**3.4.1.3 Thrombolytic agents**

The agent of choice is rt-PA. Streptokinase should not be used because of its allergic reactions. The use of urokinase at least in the USA is restricted for safety concerns. rt-PA may be indicated if thrombosis is extensive or organ/life threatening. The established contraindications in adults apply for children as well but should be considered relative.53 Therapeutic recommendations are listed in **Table 5.** 


Indications: extensive and/or life/organ-threatening thrombosis. Contraindications: on an individual basis to be considered relative, not absolute; keep fibrinogen > 0.5 g/L and platelets > 50 g/L; increasing D-dimers indicate effective fibrinolysis; dose reduction or cessation of rt-PA if major bleeding occurs; minor bleeding (oozing from catheter puncture site or wound) treat with local pressure; optimal duration of rt-PA therapy uncertain, mostly up to 7 days, shorter/longer courses

Table 5. Recommendations for systemic thrombolysis in neonates and children

#### **3.4.1.4 Vitamin K antagonists**


Table 6. Recommended dosing of oral anticoagulants (OAC) in neonates and children.

Warfarin and phenprocoumon are usually administered for oral anticoagulation and inhibit g-carboxylation of vitamin K–dependent proteins. Considerable variation due to nutrition, co-medication, intercurrent illness and difficult monitoring requires close supervision and dose adjustment. We administer vitamin K antagonists in cases of prophylaxis exceeding 6 months (**Table 6**).
