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Pediatric Thromboembolism Clinical Presentation

  • Author: Scott C Howard, MD; Chief Editor: Hassan M Yaish, MD  more...
Updated: Aug 23, 2016


Elicit a history of previous thrombosis. Document the age at which thrombosis occurred and the type of thrombosis (DVT, PE, myocardial infarction, stroke) that developed. Also obtain a thorough family history.

The contribution of the following factors to thrombosis is most thoroughly documented in adults, but these factors can contribute to thrombosis in children as well:

  • Recent surgery
  • Trauma
  • Immobilization
  • Prolonged bedrest

The use of estrogen-containing medications, such as oral contraceptives, increases the risk of thrombosis in women and female adolescents. The risk is further increased in those who are heterozygous for factor V Leiden or have other prothrombotic risk factors.

Heart disease

Congenital heart disease and/or recent cardiac catheterization are the most common causes of arterial thrombosis in children. Noteworthy factors include the following:

  • Dizziness
  • Bilateral extremity swelling
  • Poor weight gain


A history or symptoms suggestive of malignancy should prompt inquiry about use of central venous catheters and recent chemotherapy with L-asparaginase. Some advocate a search for occult malignancy in adults who develop thrombosis with few risk factors (“unprovoked thrombosis”), but this is not necessary in children since thrombosis is very rarely the first sign of cancer.

Deep venous thrombosis

Symptoms of DVT can include an acute onset of pain and swelling of the affected limb(s). These symptoms are nonspecific and can have multiple etiologies, including trauma, sports injuries, congestive heart failure, or nephrotic syndrome.

Swelling and pain in an upper extremity suggest thrombosis if a central venous catheter or other localized risk factors are present.

Pulmonary embolism

Symptoms of PE can include an acute onset of chest pain and shortness of breath. Chest pain due to PE is usually not constant; most chest pain in children does not signify a significant medical condition. In adults, the first sign of PE may be cardiovascular collapse, cardiac arrest, or sudden death.

CNS thrombosis

Symptoms of CNS thrombosis include vomiting, lethargy, seizures, and weakness in an extremity. Most strokes that occur in utero cause early, pathologic hand preference late in the first year of life.

Neonates often present with seizures and lethargy. Older children usually present with headaches and an acute onset of weakness in an extremity.

Infection and dehydration are common precipitating causes of CNS thrombosis among infants and young children.

Renal vein thrombosis

Patients with renal vein thrombosis may present with flank pain and hematuria.


Physical Examination

In children, as well as in adults, findings from the physical examination are often misleading. A diagnosis of thrombosis may be missed or delayed because of the nonspecific nature of the patient's presenting signs.

Although DVT is frequently asymptomatic, signs of the condition can include the following:

  • Leg or arm edema
  • Erythema
  • Increased warmth
  • Palpable cord
  • Tenderness
  • Positive Homans sign (ie, pain on dorsiflexing the foot)

Other important features in patients with thromboembolism are predisposing conditions, such as those listed below:

  • Congestive heart failure or heart disease
  • Malignancy
  • Presence of a central venous catheter

Thrombosis of the inferior vena cava and/or renal vein can cause nephromegaly and flank tenderness.

Signs of PE are nonspecific and include the following:

  • Apprehension
  • Diaphoresis
  • Tachycardia
  • Tachypnea
  • Chest pain
  • Hypotension

Hemoptysis is seldom present in children but can be a sign in adolescents or adults.

Signs of arterial thrombosis include absent or diminished peripheral pulses and a cool extremity with or without mottling of the skin.

Contributor Information and Disclosures

Scott C Howard, MD Founder and CEO, Resonance, LLC; Consultant in Oncology, Healthcare Informatics, Global Health, Research; Adjunct Professor, University of Memphis School of Health Studies

Scott C Howard, MD is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Central American Pediatric Hematology-Oncology Association, Columbian Pediatric Hematology/Oncology Society, International Society of Paediatric Oncology

Disclosure: Nothing to disclose.

Chief Editor

Hassan M Yaish, MD Medical Director, Intermountain Hemophilia and Thrombophilia Treatment Center; Professor of Pediatrics, University of Utah School of Medicine; Director of Hematology, Pediatric Hematologist/Oncologist, Department of Pediatrics, Primary Children's Medical Center

Hassan M Yaish, MD is a member of the following medical societies: American Academy of Pediatrics, New York Academy of Sciences, American Medical Association, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Michigan State Medical Society

Disclosure: Nothing to disclose.


James L Harper, MD Associate Professor, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplantation, Associate Chairman for Education, Department of Pediatrics, University of Nebraska Medical Center; Assistant Clinical Professor, Department of Pediatrics, Creighton University School of Medicine; Director, Continuing Medical Education, Children's Memorial Hospital; Pediatric Director, Nebraska Regional Hemophilia Treatment Center

James L Harper, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Federation for Clinical Research, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Council on Medical Student Education in Pediatrics, and Hemophilia and Thrombosis Research Society

Disclosure: Nothing to disclose.

J Martin Johnston, MD Associate Professor of Pediatrics, Mercer University School of Medicine; Director of Hematology/Oncology, The Children's Hospital at Memorial University Medical Center; Consulting Oncologist/Hematologist, St Damien's Pediatric Hospital

J Martin Johnston, MD is a member of the following medical societies: American Academy of Pediatrics and American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

Philip M Monteleone, MD Associate Professor, Department of Pediatrics, Division of Oncology, University of Pennsylvania and Children's Hospital of Philadelphi

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Virchow triad for the pathophysiology of thrombus formation.
Coagulation cascade. Solid arrows represent activation events, dashed arrows represent inhibition events, and dotted lines with circles represent inactivation events. a = active; APC = activated protein C; F = factor; FDP= fibrin degradation products; HMW = high molecular weight; PAI-1 = plasminogen activator inhibitor-1; PL = phospholipid; TM = thrombomodulin; t-PA = tissue type plasminogen activator; u-PA = urokinase plasminogen activator; XL= crosslinked.
Nomogram for adjusting the dosage of heparin. Reproduced with permission from Michelson et al (1998). APTT = activated partial thromboplastin time.
Dosing of low-molecular-weight heparins (LMWHs) in children. Reproduced with permission from Michelson et al (1998).
Warfarin dosing in children. INR = international normalized ratio. Reproduced with permission from Michelson et al (1998).
The pathophysiology of pulmonary embolism. Although pulmonary embolism can arise from anywhere in the body, most commonly it arises from the calf veins. The venous thrombi predominately originate in venous valve pockets (inset) and at other sites of presumed venous stasis. To reach the lungs, thromboemboli travel through the right side of the heart. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.
Axial CT scan of thorax shows an embolus in the distal left pulmonary artery with an associated pleural effusion.
Thrombosis and thrombophilia.
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