Introduction: Thrombocytopenia, defined as a platelet count of less than 150 × 10^9/L, is common among neonates, particularly those in Neonatal Intensive Care Units (NICUs), with an occurrence rate of up to 30%. Neonates often receive platelet transfusions, many of which may be unnecessary. This study aimed to evaluate the prevalence of thrombocytopenia, its causes, and the effect of platelet transfusions on neonatal outcomes in NICU admissions at Saraswathi Institute of Medical Sciences, Hapur, UP. Objectives: 1. To estimate the prevalence of thrombocytopenia in neonates admitted to NICU. 2. To assess the common causes of neonatal thrombocytopenia. 3. To evaluate neonatal outcomes in thrombocytopenic patients following platelet transfusion. Methods: This cross-sectional study was conducted from August 2022 to July 2024 at the Saraswathi Institute of Medical Sciences. A total of 500 neonates admitted to the NICU were included. Neonates with various conditions were excluded based on predefined criteria. Data on maternal history, neonatal demographics, and clinical characteristics were collected. Platelet counts were measured on the first, third, and fifth day of life. Statistical analyses were performed to determine the associations between clinical variables and thrombocytopenia severity. Result: Out of 500 neonates, 126 (25.3%) had thrombocytopenia. Of these, 99 cases (19.8%) were early-onset and 27 cases (5.4%) were late-onset. Thrombocytopenia was more common in preterm, low birth weight (LBW), and small for gestational age (SGA) neonates. Significant associations were found between thrombocytopenia and maternal conditions such as pregnancy-induced hypertension (PIH), as well as neonatal conditions like sepsis, gastrointestinal bleeding, and intraventricular hemorrhage (IVH). Among neonates with thrombocytopenia, those receiving platelet transfusions had higher severity of the condition. The mortality rate among thrombocytopenic neonates was 6.3%, with severe thrombocytopenia being a significant factor. Conclusion: Thrombocytopenia in neonates is prevalent in NICUs and is significantly associated with prematurity, LBW, SGA status, and maternal PIH. The severity of thrombocytopenia impacts neonatal outcomes, with severe cases leading to higher mortality. Effective guidelines and protocols for platelet transfusion are essential to improve neonatal care and minimize unnecessary donor exposure.