Slow progress. How do we shift the paradigm of thinking in pediatric thrombosis and anticoagulation?

Since Maureen Andrew began systematically describing thrombosis in children in 1994, there has been surprisingly slow process in advancing our knowledge in terms of diagnosis, prevention and treatment of thrombosis in children. There are a variety of reasons for this slow progress. Overwhelmingly the low incidence of thrombosis in children has been a major barrier. Second, the developmental, age related, changes in haemostasis mean that the physiology of haemostasis in children, and the interaction of the haemostatic system with anticoagulant drugs is constantly changing. This presents further challenges in identifying the risk benefit ratio of therapies. In addition, the failure to adequately understand the subtleties of pathogenesis of the variety of thrombotic syndromes, and the failure to know the natural history of many types of thrombosis are also significant problems. We continue to try and solve these problems by extrapolation, not just of adult based data, but of methodologies for research founded in the adult paradigm. If we are truly going to improve our understanding of thrombosis in children and improve our ability to prevent and adequately treat thrombosis in this population, then we need multiple paradigm shifts; First, in the way we think about thrombosis and anticoagulation in children. Second in the way we design and conduct research studies to provide evidence on which to base the care of children suffering from thrombosis in the future. Crown