Aspects of anticoagulation in children

Abstract

SummaryThe number of children receiving anticoagulation is increasing. Thromboembolic events are associated with significant risk of morbidity and mortality although the optimal management of asymptomatic events remains unclear. Specific challenges in paediatrics include the diagnosis of thrombosis, delivery and monitoring of anticoagulation in a wide range of ages from neonates through to adolescents. The development of the haemostatic system as children age results in changing pathophysiology of thrombosis and response to anticoagulation agents. Although registry and observational studies have provided vital information, specific paediatric, prospective anticoagulation studies have been few and limited in design. The result is that much of current practice is extrapolated from adult studies. Traditional anticoagulants have significant limitations. Both heparin and warfarin are in widespread use but many fundamental questions regarding dose, therapeutic range, efficacy and optimum duration have not been fully answered. Alternative agents, such as direct thrombin inhibitors and the selective anti-factor Xa inhibitor fondaparinux, may have advantages for children. Clinical trials in adults and preliminary data in children are promising but caution should be applied until specific paediatric studies have demonstrated safety and efficacy.

Thrombosis and embolism in pediatric cardiomyopathy

“…Recently, low molecular weight heparins (LMWHs), particularly enoxaparin, have become a common agent for primary prophylaxis and treatment of embolism in children [44]. Despite the lack of proven efficacy and the scarcity of therapeutic dosing studies in children, LMWHs offer many practical advantages over warfarin such as more stable pharmacokinetics [45]. Although LMWH has been used successfully as embolic prophylaxis in children with cardiomyopathy [41], no studies have compared its efficacy directly with warfarin.…”

Oral anticoagulant therapy interruption in children: A single centre experience

“…The median duration for post-procedure bridging therapy was 6 (2-17) days. Median duration of post-procedure enoxaparin treatment, when instituted alone or after UFH, was 8 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) days. UFH used as part of a postprocedural bridging regime was typically started 6 h post procedure.…”

“…The indications for anticoagulation in the paediatric setting are markedly different to that of adults. The most common reason for anticoagulation is for primary thromboprophlyaxis in the setting of congenital cardiac disease [3,4]. This is commonly for a single ventricle with a Fontan circuit, mechanical heart valve or dilated cardiomyopathy.…”

Strategies to Prevent and Manage Thrombotic Complications of Acute Lymphoblastic Leukemia in Children and Young People Vary Between Centers in the United Kingdom

“…[22][23][24] Management of periods of thrombocytopenia during therapeutic anticoagulation for thrombosis varied, unsurprisingly given the lack of evidence on which to base practice. There was a greater tendency to support the platelet count using transfusion of platelet concentrates, rather than reducing anticoagulant dose or temporarily suspending anticoagulant therapy, during treatment of CSVT when compared with treatment of line-associated thrombosis.…”