A 4-Year-Old Girl in Significant Distress

Alba Morales Pozzo, MD


March 05, 2019

The problem of DVT in children has become significant, yet evidence-based guidelines for the treatment of pediatric patients with DVT are lacking.[11] Current management recommendations are based on adult data, large tertiary care pediatric center observations and experience, and consensus statements of pediatric specialists.

In the acute setting, the goals of therapy for venous thromboembolism include re-establishing flow through the occluded vessel, preventing thrombus extension, and preventing embolism. Heparins (unfractionated and low-molecular-weight) are still used most often to treat DVT in children. Low-molecular-weight heparin has the advantage of lower risks for bleeding and heparin-induced thrombocytopenia compared with unfractionated heparin.[4] Pediatricians have the longest experience with unfractionated heparin, which has the disadvantage of increased bleeding risk and the requirement of normal antithrombin III levels. The suggested duration of anticoagulation is approximately 3 months; however, case reports have documented treatment for as long as 6 months.[7] Because heparin is administered once or twice daily subcutaneously, this places a significant burden and trauma on young children and their caretakers.

Children, especially toddlers, who have diabetic ketoacidosis seem to be at an increased risk of developing CVC-related DVT. If placement of a CVC is absolutely required for resuscitation, it should be immediately removed after the acute rehydration goals have been achieved. Prophylaxis with low-molecular-weight heparin should be considered in patients who require prolonged use of CVCs for prevention of DVT. A review of the impact of CVC use on the incidence of pediatric thromboembolism describes the potentially life-threatening complications that can arise from the use of CVCs in critically ill children and highlights the need for clinical studies that can lead to the delineation of guidelines for the safe use of CVCs in this fragile population.[12]

The patient in this case underwent Doppler ultrasound of the right lower extremity, which confirmed the diagnosis of DVT. Biochemical markers for coagulation disorders were negative. All of her coagulation factor levels were measured within normal limits. Therapy with subcutaneous low-molecular-weight heparin was initiated on the second to last day of hospitalization. Her signs and symptoms had completely resolved by her 6-week follow-up appointment in the pediatric diabetes clinic. Heparin treatment was continued for 6 months after discharge from the hospital and then discontinued without complications.


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