How I treat How I treat venous thrombosis in children

Evidence-based medicine for pediatric thrombosis is in its infancy. As recently as 10 years ago, antithrombotic therapy for infants and children was largely based on individual empiric experience, small case series, or was extrapolation from adult recommendations.1-4 Due to fear of bleeding complications associated with anticoagulation, clinicians were especially reluctant to treat neonates with thrombosis aggressively with antithrombotic therapy despite a high prevalence of shortand long-term sequelae in this age group.5-7 Most published reports failed to describe therapeutic dosing or duration, and documentation of anticoagulant activity achieved was almost nonexistent. Many thrombi, particularly renal, central nervous system sinovenous thrombosis (CSVT), and catheter-related venous thrombosis, were treated “conservatively,” which meant using supportive care with fluid, electrolyte, and blood pressure management.8-10 The prevalence and pathologic significance of central and proximal venous thrombi affecting the atrium and vena cava, as well as the subclavian, jugular, iliac, and femoral veins, was not appreciated widely until the ability to detect these clots in infants and children was enhanced by the development of noninvasive imaging techniques using color-flow and pulsed Doppler in addition to gray scale ultrasound (US), echocardiography, and computerized tomography and magnetic resonance with or without angiography (CT, CTA, MR, and MRA). In addition, it is clear that advances in intensive support of critically ill children have involved widespread use of indwelling central venous catheters and invasive procedures that have increased the incidence of deep venous thrombosis (DVT) in children.11 The development of national and international registries helped to increase awareness of thrombosis in children and focus attention on the serious need for objective data regarding epidemiology, etiology, diagnosis, treatment, and outcome.5,11-13 The following discussion presents the individual approach of one pediatric hematologist that has developed over 25 years of clinical practice, clinical research, and review of the results of others. Literature is cited to support treatment practices and recommendations, as available. Where not otherwise supported, the treatment decisions are based upon the author’s personal experience and professional judgment.