Medscape is available in 5 Language Editions – Choose your Edition here.


Pediatric Thromboembolism Treatment & Management

  • Author: Scott C Howard, MD; Chief Editor: Robert J Arceci, MD, PhD  more...
Updated: Feb 18, 2015

Approach Considerations

Initial care and evaluation for thromboembolism should occur in a pediatric inpatient ward or the ICU if severe respiratory distress or neurologic deterioration occurs. Management includes assessment of the extent of the thrombosis and clinical consequences, a search for thrombophilic risk factors, and anticoagulation therapy.

The duration of anticoagulation depends on the extent and location of the thrombosis, whether the thrombophilic risk factors have resolved, and, in some cases, the degree of thrombotic resolution after the initial therapy.[3, 4, 16, 17, 18, 19]

Neonatal care

Developmental differences in the hemostatic systems of newborns create difficulties in the management of thromboembolism. In addition, neonates have low levels of antithrombin and plasminogen, which cause relative resistance to heparin and thrombolytic agents, respectively.

Moreover, newborns need 11 times the usual concentration of urokinase given to adults and 5 times the usual concentration of tissue plasminogen activator (t-PA) in order to achieve the same rate of plasminogen activation.


On occasion, surgical thrombectomy may be necessary, especially after major cardiac surgery or if thrombolytic agents fail or are contraindicated.


A pediatric hematologist should be involved in the care of all neonates, infants, and children with thromboembolism, and a pediatric neurologist should be involved in the care of children with suspected or proven CNS thrombosis.


Inpatient Care

Admit patients with thromboembolisms to a pediatric or adolescent ward or ICU, depending on their respiratory and neurologic status.

Anticoagulation is begun with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH), followed by oral anticoagulation with warfarin. Children require daily follow-up until their international normalized ratio (INR) is more than 2 on 2 successive days. Monitor the patient's INR more closely than usual if changes occur in the patient’s medications or diet.

Obtain daily CBC, prothrombin time (PT), and activated partial thromboplastin time (aPTT) values while children are inpatients. If LMWH is used, obtain an anti–activated factor X (anti-Xa) level and adjust the dose to achieve a level of 0.5-1 U/mL.

A patient's medication may include heparin or LMWH, oral anticoagulants, thrombolytic agents, and, occasionally, antiplatelet agents (for arterial thrombosis). Avoid giving antiplatelet agents to children receiving anticoagulation unless they are absolutely necessary.


Duration of Therapy

The duration of therapy depends on the underlying problem. Children with mechanical heart valves or recurrent thromboembolism require anticoagulation indefinitely. Children with thromboembolism and persistent risk factors may be treated for 3 months and then switched to low-dose warfarin until the risk factor is no longer present. Uncomplicated DVT can be treated for 3-6 months.

Monitor children who are taking LMWH for more than 4 weeks; obtain a CBC count every 1-4 weeks to look for heparin-induced thrombocytopenia and an anti–activated factor X level (every 2-6 wk once a therapeutic level is achieved). Enoxaparin may accumulate over time, and dosage adjustments may be necessary.

After discontinuation of anticoagulation, reducing subsequent risk factors for thrombosis is an important component of lifelong management. For example, patients with a history of thrombosis should avoid smoking and the use of oral contraceptives that include estrogens (desogestrel, gestodene, or drospirenone).[20]



Vitamin K directly interferes with the effectiveness of warfarin and potentially increases the risk for recurrent thrombosis. Daily intake of foods high in vitamin K, such as green, leafy vegetables, should be kept at a consistent level. For example, patients should eat similar amounts of vitamin-K rich foods each day. The patient or family should inform the physician of any changes in the patient’s diet or medications.

Maternal intake of vitamin K can affect levels in breast milk and cause problems in neonates and infants that are similar to those in other patients who consume vitamin K in food. Supplementation with a consistent amount of formula per day has been recommended. Formula-fed infants should receive formula with the lowest concentration of vitamin K available.

Vitamin K should be removed from parenteral nutrition or a constant, small amount should be used each day. Because regulation of dietary vitamin K intake is very difficult, one study found that daily administration of 1 mg of vitamin K plus a somewhat higher dose of warfarin led to more stable INR values in patients receiving long-term anticoagulation.[21]



Children with thromboembolism are sometimes restricted to bed rest for the first 24-48 hours to decrease the risk of PE. However, this practice has never been shown to reduce the risk of embolization, and adults treated for DVT as outpatients (without bed rest) have been found to have no higher incidence of PE than those treated as inpatients. Children with lower-extremity DVT should be fitted for compression stockings to reduce the risk of postthrombotic syndrome.[22, 23]

Patients should avoid participating in contact sports while they are receiving anticoagulation.

Sexually active female adolescents should use some form of birth control, preferably not oral contraceptives, if they are receiving oral anticoagulants. Warfarin is teratogenic, so women on chronic warfarin therapy must not become pregnant.



For patients receiving oral anticoagulation, monitor the PT and/or INR within 3 days of their discharge from the hospital. Always check the INR 5-7 days after adjusting the dose. After the INR is 2-3 (or 2.5-3.5 in patients with mechanical heart valves) on 2 successive measurements obtained 1 week apart, the monitoring interval can be lengthened to every 2 weeks. In general, the INR is monitored monthly. Children taking warfarin for more than a year should be monitored for decreased bone density.

Point-of-care monitoring of oral anticoagulation may be available for home use or at specialized pediatric anticoagulation clinics. Point-of-care monitoring is especially helpful for children who require indefinite oral anticoagulation as part of treatment for congenital heart disease or inherited hypercoagulable disorders.

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

Robert J Arceci, MD, PhD Director, Children’s Center for Cancer and Blood Disorders, Department of Hematology/Oncology, Co-Director of the Ron Matricaria Institute of Molecular Medicine, Phoenix Children’s Hospital; Editor-in-Chief, Pediatric Blood and Cancer; Professor, Department of Child Health, University of Arizona College of Medicine

Robert J Arceci, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American Pediatric Society, American Society of Hematology, American Society of Pediatric Hematology/Oncology

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.

  1. Askegard-Giesmann JR, O'Brien SH, Wang W, Kenney BD. Increased use of enoxaparin in pediatric trauma patients. J Pediatr Surg. 2012 May. 47(5):980-3. [Medline].

  2. Nuss R, Hays T, Chudgar U, et al. Antiphospholipid antibodies and coagulation regulatory protein abnormalities in children with pulmonary emboli. J Pediatr Hematol Oncol. 1997 May-Jun. 19(3):202-7. [Medline].

  3. Goldenberg NA, Bernard TJ. Venous thromboembolism in children. Pediatr Clin North Am. 2008 Apr. 55(2):305-22, vii. [Medline].

  4. Sandoval JA, Sheehan MP, Stonerock CE, Shafique S, Rescorla FJ, Dalsing MC. Incidence, risk factors, and treatment patterns for deep venous thrombosis in hospitalized children: an increasing population at risk. J Vasc Surg. 2008 Apr. 47(4):837-43. [Medline].

  5. Gruenwald CE, Manlhiot C, Abadilla AA, Kwok J, Maxwell S, Holtby HM, et al. Heparin brand is associated with postsurgical outcomes in children undergoing cardiac surgery. Ann Thorac Surg. 2012 Mar. 93(3):878-82. [Medline].

  6. Kosch A, Koch HG, Heinecke A, et al. Increased fasting total homocysteine plasma levels as a risk factor for thromboembolism in children. Thromb Haemost. 2004. 91(2):308-14. [Medline].

  7. Altinisik J, Ates O, Ulutin T, et al. Factor V Leiden, prothrombin G20210A, and protein C mutation frequency in Turkish venous thrombosis patients. Clin Appl Thromb Hemost. 2008 Oct. 14(4):415-20. [Medline].

  8. Yamamura K, Joo K, Ohga S, Nagata H, Ikeda K, Muneuchi J, et al. Thrombocytosis in asplenia syndrome with congenital heart disease: A previously unrecognized risk factor for thromboembolism. Int J Cardiol. 2012 Jun 22. [Medline].

  9. Stein PD, Kayali F, Olson RE. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004. 145(4):563-5. [Medline].

  10. Raffini L, Huang YS, Witmer C, Feudtner C. Dramatic increase in venous thromboembolism in children's hospitals in the United States from 2001 to 2007. Pediatrics. 2009 Oct. 124(4):1001-8. [Medline]. [Full Text].

  11. Nowak-Gottl U, Kosch A. Factor VIII, D-Dimer, and thromboembolism in children. N Engl J Med. 2004 Sep 9. 351(11):1051-3. [Medline].

  12. Goldenberg NA, Knapp-Clevenger R, Manco-Johnson MJ. Elevated plasma factor VIII and D-dimer levels as predictors of poor outcomes of thrombosis in children. N Engl J Med. 2004 Sep 9. 351(11):1081-8. [Medline].

  13. Andrew M, David M, Adams M, et al. Venous thromboembolic complications (VTE) in children: first analyses of the Canadian Registry of VTE. Blood. 1994 Mar 1. 83(5):1251-7. [Medline].

  14. Monagle P, Adams M, Mahoney M, et al. Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry. Pediatr Res. 2000 Jun. 47(6):763-6. [Medline].

  15. Kuhle S, Koloshuk B, Marzinotto V, et al. A cross-sectional study evaluating post-thrombotic syndrome in children. Thromb Res. 2003. 111(4-5):227-33. [Medline].

  16. Athale U, Siciliano S, Thabane L, Pai N, Cox S, Lathia A. Epidemiology and clinical risk factors predisposing to thromboembolism in children with cancer. Pediatr Blood Cancer. 2008 Dec. 51(6):792-7. [Medline].

  17. Athale UH, Nagel K, Khan AA, Chan AK. Thromboembolism in children with lymphoma. Thromb Res. 2008. 122(4):459-65. [Medline].

  18. Biss TT, Brandao LR, Kahr WH, Chan AK, Williams S. Clinical features and outcome of pulmonary embolism in children. Br J Haematol. 2008 Sep. 142(5):808-18. [Medline].

  19. Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141(2 Suppl):e737S-801S. [Medline]. [Full Text].

  20. Lidegaard O, Nielsen LH, Skovlund CW, Skjeldestad FE, Løkkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ. 2011 Oct 25. 343:d6423. [Medline]. [Full Text].

  21. Sconce E, Avery P, Wynne H, Kamali F. Vitamin K supplementation can improve stability of anticoagulation for patients with unexplained variability in response to warfarin. Blood. 2007 Mar 15. 109(6):2419-23. [Medline].

  22. Aissaoui N, Martins E, Mouly S, Weber S, Meune C. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009 Sep 11. 137(1):37-41. [Medline].

  23. Anderson CM, Overend TJ, Godwin J, Sealy C, Sunderji A. Ambulation after deep vein thrombosis: a systematic review. Physiother Can. 2009 Summer. 61(3):133-40. [Medline]. [Full Text].

  24. Massicotte P, Julian JA, Gent M, et al. An open-label randomized controlled trial of low molecular weight heparin compared to heparin and coumadin for the treatment of venous thromboembolic events in children: the REVIVE trial. Thromb Res. 2003. 109(2-3):85-92. [Medline].

  25. Skinner R, Koller K, McIntosh N, McCarthy A, Pizer B. Prevention and management of central venous catheter occlusion and thrombosis in children with cancer. Pediatr Blood Cancer. 2008 Apr. 50(4):826-30. [Medline].

  26. Monagle P, Chalmers E, Chan A, et al. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun. 133(6 Suppl):887S-968S. [Medline].

  27. Agnelli G, Verso M. Epidemiology of cerebral vein and sinus thrombosis. Front Neurol Neurosci. 2008. 23:16-22. [Medline].

  28. Aissaoui N, Martins E, Mouly S, et al. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2008 Aug 6. [Medline].

  29. Akl EA, Rohilla S, Barba M, et al. Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer: a systematic review. Cancer. 2008 Oct 1. 113(7):1685-94. [Medline].

  30. Alioglu B, Avci Z, Tokel K, et al. Thrombosis in children with cardiac pathology: analysis of acquired and inherited risk factors. Blood Coagul Fibrinolysis. 2008 Jun. 19(4):294-304. [Medline].

  31. Athale U, Siciliano S, Thabane L, et al. Epidemiology and clinical risk factors predisposing to thromboembolism in children with cancer. Pediatr Blood Cancer. 2008 Dec. 51(6):792-7. [Medline].

  32. Babyn PS, Gahunia HK, Massicotte P. Pulmonary thromboembolism in children. Pediatr Radiol. 2005 Mar. 35(3):258-74. [Medline].

  33. Barnes C, Newall F, Ignjatovic V, et al. Reduced bone density in children on long-term warfarin. Pediatr Res. 2005. 57(4):578-81. [Medline].

  34. Billett HH. Antiplatelet agents and arterial thrombosis. Cardiol Clin. 2008 May. 26(2):189-201, vi. [Medline].

  35. Dentali F, Gianni M, Agnelli G, et al. Association between inherited thrombophilic abnormalities and central venous catheter thrombosis in patients with cancer: a meta-analysis. J Thromb Haemost. 2008 Jan. 6(1):70-5. [Medline].

  36. Faustino EV, Hanson S, Spinella PC, Tucci M, O'Brien SH, Nunez AR, et al. A multinational study of thromboprophylaxis practice in critically ill children. Crit Care Med. 2014 May. 42(5):1232-40. [Medline].

  37. Gist KM, Chima RS. The landscape of thromboprophylaxis utilization in critically ill children: sparse and variable. Crit Care Med. 2014 May. 42(5):1317-8. [Medline].

  38. Goldenberg NA, Everett AD, Graham D, Bernard TJ, Nowak-Göttl U. Proteomic and other mass spectrometry based "omics" biomarker discovery and validation in pediatric venous thromboembolism and arterial ischemic stroke: Current state, unmet needs, and future directions. Proteomics Clin Appl. 2014 Dec. 8(11-12):828-36. [Medline].

  39. Journeycake JM, Manco-Johnson MJ. Thrombosis during infancy and childhood: what we know and what we do not know. Hematol Oncol Clin North Am. 2004. 18(6):1315-38, viii-ix. [Medline].

  40. Male C, Chait P, Ginsberg JS, et al. Comparison of venography and ultrasound for the diagnosis of asymptomatic deep vein thrombosis in the upper body in children: results of the PARKAA study. Prophylactic Antithrombin Replacement in Kids with ALL treated with Asparaginase. Thromb Haemost. 2002. 87(4):593-8. [Medline].

  41. Morgan J. Perioperative venous thrombosis in children: is it time for primary prophylaxis?. Paediatr Anaesth. 2007 Feb. 17(2):99-101. [Medline].

  42. Price VE, Chan AK. Arterial thrombosis in children. Expert Rev Cardiovasc Ther. 2008 Mar. 6(3):419-28. [Medline].

  43. Price VE, Chan AK. Venous thrombosis in children. Expert Rev Cardiovasc Ther. 2008 Mar. 6(3):411-8. [Medline].

  44. Streif W, Andrew M, Marzinotto V, et al. Analysis of warfarin therapy in pediatric patients: a prospective cohort study of 319 patients. Blood. 1999. 94(9):3007-14. [Medline].

  45. van Beynum IM, Smeitink JA, den Heijer M, et al. Hyperhomocysteinemia: a risk factor for ischemic stroke in children. Circulation. 1999 Apr 27. 99(16):2070-2. [Medline].

  46. Vidal E, Sharathkumar A, Glover J, Faustino EV. Central venous catheter-related thrombosis and thromboprophylaxis in children:a systematic review and meta-analysis. J Thromb Haemost. 2014 May 6. [Medline].

  47. Vu LT, Nobuhara KK, Lee H, et al. Determination of risk factors for deep venous thrombosis in hospitalized children. J Pediatr Surg. 2008 Jun. 43(6):1095-9. [Medline].

  48. Wasay M, Dai AI, Ansari M, et al. Cerebral venous sinus thrombosis in children: a multicenter cohort from the United States. J Child Neurol. 2008 Jan. 23(1):26-31. [Medline].

  49. Young G, Albisetti M, Bonduel M, et al. Impact of inherited thrombophilia on venous thromboembolism in children: a systematic review and meta-analysis of observational studies. Circulation. 2008 Sep 23. 118(13):1373-82. [Medline].

  50. Young G, Manco-Johnson M, Gill JC, et al. Clinical manifestations of the prothrombin G20210A mutation in children: a pediatric coagulation consortium study. J Thromb Haemost. 2003 May. 1(5):958-62. [Medline].

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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.