Treatment of Pediatric Venous Thromboembolism

Publication Date: November 27, 2018

Recommendations

Anticoagulation in symptomatic and asymptomatic deep vein thrombosis or pulmonary embolism

The American Society of Hematology (ASH) guideline panel recommends using anticoagulation rather than no anticoagulation in pediatric patients with symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE). (1⊕ooo)
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The ASH guideline panel suggests either using anticoagulation or no anticoagulation in pediatric patients with asymptomatic DVT or PE. (2⊕ooo)
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Thrombolysis, thrombectomy, and inferior vena cava filters

The ASH guideline panel suggests against using thrombolysis followed by anticoagulation; rather, anticoagulation alone should be used in pediatric patients with DVT. (2⊕ooo)
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The ASH guideline panel suggests against using thrombolysis followed by anticoagulation; rather, anticoagulation alone should be used in pediatric patients with submassive PE. (2⊕ooo)
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The ASH guideline panel suggests using thrombolysis followed by anticoagulation, rather than anticoagulation alone, in pediatric patients with PE with hemodynamic compromise. (2⊕ooo)
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The ASH guideline panel suggests against using thrombectomy followed by anticoagulation; rather, anticoagulation alone should be used in pediatric patients with symptomatic DVT or PE. (2⊕ooo)
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The ASH guideline panel suggests against using inferior vena cava (IVC) filter; rather anticoagulation alone should be used in pediatric patients with symptomatic DVT or PE. (2⊕ooo)
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Antithrombin replacement therapy

The ASH guideline panel suggests against using antithrombin (AT)-replacement therapy in addition to standard anticoagulation; rather, standard anticoagulation alone should be used in pediatric patients with DVT/cerebral sino venous thrombosis (CSVT)/PE. (2⊕ooo)
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The ASH guideline panel suggests using AT replacement therapy in addition to standard anticoagulation rather than standard anticoagulation alone in pediatric patients with DVT/CSVT/PE who have failed to respond clinically to standard anticoagulation treatment and in whom subsequent measurement of AT concentrations reveals low AT levels based on age-appropriate reference ranges. (2⊕ooo)
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Central venous access device (CVAD)-related thrombosis

The ASH guideline panel suggests no removal, rather than removal, of a functioning CVAD in pediatric patients with symptomatic CVAD-related thrombosis who continue to require venous access. (2⊕ooo)
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The ASH guideline panel recommends removal, rather than no removal, of a nonfunctioning or unneeded CVAD in pediatric patients with symptomatic CVAD-related thrombosis. (1⊕ooo)
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The ASH guideline panel suggests delayed removal of a CVAD until after initiation of anticoagulation (days), rather than immediate removal in pediatric patients with symptomatic central venous line–related thrombosis who no longer require venous access or in whom the CVAD is nonfunctioning. (2⊕ooo)
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The ASH guideline panel suggests either removal or no removal of a functioning CVAD in pediatric patients who have symptomatic CVAD-related thrombosis with worsening signs or symptoms, despite anticoagulation and who continue to require venous access. (2⊕ooo)
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Low-molecular-weight heparin vs vitamin K antagonists

The ASH guideline panel suggests using either low-molecular-weight heparin or vitamin K antagonists in pediatric patients with symptomatic DVT or PE. (2⊕ooo)
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The ASH guideline panel suggests using anticoagulation for ≤3 months rather than anticoagulation for >3 months in pediatric patients with provoked DVT or PE. (2⊕ooo)
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Unprovoked DVT or PE

The ASH guideline panel suggests using anticoagulation for 6 to 12 months rather than anticoagulation for >6 to 12 months in pediatric patients with unprovoked DVT or PE. (2⊕ooo)
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CVAD-related superficial vein thrombosis

The ASH guideline panel suggests using either anticoagulation or no anticoagulation in pediatric patients with CVAD-related superficial vein thrombosis. (2⊕ooo)
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Right atrial thrombosis

The ASH guideline panel suggests using anticoagulation, rather than no anticoagulation, in pediatric patients with right atrial thrombosis. (2⊕ooo)
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The ASH guideline panel suggests against using thrombolysis or surgical thrombectomy followed by standard anticoagulation; rather, anticoagulation alone should be used in pediatric patients with right atrial thrombosis. (2⊕ooo)
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Renal vein thrombosis

The ASH guideline panel suggests using anticoagulation, rather than no anticoagulation, in neonates with renal vein thrombosis (RVT). (2⊕ooo)
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The ASH guideline panel recommends against using thrombolysis followed by standard anticoagulation; rather, anticoagulation alone should be used in neonates with non–life-threatening RVT. (1⊕ooo)
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The ASH guideline panel suggests using thrombolysis followed by standard anticoagulation rather than anticoagulation alone in neonates with life-threatening RVT. (2⊕ooo)
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Portal vein thrombosis

The ASH guideline panel suggests using anticoagulation, rather than no anticoagulation, in pediatric patients with portal vein thrombosis (PVT) with occlusive thrombus, postliver transplant, and idiopathic PVT. (2⊕ooo)
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The ASH guideline panel suggests using no anticoagulation, rather than anticoagulation, in pediatric patients with PVT with nonocclusive thrombus or portal hypertension. (2⊕ooo)
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Cerebral sino venous thrombosis (CSVT)

The ASH guideline panel recommends using anticoagulation, rather than no anticoagulation, in pediatric patients with CSVT without hemorrhage. (1⊕ooo)
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The ASH guideline panel suggests using anticoagulation, rather than no anticoagulation, in pediatric patients with CSVT with hemorrhage. (2⊕ooo)
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The ASH guideline panel suggests against using thrombolysis followed by standard anticoagulation; rather, anticoagulation alone should be used in pediatric patients with CSVT. (2⊕ooo)
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Purpura fulminans due to homozygous protein C deficiency

The ASH guideline panel suggests using protein C replacement, rather than anticoagulation, in pediatric patients with congenital purpura fulminans due to homozygous protein C deficiency. (2⊕ooo)
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The ASH guideline panel suggests using anticoagulation plus protein C replacement, rather than anticoagulation alone, in pediatric patients with congenital purpura fulminans due to homozygous protein C deficiency. (2⊕ooo)
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The ASH guideline panel suggests using either liver transplantation or no liver transplantation (anticoagulation or protein C replacement) in pediatric patients with congenital purpura fulminans due to homozygous protein C deficiency. (2⊕ooo)
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The panel agreed that a pediatric hematologist or a pediatrician in consultation with a hematologist will be best suited to implement these recommendations given the complexity of the care involved in children with VTE. (UGPS, )
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Recommendation Grading

Disclaimer

Overview

Title

Treatment of Pediatric Venous Thromboembolism

Authoring Organization

Publication Month/Year

November 27, 2018

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE.

Inclusion Criteria

Female, Male, Child

Health Care Settings

Ambulatory, Hospital, Outpatient, School

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis, D010372 - Pediatrics

Keywords

anticoagulation, pediatric, Venous Thromboembolism, deep vein thrombosis, Anticoagulation

Source Citation

Blood Adv (2018) 2 (22): 3292–3316.