Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
BACKGROUND
Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children.


METHODS
The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.


RESULTS
We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C).


CONCLUSIONS
The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
Paul
P
Monagle
Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
Anthony K C
AKC
Chan
Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO.
Neil A
NA
Goldenberg
Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA.
Rebecca N
RN
Ichord
Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
Janna M
JM
Journeycake
Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany.
Ulrike
U
Nowak-Göttl
Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK. Electronic address: sara-vesely@ouhsc.edu.
Sara K
SK
Vesely
D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001780:Blood Coagulation Tests; D006328:Cardiac Catheterization; D002648:Child; D002675:Child, Preschool; D003299:Cooperative Behavior; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D019317:Evidence-Based Medicine; D065427:Factor Xa Inhibitors; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006470:Hemorrhage / Q000097:blood / Q000139:chemically induced / Q000517:prevention & control; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D007231:Infant, Newborn; D033183:Interdisciplinary Communication; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D012082:Renal Veins; D012307:Risk Factors; D055502:Secondary Prevention; D012955:Societies, Medical; D013927:Thrombosis / Q000097:blood / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control*; D056824:Upper Extremity Deep Vein Thrombosis / Q000097:blood / Q000188:drug therapy / Q000517:prevention & control; D014812:Vitamin K / Q000037:antagonists & inhibitors
D000925:Anticoagulants; D065427:Factor Xa Inhibitors; D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D010975:Platelet Aggregation Inhibitors; D014812:Vitamin K; D006493:Heparin