In 2009, a large multicenter study demonstrated that the rate of pediatric venous thromboembolism (VTE) across US children's hospitals had significantly increased from 2001 to 2007. The objective of ...this study was to evaluate the rate of pediatric VTE from 2008 to 2019 using similar methodology.
A retrospective cohort study using the Pediatric Health Information System (PHIS) database. Subjects from birth to <18 years admitted from 2008 through 2019 who had an ICD-9-CM or ICD-10-CM code for VTE were included. Demographics, underling medical comorbidities and mortality were collected. VTE location and anticoagulation data during admission were extracted.
During the 12-year study period, there were 52 401 hospital admissions among 39 713 pediatric patients with a diagnosis of VTE. The VTE admission rate increased from 46 VTE cases per 10 000 admissions in 2008 to 106 VTE cases per 10 000 admissions in 2019, a 130% increase (P < .0001) in VTE events. The median age at admission was 6.1 years, and almost one-third (31.3%) of patients with VTE were in the adolescent age group (13-17 years). Most patients (78%) had an underlying chronic medical condition.
The rate of VTE in hospitalized pediatric patients continues to increase from a 70% increase reported from 2001 to 2007 to the 130% increase from 2008 to 2019. These findings support the need for more effective VTE prevention strategies. Clinical trials focused on risk stratification and VTE prevention are needed.
Frequently, pediatric hematologists need to provide guidance regarding sports participation for children with congenital coagulopathies, immune thrombocytopenia, and those receiving anticoagulation. ...Although sports participation has clear health and psychosocial benefits, it can be associated with harm secondary to bleeding from injury. Decision‐making for sports involvement should be individualized, patient centered, and well informed. This review focuses on the current data regarding the benefit as well as risks for sports participation and provides a framework for advising and supporting the student athlete who is at risk for bleeding.
Abstract
Background/objectives
Pediatric patients with chronic immune thrombocytopenia (ITP) commonly have activity limitations placed to prevent injury without data guiding clinical decision‐making. ...The objective of this study was to determine risk factors associated with injury in children with chronic ITP.
Design/methods
Retrospective single‐center cohort study from January 1, 2008 to March 31, 2019 in subjects age 5–21 years with chronic ITP (platelet count < 100,000/µL for >1 year).
Results
One‐hundred‐two subjects were included, with a mean diagnosis age of 9.3 ± 4.6 years. Mean follow‐up 3.8 ± 2.3 years; 61% (62) of subjects were female; 60% (61) participated in organized sports, mean 2 ± 1 sports/subject; 8.8% (9) received ITP therapy for sports participation. Common sports: basketball (28%) and soccer (28%). There were 31 injuries in 26 subjects, and 68% (21) occurred while at play. Most common injuries: 68% (21/31) soft tissue and 23% (7/31) head trauma. Fifteen (48%) injuries were severe enough for medical evaluation at the time of injury. Only one patient received acute ITP treatment for their injury. Injury was associated with participation in high‐risk sports (
p
< .001), male sex (
p
= .007), and participation in multiple organized sports (
p
= .008).
Conclusion
In this study of 102 pediatric subjects with chronic ITP, injury was mild and infrequent predominantly occurring while at play. The majority participated in organized sports safely. Risk of injury was associated with high‐risk sport participation (
p
< .001). Only one injury necessitated ITP treatment, suggesting that participation in most sports is likely safe in children with chronic ITP.
Factor VIII (FVIII) replacement therapy is the foundation of treatment in hemophilia A and is effective unless a patient develops an alloantibody (inhibitor) against exogenous FVIII. Inhibitor ...development is currently the most significant treatment complication seen in patients with hemophilia and is associated with considerable morbidity and a decreased quality of life. The development of an inhibitor is the result of a complex interaction between a patient’s immune system and genetic and environmental risk factors. The mainstay of treatment is the eradication of the inhibitor through immune tolerance. This review summarizes the current evidence regarding inhibitor risk factors, eradication, and hemostatic bypassing agents.
Background
Differentiating childhood immune thrombocytopenia (ITP) from other cause of thrombocytopenia remains a diagnosis of exclusion. Additionally factors that predict bleeding risk for those ...patients with ITP are currently not well understood. Previous small studies have suggested that immature platelet fraction (IPF) may differentiate ITP from other causes of thrombocytopenia and in combination with other factors may predict bleeding risk.
Methods
We performed a retrospective chart review of thrombocytopenic patients with an IPF measured between November 1, 2013 and July 1, 2015. Patients were between 2 months and 21 years of age with a platelet count <50 × 109/l. Each patient chart was reviewed for final diagnosis and bleeding symptoms. A bleeding severity score was retrospectively assigned.
Results
Two hundred seventy two patients met inclusion criteria, 97 with ITP, 11 with bone marrow failure (BMF), 126 with malignancy, and 38 with other causes of thrombocytopenia. An IPF > 5.2% differentiated ITP from BMF with 93% sensitivity and 91% specificity. Absolute immature platelet number (AIPN) was significantly lower in ITP patients with severe to life‐threatening hemorrhage than those without, despite similar platelet counts. On multivariate analysis, an IPF < 10.4% was confirmed as an independent predictor of bleeding risk at platelet counts <10 × 109/l in patients with ITP.
Conclusions
IPF measurement alone has utility in both the diagnosis of ITP and identifying patients at increased risk of hemorrhage. Further study is required to understand the pathophysiological differences of ITP patients with lower IPF/AIPN.
Abstract
Background
Iron deficiency (ID) and anemia are one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD), usually complicating the course both in ulcerative ...colitis and Crohn’s disease. Despite their high prevalence and significant impact on patients, this particular aspect is still underestimated by clinicians. Although guidelines have been recently published to address this problem, these recommendations do not address pediatric specific concerns and do not provide guidance as to how implement these guidelines in clinical practice. The aims of this quality improvement (QI) initiative were to improve the rates of detection and treatment of anemia in children with IBD.
Methods
After the creation of a multidisciplinary team of skateholders in IBD and anemia, we launched a multifaceted QI strategy that included the development of a pediatric evidence-based care pathway, utilization of an electronic medical record (EMR)-integrated dashboard to track patients, and generation of an automated provider-based monthly report. Data were collected and graphed into statistical process control charts.
Results
These key strategies resulted in improved rates of ID screening from 31.7% to 63.6%, in increased treatment rates from 38.2% to 49.9%, and in decreased prevalence of anemia from 35.8% to 29.7%, which was reflected by a greater decline in patients with quiescent disease.
Conclusions
Quality improvement strategies incorporating the creation of a pediatric evidence-based care pathway with an EMR-supported electronic dashboard were the foundation of a successful intervention in the management of ID and anemia in pediatric IBD. Our positive results demonstrate the potential of QI initiatives using automated technology to assist clinicians in their commitment to provide evidence-based IBD care and enhance patient outcomes.
To describe antithrombin concentrate use and to compare thrombotic and hemorrhagic outcomes throughout the hospital stay in pediatric subjects who received extracorporeal membrane oxygenation in a ...Pediatric Health Information System-participating children's hospital.
Retrospective, multi-center, cohort study.
Forty-three free-standing children's hospitals participating in Pediatric Health Information System.
Children older than or equal to 18 years of age who underwent extracorporeal membrane oxygenation between 2003 and 2012.
Subjects were classified as receiving antithrombin if they received at least one dose of antithrombin while on extracorporeal membrane oxygenation.
International Classification of Diseases, Ninth Revision, Clinical Modification codes codes were used to identify hemorrhagic and thrombotic complications during their hospitalization. Pediatric Health Information System data were analyzed to determine hospital-length of stay and in-hospital mortality. A total of 1,931 of 8,601 eligible subjects (21.5%) received at least one dose of antithrombin during their extracorporeal membrane oxygenation course. Antithrombin use during extracorporeal membrane oxygenation increased from 2.4% to 51.9% (p < 0.001) over the 10-year study period. Subjects who received antithrombin while on extracorporeal membrane oxygenation were younger (p = 0.02), had more chronic conditions (p < 0.001), and longer hospital stays (p < 0.001). On multivariate analysis, antithrombin use was associated with thrombotic events (odds ratio, 1.55; 95% CI, 1.36-1.77; p < 0.001), hemorrhagic events (odds ratio, 1.27; 95% CI, 1.14-1.42; p < 0.001), and longer hospital length of stays (slope coefficient, 1.05 d; 95% CI, 1.04-1.06; p < 0.001). No difference was observed in mortality (odds ratio, 0.99; 95% CI, 0.89-1.11; p = 0.90).
In this multicenter retrospective cohort study, subjects who received antithrombin during extracorporeal membrane oxygenation had a higher number of thrombotic and hemorrhagic events throughout the hospitalization and longer length of stays without an associated difference in mortality. While limitations exist with this analysis and results should be interpreted with caution, the fact remains that over half of pediatric patients on extracorporeal membrane oxygenation are currently receiving antithrombin without clear benefit, with extra cost, and potential harms, there needs to be strong consideration for a clinical trial.
Pediatric hospital acquired venous thromboembolism (HA-VTE) is an increasing problem with an estimated increase from 5.3 events per 10,000 pediatric hospital admissions in the early 1990s to a ...current estimate of 30-58 events per 10,000 pediatric hospital admissions. Pediatric HA-VTE is associated with significant morbidity and mortality. The etiology is multifactorial but central venous catheters remain the predominant risk factor. Additional HA-VTE risk factors include both acquired (recent surgery, immobility, inflammation, and critical illness) and inherited risk factors. Questions remain regarding the most effective method to assess for HA-VTE risk in hospitalized pediatric patients and what preventative strategies should be implemented. While several risk-assessment models have been published in pediatric patients, these studies have limited power due to small sample size and require prospective validation. Potential thromboprophylactic measures include mechanical and pharmacologic methods both of which have associated harms, the most significant of which is bleeding from anticoagulation. Standard anticoagulation options in pediatric patients currently include unfractionated heparin, low molecular weight heparin, or warfarin all of which pose a monitoring burden. Ongoing pediatric studies with direct oral anticoagulants could potentially revolutionize the prevention and treatment of pediatric thrombosis with the possibility of a convenient route of administration and no requirement for monitoring. Further studies assessing clinical outcomes of venous thromboembolism (VTE) prevention strategies are critical to evaluate the effectiveness and harm of prophylactic interventions in children. Despite HA-VTE prevention efforts, thrombotic events can still occur, and it is important that clinicians have a high clinical suspicion to ensure prompt diagnosis and treatment to prevent further associated harms.
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