THE DIAGNOSIS, TREATMENT, AND PREVENTION OF THROMBOSIS IN PAEDIATRIC AGE GROUPS

- Implementation strategies or interventions

1. Leadership commitment, engagement, and support.

2. Local clinical and quality champions.

3. Dissemination (printed and electronic).

4. Regular training and education.

5. Regular audit and feedback (along with regular review and update promotes the concept of the ‘living CPGs’.

6. Networking with relevant existing projects.

7. Parents or carers as champions for changes.

➡️Implementation tools

Figure1: Diagnostic algorithm for Pediatric DVT

Figure 2: Algorithm for management of venous thrombosis

Figure 3: Management plan of cerebral sinovenous thrombosis

Figure 4: Pathway for management of acute CVAD-associated thrombosis in neonates and children.

Drug

Route

Dose

Therapeutic monitoring

UFH

Continuous IV infusion

Age < 12 mo: bolus 75 U/kg followed by 28 U/kg/h

Age 1 to < 12 y: bolus 75 U/kg followed by 20 U/kg/h

Age > 12 y: bolus 80 U/kg followed by 18 U/kg/h

Target range:

aPTT: 1.5-2.5 times control

or

Anti-Xa level 0.3-0.7 U/mL

Enoxaparin

(LMWH)

Subcutaneous injection

Age < 2 mo: 1.5-1.7 mg/kg q12 h

Age > 2 mo: 1 mg/kg q12 h

Target range:

Anti-Xa 0.5-1.0 U/mL

(Sample 3 to 4 h after third dose)

Warfarin

Oral

Loading: 0.2 mg/kg x 1 (if INR < 1.3), max 10 mg

Maintenance: adjust according to INR

(Measure INR daily days 2 to 4)

INR 1.1-1.3: repeat loading dose

INR 1.4-1.9: 50% of loading dose

INR 2.0-3.0:

INR 3.1-3.5: 25% of loading dose

INR >3.5: Hold until INR < 3.5, reinitiate at 50% of loading dose.

Target range: INR 2.0 to 3.0

Rivaroxaban

(DOAC)

Oral

According to weight

2.6 to < 3 kg:0.8 mg per dose TDS

3 to < 4 kg: 0.9 mg per dose TDS

4 to < 5 kg: 1.4 mg per dose TDS

5 to < 7 kg: 1.6 mg per dose TDS

7 to < 8 kg: 1.8 mg per dose TDS

8 to < 9 kg: 2.4 mg per dose TDS

9 to < 10 kg: 2.8 mg per dose TDS

10 to < 12 kg: 3 mg per dose TDS

12 to < 30 kg: 5 mg per dose BD

30 to < 50 kg: 15 mg OD

≥ 50 kg: 20 mg OD

Table 2: Common anticoagulant therapies for use in pediatric VTE

Figure 5: Management plan of arterial ischemic stroke

Drug	Route	Dose	Therapeutic monitoring
UFH	Continuous IV infusion	Age < 12 mo: bolus 75 U/kg followed by 28 U/kg/h Age 1 to < 12 y: bolus 75 U/kg followed by 20 U/kg/h Age > 12 y: bolus 80 U/kg followed by 18 U/kg/h	Target range: aPTT: 1.5-2.5 times control or Anti-Xa level 0.3-0.7 U/mL
Enoxaparin (LMWH)	Subcutaneous injection	Age < 2 mo: 1.5-1.7 mg/kg q12 h Age > 2 mo: 1 mg/kg q12 h	Target range: Anti-Xa 0.5-1.0 U/mL (Sample 3 to 4 h after third dose)
Warfarin	Oral	Loading: 0.2 mg/kg x 1 (if INR < 1.3), max 10 mg Maintenance: adjust according to INR (Measure INR daily days 2 to 4) INR 1.1-1.3: repeat loading dose INR 1.4-1.9: 50% of loading dose INR 2.0-3.0: INR 3.1-3.5: 25% of loading dose INR >3.5: Hold until INR < 3.5, reinitiate at 50% of loading dose.	Target range: INR 2.0 to 3.0
Rivaroxaban (DOAC)	Oral	According to weight 2.6 to < 3 kg:0.8 mg per dose TDS 3 to < 4 kg: 0.9 mg per dose TDS 4 to < 5 kg: 1.4 mg per dose TDS 5 to < 7 kg: 1.6 mg per dose TDS 7 to < 8 kg: 1.8 mg per dose TDS 8 to < 9 kg: 2.4 mg per dose TDS 9 to < 10 kg: 2.8 mg per dose TDS 10 to < 12 kg: 3 mg per dose TDS 12 to < 30 kg: 5 mg per dose BD 30 to < 50 kg: 15 mg OD ≥ 50 kg: 20 mg OD