Nursing management of deep vein thrombosis in children: a narrative review of challenges, evidence-based strategies, and systematic pathways

Introduction

Background: epidemiological trends and health threats

Deep vein thrombosis (DVT) in children is a relatively rare but potentially life-threatening disease in clinical practice (1). In recent years, the incidence of pediatric DVT has demonstrated a progressive increase, a trend closely associated with the development of modern medical technology that enables more severely ill children to receive invasive treatments and long-term central venous catheter (CVC) (2). Common triggers in children include congenital cardiovascular abnormalities, infections, the use of CVCs, and certain systemic diseases such as antiphospholipid syndrome (APS) and Behçet’s disease (3).

Furthermore, the anatomical and physiological uniqueness of children contributes to the complexity of the disease. For instance, the anatomical variations of the cerebral veins are more diverse in children and differ significantly from those in adults, which may affect local hemodynamics and the risk of thrombosis (4,5). Moreover, infectious diseases such as coronavirus disease 2019 (COVID-19) and Mycoplasma pneumoniae infection have been proven to induce thrombosis in children by activating vascular endothelial damage and immune-inflammatory responses (6,7). While pulmonary embolism (PE) remains a relatively rare event in children compared to the adult population, when pediatric DVT does progress to such severe complications, it can significantly increase the mortality rate and the risk of long-term disability (8-10). Therefore, early identification and nursing intervention for DVT in children have significant clinical significance.

The uniqueness of pediatric DVT: distinctions in anatomy, coagulation, and triggers

Pediatric DVT is characterized by a unique pathophysiology that fundamentally distinguishes it from adult cases, primarily involving developmental variations in vascular anatomy and the coagulation system (11). Unlike adults, children possess thinner vessel walls and higher elasticity, which generally provides a protective effect. However, these physiological advantages are sometimes offset by congenital structural anomalies. For instance, congenital absence or atresia of the inferior vena cava (IVC) is recognized as a rare but critical trigger for extensive DVT in adolescents (12-14). These anatomical malformations, often coexisting with genetic defects like antithrombin deficiency, lead to significant localized hemodynamic stasis.

Furthermore, the “developmental hemostasis” in children creates a dynamic and age-dependent coagulation balance that differs significantly from the mature adult system. This maturation process directly influences the clinical management of DVT, as the pharmacokinetics and pharmacodynamics of anticoagulant agents (e.g., apixaban) are distinctly different in pediatric subjects, requiring precise weight-based dosing and individualized monitoring (15). Additionally, the clinical impact of complications such as PE is particularly severe in the pediatric population, in which unique prognostic factors determine long-term outcomes and survival (16). These distinctions necessitate the move away from adult-centric models toward specialized, pediatric-focused nursing protocols, as shown in Table 1.

Research gaps and objectives

At present, the nursing management of DVT in children suffers from a significant lack of systematic norms and individualized management plans. A primary clinical challenge remains the inadequate surveillance and specialized care for central venous line (CVL)-associated DVT, which is identified as a predominant risk factor in hospitalized pediatric patients (17). Furthermore, there is a distinct lack of standardized nursing protocols for identifying DVT in children with specific inflammatory conditions, such as pediatric osteomyelitis, which significantly increases thrombotic risk (11).

Emerging clinical evidence also highlights the complexity of managing thrombosis associated with severe infections, such as methicillin-resistant Staphylococcus aureus (MRSA), which can manifest as uncommon and life-threatening systemic complications (18). The management of these severe infections, particularly those involving Panton-Valentine-Leukocidin-positive strains, remains insufficiently addressed in current nursing guidelines (19-21). Consequently, optimizing the nursing process for pediatric DVT is urgent. This article aims to systematically review the etiology and clinical manifestations of pediatric DVT, identify existing deficiencies in nursing practice, and discuss scientific assessment and intervention measures to provide practical guidance for improving the quality of care and patient prognosis. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0096/rc).

Methods

A narrative literature review was conducted by searching the MEDLINE database via the PubMed search engine. The search utilized keywords including “Children”, “Deep vein thrombosis”, “Nursing management”, “Risk factors”, “Evidence-based strategies”, and “Systematic pathways”. The inclusion period was strictly defined from January 1, 2010, to November 31, 2025. This specific timeframe was selected to capture contemporary clinical practices, including modern CVC maintenance protocols, the introduction of novel oral anticoagulants (NOACs) in pediatric populations, and emerging thrombotic triggers such as COVID-19. Based on the predefined inclusion and exclusion criteria detailed in Table 2, a total of 79 peer-reviewed articles were ultimately selected and included in this qualitative synthesis. Table 2 summarizes our search strategy, which aims to identify previously published journal articles that have conducted research, analysis, and discussion on the care for children with DVT.

Pathophysiological basis and risk factors

Analysis of the main causes of DVT in children

The etiology of DVT in the pediatric population is highly complex and multifactorial, generally categorized into genetic coagulation dysfunction, acquired risk factors, and immune-mediated inflammatory responses.

Genetic and acquired triggers

Genetic coagulation dysfunction serves as a critical endogenous foundation for pediatric DVT. Common defects include deficiencies in protein C, protein S, and antithrombin III, which disrupt the homeostatic balance of the coagulation system and predispose the patient to thrombotic events (22,23). The risk is significantly amplified when these genetic disorders coexist with structural abnormalities, such as congenital IVC insufficiency.

Acquired factors, however, play a more dominant role in clinical settings. CVCs represent the most significant acquired risk factor in hospitalized children. However, high thrombotic rates are rarely attributable to the catheter alone. For instance, Lovett et al. reported a striking DVT incidence of 29.9%, but this was specifically observed in a cohort of children with severe traumatic brain injury who were simultaneously subjected to mechanical ventilation, prolonged immobilization, and maximum intensive care, illustrating that severe DVT typically results from the accumulation of multiple major risk factors. Additionally, severe infections such as osteomyelitis and sepsis, specifically those involving MRSA, induce thrombosis by mediating platelet aggregation and toxins that damage the vascular endothelium (24).

Acquired risk factors

Acquired risk factors play a decisive role in the clinical manifestation of pediatric DVT, often acting as the immediate trigger in patients with or without an underlying genetic predisposition. CVCs represent the most significant acquired risk factor in hospitalized children (25). However, it is crucial to recognize that the isolated presence of a CVC is often part of a broader clinical picture of critical illness or severe trauma. As demonstrated by O’Brien and Candrilli, in the absence of a CVC, the baseline risk of venous thromboembolism remains extremely low even in critically injured children, underscoring the catheter’s pivotal role as a primary trigger when combined with other trauma-related hemodynamic alterations. Beyond these mechanical interventions, severe infectious diseases and prolonged immobilization significantly elevate thrombotic risk. Osteomyelitis and sepsis, particularly those involving MRSA, promote thrombus formation by releasing toxins that induce vascular endothelial damage and mediate platelet aggregation (26). Furthermore, surgical procedures, traumatic injuries, and the subsequent necessity for long-term bed rest contribute to hemorheological changes and local vascular trauma, which synergistically induce thrombosis (27). In critically ill children, such as those with severe traumatic brain injury, the requirement for prolonged mechanical ventilation has also been identified as a factor associated with the occurrence of DVT (28).

The role of immune and inflammatory responses in acquired DVT has gained increasing recognition (29). Systemic inflammatory states activate the coagulation cascade, as seen in patients with multisystem inflammatory syndrome in children (MIS-C) related to COVID-19, where significant vascular endothelial damage and elevated inflammatory markers such as D-dimer are observed (30,31).

Pathophysiological characteristics of pediatric DVT

The pathophysiological mechanisms of pediatric DVT represent a complex interaction between genetic, structural, hemodynamic, and immune-inflammatory factors. Significant differences in vascular structure and hemodynamics exist between children and adults, which profoundly influence the mechanism of thrombus formation (32). Pediatric patients generally possess thinner vessel walls with greater elasticity and higher blood flow velocities, characteristics that typically serve to reduce the baseline risk of thrombosis. However, congenital vascular malformations, such as IVC occlusion and May-Thurner syndrome, create structural abnormalities that lead to localized blood stasis, thereby significantly elevating the risk of thrombotic events (33).

A cornerstone of pediatric pathophysiology is “developmental hemostasis”, referring to the maturation of blood components and the coagulation system (34). During the neonatal and infant stages, the coagulation cascade differs fundamentally from that of adults; for instance, neonates naturally present with markedly lower plasma levels of vitamin K-dependent factors (II, VII, IX, X) as well as critical natural anticoagulants (protein C, protein S, and antithrombin), resulting in a fragile physiological balance. As children mature, these factors gradually approach adult levels, creating stage-specific differences in coagulation function that increase the complexity of thrombus formation and dissolution (35).

Furthermore, the highly active immune system in children plays a pivotal role, as inflammatory responses are more likely to activate the coagulation pathway. For instance, endothelial damage and immune-mediated coagulation activation observed in MIS-C have been identified as critical pathological mechanisms in pediatric DVT. Additionally, unique factors such as the reactivity of pediatric platelets and the activity of the fibrinolytic system further influence thrombus stability and the subsequent treatment response. In rare cases, nutritional deficiencies like pediatric scurvy can lead to spontaneous hematomas that compress vessels and induce secondary DVT, underscoring the necessity for individualized management based on age-specific clinical characteristics (36).

Pathophysiological process: Virchow’s Triad in children

The formation of DVT in children is traditionally governed by the three components of Virchow’s Triad (37): vascular endothelial injury, stasis of blood flow, and hypercoagulability (Figure 1 and Table 3). However, the manifestation of these factors in the pediatric population is uniquely influenced by age-specific physiological and environmental triggers (38).

Figure 1 Multi-factorial pathophysiological mechanism of pediatric DVT. CVC, central venous catheter; DVT, deep vein thrombosis; IVC, inferior vena cava; MIS-C, multisystem inflammatory syndrome in children; MRSA, methicillin-resistant Staphylococcus aureus.

In contrast to adults, where endothelial damage is often a result of chronic atherosclerotic changes, pediatric endothelial injury is primarily driven by mechanical trauma and medical interventions. The use of CVC is a predominant factor, as the presence of the catheter and the insertion process directly disrupts the integrity of the vascular wall. Furthermore, toxins from severe infections, such as those produced by MRSA, can mediate direct endothelial damage, facilitating platelet aggregation and subsequent thrombus formation.

Hemodynamic stasis in children is frequently associated with prolonged immobilization following major surgery or trauma, as well as critical care requirements like mechanical ventilation. Specifically, positive-pressure ventilation significantly increases intrathoracic pressure, which in turn reduces venous return from the extremities and exacerbates localized hemodynamic stasis. In some instances, severe conditions such as pediatric burns can significantly slow blood flow, increasing the localized risk of DVT. Structural anomalies, including May-Thurner syndrome or IVC atresia, also contribute to severe localized stasis that can precipitate extensive thrombosis in otherwise healthy adolescents (39).

The “developmental hemostasis” in children creates a unique procoagulant environment. The immature coagulation system, characterized by fluctuating levels of factors and natural anticoagulants, remains in a fragile balance that is easily tipped by acute inflammatory responses. Systemic inflammation, particularly in cases of MIS-C or severe viral infections, activates the coagulation cascade and elevates markers such as D-dimer, indicating a profound state of hypercoagulability (40,41).

Nursing assessment and monitoring

Clinical symptom assessment: early identification of atypical and occult symptoms

The early clinical identification of pediatric DVT presents a significant challenge for nursing staff due to the highly heterogeneous and often atypical nature of symptoms in children (42). Unlike adult patients who frequently present with the classic triad of swelling, redness, and pain, pediatric symptoms can be subtle and easily overlooked or misdiagnosed, leading to critical delays in treatment (43).

Limb pain and swelling remain the most common clinical manifestations; however, a significant subset of children may present with only mild discomfort or even no obvious symptoms, particularly in cases of CVL-related thrombosis (11). Nursing assessment must therefore prioritize the detection of occult signs, such as subtle changes in skin color, localized temperature alterations, and non-specific limb dysfunction or “heaviness”, which may serve as early indicators of thrombus formation (44). Nurses should utilize age-appropriate pain assessment tools to quantify the severity of limb discomfort, as persistent or unexplained pain in a high-risk child warrants immediate further investigation (45).

Furthermore, the clinical presentation of complications such as PE is markedly more covert in children than in adults. Respiratory distress or chest pain may be the only signals, yet these are often less pronounced in the pediatric population. In rare and complex cases, DVT can even present with neurological symptoms, such as deep cerebral vein thrombosis being misdiagnosed as acute necrotizing encephalopathy, further emphasizing the need for a high index of clinical suspicion and a multi-dimensional nursing assessment approach (46).

Imaging and laboratory monitoring in nursing: application of Doppler ultrasound, D-dimer, and emerging biomarkers

Imaging examinations represent the gold standard for the diagnosis and continuous monitoring of pediatric DVT (11,47). Among these modalities, Doppler ultrasound vascular imaging is the preferred tool for nursing monitoring due to its non-invasive nature, convenience, and suitability for the pediatric population. Regular ultrasound assessments allow nursing staff to accurately monitor the extent of the thrombus, evaluate changes in blood flow status, and identify potential thrombus expansion, which directly guides the adjustment of nursing care plans (48-50). Because a substantial proportion of pediatric DVT cases—especially CVC-related ones—remain completely asymptomatic, relying solely on clinical symptom assessment is grossly inadequate. Therefore, implementing routine DVT ultrasound screening protocols is vital in pediatric intensive care units (PICUs). For high-risk children, particularly those requiring long-term CVC or recovering from severe trauma, a structured, proactive ultrasound screening schedule enables the early detection of silent thrombi, allowing for timely therapeutic intervention before life-threatening complications occur. While CT angiography and magnetic resonance imaging (MRI) can complement ultrasound, especially for pelvic or abdominal vein thrombosis, their clinical application in children is often limited by issues regarding patient cooperation, the complexity of the examination process, and potential radiation exposure.

In terms of laboratory monitoring, the utility of traditional markers such as D-dimer is notably limited in the pediatric setting. Clinical studies indicate that D-dimer testing exhibits poor sensitivity and specificity in children with complex underlying diseases, showing reliable diagnostic performance only in otherwise healthy children (51). Consequently, nursing monitoring must focus heavily on regular coagulation function tests, including clotting time and activated partial thromboplastin time (APTT), to evaluate the safety and efficacy of anticoagulation therapy and mitigate bleeding risks. Looking forward, emerging biomarkers such as plasma fibrin degradation products and platelet activation markers are showing promise as auxiliary tools for risk stratification and prognosis judgment. Integrating these advanced laboratory indicators into a multi-dimensional nursing assessment system could facilitate more precise, individualized management of pediatric DVT in the future.

Application status and improvement of nursing risk assessment tools

The current clinical tools utilized for assessing the risk of DVT were predominantly designed based on adult clinical data. Due to the distinct physiological and pathological characteristics of the pediatric population, these adult-centric tools exhibit significant deficiencies in both applicability and accuracy when applied to children. For instance, the traditional Wells score, a cornerstone of thrombotic risk assessment in adults, demonstrates notably low sensitivity and specificity in pediatric subjects (52). This is primarily because the Wells score fails to account for pediatric-specific risk factors, such as congenital vascular malformations or the developmental status of the coagulation system.

To overcome these limitations, recent research efforts have shifted toward utilizing big data and large-scale clinical datasets to develop dedicated pediatric risk assessment models (53,54). These specialized models aim to improve the precision and practicality of predictions by integrating variables unique to children. Furthermore, enhancing the professional training of nursing staff is identified as a critical factor in optimizing DVT management. Systematic training empowers nurses to more effectively identify early clinical symptoms and high-risk factors, facilitating the implementation of timely intervention and preventive measures. Such improvements in nursing identification and assessment are essential for reducing the incidence of DVT and enhancing the overall quality of pediatric care.

Evidence-based nursing intervention strategies

Preventive nursing measures are paramount in reducing the incidence of thrombosis and ensuring the safety of pediatric patients. By implementing a multi-dimensional and individualized preventive nursing system, healthcare providers can mitigate risk factors and significantly improve patient outcomes.

Preventive nursing measures

Catheter-related management: standardized placement, maintenance, and removal

CVCs are identified as one of the most significant risk factors for DVT in the pediatric population, particularly among critically ill children. Research indicates that the use of multiple catheters, the presence of multiple lumens in use simultaneously, and a prolonged duration of catheter stay are all significantly associated with an increased risk of DVT (55). Notably, in critically ill pediatric populations (e.g., severe neurotrauma), CVC-associated DVT incidence can approach 29.9% due to cumulative intensive care risks. Furthermore, the anatomical insertion site plays a critical role in nursing risk assessment. Recent meta-analyses indicate that femoral vein access generally carries a significantly higher thrombotic risk compared to jugular or subclavian accesses, necessitating heightened vigilance and site-specific preventive strategies when femoral lines are unavoidable (56).

To mitigate these risks, nursing staff must adhere to the following evidence-based practices:

• Standardized insertion and operational norms: nurses must strictly follow clinical indications and operational norms during catheter insertion to minimize mechanical injury to the vascular endothelium.
• Rational use and minimization: reducing unnecessary catheter insertions and avoiding multiple concurrent catheters whenever possible are critical steps in risk reduction.
• Regular necessity assessment: the clinical necessity of the CVC should be assessed daily by the nursing team.
• Timely removal: redundant or useless catheters must be removed promptly to minimize the risks of catheter-related infection and mechanical injury.
• Infection control and surveillance: strengthening nursing management to prevent catheter-related bloodstream infections (CRBSIs) is essential. Routine site care using chlorhexidine gluconate and the strict implementation of aseptic non-touch techniques (ANTT) have been shown to significantly reduce localized inflammation, which otherwise serves as a potent trigger for the coagulation cascade and subsequent thrombus formation.

Physical prevention and early mobilization: implementation of early mobility, compression stockings, and mechanical assistive devices

Physical preventive measures are fundamental to mitigating venous blood stasis, a primary component of Virchow’s Triad in the pediatric population. Clinical evidence suggests that long-term bed rest is a significant factor contributing to slowed blood flow and subsequent thrombus formation. Therefore, nursing interventions must prioritize early mobilization as a proactive strategy to maintain hemodynamic stability.

Nursing staff should actively encourage and assist children in performing early limb movements and functional exercises to promote blood circulation and reduce venous stasis. Structured early mobilization protocols, even in PICUs, have been proven to safely enhance venous return and mitigate the hemodynamic stasis associated with prolonged bed rest, without increasing the risk of catheter dislodgement For patients with impaired mobility, early rehabilitation protocols, including limb function exercises, balance training, and structured functional activities, are essential to help the child regain movement capacity and minimize long-term sequelae.

For children who are unable to move independently, nurses should implement passive limb movement and massage techniques. These interventions are often supplemented by mechanical assistive devices, such as intermittent pneumatic compression (IPC) pumps, to enhance venous return.

The use of medical elastic stockings is a critical nursing measure to facilitate venous return and prevent complications such as chronic venous insufficiency, varicose veins, and skin ulcers. These stockings are particularly valuable in high-risk pediatric trauma patients, where screening and preventive physical therapy are necessitated.

By integrating these mechanical and physical measures, a multi-dimensional and individualized preventive nursing system can be established. Research indicates that the rational use of mechanical assistive devices and strict adherence to early activity guidance significantly reduce both the incidence and recurrence risk of DVT.

Nursing management during anticoagulation therapy

Anticoagulation therapy is the cornerstone of treatment for pediatric DVT; however, the physiological diversity of the pediatric population necessitates meticulous drug monitoring and a robust adverse reaction observation framework. Nursing management must focus on balancing therapeutic efficacy with the inherent risk of bleeding complications.

Drug monitoring

Nursing staff must closely monitor the efficacy and potential side effects of anticoagulant agents to facilitate timely medication adjustments. While traditional agents like low-molecular-weight heparin (LMWH) remain widely used, new oral anticoagulants (NOACs), such as apixaban and rivaroxaban, have demonstrated favorable safety and efficacy profiles in the pediatric setting (57,58).

The anticoagulation effect must be evaluated through regular laboratory testing. For LMWH, monitoring anti-Xa activity is essential to ensure the dose is within the therapeutic range, while other agents may require monitoring of the international normalized ratio (INR) or APTT (59,60). Nurses must be familiar with the distinct pharmacological characteristics of each drug and cooperate with physicians to adjust dosages based on the child’s weight and developmental status. For instance, the pharmacokinetics and safety of apixaban have been specifically evaluated in pediatric subjects to guide clinical dosing (61). Similarly, rivaroxaban has shown effectiveness in treating acute DVT in pediatric orthopedic trauma patients.

The most critical adverse reaction is bleeding. Nursing teams should perform standardized observations for signs of hemorrhage in the skin, mucous membranes, and gastrointestinal tract. However, nurses must be aware of specific pharmacological contraindications. In patients with complex autoimmune conditions, such as systemic lupus erythematosus (SLE) associated with APS, the use of NOACs is highly controversial and generally not recommended. Drawing from adult trials (e.g., the TRAPS trial), NOACs in high-risk APS populations have been linked to an unacceptable rate of recurrent arterial thrombotic events; thus, traditional anticoagulation regimens remain the standard of care for these specific pediatric patients (62).

Since pediatric patients rely on family members for medication administration, comprehensive education is a core nursing responsibility. Nurses must provide detailed guidance on administration timing, dosage accuracy, and the identification of adverse reactions. Distributing medication guidance manuals and conducting safety education can significantly promote adherence to prescribed medical orders and enhance family self-management.

Complication warning and bleeding risk control

The prevention and management of bleeding complications represent a critical aspect of nursing care during anticoagulation therapy. Nursing staff must implement a standardized identification process to detect hemorrhage in the skin, mucous membranes, and internal organs at the earliest possible stage. This systematic approach involves continuous monitoring of the skin for petechiae, ecchymosis, or hematomas, especially at injection or catheter sites. Mucous membranes should be inspected regularly for signs of epistaxis or gingival bleeding during daily oral care. For internal bleeding, nurses must remain highly vigilant for subtle clinical indicators such as microscopic hematuria, melena, or hematemesis. Moreover, unexpected drops in hemoglobin levels or sudden unexplained tachycardia should immediately prompt suspicion of occult gastrointestinal or urinary tract hemorrhage, triggering rapid escalation to the medical team, as summarized in Table 4.

Furthermore, the regular assessment of vital signs, including heart rate and blood pressure, is essential to identify hemodynamic instability associated with occult internal bleeding. To ensure a rapid response, a comprehensive emergency nursing plan should be established, mandating immediate physician notification upon the discovery of bleeding signs and the swift implementation of hemostatic measures and supportive treatment. Such protocols are vital in managing high-risk scenarios, such as spontaneous sublingual hematomas or acute hemorrhagic events during heparin therapy.

Family-centered psychological support and health education: improving compliance and family management ability

Pediatric patients and their families often experience profound psychological stress, including anxiety and fear, stemming from the diagnosis and the complexities of DVT treatment. It is imperative for nursing staff to provide consistent psychological counseling and emotional support to mitigate these stressors and reduce the overall family burden. Implementing specialized psychosocial interventions is a vital nursing strategy to address the emotional needs of the family and improve the child’s coping mechanisms.

Health education is another cornerstone of effective management, focusing on popularizing DVT prevention knowledge and empowering the family to take an active role in the child’s care. Given that pediatric medication management is largely the responsibility of the family, nurses must provide clear and detailed guidance regarding the timing, dosage, and identification of adverse reactions associated with anticoagulant therapies. A multidisciplinary approach, involving pediatrics, pharmacy, and rehabilitation services, is essential for providing comprehensive education and rehabilitation guidance. Such integrated efforts are critical for improving the quality of life for children with DVT and ensuring successful long-term management and functional recovery. Figure 2 presents the systematic nursing management pathway flowchart for pediatric DTV.

Figure 2 Systematic nursing management pathway flowchart for pediatric DVT (algorithm). CVC, central venous catheter; DVT, deep vein thrombosis; PE, pulmonary embolism; PTS, post-thrombotic syndrome.

Rehabilitation and long-term management

The long-term management of pediatric DVT is essential for restoring limb function and preventing chronic vascular complications, as shown in Table 5. A systematic approach to rehabilitation significantly improves the quality of life and minimizes the risk of permanent disability.

Functional training plan: individualized limb recovery and balance training

Rehabilitation training guidance is the core component of functional recovery for children with DVT. Early rehabilitation protocols include structured limb function exercises, proprioceptive balance training, and progressive functional activities. Evidence suggests that initiating these individualized, graded exercise programs once the acute risk of PE has passed can significantly enhance collateral circulation development and help children regain normal movement and strength faster than strict immobilization. Nursing staff must formulate individualized rehabilitation plans tailored to the child’s age and developmental stage, ensuring that training intensity is adjusted based on regular evaluations of progress. Engaging family members in assisting with these exercises is critical for maintaining consistency and achieving long-term functional goals.

Sequelae prevention [post-thrombotic syndrome (PTS) management]: identification and long-term compression therapy

PTS is arguably the most clinically relevant long-term complication of pediatric DVT, affecting up to 20–30% of survivors (63,64). Given its potential for lifelong morbidity—characterized by intractable chronic venous insufficiency, debilitating limb swelling, chronic pain, and potential skin ulceration—PTS prevention must be viewed as a central priority in the DVT care continuum, rather than an afterthought (65,66). The risk of PTS is particularly high if the diagnosis is delayed or if initial thrombus management is suboptimal. For established cases of pediatric PTS, advanced interventions such as percutaneous transluminal angioplasty (PTA) may be required to alleviate symptoms.

Nursing care for PTS prevention focuses on promoting venous return and preventing the progression of chronic venous insufficiency. The application of medical elastic stockings (compression therapy) is a primary nursing measure to facilitate blood flow and prevent complications like varicose veins, for patients who cannot maintain active mobility, mechanical assistive devices such as IPC pumps are recommended to maintain hemodynamic stability and reduce stasis. Consistent monitoring for skin changes and limb discomfort is necessary to identify early signs of PTS and intervene promptly.

Discussion and future perspectives

Multidisciplinary team (MDT) mode

The complexity of pediatric DVT management necessitates a transition from traditional siloed care to an MDT model. Within this framework, nursing staff serves as the central hub for coordination among various specialties, including pediatric hematology, vascular surgery, pharmacy, and physical therapy. Nurses are uniquely positioned to ensure the continuity of care by translating specialized medical plans into daily bedside interventions and monitoring protocols.

Effective MDT collaboration facilitates the delivery of comprehensive education to patients and families, which is critical for long-term therapeutic success. By integrating pharmacokinetic expertise from clinical pharmacists and functional recovery strategies from physical therapists, the nursing-led coordination model optimizes drug administration safety and therapeutic compliance. Studies evaluating MDT interventions in complex pediatric hematology have demonstrated that having a designated nurse coordinator significantly improves the continuity of care, reduces medication errors, and ensures that critical rehabilitation goals are met throughout the vulnerable transition from hospital discharge to home-based management.

Challenges of individualized care

One of the most significant challenges in pediatric nursing is achieving a precise balance between preventing thrombus progression and mitigating the risk of hemorrhage. Unlike adults, children exhibit age-specific pharmacokinetic profiles that make standardized dosing models inadequate. While NOACs such as apixaban have demonstrated favorable safety profiles, their application still requires rigorous monitoring of anti-Xa activity and clinical observation for occult bleeding.

Nursing management must focus on the development of standardized identification processes for early signs of bleeding across different developmental stages. For instance, recognizing subtle clinical indicators of spontaneous sublingual hematomas or gastrointestinal hemorrhage is vital when managing children on intensive heparin or NOAC therapy. The challenge lies in maintaining high therapeutic efficacy in complex pediatric cases, such as those involving SLE or severe infections, where the procoagulant environment is highly volatile.

Future research trends

Future advancements in pediatric DVT nursing will likely be driven by the integration of big data and artificial intelligence (AI). Current risk assessment tools, such as the Wells score, are largely derived from adult populations and frequently fail to capture pediatric-specific triggers like congenital vascular malformations or CVL-associated risks.

There is an urgent need to establish large-scale clinical databases to develop AI-driven risk stratification models specifically for the pediatric population. These models could analyze high-dimensional data, including genetic predispositions, catheter types, and dynamic inflammatory markers, to provide real-time, personalized risk scores for hospitalized children. By moving toward a “precision nursing” paradigm, healthcare providers can implement targeted preventive interventions, such as early mechanical prophylaxis or intensified ultrasound surveillance, for the most vulnerable patients.

Strengths and limitations

This review provides a comprehensive, nursing-centric framework for managing the multifactorial challenges of pediatric DVT, an area that currently lacks standardized protocols. However, several methodological limitations must be acknowledged. First, as a narrative review, the literature search strategy was inherently limited. We relied on single keyword searches without the expansion of controlled vocabulary (such as MeSH terms) or advanced Boolean operators, which may have resulted in the omission of some relevant literature. Second, while the initial search focused primarily on nursing management, the complexity of DVT necessitated a broader discussion encompassing medical etiology, pharmacology, and diagnostics to provide adequate context for nursing interventions. Finally, due to the rarity of pediatric DVT, our synthesis included a substantial number of single-case reports. While these reports provide valuable insights into atypical clinical presentations and rare triggers, their findings have limited generalizability compared to large-scale cohort studies.

Conclusions

The management of DVT in children has evolved into a highly specialized field that demands a departure from adult-centric clinical models. This review underscores that the core of effective pediatric DVT care lies in a multi-dimensional approach centered on four fundamental pillars: early identification, precision monitoring, multidisciplinary collaboration, and family-centered engagement.

Early identification remains the critical first line of defense, necessitating a persistently high index of clinical suspicion for atypical or “silent” symptoms. This is particularly crucial in high-risk pediatric populations, such as those burdened by CVCs, severe systemic infections, or prolonged critical care stays, where delayed diagnosis correlates directly with poorer long-term outcomes. Precision monitoring is equally critical, moving beyond traditional diagnostic tools toward the integration of age-specific ultrasound protocols and individualized laboratory surveillance for weight-based anticoagulation therapy. Furthermore, the complexity of these cases requires a robust MDT model, where the nursing professional serves as the central coordinator to ensure the continuity and safety of care across various medical specialties.

Finally, family-centered involvement is indispensable for ensuring long-term therapeutic adherence and managing the psychological burden associated with chronic thrombotic conditions. Ultimately, while the multidimensional management of existing thrombi is critical, this review reiterates that proactive prevention remains the primary and most impactful goal of pediatric DVT nursing. By prioritizing early risk stratification, strictly minimizing the duration of CVC, and implementing early mobilization, healthcare providers can preemptively disrupt the coagulation cascade. Fostering the development of AI-driven, pediatric-specific risk assessment tools will further empower this preventive paradigm, significantly reducing the incidence of severe complications such as PE and PTS, and ultimately safeguarding the long-term quality of life for vulnerable children.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0096/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0096/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0096/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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