Antithrombotic Therapy in Children: Recommendations

Treatment of VTE in Children
1.    Children (s2 months of age) with DVT or pulmonary embolism should be treated with IV heparin sufficient to prolong the APTT to a range that corresponds to an anti-factor Xa level of 0.3 to 0.7 U/mL. This grade Cl recommendation is based on grade A recommendations for adults and one level IV study in children. LMWH sufficient to achieve an anti-factor Xa level of 0.5 to 1.0 U/mL 4 to 6 h after an injection is an alternative to initial therapy with heparin. This grade C2 recommendation is based on grade A recommendations for adults and two level IV studies in children.
2.    It is recommended that treatment with heparin or LMWH should be continued for 5 to 10 days and that oral anticoagulation should be overlapped with heparin for 4 to 5 days. For many patients, heparin and warfarin can be started together and heparin discontinued on day.
6 if the prothrombin time (INR) is therapeutic. For massive PE or extensive DVT, a longer period of heparin therapy should be considered. This grade Cl recommendation is based on grade Al recommendations for adults and two level IV studies in children.
3.    Long-term anticoagulant therapy should be continued for at least 3 months using oral anticoagulants to prolong the PT to an INR of 2.0 to 3.0. This grade C2 recommendation is based on grade A recommendations for adults and one level IV1 and six level V studies45-50 in children itat on ventolin inhaler. Alternatively, LMWH is an option in children in whom long-term oral anticoagulant therapy is problematic. If LMWH is chosen for long-term use, studies of bone density should be considered to detect osteoporosis at an early stage.
4.    Either indefinite oral anticoagulant therapy with an INR of 2 to 3, low-dose anticoagulant therapy (INR <2.0), low-dose LMWH, or close monitoring should be considered for children with a first recurrence of venous thrombosis or an initial venous thrombosis and a continuing risk factor, such as a CVL, AT deficiency, PC or PS deficiency, activated PC resistance, prothrombin gene 20210, lupus anticoagulants in the antiphospholipid antibody syndrome, or systemic lupus erythematosus. This grade C recommendation is based on grade C2 recommendations for adults and one level V study in children.