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Is aspirin dosage of 5mg/kg or 10mg/kg is better to prevent thrombosis in pediatric patients with single-ventricle physiology who required single-ventricle palliation?

According to ACCP 2012 (1), the best dosage of aspirin in pediatrics for thrombosis is 3–5 mg/kg. According to ACCP guidelines, this dosage is empirical based on the data collected till this point(2), giving a grade of recommendation of 2C.

A single cohort study is suggesting to use 10mg/kg in pediatric patients as anti-thrombotic if they are having aspirin resistance (defined as less than 50% AA inhibition after 5th days on 5mg/kg). (3)
This study has two major limitations that makes it inapplicable at this point; First, the sample size is very small resulting in p-values that shows non-significant statistical difference and wide 25th%–75th% that encompass at several values at most comparisons between 2 arms. Secondly, this study is not followed up with clinical outcomes research and patients are not followed-up for a duration to elicit any clinical benefit.
However, pediatric studies have not been performed on the optimal dose for adequate platelet inhibition and dosing recommendations are based on extrapolation from adult data.(1)  3 to 5 mg/kg/dose PO once daily is recommended as the initial dose for secondary prevention in the guidelines for stroke management in infants and children. If this dose is not tolerated, a dose reduction to 1 to 3 mg/kg/dose PO once daily may be considered.(4)

The data is very limited for the best anti-thrombotic dosage in aspirin for pediatrics (either in ventricle physiology or stroke), however the best recommendation till now according to evidence is 1-5 mg/kg and the data is very limited and unreliable to consider 10mg/kg in practice.

1. Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, et al. Antithrombotic Therapy in Neonates and Children. Chest. 2012 Feb;141(2):e737S-e801S.
2. Israels SJ, Michelson AD. Antiplatelet therapy in children. Thromb Res. 2006 Jan;118(1):75–83.
3. Mir A, Frank S, Journeycake J, Wolovits J, Guleserian K, Heistein L, et al. Aspirin Resistance in Single-Ventricle Physiology: Aspirin Prophylaxis Is Not Adequate to Inhibit Platelets in the Immediate Postoperative Period. Ann Thorac Surg. 2015 Jun;99(6):2158–64.
4. Roach ES, Golomb MR, Adams R, Biller J, Daniels S, deVeber G, et al. Management of Stroke in Infants and Children: A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008 Sep;39(9):2644–91.

Dr. Omar Al-Ashkar