Treatment of Pediatric Venous Thromboembolism

Venous thromboembolism (VTE) occurs uncommonly in pediatrics, affecting 0.07-0.14 per 10,000 children.^1,2 Yet, in the last 20 years, the incidence of VTE in hospitalized children has increased dramatically to approximately 58 per 10,000 admissions.³ This increase may be attributed to improved survival of very ill children, better diagnostic imaging modalities, and heightened awareness by managing physicians.³ Randomized controlled trials are lacking in pediatric thrombosis, and clinical care is based on extrapolation of adult data and expert consensus guidelines.^4,5 In 2014, the American Society of Hematology (ASH) sought to develop comprehensive guidelines on thrombosis. The pediatric VTE treatment guideline is one of six published to date.

The following are five selected guideline recommendations thought most relevant to pediatric hospitalists. Three focus on the central venous access device (CVAD), since it is the most common risk factor for pediatric VTE.¹ Recommendations were graded as “strong” if most providers, patients, and policy makers agreed with the intervention and if it was supported by credible research. Conditional recommendations had less uniform agreement with an emphasis on individualized care and weighing patients’ values and preferences.⁶

Recommendation 1. It is recommended that pediatric patients receive anticoagulation, versus no anticoagulation, for symptomatic VTE (evidence quality: low certainty; recommendation strength: strong).

There is strong indirect data in adults that symptomatic VTE requires treatment, with limited direct evidence in children. As VTE occurs most commonly in ill, hospitalized children with the potential for VTE to be life threatening, the benefit was felt to justify the strong recommendation despite low-quality evidence.

The primary benefit of anticoagulation in children with symptomatic VTE is the prevention of progressive or recurrent thrombosis with high morbidity and the prevention of life-threatening VTE. The greatest potential harm from the use of anticoagulation, particularly in very ill children, is the risk for major bleeding.⁴Recommendation 2. Children with asymptomatic VTE can be managed with or without anticoagulation (evidence quality: poor; recommendation strength: conditional).
Recommendation 2. Children with asymptomatic VTE can be managed with or without anticoagulation (evidence quality: poor; recommendation strength: conditional).

The panel focused on the unique features of pediatric VTE related to the heterogeneity in both the site and pathophysiology of VTE in children, such as age, presence of a CVAD, and comorbidities. There is little certainty that treating asymptomatic VTE is beneficial in the same way that treating symptomatic VTE would be in preventing recurrent thrombosis and embolization.

Until better evidence is available to guide care, the primary benefit of this recommendation is individualization of care related to each patient’s risk-benefit profile and parental preferences.

Potential problems with using this recommendation include the cost of anticoagulant drugs and major bleeding if anticoagulation is used. Potential problems with not using anticoagulation would be progressive or recurrent thromboembolism. Close monitoring of children with VTE—regardless of whether anticoagulation is prescribed—is warranted.