Venous thromboembolism in pediatrics: Management of special clinical scenarios.
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INTRODUCTION: The incidence of pediatric venous thromboembolism (VTE) has increased due to increased health care complexity, improved diagnostic techniques, and greater clinical awareness. Most episodes are associated with iatrogenic risk factors, particularly the use of central venous catheters, and occur in vulnerable populations such as neonates or children with cancer, congenital heart disease, and/or short bowel syndrome. OBJECTIVE: To review special clinical scenarios of pediatric VTE and propose a practical approach to support decision-making in complex clinical settings. METHODS: Narrative review focused on clinical practice, addressing pathophysiological features, diagnosis, treatment, and follow-up, integrating recent guideline recommendations, observational case series, and clinical experience reports. RESULTS: In neonatology, developmental hemostasis, bleeding risk, and pharmacokinetics influence the indication, selection, and monitoring of anticoagulation therapy. The review discusses umbilical venous catheter-associated thrombosis, neonatal purpura fulminans, and renal and portal vein thrombosis, highlighting the criteria for anticoagulation and/or thrombolysis and the need for long-term follow-up to detect sequelae. In children with cancer, congenital heart disease, or short bowel syndrome, VTE is multifactorial and frequently catheter-related, requiring therapeutic adjustments (eg, thrombocytopenia, invasive procedures, preservation of vascular access). We summarize the current strategies for anticoagulation-including the emerging role of direct oral anticoagulants, with caution in selected subgroups-and thrombolysis. CONCLUSIONS: In special pediatric populations, VTE requires individualized and multidisciplinary management. Disease severity, residual risk, and the need to balance bleeding and thrombosis should guide decisions regarding treatment intensity/duration as well as prophylaxis, with emphasis on organ preservation, maintenance of venous capital, and prevention of long-term complications.