. The incidence of thrombocytopenia is 55-65%, if definition of thrombocytopenia is taken as < 100,000/cmm, whereas if platelet count < 150,000/cmm is taken as criteria, then thrombocytopenia is seen in practically 80% of the neonates (16,44, 45, 46).

Initial complete blood count (CBC) changes are leucocyte left shift with increased immature cells and band cells and increased I:T ratio. It is soon followed by drop in platelet counts. In general by the time child develops the sepsis, clinically about 25% of neonates and by 36-48 hours majority of them develop thrombocytopenia and average duration of thrombocytopenia is around 6 days (16,44,45,47,48,49,50). Other factor responsible for thrombocytopenia in neonate with sepsis is due to clinical or subclinical DIC. However, often they may have thrombocytopenia without evidence of DIC. The mechanism responsible for thrombocytopenia in these infected neonates, is accelerated platelet destruction due to:-

• Endothelial damage that occurs during sepsis with platelet adhesion and aggregation or due to platelet lysis or removal of platelets by reticulo-endothelial system (44,45,50). Reticuloendothelial hyperplasia is often associated with infection.
  
  
• Decreased platelet production also has been proposed as contributing factor (49, 50). Increased thrombopoietin level ( > 1000 pg/ml) in some neonates with sepsis suggest that decrease in marrow megakaryocytes mass (43).
  
  
• Many infections are associated with DIC, a common cause of platelet consumption.

Fungal infection :

Secondary fungal infection are increasing particularly in very low birth weight babies <1500 gms and extremely very low birth weight babies < 1000 gms. Thrombocytopenia is one of the most consistent laboratory finding seen in many of the neonates with fungal sepsis in as much as in 73% cases. Some have even recommended empirical fungal treatment while waiting for culture result particularly in extremely low birth weight babies who is clinically septic with nosocomial infection and associated with thrombocytopenia (17,53,54). Fungal infections have been reported in very low birth weight babies receiving intravenous lipid emulsions (55).

Viral infection :

Congenital viral infections are important causes of thrombocytopenia in neo-natal period and early infancy. All TORCH group of organisms particularly cytomegalovirus , toxoplasmosis, rubella and herpes simplex can cause severe thrombocytopenia. Though thrombocytopenia is fairly common in HIV positive women either due to disease progression or due to antiviral therapy, however, thrombocytopenia is rare in HIV infected neonates of these women. Other viral infections like coxsackie virus B along with thrombocytopenia can cause involvement of multi organ leading to myocarditis, hepatitis and CNS involvement. Other viruses leading to thrombocytopenia are echovirus 11, parvovirus 19, Epstein Barr virus, mumps, adenovirus etc. and may be associated with hydrops, anemia and thrombocytopenia. These infection lead to thrombocytopenia due to various mechanisms like diminished production or destruction in the spleen and reticuloendothelial damage due to viral function leading to platelet adhesion and aggregates.