Current and future management of pediatric venous thromboembolism

Abstract

Venous thromboembolism (VTE) is an increasingly common complication encountered in tertiary care pediatric settings. The purpose of this review is to summarize the epidemiology, current and emerging pharmacotherapeutic options, and management of this disease. Over 70% of VTE occur in children with chronic diseases. Although they are seen in children of all ages, adolescents are at greatest risk. Pediatric VTE is associated with an increased risk of in-hospital mortality; recurrent VTE and post-thrombotic syndrome are commonly seen in survivors. In recent years, anticoagulation with low molecular weight heparin has emerged as the mainstay of therapy, but compliance is limited by its onerous subcutaneous administration route. New anticoagulants either already approved for use in adults or in the pipeline offer the possibility of improved dose stability and oral routes of administration. Current recommended anticoagulation course durations are derived from very limited case series and cohort data, or extrapolations from adult literature. However, the pathophysiologic underpinnings of pediatric VTE are dissimilar from those seen in adults and are often variable within groups of pediatric patients. Clinical studies and trials in pediatric VTE are underway which will hopefully improve the quality of evidence from which therapeutic guidelines are derived.

Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population

“…In a pediatric critical care study of 655 patients by Faustino et al, 24 23.8% of those aged ≥8 years received mechanical prophylaxis; however, no data exist regarding the efficacy of mechanical prophylaxis in children, in part because of its very low rate of occurrence. Although the costs of VTE events in the pediatric population are similar to that of adults (ie, approximately $20,000 per episode), 25,26 the cost of complications from anticoagulation remains unknown. We believe additional investigation is needed before endorsing recommendations for universal prophylactic anticoagulation for pediatric orthopaedic procedures.…”

Venous thromboembolism in pediatric nephrotic syndrome

“…Overall, childhood VTE is associated with an approximate sixfold increase in the likelihood of in-hospital death (relative risk 6.27; 95 % CI 5.41–7.25) [3]. Both mean and median length of hospital stays are also significantly increased [16], likely resulting in greater healthcare expenditures [21, 22]. Long-term morbidity may be significant, with an estimated 6– 21 % of children suffering from recurrent VTE [23].…”

Healthcare burden of venous thromboembolism in childhood chronic renal diseases

“…Pediatric VTE is associated with a 2-6 fold increased mortality risk, a 5-10% prevalence of post-thrombotic syndrome (disabling venous insufficiency), and about 10% of VTE patients develop recurrent VTE [13]. Better understanding the epidemiology and risk factors for this potentially devastating complication is a necessary step toward VTE prevention and improved treatment.…”