T E C H N I C A L B U L L E T I N 11 1 Point Of Care Anticoagulation Monitoring In Pediatric Patients
The relatively recent successes in tertiary care of critically ill
children have increased the frequency of long term secondary
The most commonly used medications in children that affect the
complications resulting in an increasing use of warfarin for both
primary and secondary prophylaxis.1, 2 Warfarin can be used
safely if administered and monitored carefully.
Monitoring oral anticoagulation therapy (OAT) in children is
Commonly Used Drugs in Children
difficult and requires close observation with frequent dose
That Affect Their INR Values
adjustments. In contrast to adults, only 10 to 20% of children can Effect of INR
be safely monitored monthly, hence require higher frequency of
Whole blood monitors use various techniques to measure the
INR (International Normalized Ratio). These devices have been
shown to be acceptable and reliable for use in the outpatient
The major advantages identified by patient families included
• Smaller sample volume compared to phlebotomy.
• Minimal interruption of school and work.
• Immediate result as compared to long waits to get results
• More frequent INR measurements lead to an increased
percentage of INR values within the target range and the use
There are many important variables that make the use of
of whole-blood monitors may assist in maintaining INR values
anticoagulant drugs in pediatric patients, different from the use
of the same drugs in adults. These variables contribute to the
• The proven reliability and accuracy of the results obtained
need for more frequency of testing and are listed as below 1:
from whole blood monitors and the short turn around time for
• The epidemiology of diseases in pediatric patients is vastly
• The parent directed or self-managed adolescent patients tend
• The response to anticoagulant drugs may be different in
to test themselves more frequently than patients who only use
an anticoagulant clinic, which can improve clinical outcome.
• The distribution, binding and clearance of anticoagulant
• Many families prefer the portable monitor because they are
emotionally less traumatic for their child, eliminating
• The frequency and type of inter-current illnesses and
laboratory waiting room anticipation for toddlers.
• Other advantages include minimal interruption of work and
• There are no pediatric specific formulations of anticoagulant
drugs, making accurate, reproducible, weight adjusted
dosing difficult, thus impacting the ability to monitor.
References: 1. Mongale P, Chan A, Massicotte P, Chlamers E, and Michelson D. Chest
• Dietary differences make the use of oral anticoagulant drugs
particularly difficult, especially in infants because infant
2. W. Streif, M. Andrew, V, Marzinotto, P. Massicotte, A.K.C. Chan, J.A.
formulas have different levels of vitamin K.
Julian, and Mitchell. Analysis of Warfarin therapy in pediatric patients. 3. Massicotte P, Marzinotto V, Vegh P, et al. Home monitoring of Warfarin
Compliance issues are vastly different in pediatric
therapy in children with a whole blood monitor. J Pediatr 1995; 127:389-a. Younger population does not understand the 4. Nowatzke W, Landt M, Smith C, et al. Whole blood international normalization ratio measurements in children using near patient b. Adolescents who intellectually may comprehend monitors. J Peadiatr Hematol Oncol 2003;25:33-37
but are emotionally unable to cooperate, and
5. Marzinotto V, Mongale P, Chan A, et al. Capillary whole blood c. Children in dysfunctional families experiencing monitoring of oral anticoagulation in children in outpatient clinics and
non-compliance due to inadequate parenting
the home setting. Pediatr Cardiol 2000;21:347-352
Most children taking anticoagulants are receiving multiple
6. Andrew M, Marzinotto V, Booker L, et al, oral anticoagulant therapy in
medications, both on a long term basis, to treat their primary
pediatric patients: a prospective study. Thromb Haemost 194; 71:265-269 7. Hirsh J. Oral anticoagulant drugs: review article. N Engl J Med 1991;
problems, or intermittently, to treat acquired problems (eg
infections). These medications influence the dose requirements
8. Michelson AD. Bovill E, Andrew M. Antithrombotic therapy in children
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