Advances in Neonatal Hematology and Hemostasis

Dear Colleagues,

Anemia and thrombocytopenia represent common hematologic disorders in neonates, particularly among very preterm infants. Simultaneously, preterm neonates are at increased risk for bleeding and hemostatic disorders. To manage anemia, thrombocytopenia, and bleeding, blood components, including red blood cells (RBCs), platelets, and fresh frozen plasma (FFP), are frequently administered in neonatal intensive care units (NICUs). Advances in neonatal care have led to improved survival, especially among preterm infants, which has consequently been associated with a significant increase in transfusion practices in recent years.

Most low-birth-weight and/or very preterm neonates receive at least one red blood cell (RBC) transfusion during their hospital stay due to anemia. Thrombocytopenia occurs in approximately 20–35% of neonates admitted to a neonatal intensive care unit (NICU), with even higher rates observed among extremely premature neonates. Anemia and thrombocytopenia have traditionally been managed with transfusion therapy. Two large randomized controlled trials, the ETTNO and TOP trials, respectively, are currently evaluating safe and effective red blood cell transfusion thresholds, with a special focus on long-term neurodevelopmental outcomes. Furthermore, the PLANET-2 study demonstrated that a restrictive platelet transfusion strategy may be superior to a liberal approach in preterm neonates with thrombocytopenia.

In contrast, there is no evidence to support the administration of fresh frozen plasma (FFP) in non-bleeding preterm neonates. Fresh-frozen plasma is commonly administered prophylactically to non-bleeding, critically ill neonates as an attempt to prevent bleeding or for non-hematologic indications. It is estimated that 6–12% of all NICU admissions involve at least one FFP transfusion. However, multiple studies have demonstrated that, despite correction of coagulation parameters, FFP administration does not improve clinical outcomes or overall survival. Despite the emerging evidence, FFP is currently used in non-bleeding neonates outside evidence-based recommendations, frequently in response to “prolonged” coagulation test results.

Current transfusion practices are therefore increasingly debated regarding their effectiveness and optimal transfusion thresholds. The absence of international consensus on RBC and platelet transfusion thresholds, as well as on indications for FFP use in neonates, has led to considerable variability in clinical practice. The assessment of transfusion requirements may be enhanced by incorporating indices that complement conventional parameters such as serum hemoglobin levels, platelet counts, and clotting times, as well as by implementing novel modalities for the evaluation of hemostasis in neonatal intensive care units (NICUs) in critically ill neonates. The identification of reliable indices to guide red blood cell, platelet transfusions, and FFP could facilitate a more individualized and evidence-based transfusion strategy.

The kind of papers we are soliciting include original papers (prospective, retrospective, and case control studies) and review papers (narrative, systematic, and state-of-the-art). This Special Issue aims to provide an overview of the etiologies, risk factors, and management of neonatal anemia, thrombocytopenia, and bleeding. Particular emphasis is placed on recent advances in transfusion practices, while also highlighting anticipated future developments in this evolving field. It is of special interest to focus on new modalities for predicting the need for RBCs, platelets, and FFP transfusions. Finally, it would be beneficial to provide evidence for the effect of transfusions on long-term outcomes such as neurodevelopment, bronchopulmonary dysplasia, retinopathy of prematurity, or other complications of prematurity.

Dr. Dimitra Gialamprinou
Prof. Dr. Georgios Mitsiakos
Guest Editors

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• anemia
• thrombocytopenia
• bleeding
• RBCs
• platelets
• FFP
• transfusion
• neonates