A Fragile Balance: Combined Thrombosis and Bleeding Disorders in Neonates

Abstract Combined thrombosis and bleeding disorders pose significant challenges in neonates, critically ill children, and patients with inherited or acquired coagulopathies, such as disseminated intravascular coagulation or liver dysfunction. These coexisting conditions are common in neonatal intensive care units (NICUs), where critically ill infants face environmental and medical interventions that may exacerbate both the risk of arterial and venous thromboembolism (VTE) or promote hemorrhagic risks. VTE affects up to 2% to 3% of NICU patients, and is primarily linked to sepsis and catheter-related events, while intracranial hemorrhage remains one of the leading causes of mortality and morbidity in preterm neonates. In the context of developmental immaturity, neonatal hemostasis predisposes these patients to an intersection of bleeding and thrombosis risks. This narrative review aims to navigate pathophysiology, clinical presentations, diagnostic dilemmas, and treatment strategies in neonates with thrombosis and bleeding disorders. We further explore emerging research and potential advances to improve outcomes in this vulnerable population.