Bleeding neonate / child

CAUSES AND CLINICAL FEATURES

Hemostasis

INJURY

Collagen Exposure

Platelet Adhesion and release reaction

Platelet aggregation

VASOCONSTRICTION

Serotonin Platelet Phospolipid

Thromboxane A2 ADP

Primary haemostatic plug

Stable haemostatic plug

Tissue Factor

Coagulation

Thrombin

Fibrin

Fibrinolysis

ETIOLOGY

Coagulation Disorders

Platelet Dysfunction

Vascular Fibrinolytic disorders

Coagulation DisordersInherited Acquired

• Hemophilia A and B• von Willebrand Disease• Factor VII, X, XIII

deficiency• Afibrinogenemia

• Liver disease• Vitamin K deficiency• Warfarin overdose• DIC

Platelet DysfunctionQuantitative Qualitative

• Decreased production• Increased destruction

• Inherited ▫ Glanzmann

thrombasthenia▫ Bernard Soulier

syndrome▫ Gray platelet syndrome▫ Wiskott Aldrich

syndrome• Acquired

▫ Medications▫ CRF▫ Cardiopulmonary

bypass

Thrombocytopenia

•ITP•TORCH•Infections

▫Kala azar, DHF, malaria, hepatitis B and C, HIV

•Medications▫Valproate, penicillins, heparin, quinine,

digoxin•Malignancies

▫Leukemia, lymphoma, neuroblastoma•Collagen vascular disorders

•Bone marrow failure syndromes▫Thrombocytopenia with absent radii▫Fanconi anemia

•Immunodeficiency syndromes▫Wiskott Aldrich syndrome

•Others ▫Hypersplenism, HUS, NAIT

Vascular causes

•Henoch Schonlein purpura•Connective tissue disorder•Scurvy •Prolonged steroid use•Hereditary hemorrhagic telangiectasia

CLINICAL FEATURES

NEONATES

•Oozing from umbilical stump•Cephalhematoma•Bruising, petechiae•Bleeding from site for venipuncture or

procedure site•Bleeding from scalp•Intracranial hemorrhage•Bleeding from mucous membranes

OTHERS

•Mucosal bleeds•Joint or muscle bleed•Bleeding after minor trauma•Petechiae and purpurae•Ecchymoses•Fever with rash•Hepatosplenomegaly •Significant lymphadenopathy•Menorrhagia

HISTORY

•Age of onset•Sex •Frequency •Location / type of bleeding•Duration •Medications •Family history•Associated symptoms

Examination

•Pallor•Petechiae, ecchymoses, rashes•Hepatosplenomegaly•Local examination of mouth and nose•Lymphadenopathy•Features of bone marrow failure•Any associated features

Platelet vs coagulation disordersPlatelet Disorder Coagulation

Disorder

Site Skin, mucous membranes

Deep in soft tissues, joint, muscles

Petechiae Yes No

Ecchymoses Small, superficial Large, deep

Bleeding after minor trauma

Yes No

Bleeding after surgery

Immediate, mild Delayed, severe

Examples von Willebrand disease, ITP

Hemophilia A and B