12 New Recommendations For Anticoagulant Prophylaxis in Pediatric Patients at Risk for Venous Thromboembolism

An expert panel published 12 new evidence-based recommendations to support clinicians’ decision-making of anticoagulant prophylaxis in pediatric patients at risk for venous thromboembolism (VTE).1

The guidelines were released on April 8, 2026, in Blood Advances, from the American Society of Hematology (ASH) and the International Society on Thrombosis and Haemostasis (ISTH), and address an unmet need in this pediatric population.1

“This patient group is often among the most vulnerable and medically complex we treat, and clinicians have long lacked clear guidance on how to best care for them,” said ASH President Robert Negrin, MD, in a statement. “These guidelines mark an important step in establishing clinical consensus to improve care and outcomes for children facing serious, life-threatening conditions. The Society is pleased to have collaborated with ISTH on this urgently needed project.”2

VTE is caused by venous thrombosis, a complete or incomplete obstruction of blood vessels. This impairment of venous return is crucial for determining cardiac output and maintaining blood pressure. The most commonly reported presentations of VTE include deep vein thrombosis (DVT) and pulmonary embolism (PE).3

The condition is linked to hospitalizations, with >90% if pediatric cases triggered by underlying risk factors, most notably central venous catheters (CVCs), malignancy, and chronic illness. Due to an increased survival rate for critically ill children, increased awareness, and more sensitive diagnostic tools, the incidence has significantly increased. In children who are hospitalized, the rate has elevated to 100–1000 times, reaching ≥58 per 10,000 admissions.3,4

The use of anticoagulant prophylaxis in VTE has been more commonly examined in adults, leading to a reliance on this data despite pediatric differences in hemostasis and bleeding risks. The challenges of understanding when to use anticoagulant prophylaxis in pediatric patients include balancing thrombotic risk against bleeding, managing needle phobia with injections, and uncertainty in identifying which patients truly benefit.1,3

To examine anticoagulant prophylaxis in pediatric VTE, ASH and ISTH assembled a panel consisting of a multidisciplinary group of experts, with guidelines intended to support patients and health care professionals in decisions about anticoagulant prophylaxis for pediatric VTE prevention.1,2

For pediatric patients with solid cancer, trauma, or critically ill, the panel issued conditional recommendations suggesting no anticoagulant prophylaxis. For pediatric patients with antiphospholipid antibody syndrome, or those on long-term total parenteral nutrition, the panel issued conditional recommendations suggesting the use of anticoagulant prophylaxis. Other pediatric subgroups addressed included patients with acute lymphoblastic leukemia or lymphoma, surgical and hospitalized patients, and those with a central venous access device.1,2

Additionally, the guidelines encourage institutions to develop protocols for managing interruptions to therapy, particularly for those undergoing lumbar puncture or spinal anesthesia procedures. They also highlight the need for further research to develop VTE risk assessment models for this population and to evaluate the safety and efficacy of prophylaxis across different pediatric subgroups.2

“Prior to the development of these clinical guidelines, much of the data we referenced for VTE prevention in pediatric patients was extrapolated from adults, whose risk profiles are generally less varied and complex,” said Marisol Betensky, MD, MPH, associate professor of pediatrics in the division of hematology at Johns Hopkins University School of Medicine, pediatric hematologist in the Johns Hopkins All Children’s Cancer & Blood Disorders Institute, and co-chair of the guidelines. “These guidelines provide physicians with an evidence-based framework to make decisions about VTE prophylaxis for children.”2

References

1. Betensky M, Azzam M, Bercovitz RS, et al. ASH ISTH 2026 guidelines for Anticoagulant Prophylaxis of Pediatric Patients at Risk of Venous Thromboembolism. Blood Advances. Published online April 8, 2026. doi:https://doi.org/10.1182/bloodadvances.2025019415

2. ASH and ISTH publish new clinical practice guidelines on anticoagulant prophylaxis in pediatric patients at risk of blood clots. EurekAlert! Published April 8, 2026. Accessed April 8, 2026. https://www.eurekalert.org/news-releases/1122908

3. Li HY, Wang J, Wang T, Wang HS. Management of venous thromboembolism in pediatric patients: Quality assessment of clinical practice guidelines and variations in recommendations. Science Direct.‌ https://www.sciencedirect.com/science/article/pii/S0049384823001226

4. Obeagu EI. Pediatric thrombosis: Risk factors, diagnosis, and prevention strategies. Medicine. 2025;104(29):e43370. doi:https://doi.org/10.1097/md.0000000000043370