Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Novel Dosing and Monitoring of Aspirin in Infants With Systemic-to-Pulmonary Artery Shunt Physiology: the SOPRANO Study

OBJECTIVES

Provision of pulmonary blood flow with a systemic-to-pulmonary artery shunt is essential in some patients with cyanotic congenital heart disease. Traditionally, aspirin (ASA) has been used to prevent thrombosis. We evaluated ASA dosing with 2 separate antiplatelet monitoring tests for accuracy and reliability.

METHODS

This is a retrospective, pre-post intervention single center study. Two cohorts were evaluated; the pre-intervention group used thromboelastography platelet mapping (TPM) and post-intervention used VerifyNow aspirin reactivity unit (ARU) monitoring. The primary endpoint was to compare therapeutic effect of TPM and ARU with regard to platelet inhibition. Inadequate platelet inhibition was defined as TPM <50% inhibition and ARU >550.

RESULTS

Data from 49 patients were analyzed: 25 in the TPM group and 24 in the ARU group. Baseline characteristics were similar amongst the cohorts. The TPM group had significantly more patients with inadequate platelet inhibition (14 [56%] vs 2 [8%]; p = 0.0006) and required escalation with additional thromboprophylaxis (15 [60%] vs 5 [21%]). There was no difference in shunt thrombosis (1 [2%] vs 0 [0%]; p = 0.32), cyanosis requiring early re-intervention (9 [36%] vs 14 [58%]; p = 0.11), or bleeding (15 [60%] vs 14 [58%]; p = 0.66).

CONCLUSION

With similar cohorts and the same ASA-dosing nomogram, ARU monitoring resulted in a reduced need for escalation of care and concomitant thromboprophylaxis with no difference in adverse outcomes. Our study suggests ARU monitoring compared with TPM may be a more reliable therapeutic platelet inhibition test for determining ASA sensitivity in children with congenital heart disease requiring systemic-to-pulmonary artery shunt.

Nomogram for Predicting Long-term Outcomes of Encephaloduroarteriosynangiosis in Toddlers with Moyamoya Disease: a Longitudinal and Cross-sectional Study

We investigated the long-term outcomes of encephaloduroarteriosynangiosis (EDAS) for stroke prevention in toddlers with moyamoya disease (MMD) using nomogram. Between January 2005 and December 2018, 74 toddlers with MMD underwent surgery in the Fifth Medical Centre, Chinese PLA General Hospital, 69 were < 4 years of age and included in the analysis. The modified Rankin scale (mRS) during follow-up evaluated clinical outcomes. To measure the effectiveness of EDAS, the annual risk of symptomatic infarction within the operated brain hemispheres was calculated. The event-free survival rate was determined using Kaplan-Meier curves. A nomogram generated using multivariate logistic regression analysis identified potential predictors associated with unfavorable outcomes. Additionally, discrimination, calibration, and clinical utility were assessed. A favorable clinical outcome was observed in 81.2% of the patients. The operated hemispheres showed an annual risk of 0.87% of symptomatic infarction and 0.23% of hemorrhage. Moreover, the 10-year event-free survival rates were 92.8% and 97.0% for symptomatic infarction and hemorrhage. Multivariate logistic analysis indicated that onset with infarction, initial mRS ≥ 3, and perioperative adverse events had significant and independent associations with unfavorable outcomes. However, an age at diagnosis of ≥ 2 years showed an association with favorable outcomes. Using these four factors, our model attained a concordance index of 0.912 (95% confidence interval, 0.842-0.982), well-fitted calibration curve, and cutoff value of 0.212 for predicting unfavorable outcomes. EDAS may prevent recurrent stroke and improve overall long-term clinical outcomes in toddlers with MMD. The developed nomogram accurately predicted unfavorable outcomes and assisted surgeons in patient evaluation.

An Evaluation of the Appropriateness of Initial Enoxaparin Dosing Among Pediatric Patients

Background Enoxaparin is a low molecular weight heparin that irreversibly inactivates factor Xa leading to the inhibition of clot formation. Despite the non-FDA approval in pediatrics, enoxaparin is recommended with an initial dose of 1.5mg/kg/q12hrs for patients aged ≤ 2 months and 1mg/kg/q12hrs for patients > 2 months, targeting therapeutic anti-Xa with a range of 0.5 to 1 units/mL. Due to more rapid clearance in pediatrics, our study aims to assess the need for initial higher doses than recommended by the guideline to reach the target anti-Xa level. Methods A retrospective chart review of all pediatric patients under all specialties who were treated with enoxaparin either in inpatient or outpatient settings between February 2021 and June 2022 at children's specialized hospital and meet the inclusion criteria, including age ≤ 15 years old and treated with enoxaparin with initial dose according to the American College of Chest Physicians (CHEST) guideline, while patients who received prophylaxis doses did not have anti-Xa levels or creatinine clearance < 30 mL/min/1.73m2 were excluded. Demographic data, laboratory data, and enoxaparin dosing were all collected to assess whether the initial enoxaparin dose will result in a therapeutic level as a primary endpoint and secondary endpoints including the average enoxaparin dose required to achieve the therapeutic level and to report any side effects. All data were entered and analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 25, Armonk, NY), and all categorical variables were reported as frequency and percentage while continuous variables expressed as mean ± SD and the study was approved by our research center institutional review board (IRB). Results Thirty patients were included in the study (17 males), 10 patients were aged ≤ 2 months, four were between 3 and 12 months and 16 were > 12 months, most of the patients received enoxaparin for deep vein thrombosis. In the majority of patients (76.7%), the initial dose failed to achieve the target anti-Xa while a mean dose of 2 mg/kg/q12hrs in patients ≤ 2 months, 1.7mg/kg/q12hrs in patients 3-12 months and 1.3 mg/kg/q12hrs in patients > 12 months was sufficient to reach the target level. After achieving a therapeutic anti-Xa level, only one patient experienced major bleeding while four patients experienced minor bleeding, no edema or thrombocytopenia were reported. Conclusion In conclusion, initiating enoxaparin according to the recommended dose by the guideline failed to achieve target anti-Xa in the majority of patients which necessitates starting enoxaparin with initial higher doses according to the patient's age to provide more prompt achievement of target anti-Xa.

Guiding warfarin self-management in children: development of a warfarin nomogram

Background

Warfarin therapy in children is impacted by many variables. To support the implementation of a self-management program within a pediatric anticoagulation service, a pediatric-specific warfarin nomogram was needed. A literature review revealed no published pediatric nomograms; therefore, a nomogram was developed drawing upon an evidence-based "Warfarin Information for Clinicians" hospital guideline.

Objectives

This study aimed to evaluate the suitability of a pediatric warfarin nomogram.

Methods

A retrospective audit of electronic medical records compared the dosing and international normalized ratio (INR) retest decisions made by hematology clinicians to the dosing and retesting recommended by a new warfarin nomogram at a pediatric hospital. Children (aged 6 months-18 years) receiving warfarin therapy for >6 months were included. Data were collected between September 2019 and February 2020. Descriptive data analysis was performed. The study was approved by the hospital's Human Research Ethics Committee.

Results

Warfarin dosing and INR retest decisions for 39 children were included, equating to 521 INRs. The nomogram matched 81.4% of clinicians dosing decisions and 30% of INR retest decisions. Moreover, 59% of the clinician-recommended retest dates were earlier than the nomogram recommendation. In the INR 2.0-3.0 group, 84.4% of dosing decisions and 72% of retest decisions matched the nomogram.

Conclusions

These results suggest that this pediatric nomogram is a suitable tool for warfarin dosing, as recommended warfarin doses matched the majority of clinicians' decisions. Modification may be needed to nomogram recommendations for the time to retest. This nomogram can be used to support warfarin self-management and may assist clinicians and patients or families in making evidence-based dosing decisions.

[Illustrated case study of a patient with pediatric multisystem inflammatory syndrome]

Between November 2020 and June 2021, twelve children were treated at a university hospital in western France for pediatric multisystem inflammatory syndrome (PIMS). While the clinical presentation may have been reminiscent of Kawasaki disease, PIMS, a new nosological entity, was mentioned in the media in the context of the Covid-19 pandemic. In 2023, research into this syndrome will continue in France and Europe.

Perinatal Stroke in a Chinese Neonatal Center: Clinical Characteristics, Long-Term Outcomes, and Prognostic Factors

BACKGROUND

Neonatal stroke manifests atypically and can potentially result in significant neurological sequelae in affected infants. Studies on long-term neurodevelopmental outcomes and prognostic factors are limited. We aimed to assess the clinical characteristics, long-term outcomes, and prognostic factors of perinatal stroke.

METHODS

Patients diagnosed with perinatal stroke were enrolled from 2009 to 2018. Clinical data including general information, clinical manifestations, and risk factors were collected and compared. Follow-up was performed for at least two years. Statistical analysis was performed using the chi-square test, t tests, and logistic regression analysis.

RESULTS

Sixty-nine cases were identified with an incidence of one of 2049 live births (51 boys and 18 girls). Twenty-seven patients (39%) experienced perinatal ischemic stroke (PIS) and 42 (61%) perinatal hemorrhagic stroke (PHS). In 48 cases (69%) onset involved acute symptomatic stroke (21 ischemic strokes and 27 hemorrhagic strokes). Seizures within 12 to 72 hours (20 cases, 29%) were the most common presentations. Most (57%) perinatal arterial ischemic strokes focused on the left middle cerebral artery. About 43% of PHS was diagnosed with temporal lobe hemorrhage, and 40% of patients exhibited multiple lesions of cerebral parenchymal hemorrhage. There was no association between adverse prognosis after perinatal stroke and different risk factors. During follow-up, six patients (10%) were dead and 22 patients (35%) experienced adverse neurodevelopmental outcomes.

CONCLUSIONS

More infants exhibited hemorrhagic stroke than ischemic stroke. Among infants with asymptomatic perinatal stroke, PHS was more common. The first symptom of perinatal stroke within 12 to 72 hours after birth is convulsions, with the left middle cerebral artery and the temporal lobe being the most common lesion sites for ischemic and hemorrhagic strokes, respectively. PIS was more likely to achieve adverse outcomes.

Anti-factor Xa level monitoring of low-molecular-weight heparin for prevention of venous thromboembolism in critically ill patients (AXaLPE): protocol of a randomised, open-label controlled clinical trial

INTRODUCTION

Whether and when to monitor the amount of anti-factor Xa (aFXa) activity in critically ill patients with complex diseases to prevent venous thromboembolism (VTE) remain unclear. This study is a randomised controlled trial to investigate the effect of aFXa level monitoring on reducing VTE and to establish a new method for accurately preventing VTE in critically ill patients with low-molecular-weight heparin (LMWH).

METHODS AND ANALYSIS

A randomised controlled trial is planned in two centres with a planned sample size of 858 participants. Participants will be randomly assigned to three groups receiving LMWH prophylaxis at a 1:1:1 ratio: in group A, peak aFXa levels will serve as the guide for the LMWH dose; in group B, the trough aFXa levels will serve as the guide for the LMWH dose; and in group C, participants serving as the control group will receive a fixed dose of LMWH. The peak and trough aFXa levels will be monitored after LMWH (enoxaparin, 40 mg, once daily) reaches a steady state for at least 3 days. The monitoring range for group A's aFXa peak value will be 0.3-0.5 IU/mL, between 0.1 and 0.2 IU/mL is the target range for group B's aFXa trough value. In order to reach the peak or trough aFXa levels, groups A and B will be modified in accordance with the monitoring peak and trough aFXa level. The incidence of VTE will serve as the study's primary outcome indicator. An analysis using the intention-to-treat and per-protocol criterion will serve as the main outcome measurement.

ETHICS AND DISSEMINATION

The Xuanwu Hospital Ethics Committee of Capital Medical University and Peking University First Hospital Ethics Committee have approved this investigation. It will be released in all available worldwide, open-access, peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05382481.

Right femoral vein and right dorsal artery thrombosis in childhood acute myeloid leukemia: A case report

BACKGROUND

It is rare for newly diagnosed (de novo) or newly treated acute myeloid leukemia (AML) complicated with thrombotic complications, especially combined arterial and venous thrombosis.

METHODS

We reported a 13-year-old boy diagnosed with AML and leukocytosis, who developed right femoral vein and right dorsal artery thrombosis during chemotherapy. After treatment with low molecular weight heparin, diosmin, and alprostadil, symptoms were relieved. Unfortunately, the child suffered from coagulopathy afterward, which was unexpectedly caused by vitamin K deficiency.

RESULTS

After supplementation with vitamin K and prothrombin complex concentrate, coagulation function recovered.

CONCLUSION

For childhood AML patients with high thrombotic risks, close monitoring during anticoagulant treatment was necessary. Concomitantly, we should be alert to past medication history and combined medication use, especially those that may lead to vitamin K deficiency, secondary bleeding, and coagulation disorders. Rational use of antibiotics, anticoagulants, and antitumor drugs must be guaranteed.

Bone Tissue Engineering (BTE) of the Craniofacial Skeleton, Part I: Evolution and Optimization of 3D-Printed Scaffolds for Repair of Defects

Bone tissue regeneration is a complex process that proceeds along the well-established wound healing pathway of hemostasis, inflammation, proliferation, and remodeling. Recently, tissue engineering efforts have focused on the application of biological and technological principles for the development of soft and hard tissue substitutes. Aim is directed towards boosting pathways of the healing process to restore form and function of tissue deficits. Continued development of synthetic scaffolds, cell therapies, and signaling biomolecules seeks to minimize the need for autografting. Despite being the current gold standard treatment, it is limited by donor sites' size and shape, as well as donor site morbidity. Since the advent of computer-aided design/computer-aided manufacturing (CAD/CAM) and additive manufacturing (AM) techniques (3D printing), bioengineering has expanded markedly while continuing to present innovative approaches to oral and craniofacial skeletal reconstruction. Prime examples include customizable, high-strength, load bearing, bioactive ceramic scaffolds. Porous macro- and micro-architecture along with the surface topography of 3D printed scaffolds favors osteoconduction and vascular in-growth, as well as the incorporation of stem and/or other osteoprogenitor cells and growth factors. This includes platelet concentrates (PCs), bone morphogenetic proteins (BMPs), and some pharmacological agents, such as dipyridamole (DIPY), an adenosine A 2A receptor indirect agonist that enhances osteogenic and osteoinductive capacity, thus improving bone formation. This two-part review commences by presenting current biological and engineering principles of bone regeneration utilized to produce 3D-printed ceramic scaffolds with the goal to create a viable alternative to autografts for craniofacial skeleton reconstruction. Part II comprehensively examines recent preclinical data to elucidate the potential clinical translation of such 3D-printed ceramic scaffolds.

Practice patterns in the management of pediatric iliofemoral arterial thrombosis

BACKGROUND

Acute arterial thrombosis can be life- and limb-threatening. Most pediatric patients with iliofemoral arterial thrombosis are treated successfully with medical therapy; however, expert consensus is limited, and many recommendations are based on the extrapolation of adult data. We aim to understand treatment patterns and long-term outcomes after pediatric acute iliofemoral arterial thrombosis, from which management recommendations can be informed.

METHODS

A single-institution retrospective study of pediatric patients diagnosed with iliofemoral arterial thrombosis from 2009 to 2018 was performed. Multiple parameters of management and follow-up were evaluated. Children anticoagulated for ≤28 days versus >28 days were compared. Data analysis used Fisher exact and Mann-Whitney U tests.

RESULTS

Two hundred thirty-six children were included. Median age at diagnosis was 65 days (interquartile range 17-163), with 207 diagnosed as infants, 15 diagnosed between 1 to 2 years, and 14 diagnosed between 2 to 16 years. The median treatment duration was 28 days (interquartile range 13-42); patients treated for >28 days had a longer time for thrombus resolution, and more follow-up ultrasounds were performed. Limb length discrepancy did not differ between the groups (1.0% vs 6.3%, P = .06), and no patients were documented to have developed peripheral arterial disease over a median 6.5-year follow-up. Multiple treatment strategies were employed, the most common being heparin bridged to enoxaparin (25.0%) and enoxaparin monotherapy (21.6%). Eight patients (3.4%) underwent surgical intervention.

CONCLUSION

Pediatric iliofemoral arterial thrombosis is primarily a disease of infants treated adequately with heparin or enoxaparin, infrequently requires surgical intervention, and is rarely associated with long-term complications. When guided by thrombus resolution on ultrasound, a four-week or shorter course of anticoagulation does not increase the need for surgical intervention or long-term complications.

Efficacy and safety of direct oral anticoagulants in the pediatric population: a systematic review and a meta-analysis

BACKGROUND

Direct oral anticoagulants (DOACs) represent a cornerstone of adult venous thromboembolism (VTE) treatment. Recently, randomized controlled trials (RCTs) investigating DOACs in pediatrics have been performed.

OBJECTIVES

To evaluate the efficacy and safety of DOACs in the pediatric population.

METHODS

We systematically searched MEDLINE (PubMed), EMBASE, and ClinicalTrials.gov from initiation up to August 20, 2022, for RCTs comparing DOACs to standard of care (SOC) in patients aged <18 years according to PRISMA guidelines (PROSPERO registration CRD42022353870). The primary analysis was performed according to the anticoagulation intensity and clinical setting (ie, prophylaxis in cardiac disease or treatment in VTE). Efficacy outcomes were all-cause mortality and VTE. Safety outcomes were major bleeding (MB), clinically relevant non-MB, any bleeding, serious adverse events, and discontinuation due to adverse events (AEs).

RESULTS

Seven RCTs were included in the systematic review and 6 in the meta-analysis (3 prophylaxis in cardiac disease and 3 treatment in VTE). DOACs showed a significant reduction of VTE recurrence for treatment (odds ratio [OR] = 0.42; 95% CI, 0.19-0.94) and a nonsignificant reduction in VTE occurrence in prophylaxis (OR = 0.22; 95% CI, 0.03-1.55). No differences were observed for any bleeding, serious AEs, and MB in prophylaxis. Nonsignificant trends were observed for clinically relevant non-MB, MB in treatment, and discontinuation due to AE in prophylaxis. We found a significant increase in discontinuation due to AE in treatment.

CONCLUSIONS

DOAC treatment seems to reduce VTE compared with SOC without major safety issues in the pediatric population, whereas DOAC prophylaxis seems at least comparable to SOC.

Questions around a case of in utero thrombosis in a premature child, concerning the management of anticoagulant treatments

We report the case of a preterm infant presenting a thrombosis, discovered on ultrasound at 22 weeks of gestational age and confirmed at birth following additional examinations. We describe the anticoagulant treatment of this patient by intravenous enoxaparin, tinzaparin and rivaroxaban, from questioning to practice.

The Hemostatic System in Newborns and the Risk of Neonatal Thrombosis

Newborns are the most vulnerable patients for thrombosis development among all children, with critically ill and premature infants being in the highest risk group. The upward trend in the rate of neonatal thrombosis could be attributed to progress in the treatment of severe neonatal conditions and the increased survival in premature babies. There are physiological differences in the hemostatic system between neonates and adults. Neonates differ in concentrations and rate of synthesis of most coagulation factors, turnover rates, the ability to regulate thrombin and plasmin, and in greater variability compared to adults. Natural inhibitors of coagulation (protein C, protein S, antithrombin, heparin cofactor II) and vitamin K-dependent coagulation factors (factors II, VII, IX, X) are low, but factor VIII and von Willebrand factor are elevated. Newborns have decreased fibrinolytic activity. In the healthy neonate, the balance is maintained but appears more easily converted into thrombosis. Neonatal hemostasis has less buffer capacity, and almost 95% of thrombosis is provoked. Different triggering risk factors are responsible for thrombosis in neonates, but the most important risk factors for thrombosis are central catheters, fluid fluctuations, liver dysfunction, and septic and inflammatory conditions. Low-molecular-weight heparins are the agents of choice for anticoagulation.

Mechanical atrioventricular valve replacement in patients with single ventricle palliation

OBJECTIVES

Atrioventricular valve (AVV) replacements in patients with single-ventricle circulations pose significant surgical risks and are associated with high morbidity and mortality.

METHODS

From 1997 to 2021, 16 consecutive patients with functionally single-ventricle physiology underwent mechanical AVV replacement. Primary outcome was transplant-free survival. Secondary outcomes included major postoperative morbidity.

RESULTS

The median age of AVV replacement was 2 years old (interquartile range 0.6-3.8 years). All AVV replacements were performed with a St. Jude Medical mechanical valve, median 24 mm (range, 19-31mm). Extracorporeal membrane oxygenation (ECMO) was required in 4 patients. Operative mortality was 38% (6/16). There were 2 late deaths and 3 transplants. Transplant-free survival was 50% at 1 year, 37.5% at 5 years, and 22% at 10 years. Transplant-free survival was higher for patients with preserved ventricular function (P = 0.01). Difference in transplant-free survival at 1 year was 75% vs 25%, at 5 years was 62.5% vs 12.5% and at 10 years was 57% vs 0%. Three (19%) patients had complete heart block requiring permanent pacemaker insertion. 6 of 13 patients (46%) patients reached Fontan completion (3 patients operated at/after Fontan). Significant bleeding events occurred in 8 patients (50%) with 3 patients suffering major cerebrovascular accidents. There were 6 events of valve thrombosis in 5 patients, resulting in 2 deaths and 2 heart transplants.

CONCLUSIONS

Mechanical valve replacement carries significant morbidity and mortality risk. While it successfully salvages about half of patients with preserved ventricular function, careful consideration of alternative options should be made before embarking upon mechanical valve replacement.

Renal vein thrombosis in neonates: a case series of diagnosis, treatment and childhood kidney function follow-up

BACKGROUND

Neonatal renal vein thrombosis (NRVT) is a rare condition with little data available.

METHODS

We retrospectively analyzed newborns diagnosed with NRVT admitted to 3 pediatric nephrology units in Paris from 2005 to 2020.

RESULTS

Twenty-seven patients were analyzed (male = 59%). The median age at diagnosis was 2.5 days (1 - 4.5). Diagnosis was suspected based on at least one of the three cardinal signs of renal vein thrombosis in 93%: flank mass (67%), hematuria (67%) and thrombocytopenia (70%). In all patients, diagnosis was confirmed by ultrasound. All patients had at least one known perinatal risk factor. A prothrombotic risk factor was found in 13 patients (48%). NRVT was unilateral in 70%, involving the left renal vein in 58%. Among 25 treated patients, 19 (76%) received low molecular weight heparin (LMWH) as initial therapy, 2 (8%) received unfractionated heparin and 4 (16%) received fibrinolysis. Median duration of treatment was 8 weeks (4 - 12). Bleeding occurred significantly more often with fibrinolysis than with LMWH/supportive therapy (3 of 4: 75% vs 0 of 4: 0%, p = 0.05). Clot resolution in patients treated with fibrinolysis did not differ significantly from those treated with LMWH/supportive therapy. After a median follow-up of 5.7 years (3 years - 9.9 years), pathological kidney features were observed in 73% of the patients (19 of 26), kidney atrophy in 18 (69%), hypertension in 2 (8%), chronic kidney disease (CKD) in 1 (4%) and proteinuria in 2 (8%).

CONCLUSIONS

NRVT remains a challenging condition, which still requires further study because of its associated morbidity. A higher resolution version of the Graphical abstract is available as Supplementary information.

French National Diagnostic and Care Protocol for antiphospholipid syndrome in adults and children

Antiphospholipid syndrome (APS) is a chronic autoimmune disease involving vascular thrombosis and/or obstetric morbidity and persistent antibodies to phospholipids or certain phospholipid-associated proteins. It is a rare condition in adults and even rarer in children. The diagnosis of APS can be facilitated by the use of classification criteria based on a combination of clinical and biological features. APS may be rapidly progressive with multiple, often synchronous thromboses, resulting in life-threatening multiple organ failure. This form is known as "catastrophic antiphospholipid syndrome" (CAPS). It may be primary or associated with systemic lupus erythematosus (associated APS) and in very rare cases with other systemic autoimmune diseases. General practitioners and paediatricians may encounter APS in patients with one or more vascular thromboses. Because APS is so rare and difficult to diagnosis (risk of overdiagnosis) any suspected case should be confirmed rapidly and sometimes urgently by an APS specialist. First-line treatment of thrombotic events in APS includes heparin followed by long-term anticoagulation with a VKA, usually warfarin. Except in the specific case of stroke, anticoagulants should be started as early as possible. Any temporary discontinuation of anticoagulants is associated with a high risk of thrombosis in APS. A reference/competence centre specialised in autoimmune diseases must be urgently consulted for the therapeutic management of CAPS.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Native Aortic Root Thrombosis in Hypoplastic Left Heart Syndrome: An Unusual Presentation (Soon after Atrial Septal Stenting) of a Relatively Unusual Complication-Experience and Literature Review with an Outlook to Diagnosis and Management

We started with the experience of thrombus formation in the native aorta of a 3-year-old male child with hypoplastic left heart syndrome (HLHS) and severely hypoplastic but patent mitral and aortic valves after Glenn palliation, which occurred soon after left heart decompression by percutaneous stenting of the atrial septum. The diagnosis was incidental, with the child completely asymptomatic, and progressively subsided in a few days with heparin infusion and chronic warfarin therapy. We reviewed the incidence, diagnosis, and management of native aortic thrombosis in HLHS after different stages of Fontan palliation through a systematic literature search. In all 32 cases, native aortic thrombosis in HLHS was found. The HLHS anatomic subtypes included mitral stenosis/aortic stenosis (fourteen cases or 45.2%), mitral stenosis/aortic atresia (eleven cases or 35.5%), and mitral atresia/aortic atresia (four cases or 12.9%). The age at diagnosis ranged from 13 days to 18 years. Clinical presentation varied from incidental findings, chest pain and/or electrocardiographic abnormalities, cardiac arrest, and transient ischemic attack. Diagnosis was feasible in most of the cases with only transthoracic echocardiography. Mostly (59.4%), patients were treated with anticoagulation, while others underwent surgical (18.7%), direct (12.5%), or systemic (9.3%) thrombolysis. Transplant-free survival was 56.2%, and fatal events occurred in 25%. Major events occurred in 26.3% of those treated with anticoagulation, in 33.3% of patients treated with surgical/systemic thrombolysis, and in 100% of patients treated with direct thrombolysis. In summary, native aortic thrombosis in HLHS may occur at different ages, with a wide spectrum of presentation from incidental finding to a sudden major event. Diagnosis is feasible with transthoracic echocardiography, and management with anticoagulation is effective despite the incidence of major events remaining high.

Lung abscess as a complication of Lemierre Syndrome in adolescents: a single center case reports and review of the literature

BACKGROUND

Fusobacterium necrophorum is an anaerobic, gram-negative, non-motile, filamentous, non-spore forming bacillus found in the oral cavity, gastrointestinal tract, and female genital tract, responsible of a rare disease named Lemierre Syndrome, characterized by septic thrombophlebitis of the internal jugular vein, which mainly affects previously healthy adolescents and young adults; some risk factors are reported, as smoking or primary viral or bacterial infection leading to the disruption of mucosa. The syndrome originates commonly from an upper respiratory infection such as pharyngotonsillitis, acute otitis media, cervical lymphadenitis, sinusitis, or odontogenic abscess, and may result in multiorgan metastasis, more frequently leading to pulmonary complications, especially lung abscesses.

CASE PRESENTATION

We describe two cases of adolescents with atypical Lemierre Syndrome evaluated in a tertiary care center, one with a confirmed infection by Fusobacterium necrophorum and one with a presumptive diagnosis based on clinical features, who developed lung abscesses needing a prolonged antibiotic course and hospitalization. Of interest, both were user of electronic cigarette, configuring a possible new risk factor. The proper diagnosis of Lemierre Syndrome is often difficult to establish, so a high degree of suspicion is needed, especially in the case of lung abscesses in otherwise healthy adolescents.

CONCLUSION

The current study will contribute to providing insight into Lemierre Syndrome clinical presentation and management in adolescents, promoting awareness for a rare but potentially fatal disease. Moreover, it suggests a possible relationship between Lemierre syndrome and the use of electronic cigarette, that should be investigated by future studies.

Stroke in Pediatric Cancer Patients: A Systematic Review

OBJECTIVE

Pediatric cancer patients have an increased risk of stroke. However, there is a knowledge gap regarding stroke in early stages of pediatric cancer. The objective of this project is to describe the current knowledge on stroke in pediatric cancer patients.

DESIGN

Systematic review.

MATERIALS AND METHODS

After Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, literature search was conducted in PubMed, Cochrane, and Google Scholar from January 1, 1995, up to February 1, 2022.

RESULTS

A total of 3499 studies were identified, of which 8 met inclusion criteria. The incidence of stroke in pediatric cancer patients varied between 0.47% and 2.9%, and prevalence between 1% and 3%. The risk factors identified were leukemia diagnosis, cranial radiation, thrombocytopenia, coagulopathy, and infection. There was a higher rate of diagnosis with magnetic resonance imaging than with computed tomography scan. Treatment was inconsistent, and patients with cancer were less likely to receive antithrombotic treatment when compared with patients without cancer. The highest mortality was among hemorrhagic stroke. Recurrence rate was 5% to 19%.

CONCLUSIONS

The risk for stroke is increased in the pediatric cancer population and can lead to devastating results. The available reports include few patients, with heterogeneous cancer diagnoses and outcomes. Large-scale multicenter studies are needed, focusing on early diagnosis, risk factors, and management strategies of stroke in children with underlying cancer.

Consistent Correlation between MTHFR and Vascular Thrombosis in Neonates-Case Series and Clinical Considerations

BACKGROUND

MTHFR polymorphism has been inconsistently linked to thrombotic events-some studies have shown its contribution to venous thrombosis, arterial thrombosis, and ischemic stroke, whereas others have found no statistically significant correlation between them.

METHODS

A descriptive case series study was performed in the Neonatal Intensive Care Unit of "Marie Sklodowska Curie" Emergency Clinical Hospital for Children in Bucharest, Romania.

RESULTS

All patients had positive results for MTHFR variants; 14 patients were positive for compound heterozygosity, 13 patients for MTHFR C677T (seven of which were homozygous), and 13 patients for MTHFR A1298C (three of which were homozygous). Eighteen patients received anticoagulants (heparin, enoxaparin, or bivalirudin), and thrombolytics (alteplase) were administered in six cases. In one case, a thrombectomy was performed; in another, vascular plasty was undertaken. Only in six cases was complete revascularization possible. Incomplete revascularization occurred for one patient with a negative outcome.

CONCLUSION

The particularity of this case series is that every patient in our unit who developed thrombi had a positive genetic result for MTHFR mutations. MTHFR mutations should be regarded as a thrombotic risk factor for critically ill patients, and screening for MTHFR mutations should be performed in every admitted patient to intensive care units, thus achieving the prevention of thrombi.

Once-daily Compared With Twice-daily Enoxaparin Maintenance Therapy Appears Safe and Efficacious in Pediatric Venous Thromboembolism

INTRODUCTION

Once-daily enoxaparin (ODE), considered standard of care for venous thromboembolism (VTE) treatment in adults, has been infrequently assessed in children. To contribute available data to a limited field, we reviewed our center's experience with ODE in treating pediatric VTE compared with twice-daily enoxaparin (TDE).

MATERIALS AND METHODS

A retrospective analysis of children and adolescents 18 years of age or below diagnosed with VTE and treated at our institution with ODE or TDE maintenance therapy between April 2015 and December 2020 was performed. Patient demographics, clinical and laboratory data pertaining to VTE diagnosis, and management were gathered from electronic medical records and compared between the 2 cohorts.

RESULTS

Seventy-one children met the eligibility criteria. All patients were initially treated with TDE for 2 weeks before transitioning to ODE maintenance therapy (n=39; 55%) or continuing with TDE dosing (n=32; 45%).Extremity VTE was more common in ODE ( P =0.051) versus pulmonary/intracardiac sites in TDE ( P =0.002) when compared with other sites. Median enoxaparin dosing was 1.5 and 1.1 mg/kg/dose in ODE and TDE cohorts, respectively. Bleeding episodes were rare without any difference between the cohorts. Two patients (6%) were lost to follow up in TDE cohort. All evaluable patients in both cohorts had either complete/partial response (ODE n=35 [90%]; TDE n=24 [75%] or stable thrombus ODE n=4 [10%]; TDE n=6 [19%]).

CONCLUSIONS

Our results indicate that ODE, used after the initial TDE treatment period, is as safe and efficacious as TDE maintenance for the treatment of pediatric VTE. The difference in VTE sites may have contributed to the equal efficacy of both the cohorts. Future prospective studies in pediatric VTE are needed to validate these results.

Three-Dimensional Printing Bioceramic Scaffolds Using Direct-Ink-Writing for Craniomaxillofacial Bone Regeneration

Defects characterized as large osseous voids in bone, in certain circumstances, are difficult to treat, requiring extensive treatments which lead to an increased financial burden, pain, and prolonged hospital stays. Grafts exist to aid in bone tissue regeneration (BTR), among which ceramic-based grafts have become increasingly popular due to their biocompatibility and resorbability. BTR using bioceramic materials such as β-tricalcium phosphate has seen tremendous progress and has been extensively used in the fabrication of biomimetic scaffolds through the three-dimensional printing (3DP) workflow. 3DP has hence revolutionized BTR by offering unparalleled potential for the creation of complex, patient, and anatomic location-specific structures. More importantly, it has enabled the production of biomimetic scaffolds with porous structures that mimic the natural extracellular matrix while allowing for cell growth-a critical factor in determining the overall success of the BTR modality. While the concept of 3DP bioceramic bone tissue scaffolds for human applications is nascent, numerous studies have highlighted its potential in restoring both form and function of critically sized defects in a wide variety of translational models. In this review, we summarize these recent advancements and present a review of the engineering principles and methodologies that are vital for using 3DP technology for craniomaxillofacial reconstructive applications. Moreover, we highlight future advances in the field of dynamic 3D printed constructs via shape-memory effect, and comment on pharmacological manipulation and bioactive molecules required to treat a wider range of boney defects.

Deep Medullary Vein Thrombosis in Newborns: A Systematic Literature Review

BACKGROUND

Deep medullary vein (DMV) thrombosis is a rare cause of brain damage in both preterm and full-term neonates. In this study, we aimed to collect data on clinical and radiological presentation, treatment, and outcome of neonatal DMV thrombosis.

METHODS

Systematic literature review on neonatal DMV thrombosis was carried out in PubMed, ClinicalTrial.gov, Scopus, and Web of Science up to December 2022.

RESULTS

Seventy-five published cases of DMV thrombosis were identified and analysed (preterm newborns were 46%). Neonatal distress, respiratory resuscitation, or need for inotropes were present in 34/75 (45%) of patients. Signs and symptoms at presentation included seizures (38/75, 48%), apnoea (27/75, 36%), lethargy or irritability (26/75, 35%). At magnetic resonance imaging (MRI), fan-shaped linear T2 hypointense lesions were documented in all cases. All had ischaemic injuries, most often involving the frontal (62/74, 84%) and parietal lobes (56/74, 76%). Signs of haemorrhagic infarction were present in 53/54 (98%). Antithrombotic treatment was not mentioned in any of the studies included. Although mortality was low (2/75, 2.6%), a large proportion of patients developed neurological sequelae (intellectual disability in 19/51 [37%] and epilepsy in 9/51 [18%] cases).

CONCLUSIONS

DMV thrombosis is rarely identified in the literature, even if it is possibly under-recognized or under-reported. Presentation in neonatal age is with seizures and non-specific systemic signs/symptoms that often cause diagnostic delay, despite the pathognomonic MRI picture. The high rate of morbidity, which determines significant social and health costs, requires further in-depth studies aimed at earlier diagnosis and evidence-based prevention and therapeutic strategies.

Symptomatic aortic thrombosis in a preterm neonate

Symptomatic aortic thrombosis is a devastating condition in the neonatal intensive care unit (NICU), which is now increasingly being diagnosed with the availability of bedside ultrasound. Early intervention can go a long way towards preventing adverse outcomes. In our case, a preterm, very low birth weight, growth-restricted baby developed aortic thrombosis with hypertensive emergency and later limb-threatening ischaemia, which usually requires thrombolysis. However, due to the parents' reservations, he was given only therapeutic anticoagulation (with closely monitored activated partial thromboplastin time targets), which resulted in complete thrombus resolution. A multidisciplinary team approach was followed, and early detection with frequent monitoring led us to a favourable outcome.

[Peripherally inserted central venous catheter-related thrombosis in a neonate]

The female infant in this case study was admitted to the hospital 4 hours after birth due to preterm birth and respiratory distress. On the third day after birth, peripherally inserted central venous catheter (PICC) catheterization was performed. On day 42, thrombus was found at the entrance of the right atrium from the inferior vena cava during a cardiac ultrasound, and it was considered to be related to PICC placement. Low-molecular-weight heparin and urokinase were given. After two weeks of treatment, ultrasonic monitoring showed thrombus shrinkage. No bleeding or pulmonary embolism occurred during the treatment. The patient discharged after improvement. This article mainly introduces a multidisciplinary team approach to diagnosis and treatment of PICC-related thrombosis in neonates.

Epidemiology and risk factors for thrombosis in children and newborns: systematic evaluation and meta-analysis

BACKGROUND

Thrombosis is a serious condition in children and neonates. However, the risk factors for thrombosis have not been conclusively determined. This study aimed to identify the risk factors for thrombosis in children and neonates in Intensive Care Unit (ICU) through a meta-analysis to better guide clinical treatment.

METHODS

A systematic search of electronic databases (PubMed, Embase, Cochrane Library, WOS, CNKI, Wanfang, VIP) was conducted to retrieve studies from creation on 23 May 2022. Data on the year of publication, study design, country of origin, number of patients/controls, ethnicity, and type of thrombus were extracted. The publication bias and heterogeneity between studies were assessed, and pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using fixed or random effects models.

RESULTS

A total of 18 studies met the inclusion criteria. The incidence of thrombosis in children was 2% per year (95% CI 1%-2%, P < 0.01). Infection and sepsis (OR = 1.95, P < 0.01), CVC (OR = 3.66, [95%CL 1.78-7.51], P < 0.01), mechanical ventilation (OR = 2.1, [95%CL1.47-3.01], P < 0.01), surgery (OR = 2.25, [95%CL1.2-4.22], P < 0.01), respiratory distress (OR = 1.39, [95%CL0.42-4.63], P < 0.01), ethnicities (OR = 0.88, [95%CL 0.79-0.98], P = 0.78), gestational age (OR = 1.5, [95%CL1.34-1.68], P = 0.65)were identified as risk factors for thrombosis.

CONCLUSIONS

This meta-analysis suggests that CVC, Surgery, mechanical ventilation, Infection/sepsis, gestational age, Respiratory distress, and different ethnicities are risk factors for thrombosis in children and neonates in ICU. These findings may help clinicians to identify high-risk patients and develop appropriate prevention strategies.

TRIAL REGISTRATION

PROSPERO (CRD 42022333449).

Comparison of Time Within Therapeutic Range Using Anti-Factor Xa Versus Activated Partial Thromboplastin Time Monitoring of Unfractionated Heparin in Children

OBJECTIVE

To compare unfractionated heparin (UFH) monitoring using time in therapeutic range of activated partial thromboplastin time (aPTT) versus anti-factor Xa activity (anti-Xa) in children.

METHODS

This retrospective chart review, with data between October 2015 and October 2019, included pediatric patients younger than 18 years on therapeutic UFH infusion with aPTT or anti-Xa monitoring. Patients receiving extracorporeal membrane oxygenation, dialysis, concomitant anticoagulants, prophylactic UFH, no stated goal, and UFH administered for less than 12 hours were excluded. The primary outcome compared the percentage of time in therapeutic range between aPTT and anti-Xa. Secondary outcomes included time to first therapeutic value, UFH infusion rates, mean rate adjustments, and adverse events.

RESULTS

A total of 65 patients were included, with 33 aPTT patients and 32 anti-Xa patients, representing 39 UFH orders in each group. Baseline characteristics were similar between groups, with an overall mean age of 1.4 years and mean weight of 6.7 kg. The anti-Xa cohort demonstrated a statistically significantly higher percentage of time in therapeutic range compared with the aPTT group (50.3% vs 26.9%, p = 0.002). The anti-Xa group also demonstrated a trend toward decreased time to first therapeutic value compared with aPTT (14 vs 23.2 hours, p = 0.12). Two patients in each group experienced new or worsening thrombosis. Six patients in the aPTT cohort experienced bleeding.

CONCLUSIONS

This study demonstrated greater time was spent within therapeutic range for children receiving UFH monitored with anti-Xa compared with aPTT. Future studies should assess clinical outcomes in a larger population.

Hemostasis assessment in Fontan patients using the new thrombodynamics test

BACKGROUND

Thromboembolic events are a well-known risk for Fontan patients and often lead to morbidity and mortality in cyanotic patients and patients with a single ventricle. Coagulopathy and thrombophilia, in addition to disturbed Fontan blood flow and endothelial injury, are major contributors to thromboembolic complications. However, there is currently no consensus regarding the optimal medication to prevent or treat these events. Identification of coagulation disorders is therefore crucial for selecting appropriate management strategies and evaluating long-term outcomes in these patients.

CASE PRESENTATION

We present the case of a 35-year-old male who underwent the Fontan procedure with a total cavopulmonary modification during childhood due to tricuspid atresia. He was admitted with complaints of headaches and visual disturbances, but no clear cardiovascular cause was identified. Standard coagulation test parameters were normal, but the thrombodynamics test indicated severe hypercoagulation and spontaneous clot formation. Anticoagulation therapy was initiated, and a subsequent thrombodynamics assay showed normalization of the coagulation parameters. The patient remained asymptomatic during the six-month follow-up period.

CONCLUSIONS

The thrombodynamics test is a valuable tool for the diagnosis of coagulation disorders, as it can assess coagulation parameters and clot growth in vitro. This method can also aid in the optimization of antithrombotic therapy. The presented clinical case highlights the potential use of the thrombodynamics test in Fontan patients to diagnose coagulation disorders and improve long-term outcomes.

Thromboprophylaxis for Coagulopathy Related to COVID-19 in Pediatrics: A Narrative Review

In addition to harming the respiratory system, COVID-19 can affect multiple organs. Children may develop a specific complication of COVID-19 called multisystem inflammatory syndrome in children (MIS-C) which could influence the vascular system of children and cause multiple coagulopathies in the body. Information on the use of thromboprophylaxis in this condition was collected via the review of various articles. In general, different factors in immune system responses can trigger the initiation of thrombotic events. Studies have shown that starting anticoagulant prophylaxis, which contributes to decreased thrombotic events, is dependent on the patient's condition and D-dimer levels. However, further studies on pediatric populations are needed to establish the role of anticoagulants in children with this condition.

Incidence of thromboembolism in children with primary nephrotic syndrome: a systematic review and metaanalysis

OBJECTIVE

To estimate the incidence of thromboembolism in children with primary nephrotic syndrome with Meta-analysis.

METHODS

Relevant studies published from January 1, 1980 to December 31, 2021 were retrieved from Pubmed, Web of science, Cochrane library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database(VIP) and Wangfang Database. Quality evaluation of the literatures included was conducted according to Agency for Healthcare Research and Quality(AHRQ) assessment tool, followed by data extraction and Meta-analysis with software RevMan 5.3.

RESULTS

A total of seven studies involving 3675 subjects were included. The overall prevalence was 4.9% with 95% CI of 2.83 to 7.05.However, a significant heterogeneity (P < 0.001) was observed with I² = 89%. The prevalence of venous thromboembolism was 3.3% with 95% CI of 1.7 to 4.9. The prevalence of arterial thromboembolism was 0.5% with 95% CI of 0.2 to 1.4.

CONCLUSION

Children with nephrotic syndrome are prone to thromboembolism, and it may lead to disability or death, therefore prevention measures is critical to decreasing the prevalence of thromboembolism.

Management of venous thromboembolism in pediatric patients: Quality assessment of clinical practice guidelines and variations in recommendations

INTRODUCTION

We performed a quality assessment and comparison of clinical practice guidelines (CPGs) for the prevention and treatment of venous thromboembolism (VTE) in pediatric patients and to provide a clinical reference.

MATERIALS AND METHODS

Electronic databases, guideline development organizations, and professional societies were searched to identify CPGs for VTE in pediatric patients between January 1, 2012, and April 7, 2022. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate quality. Recommendations for preventing and treating VTE in pediatric patients were extracted via descriptive synthesis.

RESULTS

Six CPGs were included. The median scores (interquartile range [IQR]) for each AGREE II domain were as follows: scope and purpose, 88.89 % (IQR: 8.33 %); stakeholder involvement, 88.89 % (25 %); rigor of development, 67.71 % (24.47 %); clarity and presentation, 88.89 % (0 %); applicability, 50 % (42.71 %); and editorial independence, 66.67 % (50.00 %). In total, 268 key recommendations were extracted, and traditional anticoagulants (heparin and warfarin) remain the standard treatment. However, in recent years direct oral anticoagulants (DOACs) have shown similar efficacy and safety results for the treatment of VTE in children to those reported in adults; therefore, this practice is recommended in recent guidelines.

CONCLUSIONS

Variability exists in the development and reporting of CPGs for VTE in pediatric patients. There may be changes to the recommendations for the prevention and treatment of VTE in pediatrics in the future due to the efficacy of DOACs in children, and recommendations should be revised periodically as new evidence emerges.

A regional anticoagulation program improves safety and outcomes for both children and adults

BACKGROUND

Evidence-based anticoagulation programs usually serve a local, adult patient population. Here we report outcomes for a regional combined pediatric-adult program.

AIMS

The aims of this study were: (1) Compare the pre- vs. post-implementation quality of therapy (% time in therapeutic range (%TTR) and compliance). (2) Assess anticoagulant-relevant outcomes (bleeding and thrombotic complications).

METHODS

Data were collected for the years 2014-2019. Rosendaal linear interpolation was used to calculate %TTR. Bleeding complications were categorized using ISTH-SSC standard nomenclature and new thrombotic events were reviewed.

RESULTS

The patients were divided into a long-term warfarin group (N = 308), 80.2% of whom had cardiac-related therapeutic indications (median age 24y), and a second group (N = 114) comprised of short-term and non-warfarin long-term anticoagulation (median age 16y). Median %TTR for those on long-term warfarin was 78.9%. The incidence of major and clinically relevant non-major bleeding events was 1.65 and 2.43 /100 person-years of warfarin use, respectively. Thromboembolism (TE) incidence was 0.78/100 patient-years of warfarin use. Neither bleeding nor thrombosis was associated with %TTR (p = 0.48). Anticoagulant indication was the only variable associated with bleeding risk (p = 0.005). The second group had no on-therapy TE events but 7.9% experienced bleeding. Complete data were available for a randomly sampled pre-program warfarin group (N = 26). Median %TTR improved from 17.5 to 87% pre- vs. post-implementation. Similarly, compliance (defined as ≥ 1 INR/month) improved by 34.3%.

CONCLUSIONS

In conclusion, this program significantly improved and sustained %TTR and compliance. The lack of association between bleeding and thrombosis events and %TTR may be related to the high median %TTR (> 70%) achieved by this approach.

Pediatric Ischemic Stroke

OBJECTIVE

Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children.

LATEST DEVELOPMENTS

High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies.

ESSENTIAL POINTS

This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.

Just DOAC: Use of direct-acting oral anticoagulants in pediatrics

PURPOSE

The aim of this article is to provide an overview of the current literature for direct-acting oral anticoagulant (DOAC) use in pediatric patients and summarize ongoing trials.

SUMMARY

In treatment of venous thromboembolism (VTE) in pediatric patients, evidence supports use of both dabigatran and rivaroxaban. Dabigatran has been shown to be noninferior to standard of care (SOC) in terms of efficacy, with similar bleeding rates. Similarly, treatment with rivaroxaban in children with acute VTE resulted in a low recurrence risk and reduced thrombotic burden, without increased risk of bleeding, compared to SOC. Treatment of pediatric cerebral venous thrombosis as well as central venous catheter-related VTE with rivaroxaban appeared to be both safe and efficacious and similar to that with SOC. Dabigatran also has a favorable safety profile for prevention of VTE, and rivaroxaban has a favorable safety profile for VTE prevention in children with congenital heart disease. Many studies with several different DOACs are ongoing to evaluate both safety and efficacy in unique patient populations, as well as VTE prevention.

CONCLUSION

The literature regarding pediatric VTE treatment and prophylaxis is growing, but the need for evidence-based pediatric guidelines remains. Additional long-term, postauthorization studies are warranted to further elucidate safety and efficacy in clinical scenarios excluded in clinical trials. Additional data on safety, efficacy, and dosing strategies for reversal agents are also necessary, especially as the use of DOACs becomes more common in the pediatric population.

Treating a limb-threatening arterial clot in a newborn with catheter-directed thrombolysis

Non-catheter related arterial thromboembolism in the neonatal population is rare and carries a significant risk of organ damage or limb loss. Thrombolysis, whether systemic or catheter- directed, is reserved either for limb or life-threatening thrombosis due to risk of bleeding especially in premature neonates. In this case, an infant male born at 34 weeks and 4 days gestational age presented with limb-threatening clot in the distal right subclavian artery and proximal right axillary artery with no known cause. After discussion of risks and benefits of various treatment options, he received thrombolysis treatment with low dose recombinant TPA via an umbilical artery catheter. There was complete resolution of the thrombus with this treatment and the patient had no significant bleeding while receiving treatment. Further investigation is needed to identify the patient population that will benefit from catheter-directed thrombolytic therapy and how to best monitor these patients.

Central Vein Recanalization and Rehabilitation in Pediatric Patients: Changing the Paradigm for Chronic Occlusions

Background

Chronic total occlusions in the central venous system limit access and increase morbidity in chronically ill pediatric patients. We report the results of transcatheter recanalization of occluded central veins using angioplasty and stenting.

Methods

Patients undergoing successful intervention for venous chronic total occlusions at our institution between April 2013 and December 2019 were retrospectively reviewed.

Results

Sixty-eight occluded central veins in 29 patients underwent recanalization with angioplasty (26 veins) or stenting (42 veins). The indications included limited access for catheterization or central line maintenance (19 patients), limb swelling (4 patients), superior vena cava syndrome (3 patients), and pleural effusion (3 patients). The primary risk factor for occlusion was a history of central venous lines after surgery or extracorporeal membrane oxygenation support in 76% of the patients. The median age and weight at the time of initial intervention were 5.8 years and 14.5 kg, respectively. There were no major complications. Of 10 patients with symptoms of venous congestion, 8 experienced symptomatic improvement. Twenty-two patients (59 veins) underwent 44 recatheterizations during a median follow-up duration of 288 days. Early reintervention was typically planned. The median time to recatheterization was 71 days. Twenty-one veins reoccluded and required repeat recanalization. Reocclusion was associated with persistent upstream collateral vein decompression, as determined using postintervention venography (odds ratio, 14.2; 95% CI, 3.3-62.6; P < .001), which was thought to indicate persistently poor venous inflow. Reinterventions were performed on 40 veins. Fifty-two veins that were followed up (88%) remained patent after the most recent intervention.

Conclusions

Invasive transcatheter rehabilitation of occluded central veins has the potential to preserve critical access sites and improve the symptoms of venous congestion in pediatric patients. Reinterventions are common for reocclusion, restenosis, and somatic growth.

Derivation and Validation of a Machine Learning Algorithm for Predicting Venous Thromboembolism in Injured Children

BACKGROUND

Venous thromboembolism (VTE) causes significant morbidity in pediatric trauma patients. We applied machine learning algorithms to the Trauma Quality Improvement Program (TQIP) database to develop and validate a risk prediction model for VTE in injured children.

METHODS

Patients ≤18 years were identified from TQIP (2017-2019, n = 383,814). Those administered VTE prophylaxis ≤24 h and missing the outcome (VTE) were removed (n = 347,576). Feature selection identified 15 predictors: intubation, need for supplemental oxygen, spinal injury, pelvic fractures, multiple long bone fractures, major surgery (neurosurgery, thoracic, orthopedic, vascular), age, transfusion requirement, intracranial pressure monitor or external ventricular drain placement, and low Glasgow Coma Scale score. Data was split into training (n = 251,409) and testing (n = 118,175) subsets. Machine learning algorithms were trained, tested, and compared.

RESULTS

Low-risk prediction: For the testing subset, all models outperformed the baseline rate of VTE (0.15%) with a predicted rate of 0.01-0.02% (p < 2.2e^-16). 88.4-89.4% of patients were classified as low risk by the models.

HIGH-RISK PREDICTION

All models outperformed baseline with a predicted rate of VTE ranging from 1.13 to 1.32% (p < 2.2e^-16). The performance of the 3 models was not significantly different.

CONCLUSION

We developed a predictive model that differentiates injured children for development of VTE with high discrimination and can guide prophylaxis use.

LEVEL OF EVIDENCE

Prognostic, Level II.

TYPE OF STUDY

Retrospective, Cross-sectional.

Intracardiac Thrombi in Preterm Infants-A Case Study and Review of the Literature

Intracardiac thrombi in preterm infants are not common but may lead to fatal outcomes. Predisposing and risk factors include small vessel size, hemodynamic instability, immaturity of the fibrinolytic system, indwelling central catheters and sepsis. In this paper, we present our own experience with a case of a catheter-related right atrial thrombus in a preterm infant, which was successfully treated with an aspiration thrombectomy. Then, we review the literature on intracardiac thrombosis in preterm infants: epidemiology, pathophysiology, clinical signs, echocardiographic diagnostic features and treatment options are discussed.

High Rate of Venous Thromboembolism in Severe Pediatric Intestinal Failure

OBJECTIVE

To quantify the rate of venous thromboembolism (VTE) in patients with pediatric intestinal failure and identify associated risk factors.

STUDY DESIGN

We performed a retrospective cohort study in pediatric patients (<21 years old) with severe pediatric intestinal failure (≥90 consecutive days of parenteral nutrition) secondary to short bowel syndrome who were treated from 2014 to 2021 at an interdisciplinary intestinal rehabilitation program. The primary outcome was the incidence of VTE. Multivariable regression was performed to identify independent clinical predictors of VTE.

RESULTS

A total of 263 patients (59.7% male) met the criteria for inclusion. The cumulative incidence of VTE was 28.1%, with a rate of 0.32 VTEs per 1000 catheter-days. On univariate analysis, the number of catheter days, number of catheters, and history of central line-associated blood stream infection were associated with VTE. On multivariable logistic regression, a higher number of catheters was an independent risk factor for VTE (aOR, 1.17; 95% CI, 1.06-1.29). Additionally, earlier gestational age was a risk factor for VTE such that every week decrease in gestational age conferred a 9% increased risk of VTE (aOR, 1.09; 95% CI, 1.02-1.16).

CONCLUSIONS

In this retrospective study, 28.1% of patients with severe pediatric intestinal failure developed VTE; the number of catheters and early gestational age were noted to be independent risk factors for VTE. This high incidence of VTE highlights the need to investigate VTE in pediatric intestinal failure prospectively, including the potential benefit of prophylactic anticoagulation.

Neonatal Arterial Ischemic Stroke Secondary to Carotid Artery Dissection: A Case Report and Systematic Literature Review

BACKGROUND

Carotid artery (CA) dissection is a rare etiology of neonatal arterial ischemic stroke (NAIS).

METHODS

We describe one novel case and conduct a systematic literature review on NAIS attributed to CA dissection, to collect data on its clinical-radiological presentation, treatment, and outcome.

RESULTS

Eight published cases of NAIS attributed to CA dissection were identified and analyzed with our case. All patients (nine of nine) were born at term, and eight of nine experienced instrumental/traumatic delivery or urgent Caesarean section. None had fetal problems during pregnancy or thrombophilia. Signs and symptoms at presentation (between days of life 0 and 6) included seizures (eight of nine), respiratory distress or irregular breathing (five of nine), hyporeactivity, decreased consciousness or irritability (four of nine), and focal neurological signs (two of nine). At magnetic resonance imaging (MRI), stroke was unilateral in seven of nine and extensive in five of nine. CA dissection was documented by neuroimaging or at postmortem studies (seven of nine), and hypothesized by the treating physicians based on delivery and neuroradiology characteristics (in the remaining two of nine). Antithrombotic treatment was used in two of nine. According to available follow-up, one of eight died at age seven days, seven of eight had neurological/epileptic sequelae, and CA recanalization occurred in three of four.

CONCLUSIONS

NAIS attributed to CA dissection is rarely identified in the literature, often preceded by traumatic/instrumental delivery, presenting with seizures and systemic signs/symptoms, and often characterized by extensive MRI lesions and neurological sequelae. Definite evidence and recommendations on antithrombotic treatment are lacking.

Current and future strategies to monitor and manage coagulation in ECMO patients

Extracorporeal membrane oxygenation (ECMO) can provide life-saving support for critically ill patients suffering severe respiratory and/or cardiac failure. However, thrombosis and bleeding remain common and complex problems to manage. Key causes of thrombosis in ECMO patients include blood contact to pro-thrombotic and non-physiological surfaces, as well as high shearing forces in the pump and membrane oxygenator. On the other hand, adverse effects of anticoagulant, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis are all established as causes of bleeding. Finding safe and effective anticoagulants that balance thrombosis and bleeding risk remains challenging. This review highlights commonly used anticoagulants in ECMO, including their mechanism of action, monitoring methods, strengths and limitations. It further elaborates on existing anticoagulant monitoring strategies, indicating their target range, benefits and drawbacks. Finally, it introduces several highly novel approaches to real-time anticoagulation monitoring methods including sound, optical, fluorescent, and electrical measurement as well as their working principles and future directions for research.

Post traumatic cerebral sinovenous thrombosis in children: A retrospective and multicenter study

CONTEXT

Cerebral sinovenous thrombosis (CSVT) is a rare but life-threatening condition in the pediatric population and there is no pediatric guidelines regarding anticoagulation for post traumatic CSVT.

OBJECTIVE

This study aims to describe a cohort of children with post traumatic CSVT and the use of anticoagulant therapy in this population.

METHODS

A multicenter retrospective study. Patients admitted with post traumatic CSVT in the six participating Pediatric Intensive Care Unit were included.

RESULTS

Overall, 29 patients (median age 8.2 years [IQR 4.8-14.6], n = 22 (76%) males) were included in the study (Table 1). CSVT was observed within the first 24 h after admission for a half of the patients (n = 14, 50%). Anticoagulation was initiated in 18 patients (62%). No patient received thrombolytic therapy or endovascular treatment. The presence of epidural hematoma was associated with the absence of anticoagulation (n = 0 versus n = 10, p = 0.003). One patient (3%) died of extracranial injury (not related with adverse event of anticoagulation) and in survivors, median Pediatric Overall Performance Category Outcome (POPC) score at discharge from PICU was 2 [IQR 2-4] (i.e., mild disability). Regarding the outcomes of patients, we found no association according to the anticoagulation status (p = 1). Overall, 23 patients (79%) had a follow-up cerebral imaging with a median delay of 42 days [IQR 6-63] after admission. CSVT was still seen in 9 patients (31%). We found no difference regarding the persistence of CSVT between patients according to the anticoagulation status (p = 0.36). The median duration of anticoagulant treatment was 58 days [IQR 44-91] and one patient (3%) experienced adverse event related to anticoagulation.

CONCLUSION

There were minimal adverse events in patients with post traumatic CSVT treated with therapeutic anticoagulation. However, the effect of anticoagulation on outcomes needs to be confirmed in further studies.

Potential drug-drug interaction between warfarin and norethindrone in adolescent females: A case series

PURPOSE

In the pediatric population, warfarin remains the recommended oral anticoagulant for valvular heart disease. Warfarin carries a risk of bleeding complications that can manifest as heavy menstrual bleeding (HMB) in postmenarchal adolescent females. As a result, these patients may be started on hormonal therapies, such as norethindrone, to suppress menstruation.

SUMMARY

This case series describes a potential drug interaction between warfarin and norethindrone in 3 adolescent females with a history of mechanical mitral valve replacement who developed HMB. These patients were on stable warfarin regimens before the initiation of norethindrone and subsequently experienced increases in their international normalized ratio (INR). In response, they required an up to 50% reduction in their weekly warfarin dose over 5 to 12 weeks.

CONCLUSION

These observations suggest that use of norethindrone for the management of HMB may significantly potentiate the anticoagulant effect of warfarin. Close INR monitoring and aggressive dose adjustments during initiation and discontinuation of norethindrone are recommended in patients on warfarin.

Clinical characteristics of 14 pediatric mycoplasma pneumoniae pneumonia associated thrombosis: a retrospective study

OBJECTIVE

This study aimed to investigate the clinical characteristics and long-term prognosis of mycoplasma pneumoniae pneumonia (MPP)-associated thrombosis and to gain a better understanding of the diagnosis and treatment of the disease.

METHODS

The medical records of 14 children with MPP-associated thrombosis between January 2016 and April 2020 were retrospectively reviewed at the Tianjin Children's Hospital.

RESULTS

The ages of the patients ranged from 3 to 12 years old. Among the 14 cases, there were five cases of pulmonary embolism, two cases of cerebral infarction, one case of splenic infarction, one case of cardiac embolism, two cases of cardiac embolism with comorbid pulmonary embolism, one case of internal carotid artery and pulmonary embolism, one case of combined internal carotid artery and the cerebral infarction, and one case combined cardiac embolism and lower limb artery embolism. All cases had elevated D-dimer levels. After thrombolysis and anticoagulation therapy, three cases with cerebral embolism still suffered from neurological sequelae. In contrast, the remaining cases did not develop complications.

CONCLUSION

MPP-associated thrombosis can occur in any vessel of the body. Thrombosis-associated symptoms may be complex and non-specific. Elevated D-dimer levels in a child with refractory mycoplasma pneumoniae pneumonia should raise suspicion of thrombosis. The long-term prognosis of thrombosis was favorable after the timely administration of anticoagulant therapy.

Monitoring Direct Thrombin Inhibitors With Calibrated Diluted Thrombin Time vs Activated Partial Thromboplastin Time in Pediatric Patients

OBJECTIVES

Activated partial thromboplastin time (aPTT) is the primary test used to monitor intravenous (IV) direct thrombin inhibitors (DTIs) but has many limitations. The plasma diluted thrombin time (dTT) has shown better correlation with DTI levels than aPTT. This study compared dose-response curves for dTT and aPTT in pediatric patients receiving argatroban and bivalirudin.

METHODS

A retrospective review of pediatric patients treated with argatroban (n = 45) or bivalirudin (n = 14) monitored with dTT and aPTT.

RESULTS

The dTT assay was calibrated to report DTI concentrations in µg/mL for argatroban and bivalirudin with good analytic sensitivity and specificity. The dTT was fivefold more likely to show a stable dose-response slope than the aPTT (P < .0002; odds ratio, 4.9). For patients in whom both dTT and aPTT showed a significant correlation between dose and assay results, dTT had a higher average correlation factor compared with aPTT (P = .007). Argatroban dose-response slopes showed more inter- and intrapatient variation than bivalirudin (dose-response slope coefficient of variation, 132% vs 52%).

CONCLUSIONS

The dTT assay was more likely to show a stable dose response and have a stronger correlation with DTI dose than aPTT. Argatroban shows more variation in dose response than bivalirudin.

Risk of venous thromboembolism and major bleeding in the clinical course of osteosarcoma and Ewing sarcoma

BACKGROUND

Patients with osteosarcoma (OS) and Ewing sarcoma (ES) are considered to have a high venous thromboembolism (VTE) risk, although the exact incidence and prognostic impact are under-researched in general as well as in relevant age groups.

AIMS

To study the impact of VTE and major bleeding (MB) in OS and ES patients, subdivided in children, Adolescents Young Adults (AYAs; aged 18-39) and older adults.

METHODS

Retrospective single-center chart review in 519 OS and 165 ES patients treated between 1980 and 2018. Patients were followed from sarcoma diagnosis until an outcome of interest (VTE, MB) or death occurred. Cumulative incidences were estimated with death as competing risk. Cox models were used to determine prognostic impact.

RESULTS

Five-year cumulative incidences of VTE were 12 % (95%CI 9.1-15) for OS and 6.7 % (95%CI 3.5-11) for ES patients, mostly happening in patients ≥18 years; the most frequent VTE presentation was catheter-related upper-extremity thrombosis (OS: 18/65, ES: 7/11). Five-year cumulative incidences for MB were 5.8 % (95%CI 4.0-8.1) in OS and 5.4 % (95%CI 2.5-9.8) in ES patients. 192 OS and 77 ES AYAs were included, who faced similar VTE and MB incidences as older adults. In OS, VTE and MB were both associated with mortality (adjusted HRs 2.0 [95%CI 1.4-2.9] and 2.4 [95%CI 1.4-4.0], respectively), whereas in ES this association was only present for MB (aHR 3.4 [95%CI 1.2-9.6]).

CONCLUSIONS

VTE is a frequent complication in adult OS and to a lesser extent in ES patients, while the rate of MB was comparably high in both sarcoma types.

Osteomyelitis and Thrombosis in a Newborn with Group A Streptococcus Infection

Neonatal osteomyelitis (OM), although exceptionally rare, has been linked to detrimental sequel, as diagnosis in the early stages is challenging and any delay in treatment can lead to disturbance in skeletal growth. In pediatric OM the most commonly grown bacteria is Staphylococcus aureus followed by group A Streptococcus (GAS). Notwithstanding, sepsis-induced coagulopathy is a well-known entity in children and adults, still sepsis-associated thrombosis is sparsely observed. we present a case of a newborn with GAS associated OM and thrombosis. A term neonate on the 11th day of life was referred to our NICU due to right (R) lower limb edema, cyanosis and core temperature up to 39 °C. Late onset sepsis was suspected and started on vancomycin and amikacin. A colour Doppler scan showed thrombosis of the R common femoral vein. The neonate started on iv unfractionated heparin. Ampicillin was added given positive for GAS blood culture. An MRI on the 5th day of admission, showed evidence of thrombosis resolution. On the 14th day of admission, a bone Tc99 scan showed evidence of OM of R femur. Antibiotic treatment switched to amoxicillin per os. The management was restricted to anticoagulant therapy with low molecular weight heparin for 3 months and antibiotic therapy for 6 months without surgery intervention and the patient recovered and discharged at 42 days of age. Early diagnosis and treatment of neonatal osteomyelitis can prevent bone destruction. Sepsis-associated thrombosis is barely observed during osteomyelitis, yet it should be considered as an emerged case requiring prompt treatment.