The Coagulation System in Children:

Developmental and Pathophysiological

Considerations
Vera Ignjatovic, B.Sc. (Hons), Ph.D.,1 Eliza Mertyn,2
and Paul Monagle, M.D., M.B.B.S., M.Sc., F.C.C.P., F.R.C.P.A., F.R.A.C.P.2,3

Downloaded by: Collections and Technical Services Department. Copyrighted material.

ABSTRACT

The coagulation system in children is complex and ever changing, a fact

encapsulated in the term developmental hemostasis. Studies confirm that there are
quantitative and almost certainly qualitative differences in the coagulation system with
age, and the control of these changes comes from something external to the liver. What
remains uncertain is the magnitude of the qualitative changes and the implications of the
changes for the growing child. At the very least, developmental hemostasis probably
provides a protective mechanism for neonates and children and hence contributes to the
decreased risk of thromboembolic and/or hemorrhagic events in these age groups. In
addition, developmental hemostasis could also reflect the role that hemostatic proteins play
in physiological development and hence the demand of other processes, such as angio-
genesis. Finally, without doubt, developmental hemostasis affects the interactions of
anticoagulant drugs with the coagulation system. This article will initially discuss the
most recent evidence with respect to qualitative age-related changes in the coagulation
system. Subsequently the article will discuss the coagulation system during childhood in
light of the three aforementioned areas of clinical impact and suggest possible strategies to
further understand this complex and exciting field of study.

KEYWORDS: Development, coagulation, plasma proteins, thromboembolism, children

T he plasma proteome is a complex milieu, which
is fundamental to health, disease development, and
response to most therapeutic agents and consists of
several protein systems that have defined functions
within the body. One of the best studied of these systems
is the coagulation system. The first proteins of the
coagulation system were identified in the 1930s, how-
ever, new proteins continue to be discovered even in the
21st century. Further, the cross-functionality of coagu-
lation proteins and their role in other bodily systems has
only recently been appreciated.1 Clinically, most of these
proteins are measured in a functional capacity, as inevi-
tably it is their ability to function rather than their
structure or even quantity that constitutes the difference
between health and disease. Certainly in terms of the
coagulation system, it is the function of proteins that

1
Department of Haematology Research, Murdoch Childrens Research
Institute, Australia; 2Department of Paediatrics, University of
Melbourne, Australia; 3Department of Clinical Haematology, Univer-
sity of Melbourne, Royal Children’s Hospital, Victoria, Australia.
Address for correspondence and reprint requests: Paul Monagle,
M.D., M.B.B.S., M.Sc., F.C.C.P., F.R.C.P.A., F.R.A.C.P., Professor,
Department of Clinical Haematology, Department of Paediatrics,
University of Melbourne, Royal Children’s Hospital, Flemington
Road, Parkville, Victoria 3052, Australia
(e-mail: paul.monagle@rch.org.au).
Hemostasis and Thrombosis of Pediatric Patients: Special Issues
and Unique Concerns; Guest Editors, Gili Kenet, M.D., Ph.D., and
Ulrike Nowak-Göttl, M.D
Semin Thromb Hemost 2011;37:723–729. Copyright # 2011 by
Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY
10001, USA. Tel: +1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0031-1297162.
ISSN 0094-6176.
723
724 SEMINARS IN THROMBOSIS AND HEMOSTASIS/VOLUME 37, NUMBER 7
indicates either the need for, or the effectiveness of,
therapy.
The coagulation system of children evolves with
age, as evidenced by marked physiological differences in
the concentration of the majority of blood-clotting
proteins, a concept known as developmental hemosta-
sis.2–6 Early evidence suggests that these age-related
changes in protein concentration are not isolated to the
coagulation system, but are in fact evident across multi-
ple protein systems within the plasma proteome. There
are numerous proteins which change in plasma abun-
dance with age.7 Age-related differences in the plasma
proteome may not just be limited to childhood. Studies
of centenarians suggest that age-related changes also
continue through the spectrum of adult life.8
To date, efforts to understand developmental
differences in the hemostatic system have mostly focused
on the quantitative differences in plasma concentration
of coagulation proteins.2–4 However, coagulation pro-
teins have complex tertiary structures, which in general
bestow multiple functions.9,10 Posttranslational modifi-
cations (PTM) affecting the structure of hemostatic
proteins are known to occur and likely have significant
impact on the function of these proteins.9,10 As an
example, fibrinogen has previously been demonstrated
to exist in a ‘‘fetal’’ form, in cord blood of term infants.10
This ‘‘fetal’’ fibrinogen was shown to have increased sialic
acid content compared with adult fibrinogen, a direct
result of PTM. Moreover, the phosphorus content of
fetal fibrinogen is increased up to fourfold compared
with the adult form of this protein.11,12 In addition,
specific thrombin clotting times were prolonged in new-
borns, suggesting differences in polymerization of fibrin
from ‘‘fetal’’ fibrinogen,13 an observation that has lead to
claims that fibrinogen in infants is ‘‘dysfunctional.’’14
Observations that an increase in sialic acid content of
fibrinogen is associated with a decreased rate of fibrin
polymerization and the removal of sialic acid residues
leads to increase in polymerization15 provide a possible
explanation for differences in thrombin clotting times.
Definite evidence of the importance of differences in
sialic acid content of fibrinogen is provided by observa-
tions that sialic residues of fibrinogen directly bind Ca2þ,
leading to a decrease in the intermolecular repulsion
between the fibrinogen chains and thereby facilitating
fibrin polymerization.16
A recent study considered the molecular weight of
individual fibrinogen chains in human fibrinogen from
people of different ages.17 Specifically, the molecular
weight of the Aa chain was consistently higher by up to
1500 Da in neonates and children compared with adults.
The trend toward a higher molecular weight in younger
age groups was also consistent for the Bb and g chains
with differences of up to 400 Da and 500 Da, respec-
tively. These differences in fibrinogen chains could
represent multiple additional sialic acid residues in the
2011
neonatal and pediatric fibrinogen compared with the
adult form of this protein. In the same study, using mass
spectrometry, the elution time of the fibrinogen mole-
cule was comparable across all age groups. However,
there were significant differences in the chromatogram
profile (area under the peak and peak height) in neonates
and children compared with adults suggesting differ-
ences in the interaction of the fibrinogen molecule from
each age group with the column, consistent with struc-
tural differences for the protein in these age groups.17
In addition, a ‘‘neonatal’’ form of protein C has
been detected in the ovine fetus.18 Compared with the
adult two-chain molecule, the ‘‘neonatal’’ protein C has
an increased proportion of single-chain molecules. Dif-
ferences have also been demonstrated in mRNA levels of
antithrombin (AT) in fetal compared with adult sheep,
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confirming age-specific differential translation of this
protein.19 Human studies of age-related differences in
these protein structures (protein C or AT) are yet to be
completed. However, as will be described subsequently,
an emerging number of functional studies in humans are
consistent with the hypothesis that qualitative changes
in coagulation proteins with age play a significant role in
explaining the apparent differences in the function of
coagulation system with age.
In a recent and novel study of children who
received livers transplanted from adult donors, Lisman
et al described that plasma levels of coagulation proteins
remain at pediatric levels posttransplant, suggesting that
control of the plasma protein levels are not primarily
driven by the liver itself.20 The possibilities for how
plasma levels of coagulation proteins are different in
children compared with adults include regulation at the
gene level, PTMs that affect protein function, delivery or
release, as well as differences in protein clearance. Given
that the liver is the site of production for most coagu-
lation proteins, it had been assumed by many that the
liver was involved in this regulation. However, the fact
that even with a transplanted adult liver in situ, children
maintain plasma levels of certain coagulation proteins at
their expected age-related levels, suggests that liver is not
the primary regulator of plasma coagulation protein
levels. The vascular endothelium in fact seems to be
the most likely controller. The endothelium is intimately
involved with the function of the coagulation proteins,21
and vascular endothelial dysfunction, as observed in
disseminated intravascular coagulation, is usually meas-
ured by the degree of disturbance in coagulation pro-
teins, even though it is not a primary disorder of
coagulation.22
Thus, there are quantitative and almost certainly
qualitative differences in the hemostatic system with age,
and the control of these changes comes from something
external to the liver. What are the implications of such
changes? At the very least, developmental hemostasis
probably provides a protective mechanism for neonates

and children and hence contributes to the decreased risk
of thromboembolic and/or hemorrhagic events in these
age groups. In addition, developmental hemostasis could
also reflect the role that hemostatic proteins play in
physiological development and hence the demand of
other processes, such as angiogenesis.10 Finally, without
doubt, developmental hemostasis affects the interactions
of anticoagulant drugs with the coagulation system. This
article will discuss the coagulation system during child-
hood in light of these three aspects and suggest possible
strategies to further understand this complex and excit-
ing field of study.
DEVELOPMENTAL HEMOSTASIS AND THE
RISK OF THROMBOEMBOLIC DISEASE IN
INFANTS AND CHILDREN
The epidemiology of thromboembolism (TE) in pedia-
tric patients is vastly different from that observed in
adults.23–35 The evidence that infants and children are
protected from thrombosis comes from several different
perspectives. Patients with congenital deficiencies of
AT, protein C, or protein S or with activated protein
C resistance36–40 usually do not present with thrombosis
until the late teenage years or even later. Similarly,
thrombosis secondary to acquired risk factors occurs
considerably less frequently in children compared with
adults. For example, thrombosis in children with neph-
rotic syndrome occurs in only 2% of children compared
with
20% of adults.41–46 Children routinely undergo
major abdominal and lower limb orthopedic surgery and
do not require anticoagulant prophylaxis because secon-
dary thrombosis is rare. In contrast, adults undergoing
similar procedures have a high risk of thrombosis and
benefit from prophylactic anticoagulant therapy.47
Thus for the same risk factor, whether inherited
or acquired, the thrombosis risk is substantially reduced
in children compared with adults, which suggests that
there are protective mechanisms in play. The most likely
candidates for this protection are age-related differences
in the coagulation system.
DEVELOPMENTAL HEMOSTASIS AND
PHYSIOLOGICAL DEVELOPMENT
Perhaps the most intriguing aspect of developmental
hemostasis is attempting to understand the rationale for
such marked age-related changes. One potential explan-
ation is that the hemostatic system is so dramatically
different in neonates and children for reasons unrelated
to hemostasis. There is increasing evidence that the
proteins involved in the hemostatic system have multiple
functions in multiple physiological systems within the
body, such as angiogenesis, inflammation, and wound
repair. These systems could drive the developmental
changes in the hemostatic system, which are therefore
COAGULATION SYSTEM IN CHILDREN/IGNJATOVIC ET AL 725
seen as necessary compensations to allow normal hemo-
static function. Evidence for this theory is mounting,
and one example of this is found in studies related to AT.
AT is a major plasma serine proteinase inhibitor
(serpin) which inhibits thrombin and activated factor X
generated on activation of the hemostatic system.48 The
three-dimensional structure of AT was determined more
than 15 years ago by two independent research
groups.49,50 AT inhibits thrombin and in the presence
of unfractionated heparin (UFH), this ability to inhibit
thrombin is increased by 1000-fold.51 AT is described as
occurring in two distinct isoforms, native AT (NAT) or
latent AT (LAT). Recent studies have demonstrated
that LAT is associated with severe and sudden onset of
thrombosis, that it has potent antiangiogenic properties,
and specifically downregulates several proangiogenic
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genes and upregulates several antiangiogenic genes.52
Preliminary experiments demonstrate that the
concentration of the LAT isoform in the healthy pop-
ulation increases significantly with age, such that day 1 to
3 neonates, <1-year-old infants and 1- to 5-year olds
have 30, 50, and 80% LAT compared with adult levels,
respectively (unpublished data, Vera Ignjatovic). In ad-
dition to NAT and LAT, in adults AT has been shown
to circulate as two glycoforms53; a-AT has four identical
syalated complex oligosaccharides attached to aspara-
gines, which account for 15% of the 58 kDa total mass;
while b-AT is only glycosylated on 3 of the potential
4 asparagines.54 In adults, a-AT constitutes 90 to 95% of
circulating AT, compared with only 5 to 10% b-AT, yet
b-AT has higher affinity for UFH, endothelial surfaces,
and is a more effective thrombin inhibitor.54–56 This
suggests physiologically and clinically specialized func-
tions for the AT glycoforms, where b-AT may be vital
for controlling thrombogenic events arising from vessel
wall injury, while a-AT may be largely responsible for
inhibition of fluid-phase thrombin. The location of the
carbohydrate side chain at Asn-135 in a-AT (absent in
b-AT) interferes with the binding of UFH due to its
proximity to the UFH-binding site.57 This demonstrates
that glycosylation or de-glycosylation of a single amino
acid, particularly in proximity to the binding site of AT,
has significant implications on the function of the AT
molecule. Despite the clinical significance of the ratio of
a-AT to b-AT in terms of their interaction with UFH,
whether this ratio changes with age or health state has
not been investigated previously.
Recently, AT has been shown to have potent
antiangiogenic properties as well as that of being an
important anticoagulant.58 AT has been shown to
downregulate several proangiogenic genes and upregu-
late several antiangiogenic genes. The antiangiogenic
forms of AT are known to include heparin-binding sites,
and heparin is shown to potentiate this effect.58 This is
one of the postulated mechanisms in the positive effect
of heparinoids on cancer survival which is independent
726 SEMINARS IN THROMBOSIS AND HEMOSTASIS/VOLUME 37, NUMBER 7
of the antithrombotic effect.59–61 AT levels are naturally
reduced in newborns to less than 50% of the levels
observed in adults and then increase to approach adult
levels by
6 months of age.5 Early evidence suggests that
there is a difference in the balance of isoforms of AT in
newborns compared with adults. One postulated reason
for the decreased levels of AT (and the altered balance of
isoforms) observed in neonates is related to the role of
this protein in angiogenesis.19 Fetal and early neonatal
life is a time of prolific angiogenesis, much more so than
any later stage of life, and given the known antiangio-
genic properties of AT, low levels of this protein are
likely beneficial for healthy development. Hence, AT
replacement therapy during neonatal life may well be
deleterious by altering the normal balance of angio-
genesis. In the only published randomized trial of AT
replacement therapy in newborns (as a treatment for
lung disease of prematurity), there were seven deaths
(11.5%) in the AT-treated group and three deaths
(4.9%) in the placebo (no treatment) group.62 A similar
trial (reported only in abstract format) also reported a
similar trend in the setting of a clinical trial; however, the
mechanism for this finding was not established.62
Preliminary evidence indicates that age-related
changes in the quantity, structure, and function of AT
are important in normal physiological development, with
implications much broader than the coagulation system
alone.
Another coagulation protein that is important in
this context is alpha-2-macroglobulin (A2M), a major
natural inhibitor of thrombin. It is present in two- to
threefold higher concentrations during childhood com-
pared with adulthood, and remain elevated until adult-
hood.3 As a major plasma protease inhibitor, A2M
represents 2 to 4% of the total protein content in adult
plasma63,64 and plays a role in multiple processes includ-
ing hemostasis, innate immunity, and inflammation. To
date there has been no evidence for a case of a total
deficiency or homozygosity of A2M and this could be an
evidence of absolute requirement for A2M for fetal
survival in utero. In the hemostatic system, A2M ex-
hibits anticoagulant, procoagulant, and antifibrinolytic
activity. A2M has also been linked to the development of
Alzheimer disease.65 In addition, A2M has a function in
the immune system, with its most well-defined bio-
logical role as a major inhibitor of metalloproteinases,
assisting in their clearance from tissue fluids.66 Recently,
A2M has been demonstrated to also function as a
molecular chaperone, where native A2M binds to plasma
proteins that are partially unfolded or inactivated by heat
or oxidative stress. Specifically, the A2M–protein com-
plex is still able to interact with and inhibit proteases and
subsequently the A2M–protein–protease complex can be
rapidly cleared via endocytosis from the circulation.67
A2M levels are increased in healthy infants and
children, and only approach adult levels in late teenage
2011
years as confirmed in several studies.3,4,63,68 A2M has
been shown to be influential in the regulation of the
hemostatic system in neonates, where A2M functions as
a major inhibitor of coagulation.69,70 Up to 64% of
thrombin in neonates is bound and inhibited by A2M,
while the corresponding inhibition of thrombin in adults
accounts for 7% of thrombin.71 In fact, in neonates and
children, A2M plays a more important role in thrombin
inhibition compared with AT, which is the predominant
inhibitor in adults.72 In AT-deficient children, thrombin
inhibition by A2M was demonstrated to be as effective
as in plasma from children and adults without AT
deficiency.69 Hence, A2M has a compensatory role for
thrombin inhibition in children with an AT deficiency.
Interestingly, decreased A2M levels have been
reported in neonates with chronic heart disease com-
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pared with otherwise healthy neonates.73 In contrast,
asymptomatic dyslipidemia in children has been associ-
ated with increased levels of A2M (as well as plasmi-
nogen and fibrinogen) compared with control subjects.74
In summary, it seems highly likely that A2M may
in fact have potential functions in the regulation of
multiple growth processes. However, the biological basis
for the significantly elevated plasma levels of A2M in
infancy and childhood has not been clearly defined to
date and much further research is clearly required.
DEVELOPMENTAL HEMOSTASIS AND
ANTICOAGULANT DRUGS
Recent functional studies have shown that the mecha-
nism of action of the anticoagulant UFH is different in
children compared with adults (higher anti-IIa to anti-
Xa ratio in children).75–77 In addition, the number of
proteins binding to UFH in neonatal and pediatric
plasma is different from that in adults.78 Further, there
is an age-specific binding affinity of UFH to its binding
partners AT and thrombin in neonatal and pediatric
compared with adult plasma, independent of the age-
related quantitative differences for these proteins. Spe-
cifically, the quantity of AT bound to UFH decreased
with age and conversely, the quantity of thrombin bound
to UFH increased with age.78
Pharmacokinetic studies of UFH in piglets show
that the clearance of this drug is faster than in adult pigs
due to a larger volume of distribution.79 Studies of UFH
in newborns are limited but nonetheless demonstrate
that the clearance is faster than that in older children due
to a larger volume of distribution.80,81 Following UFH
single bolus in children, the half-life, volume of distri-
bution, clearance, and peak serum concentration of UFH
vary in children compared with adults. Further, the
pharmacokinetics of UFH in children fits a first-order
model and is a function of weight rather than age per
se.82 True pharmacodynamic studies of UFH in children
have not been performed.

There is also a significant age-related variation in
response to the anticoagulant enoxaparin (low molec-
ular-weight heparin).83 Specific pharmacokinetics of
enoxaparin in children have only recently been reported.
A two-compartment model was adequate for
describing the enoxaparin kinetics with body weight
being the most predictive covariate for clearance and
central volume of distribution. Interindividual variability
was found to be 54% for clearance and 42% for volume of
distribution.84 This study did not include any adults as
comparators.
Warfarin is the most commonly used vitamin K
antagonist worldwide. Most of the studies in children on
oral anticoagulation therapy have been performed using
this drug.85–89 Acenocoumarol is administered with high
frequency in some European and South American coun-
tries,90,91 while phenprocoumon is the preferred vitamin
K antagonist in some other parts of Europe. No data
about doses of phenprocoumon in pediatric patients have
been reported. The capacity of plasma from children
receiving vitamin K antagonists to generate thrombin is
delayed and decreased by 25% compared with plasmas
from adults with similar international normalized ratios
(INRs).25 Plasma concentrations of a marker of endog-
enous thrombin generation, prothrombin fragment 1.2,
is significantly lower in children compared with adults at
similar INR values.25
These data suggest that the coagulation system in
children is interacting with anticoagulant drugs differ-
ently to the coagulation system in adults. Further, the
magnitude of these findings cannot be accounted for by
the quantitative changes in plasma concentrations of
proteins alone, suggesting there remains a lot to be
discovered about the qualitative age-related differences
in the coagulation system.
In summary, there is increasing evidence that the
age-related changes reported in the coagulation system
are in fact reflective of age-related changes in the entire
plasma proteome. Further these changes are not just
quantitative in nature but involve intricate and subtle
changes in qualitative structure that almost certainly
alter protein function. The impact of these changes on
the epidemiology of thromboembolic diseases in chil-
dren is likely substantial, however, whether the changes
are driven by the coagulation system or in fact by the
need for variation of the roles these multifaceted proteins
play in other body systems remains unclear. Whatever,
the impact on the interaction of the plasma with anti-
coagulant drugs in particular is of real clinical relevance.
Further studies to elucidate the extent of the qualitative
changes in plasma proteins with age, and the role of
these proteins in fundamental biological systems of
growth and development are crucial. Only once these
factors are understood, can the true impact of therapeutic
interventions that manipulate the coagulation system
during childhood be established.
COAGULATION SYSTEM IN CHILDREN/IGNJATOVIC ET AL 727
REFERENCES
1. Monagle P, Ignjatovic V, Savoia H. Hemostasis in neonates
and children: pitfalls and dilemmas. Blood Rev 2010;24 (2):
63–68
2. Andrew M, Paes B, Johnston M. Development of the
hemostatic system in the neonate and young infant. Am J
Pediatr Hematol Oncol 1990;12(1):95–104
3. Andrew M, Paes B, Milner R, et al. Development of the
human coagulation system in the full-term infant. Blood
1987;70(1):165–172
4. Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F,
Mitchell L. Maturation of the hemostatic system during
childhood. Blood 1992;80(8):1998–2005
5. Monagle P, Barnes C, Ignjatovic V, et al. Developmental
haemostasis. Impact for clinical haemostasis laboratories.
Thromb Haemost 2006;95(2):362–372
6. Monagle P, Chan A, de Veber G, Massicotte P. Devel-
Downloaded by: Collections and Technical Services Department. Copyrighted material.
opmental Hemostasis. Pediatric Thromboembolism and
Stroke Handbook. 3rd ed. Hamilton, Ontario: BC Decker
Inc.; 2006:3–30
7. Ignjatovic V, Lai C, Summerhayes R, et al. Age-related
differences in plasma proteins: how plasma proteins change
from neonates to adults. PLoS ONE 2011;6(2):e17213
8. Mari D, Mannucci PM, Coppola R, Bottasso B, Bauer KA,
Rosenberg RD. Hypercoagulability in centenarians: the
paradox of successful aging. Blood 1995;85(11):3144–3149
9. Bock SC. Antithrombin III and heparin cofactor II. In:
Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN,
eds. Hemostasis and Thrombosis: Basic Principles and
Clinical Practice. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2001:321–334
10. Monagle P, Hagstrom J. Developmental haemostasis. In:
Polin RA, Fox WW, Abman SH, eds. Fetal and Neonatal
Physiology. 3rd ed. St. Louis: Elsevier; 2003:1435–1447
11. Witt I, Müller H. Phosphorus and hexose content of human
foetal fibrinogen. Biochim Biophys Acta 1970;221(2):402–404
12. Hamulyák K, Nieuwenhuizen W, Devilée PP, Hemker HC.
Reevaluation of some properties of fibrinogen, purified from
cord blood of normal newborns. Thromb Res 1983;32 (3):
301–310
13. Witt I, Müller H, Künzer W. Evidence for the existence of
foetal fibrinogen. Thromb Diath Haemorrh 1969;22(1):
101–109
14. Miller BE, Tosone SR, Guzzetta NA, Miller JL, Brosius KK.
Fibrinogen in children undergoing cardiac surgery: is it
effective?. Anesth Analg 2004;99(5):1341–1346
15. Martinez J, MacDonald KA, Palascak JE. The role of sialic
acid in the dysfibrinogenemia associated with liver disease:
distribution of sialic acid on the constituent chains. Blood
1983;61(6):1196–1202
16. Dang CV, Shin CK, Bell WR, Nagaswami C, Weisel JW.
Fibrinogen sialic acid residues are low affinity calcium-
binding sites that influence fibrin assembly. J Biol Chem
1989;264(25):15104–15108
17. Ignjatovic V, Ilhan A, Monagle P. Evidence for age-related
differences in human fibrinogen. Blood Coagul Fibrinolysis
2011;22(2):110–117
18. Manco-Johnson MJ, Spedale S, Peters M, et al. Identifica-
tion of a unique form of protein C in the ovine fetus:
developmentally linked transition to the adult form. Pediatr
Res 1995;37(3):365–372
19. Niessen RW, Lamping RJ, Peters M, Lamers WH, Sturk A.
Fetal and neonatal development of antithrombin III plasma
728 SEMINARS IN THROMBOSIS AND HEMOSTASIS/VOLUME 37, NUMBER 7
activity and liver messenger RNA levels in sheep. Pediatr Res
1996;39(4 Pt 1):685–691
20. Lisman T, Platto M, Meijers JC, Haagsma EB, Colledan M,
Porte RJ. The hemostatic status of pediatric recipients of
adult liver grafts suggests that plasma levels of hemostatic
proteins are not regulated by the liver. Blood 2011;117 (6):
2070–2072
21. Mosnier LO, Zlokovic BV, Griffin JH. The cytoprotective
protein C pathway. Blood 2007;109(8):3161–3172
22. Taylor FB Jr, Kinasewitz GT. The diagnosis and manage-
ment of disseminated intravascular coagulation. Curr Hem-
atol Rep 2002;1(1):34–40
23. Andrew M, Mitchell L, Vegh P, Ofosu F. Thrombin
regulation in children differs from adults in the absence and
presence of heparin. Thromb Haemost 1994;72(6):836–842
24. Gibson BE, Chalmers E, Bolton-Maggs P, Henderson DJ,
Lynn R. Thrombembolism in childhood: a prospective 2 year
BPSU study in the United Kingdom. Thromb Haemost
2003;1(Suppl 1):OC422
25. Massicotte P, Leaker M, Marzinotto V, et al. Enhanced
thrombin regulation during warfarin therapy in children
compared to adults. Thromb Haemost 1998;80(4):570–574
26. Mitchell LG, Andrew M, Hanna K, et al; Prophylactic
Antithrombin Replacement in Kids with Acute Lympho-
blastic Leukemia Treated with Asparaginase Group (PAR-
KAA). A prospective cohort study determining the
prevalence of thrombotic events in children with acute
lymphoblastic leukemia and a central venous line who are
treated with L-asparaginase: results of the Prophylactic
Antithrombin Replacement in Kids with Acute Lympho-
blastic Leukemia Treated with Asparaginase (PARKAA)
Study. Cancer 2003;97(2):508–516
27. Monagle P, Adams M, Mahoney M, et al. Outcome of
pediatric thromboembolic disease: a report from the Cana-
dian Childhood Thrombophilia Registry. Pediatr Res 2000;
47(6):763–766
28. Newall F, Wallace T, Crock C, et al. Venous thromboem-
bolic disease: a single-centre case series study. J Paediatr
Child Health 2006;42(12):803–807
29. Nowak-Göttl U, Heinecke A, von Kries R, Nürnberger W,
Münchow N, Junker R. Thrombotic events revisited in
children with acute lymphoblastic leukemia: impact of
concomitant Escherichia coli asparaginase/prednisone
administration. Thromb Res 2001;103(3):165–172
30. Nowak-Göttl U, von Kries R, Göbel U. Neonatal sympto-
matic thromboembolism in Germany: two year survey. Arch
Dis Child Fetal Neonatal Ed 1997;76(3):F163–F167
31. Schmidt B, Andrew M. Neonatal thrombosis: report of a
prospective Canadian and international registry. Pediatrics
1995;96(5 Pt 1):939–943
32. van Ommen CH, Heijboer H, Büller HR, Hirasing RA,
Heijmans HS, Peters M. Venous thromboembolism in
childhood: a prospective two-year registry in The Nether-
lands. J Pediatr 2001;139(5):676–681
33. White RH. The epidemiology of venous thromboembolism.
Circulation 2003;107(23, Suppl 1):I4–I8
34. Kuhle S, Massicotte P, Chan A, et al. Systemic throm-
boembolism in children. Data from the 1-800-NO-CLOTS
Consultation Service. Thromb Haemost 2004;92(4):722–728
35. Raffini L, Huang YS, Witmer C, Feudtner C. Dramatic
increase in venous thromboembolism in children’s hospitals
in the United States from 2001 to 2007. Pediatrics 2009; 124
(4):1001–1008
2011
36. Bjarke B, Herin P, Blombäck M. Neonatal aortic thrombosis.
A possible clinical manifestation of congenital antithrombin
3 deficiency. Acta Paediatr Scand 1974;63(2):297–301
37. De Stefano V, Leone G, Ferrelli R, et al. Severe deep vein
thrombosis in a 2-year-old child with protein S deficiency.
Thromb Haemost 1987;58(4):1089
38. Israels SJ, Seshia SS. Childhood stroke associated with
protein C or S deficiency. J Pediatr 1987;111(4):562–564
39. Mannino FL, Trauner DA. Stroke in neonates. J Pediatr
1983;102(4):605–610
40. Shapiro ME, Rodvien R, Bauer KA, Salzman EW. Acute
aortic thrombosis in antithrombin III deficiency. JAMA
1981;245(17):1759–1761
41. Andrassy K, Ritz E, Bommer J. Hypercoagulability in the
nephrotic syndrome. Klin Wochenschr 1980;58(19):1029–1036
42. Kanfer A, Kleinknecht D, Broyer M, Josso F. Coagulation
studies in 45 cases of nephrotic syndrome without uremia.
Thromb Diath Haemorrh 1970;24(3):562–571
Downloaded by: Collections and Technical Services Department. Copyrighted material.
43. Kauffmann RH, Veltkamp JJ, Van Tilburg NH, Van Es LA.
Acquired antithrombin III deficiency and thrombosis in the
nephrotic syndrome. Am J Med 1978;65(4):607–613
44. Kuhlmann U, Blättler W, Pouliadis G, Siegenthaler W.
[Complications of nephrotic syndrome with special reference
to thromboembolic accidents]. Schweiz Med Wochenschr
1979;109(6):200–209
45. Schrader J, Köstering H, Züchner C, Kaiser H, Kramer P,
Scheler F. Antithrombin III-Bestimmungim Schnelltest: Ein
Vergleich mit Partigen-Platten undeinem chromogenen
Substrat. Lab Med 1981;5:211–218
46. Thaler E, Balzar E, Kopsa H, Pinggera WF. Acquired
antithrombin III deficiency in patients with glomerular
proteinuria. Haemostasis 1978;7(5):257–272
47. Hirsh J. Heparin. N Engl J Med 1991;324(22):1565–1574
48. Olson ST, Björk I, Shore JD. Kinetic characterization of
heparin-catalyzed and uncatalyzed inhibition of blood
coagulation proteinases by antithrombin. Methods Enzymol
1993;222:525–559
49. Carrell RW, Stein PE, Fermi G, Wardell MR. Biological
implications of a 3 A structure of dimeric antithrombin.
Structure 1994;2(4):257–270
50. Schreuder HA, de Boer B, Dijkema R, et al. The intact and
cleaved human antithrombin III complex as a model for
serpin-proteinase interactions. Nat Struct Biol 1994;1(1):
48–54
51. Levi M. All heparins are equal, but some are more equal than
others. J Thromb Haemost 2003;1(5):884–885
52. Schedin-Weiss S, Richard B, Hjelm R, Olson ST. Anti-
angiogenic forms of antithrombin specifically bind to the
anticoagulant heparin sequence. Biochemistry 2008;47 (51):
13610–13619
53. Chan AK, Berry LR, Paredes N, Parmar N. Isoform
composition of antithrombin in a covalent antithrombin-
heparin complex. Biochem Biophys Res Commun 2003;309
(4):986–991
54. Picard V, Ersdal-Badju E, Bock SC. Partial glycosylation of
antithrombin III asparagine-135 is caused by the serine in the
third position of its N-glycosylation consensus sequence and
is responsible for production of the beta-antithrombin III
isoform with enhanced heparin affinity. Biochemistry 1995;
34(26):8433–8440
55. Carlson TH, Atencio AC, Simon TL. Comparison of the
behaviour in vivo of two molecular forms of antithrombin III.
Biochem J 1985;225(3):557–564

56. Witmer MR, Hatton MW. Antithrombin III-beta associates
more readily than antithrombin III-alpha with uninjured and
de-endothelialized aortic wall in vitro and in vivo. Arte-
rioscler Thromb 1991;11(3):530–539
57. Turk B, Brieditis I, Bock SC, Olson ST, Björk I. The
oligosaccharide side chain on Asn-135 of alpha-antithrom-
bin, absent in beta-antithrombin, decreases the heparin
affinity of the inhibitor by affecting the heparin-
induced conformational change. Biochemistry 1997;36(22):
6682–6691
58. Schedin-Weiss S, Richard B, Hjelm R, Olson ST. Anti-
angiogenic forms of antithrombin specifically bind to the
anticoagulant heparin sequence. Biochemistry 2008;47 (51):
13610–13619
59. Adcock DM, Fink LM, Marlar RA, Cavallo F, Zangari M.
The hemostatic system and malignancy. Clin Lymphoma
Myeloma 2008;8(4):230–236
60. Akl EA, van Doormaal FF, Barba M, et al. Parenteral
anticoagulation for prolonging survival in patients with
cancer who have no other indication for anticoagulation.
Cochrane Database Syst Rev 2007;(3):CD006652
61. Wojtukiewicz MZ, Sierko E, Rak J. Contribution of the
hemostatic system to angiogenesis in cancer. Semin Thromb
Hemost 2004;30(1):5–20
62. Schmidt B, Gillie P, Mitchell L, Andrew M, Caco C,
Roberts R. A placebo-controlled randomized trial of
antithrombin therapy in neonatal respiratory distress syn-
drome. Am J Respir Crit Care Med 1998;158(2):470–476
63. Ganrot PO. Inhibition of plasmin activity by alpha-2-
macroglobulin. Clin Chim Acta 1967;16(2):328–329
64. Sottrup-Jensen L. Alpha-macroglobulins: structure, shape,
and mechanism of proteinase complex formation. J Biol
Chem 1989;264(20):11539–11542
65. Blacker D, Wilcox MA, Laird NM, et al. Alpha-2 macro-
globulin is genetically associated with Alzheimer disease. Nat
Genet 1998;19(4):357–360
66. Baker AH, Edwards DR, Murphy G. Metalloproteinase
inhibitors: biological actions and therapeutic opportunities.
J Cell Sci 2002;115(Pt 19):3719–3727
67. French K, Yerbury JJ, Wilson MR. Protease activation of
alpha2-macroglobulin modulates a chaperone-like action
with broad specificity. Biochemistry 2008;47(4):1176–1185
68. Andrew M, Paes B, Milner R, et al. Development of the
human coagulation system in the healthy premature infant.
Blood 1988;72(5):1651–1657
69. Mitchell L, Piovella F, Ofosu F, Andrew M. Alpha-2-
macroglobulin may provide protection from thromboembolic
events in antithrombin III-deficient children. Blood 1991;
78(9):2299–2304
70. Schmidt B, Mitchell L, Ofosu FA, Andrew M. Alpha-2-
macroglobulin is an important progressive inhibitor of
thrombin in neonatal and infant plasma. Thromb Haemost
1989;62(4):1074–1077
71. Ignjatovic V, Greenway A, Summerhayes R, Monagle P.
Thrombin generation: the functional role of alpha-2-macro-
globulin and influence of developmental haemostasis. Br J
Haematol 2007;138(3):366–368
72. Ling X, Delorme M, Berry L, et al. alpha 2-Macroglobulin
remains as important as antithrombin III for thrombin
regulation in cord plasma in the presence of endothelial cell
surfaces. Pediatr Res 1995;37(3):373–378
73. Guzzetta NA, Miller BE, Todd K, et al. Clinical measures of
heparin’s effect and thrombin inhibitor levels in pediatric
COAGULATION SYSTEM IN CHILDREN/IGNJATOVIC ET AL 729
patients with congenital heart disease. Anesth Analg 2006;
103(5):1131–1138
74. Albisetti M, Chan AK, McCrindle BW, Wong D, Monagle
P, Andrew M. Impaired fibrinolytic activity is present in
children with dyslipidemias. Pediatr Res 2004;55(4):576–580
75. Ignjatovic V, Furmedge J, Newall F, et al. Age-related
differences in heparin response. Thromb Res 2006;118 (6):
741–745
76. Ignjatovic V, Summerhayes R, Newall F, Monagle PT. The
in vitro response to low-molecular-weight heparin is not age-
dependent in children. Thromb Haemost 2010;103(4):
855–856
77. Newall F, Ignjatovic V, Summerhayes R, et al. In vivo age
dependency of unfractionated heparin in infants and children.
Thromb Res 2009;123(5):710–714
78. Ignjatovic V, Straka E, Summerhayes R, Monagle P. Age-
specific differences in binding of heparin to plasma proteins. J
Thromb Haemost 2010;8(6):1290–1294
Downloaded by: Collections and Technical Services Department. Copyrighted material.
79. Andrew M, Ofosu F, Schmidt B, Brooker L, Hirsh J,
Buchanan MR. Heparin clearance and ex vivo recovery in
newborn piglets and adult pigs. Thromb Res 1988;52(6):
517–527
80. McDonald MM, Jacobson LJ, Hay WW Jr, Hathaway WE.
Heparin clearance in the newborn. Pediatr Res 1981;15 (7):
1015–1018
81. Turner Gomes S, Nitschmann E, Benson L, Burrows P,
Andrew M. Heparin is cleared faster in children with
congenital heart disease than adults. J Am Coll Cardiol 1993;
21(2):59a
82. Newall F, Ignjatovic V, Johnston L, et al. Age is a
determinant factor for measures of concentration and effect
in children requiring unfractionated heparin. Thromb Hae-
most 2010;103(5):1085–1090
83. Ignjatovic V, Najid S, Newall F, Summerhayes R, Monagle
P. Dosing and monitoring of enoxaparin (Low molecular
weight heparin) therapy in children. Br J Haematol 2010;149
(5):734–738
84. Trame MN, Mitchell L, Krümpel A, Male C, Hempel G,
Nowak-Göttl U. Population pharmacokinetics of enoxaparin
in infants, children and adolescents during secondary
thromboembolic prophylaxis: a cohort study. J Thromb
Haemost 2010;8(9):1950–1958
85. Andrew M, Marzinotto V, Brooker LA, et al. Oral
anticoagulation therapy in pediatric patients: a prospective
study. Thromb Haemost 1994;71(3):265–269
86. Streif W, Andrew M, Marzinotto V, et al. Analysis of
warfarin therapy in pediatric patients: a prospective cohort
study of 319 patients. Blood 1999;94(9):3007–3014
87. Carpentieri U, Nghiem QX, Harris LC. Clinical experience
with an oral anticoagulant in children. Arch Dis Child 1976;
51(6):445–448
88. Doyle JJ, Koren G, Cheng MY, Blanchette VS. Anti-
coagulation with sodium warfarin in children: effect of a
loading regimen. J Pediatr 1988;113(6):1095–1097
89. Evans DI, Rowlands M, Poller L. Survey of oral anti-
coagulant treatment in children. J Clin Pathol 1992;45 (8):
707–708
90. Bonduel M, Sciuccati G, Hepner M, et al. Acenocoumarol
therapy in pediatric patients. J Thromb Haemost 2003;1 (8):
1740–1743
91. Piquet P, Losay J, Doubine S. [Acenocoumarol (Sintrom)
and fluinidione (Previscan) in pediatrics after cardiac surgical
procedures]. Arch Pediatr 2002;9(11):1137–1144