© F e r r a t a S t o r t i F o u n d a t i o ntors include the relatively low incidence compared with that in adults, slow acceptance by some pediatricians of the increasing incidence of HA-VTE, lack of evidence on preventability, and -in particular -the paucity of studies applying appropriate methodologies for establishing independent risk factors and validating risk models derived from them. Challenges regarding how to best/consistently define a risk factor -e.g. immobility-also exist, as they do in adults.Lending further credence to the importance of developing evidence-based HA-VTE prevention guidelines for children, the International Society of Thrombosis and Haemostasis (ISTH) convened a Working Group, via the Pediatric/Neonatal Hemostasis and Thrombosis Subcommittee Scientific and Standardization Committee (SSC), to develop recommendations for standardization and future research regarding pediatric HA-VTE risk factors and risk assessment models. As a prerequisite to the development of guidelines, current evidence must be rigorously analyzed. Accordingly, the purpose of this report is to present findings of a systematic review and metaanalysis of the literature on pediatric HA-VTE risk factors and risk-assessment models. Methods Search strategyWe identified English articles using PubMed (1946-May, 2014 and Embase (1980-May, 2014. The search strategies comprised "venous thromboembolism," "risk" and "children" with multiple subject headings and text-words per concept. Given the large body of VTE literature, we began with a sensitive query and progressively specified subsequent queries using major focus syntax and text-word title field restrictions. Selectively exploding subject headings, with relevant subcategories, permitted ever-increasing specificity. The full search strategy for Pubmed is available as Online Supplementary Table S1. Study selectionWe excluded studies of patients older than 21 years based on the definition of pediatric age from the National Institute of Child Health and Human Development. 9 For studies that included pediatric and adult patients, we excluded those without clear subanalyses for patients under 21 years. Similarly, we excluded studies on arterial thromboembolism unless cases of VTE were included and clearly delineated in sub-analyses. Studies were categorized as narrative reviews, commentaries, single case reports, retrospective case series, cross-sectional studies, case-control studies, cohort studies (retrospective and prospective), registry studies, or clinical trials, the first three of which were excluded. Cases series were retained if they included at least 40 cases. Conflicting opinions regarding study design, where insufficiently or inconsistently described, were resolved through group consensus. Data extractionThe following data were initially extracted by a pair of reviewers (BB, AM) and independently confirmed by a second pair (LR, CHvO): study design; number of patients/hospital unit; summary statistics on patients' age, gender; VTE location; time from VT...

Summary. Background: The prevalence of VTE is increasing in tertiary pediatric hospitals. Identification of high-risk populations using uniform criteria is required to develop evidence-based VTE prevention guidelines. Objective: To develop a VTE risk prediction rule, the Peds-Clot clinical Decision Rule (PCDR), to identify high-risk children who were at increased risk of developing VTE. Methods: This retrospective case-control study developed the PCDR using a derivation cohort (173 cases, 346 controls) and validated it on a separate validation cohort (100 cases, 100 controls). A uniform data collection strategy was applied to derive both the samples. Conditional logistic regression analyses were used to develop a risk-prediction model. Each significant predictor was assigned a score based on its beta coefficient and the PCDR was developed. ROC curves were derived to test the performance of the PCDR. Results: Characteristics of derivation and validation cohorts were comparable. Six risk factors (positive blood stream infection, central venous catheter, direct admission to ICU/ NICU, hospitalization for ‡ 7 days, immobilization for > 72 h, and use of birth control pills) formed the final risk prediction model (risk score range, 0.5-9.5). A risk score of 3 or more identified high-risk children at a sensitivity of 70% and specificity of 80% and AUC of 0.852 (95% confidence interval, 0.814-0.890). The application of a risk score to the validation sample showed sensitivity 57% and specificity 88% and an AUC of 0.875 (95% confidence interval, 0.82-0.924). Conclusion: Incorporation of the PCDR in routine clinical care can be an attractive strategy to identify high-risk hospitalized children with a predisposition for VTE. The clinical utility of the PCDR needs validation in prospective studies.

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The incidence of diagnosed venous thromboembolism (VTE) has been increasing concurrent with advances in technology and medical care that enhance our ability to treat pediatric patients with critical illness or complex multiorgan system dysfunction. Although the overall incidence of VTE is estimated at 0.07–0.49 per 10,000 children, higher rates are observed in specific populations including hospitalized children, those with central venous catheters (CVCs) or patients convalescing from a major surgery. While the absolute number of pediatric VTE events may seem trivial compared to adults, the increasing incidence, associated with increased mortality and morbidity, the availability of novel therapies, and the impact on the cost of care have made investigation of VTE risk factors and prevention strategies a high priority. Many putative risk factors for pediatric VTE have been reported, primarily from single-institution, retrospective studies which lack appropriate methods for verifying independent risk factors. In addition, some risk factors have inconsistent definitions, which vex meta-analyses. CVCs are the most prevalent risk factors but have not consistently been assigned the highest level of risk as defined by odds ratios from retrospective, case–control studies. Few risk-assessment models for hospital-acquired pediatric VTE have been published. Some models focus exclusively on hospitalized pediatric patients, while others target specific populations such as patients with cancer or severe trauma. Multicenter, prospective studies are needed to identify and confirm risk factors in order to create a pediatric risk-assessment tool and optimize preventive measures and reduce unintended harm.

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Superior vena cava syndrome (SVCS) results in vascular, respiratory, and neurologic compromise. A systematic search was conducted to determine the prevalence of pediatric SVCS subtypes and identify clinical characteristics/treatment strategies that may influence overall outcomes. Data from 101 case reports/case series (142 patients) were analyzed. Morbidity (30%), mortality (18%), and acute complications (55%) were assessed as outcomes. Thrombosis was present in 36%, with multi-modal anticoagulation showing improved outcome by >50% (P = 0.004). Infant age (P = 0.04), lack of collaterals (P = 0.007), acute complications (P = 0.005), and clinical presentation may have prognostic utility that could influence clinical decisions and surveillance practices in pediatric SVCS.

Systematic review/meta-analysis, level III.

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