Marisol Betensky, MD, explains flexible pediatric VTE prophylaxis

In this discussion, Marisol Betensky, MD, assistant professor at Johns Hopkins Medicine, outlines how pediatric institutions and clinicians can translate conditional American Society of Hematology/International Society on Thrombosis and Haemostasis prophylaxis into practical, patient-centered care while navigating significant evidence gaps.

Betensky emphasizes that conditional recommendations should function as flexible defaults rather than rigid rules. Because high-quality pediatric evidence remains limited, institutions are encouraged to develop subgroup-specific clinical algorithms informed by guideline “remarks,” which highlight populations at elevated risk. Examples include critically ill children with central venous lines and mechanical ventilation, or patients with leukemia receiving L-asparaginase.

Where available, validated risk assessment tools—such as intensive care unit-based scoring systems—can be embedded into electronic medical records to automate risk stratification. These institutional protocols should define local thresholds for intervention, establish triggers for specialist consultation, and incorporate shared decision-making with families. Importantly, clinicians must document any deviations from guideline-based recommendations to enable outcome tracking and support future evidence generation.

Addressing the tension between avoiding routine anticoagulant prophylaxis and preventing hospital-acquired VTE, Betensky highlights 2 key principles: the distinction between relative and absolute risk, and the need to balance thrombosis prevention with bleeding risk. While factors such as central lines significantly increase relative VTE risk, the absolute risk in children often remains low. Moreover, anticoagulation carries inherent bleeding risks, which may be heightened in the same patients most vulnerable to thrombosis.

This dual-risk consideration underpins the guideline’s conditional recommendation against universal prophylaxis, even in high-risk groups such as children with cancer, trauma, or critical illness. Unlike adults, pediatric VTE typically requires multiple concurrent risk factors, reinforcing the importance of targeted risk stratification rather than broad preventive strategies. Clinicians are encouraged to focus on identifying the highest-risk subsets and ensuring timely recognition and treatment when VTE occurs.

Finally, Betensky discusses barriers to advancing pediatric VTE research, including the rarity of the condition, which limits sample sizes and necessitates multi-institutional collaboration. Additional challenges include the heterogeneity of pediatric populations across age groups and conditions, the complexities of developmental hemostasis, and inconsistent data collection practices.

The guidelines aim to accelerate progress by identifying key research priorities, particularly the development of validated, subgroup-specific risk assessment models and the evaluation of risk-adapted prophylaxis strategies. By promoting standardized data collection and clearer documentation of clinical decisions, these guidelines may help generate more reliable cohort data, foster collaboration, and ultimately strengthen the evidence base for pediatric VTE prevention.

This video is part 1 of a 2-part series. Check back tomorrow for part 2.

No relevant disclosures.

Reference

ASH and ISTH publish new clinical practice guidelines on anticoagulant prophylaxis in pediatric patients at risk of blood clots. American Society of Hematology. April 8, 2026. Accessed April 20, 2026. https://www.eurekalert.org/news-releases/1122908?