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Nagy R, Hemmelgarn T, Deptola S, Hemmann B. Evaluation of Initial Enoxaparin Dosing and Antifactor Xa Levels in Infants Admitted to the Neonatal Intensive Care Unit. Biomed Hub 2024; 9:54-61. [PMID: 38616894 PMCID: PMC11014719 DOI: 10.1159/000537797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/05/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Infants are at risk for thrombotic conditions due to multiple risk factors such as congenital heart defects and sepsis. According to the American College of Chest Physicians (ACCP) 2012 guidelines, enoxaparin may be given for thrombotic conditions at a dose of 1.5 mg/kg/dose every 12 h for patients less than 2 months of age and 1 mg/kg/dose every 12 h for those older than 2 months. Several studies have reported that infants typically require a higher initial dose of enoxaparin to reach therapeutic antifactor Xa levels than what is currently recommended. Methods This is a single-center retrospective case-control study of hospitalized infants less than 12 months of age who received treatment with enoxaparin while admitted to the neonatal intensive care unit (NICU) at a freestanding children's hospital. The primary objective was the difference between the initial enoxaparin dose (mg/kg) compared to the enoxaparin dose in which the patient first achieved a therapeutic antifactor Xa level of 0.5-1.0 units/mL. Results A total of 56 infants were included in this study. The median enoxaparin dose at initiation was 1.5 mg/kg/dose, and the median enoxaparin dose at the first therapeutic antifactor Xa level was 1.9 mg/kg/dose (z = -12.7, p < 0.0001). There was no correlation between gestational age and weight with the enoxaparin dose required to reach a therapeutic antifactor Xa level. Conclusion Infants admitted to the NICU, specifically those less than 4 months of age, require higher initial enoxaparin dosing to reach therapeutic antifactor Xa levels than what is currently recommended.
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Affiliation(s)
- Rosemarie Nagy
- Department of Pharmacy, Nemours Children’s Hospital, Orlando, FL, USA
| | - Trina Hemmelgarn
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Stephen Deptola
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Brianna Hemmann
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Ooi BS, Gopagondanahalli KR, Vora S. Acute aortic thrombosis following umbilical artery catheterisation in extremely low birthweight infants: walking the tight rope of management. BMJ Case Rep 2023; 16:e256902. [PMID: 37993142 PMCID: PMC10668172 DOI: 10.1136/bcr-2023-256902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
Umbilical artery catheterisation (UAC) is crucial in the management of clinically sick infants. One of its dreaded complications is aortic thrombus formation which accounts for significant morbidity and mortality. We present the case of a premature infant born at 32 weeks of gestation and with a birth weight of 960 gm, who developed signs of acute lower limb ischaemia following UAC cannulation. Ultrasound Doppler scan confirmed large aortic thrombus involving iliac arteries. Heparin infusion was started with clinical improvement over the next 12 hours and eventual complete resolution of clot size. This case underscores the importance of prompt detection of acute aortic thrombosis and cautions the use of heparin infusion in preterm infants can be lifesaving. Management can be challenging as risk of bleeding from anticoagulation and thrombolytic therapy can be catastrophic in extreme low birthweight premature infants and need to weigh with risk of severe intravascular haemorrhage.
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Affiliation(s)
- Boon Siew Ooi
- Neonatology, KK Women's and Children's Hospital, Singapore
| | | | - Shrenik Vora
- Neonatology, KK Women's and Children's Hospital, Singapore
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El-Sabrout H, Ganta S, Guyon P, Ratnayaka K, Vaughn G, Perry J, Kimball A, Ryan J, Thornburg CD, Tucker S, Mo J, Hegde S, Nigro J, El-Said H. Neonatal Myocardial Infarction: A Proposed Algorithm for Coronary Arterial Thrombus Management. Circ Cardiovasc Interv 2022; 15:e011664. [PMID: 35485231 PMCID: PMC11225359 DOI: 10.1161/circinterventions.121.011664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/28/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neonatal myocardial infarction is rare and is associated with a high mortality of 40% to 50%. We report our experience with neonatal myocardial infarction, including presentation, management, outcomes, and our current patient management algorithm. METHODS We reviewed all infants admitted with a diagnosis of coronary artery thrombosis, coronary ischemia, or myocardial infarction between January 2015 and May 2021. RESULTS We identified 21 patients (median age, 1 [interquartile range (IQR), 0.25-9.00] day; weight, 3.2 [IQR, 2.9-3.7] kg). Presentation included respiratory distress (16), shock (3), and murmur (2). Regional wall motion abnormalities by echocardiogram were a key criterion for diagnosis and were present in all 21 with varying degrees of depressed left ventricular function (severe [8], moderate [6], mild [2], and low normal [5]). Ejection fraction ranged from 20% to 54% (median, 43% [IQR, 34%-51%]). Mitral regurgitation was present in 19 (90%), left atrial dilation in 15 (71%), and pulmonary hypertension in 18 (86%). ECG was abnormal in 19 (90%). Median troponin I was 0.18 (IQR, 0.12-0.56) ng/mL. Median BNP (B-type natriuretic peptide) was 2100 (IQR, 924-2325) pg/mL. Seventeen had documented coronary thrombosis by cardiac catheterization. Seventeen (81%) were treated with intracoronary tPA (tissue-type plasminogen activator) followed by systemic heparin, AT (antithrombin), and intravenous nitroglycerin, and 4 (19%) were treated with systemic heparin, AT, and intravenous nitroglycerin alone. Nineteen of 21 recovered. One died (also had infradiaphragmatic total anomalous pulmonary venous return). One patient required a ventricular assist device and later underwent heart transplant; this patient was diagnosed late at 5 weeks of age and did not respond to tPA. Nineteen of 21 (90%) regained normal left ventricular function (ejection fraction, 60%-74%; mean, 65% [IQR, 61%-67%]) at latest follow-up (median, 6.8 [IQR, 3.58-14.72] months). Two of 21 (10%) had residual trivial mitral regurgitation. After analysis of these results, we present our current algorithm, which developed and matured over time, to manage neonatal myocardial infarction. CONCLUSIONS We experienced a lower mortality rate for infants with neonatal infarction than that reported in the literature. We propose a post hoc algorithm that may lead to improvement in patient outcomes following coronary artery thrombus.
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Affiliation(s)
- Hannah El-Sabrout
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Srujan Ganta
- Division of Pediatric Cardiac Surgery (S.G., J.N.), Rady Children's Hospital/University of California, San Diego
| | - Peter Guyon
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Gabrielle Vaughn
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - James Perry
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Amy Kimball
- Division of Neonatology (A.K.), Rady Children's Hospital/University of California, San Diego
| | - Justin Ryan
- 3D Innovation Lab (J.R.), Rady Children's Hospital/University of California, San Diego
| | - Courtney D Thornburg
- Division of Hematology (C.D.T.), Rady Children's Hospital/University of California, San Diego
| | - Suzanne Tucker
- Division of Pathology (S.T., J.M.), Rady Children's Hospital/University of California, San Diego
| | - Jun Mo
- Division of Pathology (S.T., J.M.), Rady Children's Hospital/University of California, San Diego
| | - Sanjeet Hegde
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - John Nigro
- Division of Pediatric Cardiac Surgery (S.G., J.N.), Rady Children's Hospital/University of California, San Diego
| | - Howaida El-Said
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
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Anderson S. Congenital Nephrotic Syndrome of the Finnish Type in a Dominican Newborn: An Overview and Case Report. Neonatal Netw 2022; 41:83-88. [PMID: 35260424 DOI: 10.1891/11-t-745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
Congenital nephrotic syndrome of the Finnish type (CNS-FT) is a rare genetic condition that causes massive proteinuria, hypoproteinemia, hypercholesterolemia, and edema that progresses to end-stage renal disease. Symptoms may manifest in utero as fetal hydrops or during the first few days to months of life. This article shares the case of a Dominican infant who presented with CNS-FT. It provides a comprehensive overview of CNS-FT including the underlying genetic cause, prenatal and postnatal diagnostic testing options, and treatment recommendations. It walks the reader through the diagnostic and initial and longer-term management of this infant and provides patient outcome at 10 months of age.
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Ting J, Yeung K, Paes B, Chan AKC, Petropoulos JA, Banfield L, Bhatt MD. How to use low-molecular-weight heparin to treat neonatal thrombosis in clinical practice. Blood Coagul Fibrinolysis 2021; 32:531-538. [PMID: 34102656 DOI: 10.1097/mbc.0000000000001052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Among children, neonates have the highest incidence of thrombosis due to risk factors such as catheter instrumentation, an evolving coagulation system and congenital heart disease. Low-molecular-weight heparins (LMWHs) are the most commonly used anticoagulants in neonates. Published guidelines delineate dosing and monitoring protocols for LMWH therapy in newborns. However, challenging clinical situations frequently present that warrant healthcare providers to think critically beyond the range of guidelines, and judiciously resolve specific problems. This review describes the use of LMWH in the neonatal population, including practical aspects such as route and site of administration, preparation from concentrated formulations and methods to minimize pain of subcutaneous injection. It is followed by a discussion on dosing, monitoring and outcomes of LMWH therapy in neonates. The risk of recurrence of thrombosis in neonates after LMWH therapy is approximately 3% based on a pooled analysis of studies reporting this outcome over the last 24 years. The article concludes with an overview of the side-effects of LMWH, including the risk of bleeding which is around 4% based on pooled analyses of more than 30 studies.
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Affiliation(s)
- James Ting
- National University of Ireland, Galway, Ireland
| | - Klement Yeung
- Internal Medicine Residency Program, McMaster University
| | - Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University
| | - Anthony K C Chan
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University
| | | | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Mihir D Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University
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Doshi BS, Ellison AM. Diagnosis and Management of Pediatric Venous Thromboembolism: New Therapies on the Horizon. Pediatr Emerg Care 2021; 37:273-279. [PMID: 33903287 DOI: 10.1097/pec.0000000000002431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The incidence of venous thromboembolism (VTE) is increasing in pediatric patients. Prompt recognition and evaluation of VTE in young patients could prevent significant morbidity or mortality. In contrast to VTE in adults, current treatment guidelines are largely based on expert opinion as limited randomized controlled trial data exist about the appropriate management in pediatric patients with traditional anticoagulants. However, recently approved direct-acting oral anticoagulants in adults are also being investigated in pediatric VTE and these data could inform future evidence-based treatment principles. Thus, healthcare providers must be well informed about the management of pediatric VTE and the data from these trials to date. This continuing medical education article will provide a summary of management of pediatric VTE with particular emphasis on emerging direct-acting oral anticoagulants.
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Effectiveness and Safety of Nadroparin Therapy in Preterm and Term Neonates with Venous Thromboembolism. J Clin Med 2021; 10:jcm10071483. [PMID: 33918440 PMCID: PMC8038284 DOI: 10.3390/jcm10071483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Optimal neonatal nadroparin dosages to treat venous thromboembolism (VTE) are unknown. OBJECTIVE To evaluate therapeutic nadroparin dosages to reach therapeutic target ranges (TTR: 0.5-1.0 International Unit (IU)/mL) and the effectiveness and safety of nadroparin in neonatal VTE. METHODS Retrospective study including neonates with VTE on nadroparin in a tertiary center between 2007 and 2018. Two groups were distinguished: neonates before (group 1) and after (group 2) switch to higher starting dosages in 2014. RESULTS Sixty-one neonates (44 preterm, 17 term) with 64 VTEs were included. TTR was reached in 32/64 (50%) VTEs (group 1: 35.7%; group 2: 61.1%). Median nadroparin dosage to reach TTR was 197 (97.9-330.3) IU/kg/12 h. No therapy-related deaths occurred. Recurrent VTE developed in 6 (9.8%) neonates. Complete clot resolution was observed in 31/41 (75.6%) VTEs. TTR was reached in 58.1% VTEs with complete clot resolution. No major bleeding occurred. Non-major clinically relevant bleedings occurred in 3/64 (4.7%) VTEs, consisting of large hematomas due to the use of subcutaneous catheters. CONCLUSIONS High nadroparin dosages are needed to reach TTR in neonates, which seem to be safe. Clot resolution may occur without reaching TTR. Subcutaneous catheters may cause important bleeding complications.
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Dobbie LJ, Lamb A, Eskell L, Ramage IJ, Reynolds BC. Thromboprophylaxis in congenital nephrotic syndrome: 15-year experience from a national cohort. Pediatr Nephrol 2021; 36:1183-1194. [PMID: 33089377 PMCID: PMC8009789 DOI: 10.1007/s00467-020-04793-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/02/2020] [Accepted: 09/19/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Congenital nephrotic syndrome (CNS) is an ultra-rare disease associated with a pro-thrombotic state and venous thromboembolisms (VTE). There is very limited evidence evaluating thromboprophylaxis in patients with CNS. This study aimed to determine the doses and duration of treatment required to achieve adequate thromboprophylaxis in patients with CNS. METHODS From 2005 to 2018 children in Scotland with a confirmed genetic or histological diagnosis of CNS were included if commenced on thromboprophylaxis. The primary study endpoint was stable drug monitoring. Secondary outcomes included VTE or significant haemorrhage. RESULTS Eight patients were included; all initially were commenced on low-molecular weight heparin (enoxaparin). Four patients maintained therapeutic anti-Factor Xa levels (time 3-26 weeks, dose 3.2-5.07 mg/kg/day), and one patient developed a thrombosis (Anti-Factor Xa: 0.27 IU/ml). Four patients were subsequently treated with warfarin. Two patients maintained therapeutic INRs (time 6-11 weeks, dose 0.22-0.25 mg/kg/day), and one patient had two bleeding events (Bleed 1: INR 6, Bleed 2: INR 5.5). CONCLUSIONS Achieving thromboprophylaxis in CNS is challenging. Similar numbers of patients achieved stable anticoagulation on warfarin and enoxaparin. Enoxaparin dosing was nearly double the recommended starting doses for secondary thromboprophylaxis. Bleeding events were all associated with supra-therapeutic anticoagulation.
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Affiliation(s)
| | - Angela Lamb
- grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Lucy Eskell
- grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Ian J. Ramage
- grid.8756.c0000 0001 2193 314XUniversity of Glasgow, Glasgow, UK ,grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Ben C. Reynolds
- grid.8756.c0000 0001 2193 314XUniversity of Glasgow, Glasgow, UK ,grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
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Challenges and Opportunities in the Pharmacological Treatment of Acute Venous Thromboembolism in Children. Paediatr Drugs 2020; 22:385-397. [PMID: 32519267 DOI: 10.1007/s40272-020-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is an important but historically under-recognized problem in pediatrics, with an incidence concentrated in hospitalized children. A number of specific VTE diseases with discrete triggers have been described, but the most common pediatric trigger is the presence of central venous access devices. VTE diseases, though heterogenous in etiology, are linked by the common therapeutic strategies shared by their management. Historically, the most commonly used drug therapies have been unfractionated heparin, low-molecular-weight heparins, and vitamin K antagonists, based on extrapolation from adult data rather than any specific pediatric trials. Although these widely used drugs appear safe and effective in expert hands, the historical lack of pediatric data is problematic in view of the recognized significant differences between children and adults with regards to hemostatic physiology, VTE etiology, and drug pharmacokinetics. The increasing adult usage of novel VTE pharmacotherapies such as direct oral anticoagulants (DOACs) has led to considerable interest in exploring the pediatric applications of these newer drugs. This review summarizes the advantages and disadvantages of existing VTE pharmacotherapies and outlines emerging novel pediatric VTE therapies, particularly DOACs, within the context of the current pediatric trial landscape.
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10
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Bhat R, Monagle P. Anticoagulation in preterm and term neonates: Why are they special? Thromb Res 2020; 187:113-121. [DOI: 10.1016/j.thromres.2019.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 01/19/2023]
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Chan JI, Noor A, Clauss C, Aggarwal R, Nayak A. Methicillin-Resistant Staphylococcus aureus Endovascular Infection in a Neonate: Prolonged, Safe, and Effective Use of Daptomycin and Enoxaparin. J Pediatr Pharmacol Ther 2020; 25:68-74. [DOI: 10.5863/1551-6776-25.1.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report on a former 28-week gestation neonate with persistent methicillin-resistant Staphylococcus aureus (MRSA) endocarditis, with a heterozygous Factor V Leiden mutation. The neonate became clinically ill after 1 week of life, with positive blood cultures for MRSA. Echocardiography revealed large thrombi in the inferior vena cava and right atrium. Bacteremia persisted despite removal of umbilical arterial and venous catheters and empiric administration of therapeutic doses of vancomycin (minimum inhibitory concentration [MIC] 2 mg/L) and ceftazidime. To narrow therapy, ceftazidime was discontinued, while gentamicin and rifampin were added. Cultures remained positive and, therefore, linezolid was added, and subsequent blood cultures became negative. Since prolonged linezolid use of 2 weeks or longer carries potential adverse effects, antibiotics were changed to daptomycin, which is bactericidal and recommended for treatment of invasive MRSA infections when vancomycin MICs are ≥2 mg/L to minimize vancomycin treatment failure.
Enoxaparin was initiated, with anti-Xa assay monitoring. A workup for thrombophilia revealed heterozygous Factor V Leiden mutation. Serial echocardiograms demonstrated decreasing size of the thrombi, which were no longer visualized at 2 months of age. Creatinine kinase remained normal. The infant had no seizures on daptomycin. The management of persistent MRSA bacteremia in neonates associated with a large thrombus poses a unique challenge due to the long duration of treatment.
To our knowledge, this is the first case of prolonged and safe daptomycin and enoxaparin use in a preterm neonate. Daptomycin may be considered in cases of clinical failure with vancomycin when a lengthy treatment course is contemplated.
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Reynolds BC, Oswald RJA. Diagnostic and Management Challenges in Congenital Nephrotic Syndrome. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2019; 10:157-167. [PMID: 31908565 PMCID: PMC6930517 DOI: 10.2147/phmt.s193684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022]
Abstract
Congenital Nephrotic Syndrome (CNS) is defined as nephrotic range proteinuria, hypoalbuminaemia and edema in the first three months of life. CNS is most commonly genetic in cause, with international variance in the incidence of causative mutations. Initially defined by the histopathological appearance, increasingly sophisticated and accessible genetic analyses now provide a body of evidence to suggest that there is a disparity between the histological appearance, the genotype of individuals and the severity of the clinical disease. Through the evolution of management approaches CNS has changed from being an invariably fatal condition to one with appreciable ongoing morbidity and mortality but comparably good outcomes to other causes of paediatric end-stage renal disease, especially following transplantation. This review briefly summarises the more commonly recognised genetic mutations leading to CNS, addresses common management decisions, and concludes with potential therapies for the future.
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Bhatt MD, Patel V, Butt ML, Chan AKC, Paes B. Outcomes following neonatal portal vein thrombosis: A descriptive, single-center study and review of anticoagulant therapy. Pediatr Blood Cancer 2019; 66:e27572. [PMID: 30520242 DOI: 10.1002/pbc.27572] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Neonatal portal vein thrombosis (PVT) is uncommon with potentially serious complications that may manifest in infancy and childhood. OBJECTIVE The primary aim of our study was to describe the short-term and long-term outcomes of neonatal PVT. METHODS A retrospective chart review was conducted from 2008 to 2016 of neonates diagnosed with PVT. A systematic review was also performed from 2000 to 2018 to evaluate anticoagulant therapy (ACT) in neonatal PVT. RESULTS Forty-four premature and 30 term infants (mean gestational age 30.7 vs 39.1 weeks, respectively) had PVT. Sixty-eight involved the left portal vein, one involved only the main portal vein, and 5 involved ≥1 vein. PVT was catheter associated in 46 (62%); none of the 7 neonates tested had thrombophilia. Of 74 neonates, 19 (26%) received ACT and 55 (74%) were untreated. The mean follow-up duration was 16.6 months (SD = 17.62; range, 0-89.6); 59.5% were followed for ≥6 months. On last ultrasound examination, thrombus resolution was documented in treated (ACT; n = 19) and nontreated (n = 55) neonates: 12 (63%) versus 32 (58%) with complete resolution, 1 (5%) versus 6 (11%) partial, 0 versus 1 (2%) extension, and 6 (32%) versus 16 (29%) had nonprogressive lesions, respectively. Seventy-one (96%) had no complications. Seventy-one articles met inclusion criteria for the systematic review and 19 were retained for analysis after assessment. CONCLUSIONS PVT resolution rate was similar to previous reports. Although a low complication rate was detected, longer follow-up is necessary to determine the need for early treatment and the precise incidence of outcomes such as portal hypertension.
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Affiliation(s)
- Mihir D Bhatt
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Vishal Patel
- Life Sciences Program, Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Michelle L Butt
- School of Nursing, and Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Anthony K C Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Klaassen IL, Sol JJ, Suijker MH, Fijnvandraat K, van de Wetering MD, Heleen van Ommen C. Are low-molecular-weight heparins safe and effective in children? A systematic review. Blood Rev 2019; 33:33-42. [DOI: 10.1016/j.blre.2018.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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Monagle P, Newall F. Management of thrombosis in children and neonates: practical use of anticoagulants in children. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:399-404. [PMID: 30504338 PMCID: PMC6245972 DOI: 10.1182/asheducation-2018.1.399] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Venous thrombosis (VTE) in children and neonates presents numerous management challenges. Although increasing in frequency, VTE in children and neonates is still uncommon compared with adults. The epidemiology of VTE is vastly different in neonates vs children vs adolescents vs adults. In reality, pediatric thrombosis should be viewed as a multitude of rare diseases (eg, renal vein thrombosis, spontaneous thrombosis, catheter-related thrombosis, cerebral sinovenous thrombosis), all requiring different approaches to diagnosis and with different short- and long-term consequences, but linked by the use of common therapeutic agents. Further, children have fundamentally different physiology in terms of blood flow, developmental hemostasis, and, likely, endothelial function. The American Society of Hematology 2017 Guidelines for Management of Venous Thromboembolism: Treatment of Pediatric VTE provides up-to-date evidence-based guidelines related to treatment. Therefore, this article will focus on the practical use of therapeutic agents in the management of pediatric VTE, especially unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists, as the most common anticoagulants used in children. Direct oral anticoagulants (DOACs) remain in clinical trials in children and should not be used outside of formal trials for the foreseeable future.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children’s Hospital, Haematology Research Murdoch Children’s Research Institute, Department of Paediatrics, University of Melbourne, and
| | - Fiona Newall
- Department of Clinical Haematology, Royal Children’s Hospital, Haematology Research Murdoch Children’s Research Institute, School of Nursing, University of Melbourne, Melbourne, VIC, Australia
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Aluloska N, Janchevska S, Tasic V. Non Catether Induced Renal and Inferior Vena Cava Trombosis in a Neonate: A Case Report. Open Access Maced J Med Sci 2018; 6:1678-1681. [PMID: 30337987 PMCID: PMC6182507 DOI: 10.3889/oamjms.2018.306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/23/2018] [Accepted: 07/27/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Neonatal renal vein thrombosis is the most common vascular condition in the newborn kidney, which could lead to serious complication in infants. CASE REPORT: We report a case of the unilateral renal vein and inferior vena cava thrombosis, presented with gross hematuria and thrombocytopenia in a neonate. The neonate was a macrosomic male born to a mother with hyperglycemia in pregnancy. The baby was born with perinatal asphyxia and early neonatal infection and massive hematuria. Clinical and laboratory examination showed enlarged kidney having corticomedullary differentiation diminished and azotemia. Diagnosis of renal vein thrombosis was suspected by renal ultrasound and confirmed by magnetic urography. Prothrombotic risk factors were evaluated. The child is being managed conservatively. Measures aimed at the prevention of end-stage renal disease because of its poor outcome were highlighted. Despite anticoagulant therapy, the right kidney developed areas of scarring and then atrophy. CONCLUSION: In this work, we present a patient with multiple entities in the aetiology of non-catheter induced renal and vena cava thrombosis in a neonate. Clinicians should suspect renal vein thrombosis in neonates when presented with early postnatal gross hematuria, palpable abdominal mass and thrombopenia.
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Affiliation(s)
- Natasha Aluloska
- Neonatology Department, University Children Hospital, Skopje, Republic of Macedonia
| | - Snezana Janchevska
- NICU, University Clinic for Gynecology and Obstetrics, Skopje, Republic of Macedonia
| | - Velibor Tasic
- Nephrology Department, University Children Hospital, Skopje, Republic of Macedonia
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17
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Sol JJ, van de Loo M, Boerma M, Bergman KA, Donker AE, van der Hoeven MAHBM, Hulzebos CV, Knol R, Djien Liem K, van Lingen RA, Lopriore E, Suijker MH, Vijlbrief DC, Visser R, Veening MA, van Weissenbruch MM, van Ommen CH. NEOnatal Central-venous Line Observational study on Thrombosis (NEOCLOT): evaluation of a national guideline on management of neonatal catheter-related thrombosis. BMC Pediatr 2018; 18:84. [PMID: 29475450 PMCID: PMC5824541 DOI: 10.1186/s12887-018-1000-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/21/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In critically ill (preterm) neonates, central venous catheters (CVCs) are increasingly used for administration of medication or parenteral nutrition. A serious complication, however, is the development of catheter-related thrombosis (CVC-thrombosis), which may resolve by itself or cause severe complications. Due to lack of evidence, management of neonatal CVC-thrombosis varies among neonatal intensive care units (NICUs). In the Netherlands an expert-based national management guideline has been developed which is implemented in all 10 NICUs in 2014. METHODS The NEOCLOT study is a multicentre prospective observational cohort study, including 150 preterm and term infants (0-6 months) admitted to one of the 10 NICUs, developing CVC-thrombosis. Patient characteristics, thrombosis characteristics, risk factors, treatment strategies and outcome measures will be collected in a web-based database. Management of CVC-thrombosis will be performed as recommended in the protocol. Violations of the protocol will be noted. Primary outcome measures are a composite efficacy outcome consisting of death due to CVC-thrombosis and recurrent thrombosis, and a safety outcome consisting of the incidence of major bleedings during therapy. Secondary outcomes include individual components of primary efficacy outcome, clinically relevant non-major and minor bleedings and the frequency of risk factors, protocol variations, residual thrombosis and post thrombotic syndrome. DISCUSSION The NEOCLOT study will evaluate the efficacy and safety of the new, national, neonatal CVC-thrombosis guideline. Furthermore, risk factors as well as long-term consequences of CVC-thrombosis will be analysed. TRIAL REGISTRATION Trial registration: Nederlands Trial Register NTR4336 . Registered 24 December 2013.
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Affiliation(s)
- Jeanine J Sol
- Department of Pediatrics, Groene Hart Hospital, Gouda, the Netherlands.,Neonatal Intensive Care Unit, Sophia Children's Hospital Erasmus MC, Rotterdam, the Netherlands
| | - Moniek van de Loo
- Neonatal Intensive Care Unit, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - Marit Boerma
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Postbus 2060, 3015 CN, Rotterdam, the Netherlands
| | - Klasien A Bergman
- Neonatal Intensive Care Unit, Beatrix Children's Hospital UMCG, Groningen, the Netherlands
| | - Albertine E Donker
- Department of Pediatric Hematology, Maxima Medisch Centrum, Veldhoven, the Netherlands
| | | | - Christiaan V Hulzebos
- Neonatal Intensive Care Unit, Neonatal Intensive Care Unit, Beatrix Children's Hospital UMCG, Groningen, the Netherlands
| | - Ronny Knol
- Neonatal Intensive Care Unit, Sophia Children's Hospital Erasmus MC, Rotterdam, the Netherlands
| | - K Djien Liem
- Neonatal Intensive Care Unit, Amalia Children's Hospital Radboud UMC, Nijmegen, the Netherlands
| | | | - Enrico Lopriore
- Neonatal Intensive Care Unit, Willem-Alexander Hospital LUMC, Leiden, the Netherlands
| | - Monique H Suijker
- Department of Pediatric Hematology, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - Daniel C Vijlbrief
- Neonatal Intensive Care Unit, Wilhelmina Children's Hospital UMCU, Utrecht, the Netherlands
| | - Remco Visser
- Neonatal Intensive Care Unit, Willem-Alexander Hospital LUMC, Leiden, the Netherlands
| | | | | | - C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Postbus 2060, 3015 CN, Rotterdam, the Netherlands.
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18
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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19
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Musgrave KM, Webber K, Murphy P, Avery P, Biss TT. Evaluation of the age-dependent dosing recommendations for the administration of daily tinzaparin in children with thrombosis. J Thromb Haemost 2017; 15:2361-2366. [PMID: 28976613 DOI: 10.1111/jth.13856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Indexed: 11/26/2022]
Abstract
Essentials The once-daily dosing of tinzaparin provides an advantage over other low molecular weight heparins. The recommended age-dependent doses of tinzaparin in children have not previously been validated. Once-daily administration of tinzaparin is a safe and effective treatment of childhood thrombosis. Recommended doses are appropriate but monitoring may be required due to inter-individual variation. SUMMARY Background The recommended starting doses of tinzaparin for the treatment of thrombosis in children have not previously been validated. There are few data to support the efficacy and safety of once-daily tinzaparin dosing in children with thrombosis. Objectives To investigate the use of tinzaparin for the treatment of childhood thrombosis, and to evaluate the age-dependent dosing recommendations and define outcomes in terms of efficacy and safety. Methods This was a retrospective cohort study of children aged 0 to < 16 years treated for thrombosis at a large teaching hospital in the UK between 2008 and 2015. Medical records were reviewed to evaluate tinzaparin dosing, anti-activated factor X (FXa) levels, and patient outcomes. Results Seventy-nine children were identified as having received tinzaparin. Dosing information was available for 57. Younger children required higher doses to reach a therapeutic level. The therapeutic dose requirement varied within age groups, supporting the use of anti-FXa monitoring. Over a median follow-up of 35 months, there were 13 (16%) bleeding episodes (two major; seven clinically relevant but non-major; and four minor). There were two (3%) recurrent episodes of thrombosis. Children were treated for a median duration of 3 months, and the majority (86%) remained on tinzaparin for the duration of their anticoagulant therapy. Conclusion Once-daily tinzaparin is a safe and effective treatment for childhood thrombosis, with rates of recurrence and bleeding similar to those for other anticoagulants used in children. The recommended starting doses are appropriate, but anti-FXa monitoring may be required, owing to interindividual variability in the therapeutic dose requirement.
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Affiliation(s)
- K M Musgrave
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - K Webber
- Newcastle University Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - P Murphy
- Blood Sciences Laboratory, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - P Avery
- School of Mathematics and Statistics, Newcastle University, Newcastle upon Tyne, UK
| | - T T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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20
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Bichell D, Raees MA. An umbrella arrives toward the end of the storm: Patient-tailored aspirin dosing improves late perioperative thromboprophylaxis. J Thorac Cardiovasc Surg 2017; 154:1731-1732. [PMID: 28863955 DOI: 10.1016/j.jtcvs.2017.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/14/2017] [Indexed: 11/28/2022]
Affiliation(s)
- David Bichell
- Department of Cardiac Surgery, Monroe Carell, Jr, Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn.
| | - Muhammad A Raees
- Department of Cardiac Surgery, Monroe Carell, Jr, Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn
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21
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Papneja K, Chan AK, Mondal TK, Paes B. Myocardial Infarction in Neonates: A Review of an Entity with Significant Morbidity and Mortality. Pediatr Cardiol 2017; 38:427-441. [PMID: 28238152 DOI: 10.1007/s00246-016-1556-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/23/2016] [Indexed: 01/24/2023]
Abstract
Coronary artery disease is a global problem with high mortality rates and significant residual sequelae that affect long-term quality of life. Myocardial infarction (MI) in neonates is a recognized, uncommon entity, but the incidence and broad spectrum of the disease is unknown and likely underestimated due to limited reporting which in the majority is confined to acute ischemic events. The challenges involve clinical diagnosis which masquerades in the early phase as non-specific symptoms and signs that are commonly found in a host of neonatal disorders. Precise diagnostic criteria for neonatal MI are lacking, and management is driven by clinical presentation and hemodynamic stabilization rather than an attempt to rapidly establish the root cause of the condition. We conducted a review of the published reports of neonatal MI from 2000 to 2014, to establish an approach to the diagnosis and management based on the existing evidence. The overall evidence from 32 scientific articles stemmed from case reports and case series which were graded as low-to-very low quality. Neonatal MI resembles childhood and adult MI with features that involve characteristic ECG changes, raised biomarkers, and diagnostic imaging, but with lack of robust, standardized criteria to facilitate prompt diagnosis and timely intervention. The mortality rate of neonatal MI ranges from 40 to 50% based on inclusion criteria, but the short-term data reflect normal quality of life in survivors. An algorithm for the diagnosis and management of neonatal MI may optimize outcomes, but at the present time is based on limited evidence. Well-designed clinical studies focusing on the definition, diagnosis, and management of neonatal MI, backed by international consensus guidelines, are needed to alter the prognosis of this serious condition.
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Affiliation(s)
- Koyelle Papneja
- Division of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Anthony K Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Tapas K Mondal
- Division of Cardiology, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Bosco Paes
- Division of Neonatology, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada. .,Department of Pediatrics, McMaster University, Room HSC-3A, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
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22
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Moffett BS, Dinh K, Placencia J, Pelkey G, Hui SKR, Teruya J. Stability and Sterility of Enoxaparin 8 mg/mL Subcutaneous Injectable Solution. J Pediatr Pharmacol Ther 2016; 21:322-326. [PMID: 27713671 DOI: 10.5863/1551-6776-21.4.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND: Enoxaparin is often diluted to accurately deliver doses to neonatal and infant patients. Current recommendations for dilutions may not be adequate for the smallest patients. METHODS: Review of dosing at our institution occurred, and an 8 mg/mL concentration of enoxaparin was chosen. A concentration of 8 mg/mL was compounded by diluting 0.4 mL of enoxaparin (100 mg/mL) into 4.6 mL of sterile water for injection into an empty sterile vial. Four syringes of the 8 mg/mL concentration were prepared by 5 technicians (20 total syringes). Stability and sterility testing occurred a 0, 7, 14, and 30 days. One-way repeated-measures analysis of variance was used to detect significant differences in Anti-Factor Xa concentrations at the testing time points. RESULTS: The dilution of enoxaparin was sterile at 30 days but exhibited significant degradation at the 30-day point (p < 0.05). CONCLUSION: A dilution of enoxaparin 8 mg/mL is stable and sterile for 14 days refrigerated but is not stable at 30 days.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | - Kimberly Dinh
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | | | - Gregory Pelkey
- Department of Laboratory, Texas Children's Hospital, Houston, Texas
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Pediatrics, Baylor College of Medicine, Houston, Texas
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23
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The non-immunosuppressive management of childhood nephrotic syndrome. Pediatr Nephrol 2016; 31:1383-402. [PMID: 26556028 PMCID: PMC4943972 DOI: 10.1007/s00467-015-3241-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/21/2015] [Accepted: 09/30/2015] [Indexed: 12/20/2022]
Abstract
Idiopathic nephrotic syndrome (INS) is one of the most common renal diseases found in the paediatric population and is associated with significant complications, including infection and thrombosis. A high proportion of children enter sustained remission before adulthood, and therapy must therefore mitigate the childhood complications, while minimising the long-term risk to health. Here we address the main complications of INS and summarise the available evidence and guidance to aid the clinician in determining the appropriate treatment for children with INS under their care. Additionally, we highlight areas where no consensus regarding appropriate management has been reached. In this review, we detail the reasons why routine prophylactic antimicrobial and antithrombotic therapy are not warranted in INS and emphasise the conservative management of oedema. When pharmacological intervention is required for the treatment of oedema, we provide guidance to aid the clinician in determining the appropriate therapy. Additionally, we discuss obesity and growth, fracture risk, dyslipidaemia and thyroid dysfunction associated with INS. Where appropriate, we describe how recent developments in research have identified potential novel therapeutic targets.
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Feasibility and safety of enoxaparin whole milligram dosing in premature and term neonates. J Perinatol 2015; 35:852-4. [PMID: 26181722 DOI: 10.1038/jp.2015.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 05/26/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The objective of our study was to determine the feasibility and safety of enoxaparin whole milligram dosing in premature and term neonates, and to assess response to treatment. STUDY DESIGN Retrospective study of neonates with thrombosis treated between January 2008 and December 2014. RESULT Nineteen premature and 21 term neonates were treated with whole milligram doses of enoxaparin. The mean starting and therapeutic enoxaparin doses were 1.72±0.17 and 1.86±0.17 mg kg(-1), respectively. Twenty-five (64%) reached therapeutic antifactor Xa (anti-Xa) levels with the starting dose, whereas 14 (36%) required dose adjustments. One neonate reached a supratherapeutic anti-Xa level (>1.0 IU ml(-1)) in the loading phase. No bleeding episodes occurred. The mean treatment duration was 12 weeks. Among 34 (85%) evaluable patients, 23 (68%) had a complete response, 9 (26%) partial and 2 (6%) had a stable thrombotic state. CONCLUSION Whole milligram dosing of enoxaparin for thrombosis is feasible, safe and effective in premature and term neonates.
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New developments in pediatric venous thromboembolism and anticoagulation, including the target-specific oral anticoagulants. Curr Opin Pediatr 2015; 27:18-25. [PMID: 25564186 DOI: 10.1097/mop.0000000000000173] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Pediatric venous thromboembolism (VTE) can affect children of all ages, requiring considerable pharmacologic intervention and is often associated with significant morbidity. Current research efforts are directed toward the development of risk-stratified VTE prevention strategies employing pharmacologic thromboprophylaxis, the optimization of conventional anticoagulation, and the investigation of the safety and efficacy of target-specific oral anticoagulants (TSOACs) in children. RECENT FINDINGS Recent research has considerably improved the understanding of risk factors of hospital-acquired VTE and how these factors may be employed in risk-stratified paradigms for VTE prevention in children. Additional insight has been gained in the optimization of conventional anticoagulants in special populations such as neonates and children with inflammatory conditions, and in improving the overall safety and compliance with periprocedural anticoagulation and the use of home International Normalized Ratio monitoring. Furthermore, the use of TSOACs has been described in children and is the focus of numerous ongoing clinical trials that are evaluating the safety and efficacy of these agents in children with VTE. SUMMARY Identification of hospital-acquired VTE risk factors may inform pediatric VTE prevention strategies. Although initial use of TSOACs may be promising, investigation of safety and efficacy in children is still underway.
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