What is the management approach for a newborn with target cells and a few Burr cells on their blood smear?

From the Guidelines

The management approach for a newborn with target cells and a few Burr cells on their blood smear should prioritize a comprehensive hematologic evaluation to identify the underlying cause, with a focus on ruling out hemoglobinopathies and liver dysfunction, as suggested by the presence of target cells 1. The initial steps in management should involve obtaining a complete blood count with differential, reticulocyte count, and hemoglobin electrophoresis to assess for conditions like thalassemia or sickle cell disease, which can be identified through newborn screening programs 1. Key considerations include:

• Liver function tests and bilirubin levels to check for liver dysfunction, as target cells can be indicative of such conditions
• Monitoring for signs of hemolysis, including jaundice, pallor, and hepatosplenomegaly
• If hemolytic anemia is suspected, performing direct and indirect Coombs tests
• Depending on the severity and underlying cause, management may range from observation to transfusion therapy
• Target cells suggest abnormal cell membrane composition or surface-to-volume ratio, while Burr cells may indicate uremia, liver disease, or artifactual changes
• Obtaining a family history to identify potential hereditary conditions Given the complexity of interpreting blood smear findings in newborns and the potential for underlying serious conditions, consultation with a pediatric hematologist is strongly recommended for definitive diagnosis and treatment planning, especially if the infant shows any signs of anemia or if the blood smear abnormalities persist beyond the neonatal period.

From the Research

Management Approach for Newborn with Target Cells and Burr Cells

• The presence of target cells and Burr cells on a newborn's blood smear can be indicative of various conditions, including hemoglobinopathies and hemolytic disease of the newborn (HDN) 2.
• Target cells are often seen in sickle cell disease, which is an autosomal recessive disorder resulting in the substitution of CTG by CAG in the sixth codon of the beta-globin gene 3.
• A hypothesis of target cell formation in sickle cell disease proposes that their formation is due to a band 3-based mechanism of the erythrocyte shape control, able to explain the erythrocyte echinocytosis by glucose depletion 4.
• Burr cells, also known as echinocytes, can be seen in various conditions, including hemolytic anemia and iron overload 5.
• The management approach for a newborn with target cells and Burr cells on their blood smear would depend on the underlying cause of these findings.
• If the cause is suspected to be HDN, immunohematological workup, including direct antiglobulin test (DAT), antibody screening, and elution tests, may be necessary to determine the implicated antibodies 2.
• In cases of hemoglobinopathies, such as sickle cell disease, management may involve hydration, pain management, and possibly exchange transfusion 3.
• It is essential to note that the presence of target cells and Burr cells can have various implications, and a comprehensive evaluation, including clinical and laboratory assessment, is necessary to determine the underlying cause and develop an appropriate management plan 6, 3, 4, 5, 2.