What Are the Indications for Anticoagulant Medication?

Patient Presentation
A 5-year-old male, previously-well, child was seen on the inpatient service for a coagulase-negative Staphylococcal empyema. He was receiving intravenous antibiotics and had had a chest tube for 4 days. On day 5 he was doing well clinically with decreased oxygen needs and his temperature was almost back to normal. However, his white blood cell count increased to 15.4 x 1000/mm² and his platelet count increased to more than 1.052 million x 1000/mm². As this was most likely a transient thrombocytosis, the team decided to monitor the patient. The following day his platelets were 898 x 1000/mm² and his white count was 13.2 x 1000/mm². He received a total of 10 days of intranvenous antibiotics and repeated complete blood counts were normal at discharge.

Discussion
While more research is being conducted on anticoagulation therapy for children, much is still gleaned from adult research and pediatric-specific research is needed. The usual adult indications for such treatment such as myocardial infarction and stroke are uncommon in the pediatric population, while other indications such as Kawasaki disease are unknown in the adult population. Fortunately for children, thromboembolic events are much less common overall.

Transient thrombocytosis is often seen in myelodysplastic conditions such as leukemia and usually does not cause thromboembolic events. Treatment of the underlying disease process such as leukemia or infection in the patient above normally resolves the thrombocytosis. Choice of medication depends on the underlying condition and age. Aspirin (for antiplatelet activity) for example is commonly used for Kawasaki disease but coumadin (for its Vitamin K antagonist effects) and its derivatives are not used much in children. Injectable heparin derivatives such as enoxaparin are sometimes used in children. Other antiplatelet medications such as dipyridamole or clopidogrel are usually not used in children.

Learning Point
Indications for anticoagulant therapy are not absolute but treatment is usually indicated for:

• Thromboembolic events, i.e. stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, etc.
• Mechanical prosthetic heart valves
• Endovascular stents
• Arrhythmias such as atrial fibrillation
• Known disease processes with increased risk for thromboembolic events such as Kawasaki disease and nephrotic syndrome

Other potential indications include:

• Central venous access devices
• Congenital heart disease procedures such as a Fontan procedure
• Myeloproliferative disorders

Antithrombotic treatment is usually not indicated for transient thrombocytosis as noted above unless an actual thromboembolic event occurs, then treatment would be deteremined by the specific patient circumstances.

Questions for Further Discussion
1. Name 2 or more other common pediatric conditions with increased risk of thrombembolic events.
2. Is anticoagulant therapy recommended for premature infants with intraventricular hemorrhage?

Related Cases

Disease: Platelet Disorders

Symptom/Presentation: Abnormal Laboratory Test

Specialty: Hematology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Platelet Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Bonduel MM. Oral anticoagulation therapy in children. Thromb Res. 2006;118(1):85-94.

Landolfi R, Di Gennaro L, Novarese L, Patrono C. Aspirin for the control of platelet activation and prevention of thrombosis in essential thrombocythemia and polycythemia vera: current insights and rationale for future studies. Semin Thromb Hemost. 2006 Apr;32(3):251-9.

Flynn RW, MacDonald TM, Murray GD, Doney AS. Systematic review of observational research studying the long-term use of antithrombotic medicines following intracerebral hemorrhage. Cardiovasc Ther. 2010 Jun;28(3):177-84.

ACGME Competencies Highlighted by Case