Key Updates from The American Society of Hematology and The International Society on Thrombosis and Haemostasis Guideline for The Treatment of Venous Thromboembolism in Pediatric Patients

Published: June 12, 2025

Guideline Video

Guideline Resources

Title: Treatment of Venous Thromboembolism in Pediatric Patients
Society: The American Society of Hematology (ASH) and International Society on Thrombosis and Haemostasis (ISTH)
Publish Date: May 27, 2025
Guideline Summary
Full-text

Video Transcription

Just published May 27th, 2025 - The American Society of Hematology (ASH) in conjunction with the International Society on Thrombosis and Haemostasis (ISTH), released their newest update for the guidelines on the treatment of venous thromboembolism (VTE) in pediatric patients.

The objective of this guideline is intended to support patients, clinicians, and other health care professionals in the management of pediatric patients with VTE.

This guideline was developed using the grade methodology, meaning for each recommendation there will be a strength of recommendation grading as strong or conditional. There will also be certainty in evidence grading as either low or very low.

There are 20 recommendations so let’s get started

For pediatric patients with symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE), the guideline suggests using anticoagulation rather than no anticoagulation (conditional recommendation based on very low certainty in the evidence).
For pediatric patients with clinically unsuspected DVT or PE, the guideline suggests either using anticoagulation or no anticoagulation (conditional recommendation based on very low certainty in the evidence)
For select pediatric patients with provoked VTE, the guideline suggests 6 weeks rather than 3 months of anticoagulation. Exclusions to this recommendation include (1) PE, (2) recurrent VTE, (3) persistent occlusive thrombus at 6 weeks, (4) cancer-associated thrombosis, (5) patients with persistent antiphospholipid antibodies (APAs) or major thrombophilia, and (6) ongoing VTE risk factors (conditional recommendation based on very low certainty in the evidence)
For pediatric patients with unprovoked DVT or PE, the guideline suggests using anticoagulation for 6 to 12 months rather than indefinite anticoagulation (conditional recommendation based on very low certainty in the evidence
For pediatric patients with cerebral sinus venous thrombosis (CSVT) with and without hemorrhage secondary to venous congestion, the guideline suggests using anticoagulation rather than no anticoagulation (conditional recommendation based on very low certainty in the evidence
For pediatric patients with CSVT, the guideline suggests using anticoagulation alone rather than thrombolysis followed by anticoagulation (conditional recommendation based on very low certainty in the evidence
For neonates and pediatric patients with right atrial thrombosis (RAT), the guideline suggests anticoagulation rather than no anticoagulation for patients with high-risk features and low perceived risk of bleeding (conditional recommendation based on very low certainty in the evidence
- For neonates and pediatric patients with RAT and the absence of high-risk features or with unacceptable perceived risk of bleeding, the guideline suggests no anticoagulation over anticoagulation (conditional recommendation based on very low certainty in the evidence
For neonates and pediatric patients with RAT requiring antithrombotic treatment, the guideline suggests using anticoagulation alone over thrombolysis followed by anticoagulation (conditional recommendation based on very low certainty in the evidence
For neonates with renal vein thrombosis (RVT), the guideline suggests using anticoagulation rather than no anticoagulation (conditional recommendation based on very low certainty in the evidence
For neonates with non–life-threatening RVT, the ASH/ISTH guideline panel recommends anticoagulation alone vs thrombolysis followed by anticoagulation (strong recommendation based on very low certainty in the evidence
- For neonates with life-threatening RVT, the ASH/ISTH guideline panel suggests using thrombolysis followed by anticoagulation, rather than anticoagulation alone (conditional recommendation based on very low certainty in the evidence
For neonates and children with occlusive portal vein thrombosis (PVT) and for children with nonocclusive PVT, post–liver transplant PVT, or unprovoked PVT, the ASH/ISTH guideline panel suggests using anticoagulation rather than no anticoagulation (conditional recommendation based on very low certainty in the evidence
- For neonates with nonocclusive PVT, and for children who have already developed portal hypertension (PHTN) secondary to PVT, the ASH/ISTH guideline panel suggests no anticoagulation rather than using anticoagulation (conditional recommendation based on very low certainty in the evidence
For pediatric patients with superficial vein thrombosis (SVT) secondary to IV cannulation in the upper limb, the ASH/ISTH guideline panel suggests no anticoagulation rather than using anticoagulation. (conditional recommendation based on very low certainty in the evidence
- For pediatric patients with SVT in the upper limb, which is not cannula related, or in the lower limbs associated with cancer or varicose veins, the ASH/ISTH guideline panel suggests anticoagulation rather than no anticoagulation (conditional recommendation based on very low certainty in the evidence
For pediatric patients with proximal DVT, the ASH/ISTH guideline panel suggests using anticoagulation alone rather than thrombolysis followed by anticoagulation (conditional recommendation based on very low certainty in the evidence
For pediatric patients with PE and echocardiographic or biochemical evidence of right ventricular dysfunction but without hemodynamic compromise, the guideline suggests using anticoagulation alone rather than thrombolysis followed by anticoagulation (conditional recommendation based on very low certainty in the evidence
For pediatric patients with PE and hemodynamic compromise the guideline suggests using thrombolysis followed by anticoagulation rather than anticoagulation alone (conditional recommendation based on very low certainty in the evidence
For pediatric patients with symptomatic CVAD-related thrombosis who no longer require venous access or whose CVAD is nonfunctioning, the guideline suggests either immediate removal or delayed removal of the CVAD (conditional recommendation based on low certainty in the evidence
For pediatric patients with VTE, the guideline suggests using DOACs (rivaroxaban/dabigatran) over SOC anticoagulants (low molecular weight heparin [LMWH], unfractionated heparin [UFH], vitamin K antagonists [VKAs], and fondaparinux; conditional recommendation based on low certainty in the evidence
For pediatric patients with VTE the guideline suggests using rivaroxaban over SOC anticoagulants (LMWH, UFH, VKA, and fondaparinux; conditional recommendation based on very low certainty in the evidence
For pediatric patients with VTE, the guideline suggests using dabigatran over SOC anticoagulants (LMWH, UFH, VKA, and fondaparinux; conditional recommendation based on very low certainty in the evidence
For pediatric patients with VTE, the guideline suggests using either rivaroxaban or dabigatran, although there may be individual populations or jurisdictional availability that would lead clinicians to choose 1 agent over the other (conditional recommendation based on very low certainty in the evidence

Make sure to check out the full guideline from the The American Society of Hematology (ASH) and the International Society on Thrombosis and Haemostasis (ISTH) and other related clinical decision support tools at guideline central dot com.