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Published on: February 10, 2023
Venous thromboembolism in pediatrics: Management of special clinical scenarios
Francisco José Climent1, Heidy Johana Campo Palacio2, María Falcón3
1Unidad Patología Crónica Compleja, Hospital Universitario La Paz. Instituto de Investigación del Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.
Insights
Pediatric venous thromboembolism (VTE) management in complex cases like neonates or cancer patients requires individualized, multidisciplinary care. Balancing bleeding and clotting risks is crucial for organ preservation and preventing long-term complications.
Area of Science:
- Pediatric Hematology
- Vascular Medicine
- Neonatology
Background:
- Pediatric venous thromboembolism (VTE) incidence is rising due to complex healthcare, advanced diagnostics, and increased awareness.
- VTE in children often links to iatrogenic factors like central venous catheters, affecting vulnerable groups such as neonates and those with cancer, heart disease, or short bowel syndrome.
Purpose of the Study:
- To review specialized clinical scenarios of pediatric VTE.
- To propose a practical decision-making framework for complex pediatric VTE cases.
Main Methods:
- Narrative review of clinical practice.
- Integration of recent guidelines, case series, and clinical experience.
- Focus on pathophysiology, diagnosis, treatment, and follow-up.
Main Results:
- Neonatal VTE management is influenced by developmental hemostasis, bleeding risks, and pharmacokinetics, with specific considerations for catheter-associated thrombosis and purpura fulminans.
- In cancer, heart disease, or short bowel syndrome patients, VTE is multifactorial, often catheter-related, necessitating tailored anticoagulation and thrombolysis strategies.
- Current anticoagulation strategies, including direct oral anticoagulants, and thrombolysis are summarized, emphasizing caution in specific subgroups.
Conclusions:
- Individualized, multidisciplinary management is essential for pediatric VTE in special populations.
- Treatment decisions should balance bleeding and thrombosis risks, prioritizing organ preservation and venous capital.
- Long-term follow-up is critical to prevent complications and manage residual risks.
Introduction:
The incidence of pediatric venous thromboembolism (VTE) has increased due to increased health care complexity, improved diagnostic techniques, and greater clinical awareness. Most episodes are associated with iatrogenic risk factors, particularly the use of central venous catheters, and occur in vulnerable populations such as neonates or children with cancer, congenital heart disease, and/or short bowel syndrome.
Objective:
To review special clinical scenarios of pediatric VTE and propose a practical approach to support decision-making in complex clinical settings.
Methods:
Narrative review focused on clinical practice, addressing pathophysiological features, diagnosis, treatment, and follow-up, integrating recent guideline recommendations, observational case series, and clinical experience reports.
Results:
In neonatology, developmental hemostasis, bleeding risk, and pharmacokinetics influence the indication, selection, and monitoring of anticoagulation therapy. The review discusses umbilical venous catheter-associated thrombosis, neonatal purpura fulminans, and renal and portal vein thrombosis, highlighting the criteria for anticoagulation and/or thrombolysis and the need for long-term follow-up to detect sequelae. In children with cancer, congenital heart disease, or short bowel syndrome, VTE is multifactorial and frequently catheter-related, requiring therapeutic adjustments (eg, thrombocytopenia, invasive procedures, preservation of vascular access). We summarize the current strategies for anticoagulation-including the emerging role of direct oral anticoagulants, with caution in selected subgroups-and thrombolysis.
Conclusions:
In special pediatric populations, VTE requires individualized and multidisciplinary management. Disease severity, residual risk, and the need to balance bleeding and thrombosis should guide decisions regarding treatment intensity/duration as well as prophylaxis, with emphasis on organ preservation, maintenance of venous capital, and prevention of long-term complications.
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