“Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.” –Thomas Sydenham, 17th century physician The prompt and sustained relief of a patient's pain is the goal of all caregivers. Although laudable, this goal is often difficult to achieve as pain is such a highly variable and individualized subjective symptom. Complicating effective pain relief are the multiple factors that influence a patient's perception of pain, both presence and magnitude, including age, emotional state, previous pain episodes, cause of pain, and environment and culture, to
Pediatric patients may be at an increased risk of adverse effects from various medications. Recently, there have been a number of serious adverse events, including several pediatric patients experiencing severe respiratory depression and death as a result of the use of codeine for pain control following tonsillectomy and adenoidectomy. To assess the safety of opioid agonists in pediatric patients undergoing operative procedures or have experienced trauma and to evaluate the risk of respiratory depression and death among this population. PubMed and Medline were searched to identify randomized controlled studies from 1994 to 2012 addressing postsurgery/trauma opioid use in pediatric patients. Relative risks and confidence intervals (CIs) were calculated using data available in clinical trials. A total of 16 clinical trials were evaluated for this review. Randomized controlled trials included studies comparing opioids versus non-opioids for a variety of painful conditions. The relative risk of respiratory depression associated with opioid use in 1 trial was 1.63 (95% CI: 0.64–6.13). The remaining 15 trials reviewed described no significant difference in respiratory depression or adverse effects associated with treatment. No deaths were attributed to opioid use in any of these studies. Opioid-associated respiratory depression was very rare and no deaths were reported in the reviewed studies. These findings under the well-defined conditions of controlled studies may not be the best means of determining overall opioid-associated side effects in pediatric patients.BACKGROUND
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Vitamin D is essential for calcium absorption and for maintaining bone health in the pediatric population. Vitamin D deficiency may develop from nutritional deficiencies, malabsorption, enzyme-inducing medications, and many other etiologies. It may present as hypocalcemia before bone demineralization at periods of increased growth velocity (infancy and adolescence) because the increased calcium demand of the body cannot be met. In children, inadequate concentrations of vitamin D may cause rickets and/or symptomatic hypocalcemia, such as seizures or tetany. In this review, we will discuss the pharmacology behind vitamin D supplementation, laboratory assessments of vitamin D status, current literature concerning vitamin D supplementation, and various supplementation options for the treatment of vitamin D deficiency in the pediatric population.
The aim of this retrospective study was to identify the frequency of recommended metabolic monitoring and follow-up in pediatric patients on second-generation antipsychotic (SGA) medications from a pediatric clinic. A retrospective review of electronic medical records of all patients on antipsychotics from an academic medical center pediatric clinic was conducted. Inclusion criteria required patients to be established members of the pediatric clinic, < 19 years of age, and on ≥ 1 SGA for at least 1 year, regardless of medical diagnosis. Data collection consisted of patient demographic information and frequency of family history, vital signs, and recommended laboratory monitoring. A total of 67 patients on antipsychotics were identified. After the application of inclusion criteria, 32 patients qualified for review. The average age was 13.5 ± 4 years and gender distribution included 72% males. Only 4 (13%) patients had documented baseline monitoring that included weight, blood pressure, and fasting lipid panel. No patient had a fasting plasma glucose recorded at any point during antipsychotic therapy. Follow-up monitoring decreased over time, with the exception of quarterly weight and annual blood pressure. The results of this study highlight the lack of baseline and periodic monitoring that occur when pediatric patients are prescribed antipsychotic medications, putting the patient at risk for adverse events. The marked increase in antipsychotic prescribing and concerns related to their safety emphasize the need for improvement in monitoring of antipsychotic medications. This gap in patient care and safety opens an excellent opportunity for a clinical pharmacy team to provide education and assistance with SGA monitoring for the purpose of providing optimal patient care.OBJECTIVES
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To determine whether an extended infusion time (24 hours) of intravenous fat emulsion is associated with an increase in microbial growth, versus a shorter infusion time (12 hours). Samples were collected from intravenous fat emulsions (n=132), from intravenous fat emulsions prepared in the current 24-hour infusion method (n=55), and from intravenous fat emulsions prepared in the twice-daily (12-hour infusion) method (n=55). In addition, samples were collected from pharmacy (n=22) to test for possible contamination. No growth was observed in either arm of the study. Current Kern Medical Center policy of preparation and administration of neonatal intensive care unit intravenous fat emulsion is safe and effective in regard to microbial growth.OBJECTIVES
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A 9-year-old obese child with a history of ulcerative colitis was admitted to the intensive care unit for significant blood loss, hemorrhagic shock, and acute renal failure. Following complications from total colectomy secondary to multiple perforations, the patient developed heparin-induced thrombocytopenia (HIT) and subsequent portal vein thrombosis. Subcutaneous (SQ) fondaparinux therapy was initiated because the patient was unable to transition to oral anticoagulation. An anti-factor Xa assay was developed and used to adjust his fondaparinux therapy. Based on hemorrhagic complications and fondaparinux-based anti-factor Xa assay results, the fondaparinux was adjusted to a final dosage of 4.5 mg (0.066 mg/kg) SQ daily. In children unable to transition to oral anticoagulation, fondaparinux may be an alternative for the treatment of thrombosis associated with HIT. We noted that our patient required a lower dose per kilogram of fondaparinux than described in previous published reports. Despite this lower dosage per kilogram, our patient developed bleeding despite dosage reductions; subsequently, a few doses were held. It is unclear if this was related to his obesity, history of renal failure, or a combination of factors. Future studies should determine the optimal dose for special populations of children (e.g., those with obesity and renal failure). Until then, clinicians should routinely monitor and titrate fondaparinux therapy, ideally using a fondaparinux-specific anti-factor Xa assay.
Obesity in children and adolescents is a growing epidemic in the United States, and physicians are increasingly looking for safe and effective treatments. In recent years, pharmacologic treatment has been considered for severe and refractory cases of adolescent obesity. We present a case of an obese adolescent who presented to an inpatient psychiatric unit with a body mass index (BMI) of 37.8 (>98th percentile for age). He was started on zonisamide for the purposes of weight loss, and a steady decrease in weight and BMI was noted through 4 months of outpatient follow-up. During this time, the patient's weight decreased from 126.8 kg to 106.2 kg, a 20.6-kg loss, representing a 16.25% reduction in weight. His most recent BMI decreased to 31.7 (96th percentile for age). We discuss the potential use of zonisamide for weight loss in adolescents, considering the potential risks and benefits.
Vancomycin is a glycopeptide antibiotic that is used by the enteral route for the treatment of Clostridium difficile infections and is not thought to be absorbed into the systemic circulation. We report on a 2-year-old, 12.5-kg patient with confirmed C difficile colitis and renal insufficiency that was treated with 125 mg of enteral vancomycin (10 mg/kg); the patient developed measurable systemic concentrations as high as 17.8 mg/L. However, as the patient's colitis began to improve, the serial vancomycin concentrations reflected little to no continued absorption of vancomycin. A review of the literature regarding this rare phenomenon is discussed.
Fondaparinux is a pentasaccharide synthetic derivative of unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH). It possesses increased affinity to inhibit factor Xa compared with UFH and LMWHs.1 Monitoring is not generally recommended except in special patient populations (e.g., pediatric, obese, or pregnant patients or patients with renal failure).1 We faced a significant challenge in determining the appropriate fondaparinux dose for our 9-year-old obese child with a history of renal failure, heparin-induced thrombocytopenia, and thrombosis. Beginning on the first day of therapy, concentrations were sent to a reference laboratory to monitor fondaparinux therapy. However, there was a 24-hour
The Board of Pharmaceutical Specialties is pleased to announce the members of the first Specialty Council on Pediatric Pharmacy. They are: Sandra Benavides Caballero, PharmD, Associate Professor of Pediatrics, Department of Pharmacy Practice, College of Pharmacy, Nova Southeastern University, Clinical Pharmacist in Pediatrics, Children's Medical Services, Department of Health, Fort Lauderdale, FL, Clinical Pharmacist Consultant, Pediatric Emergency Standards, Weston, FL, and Clinical Pharmacist in Pediatrics, Joe DiMaggio Children's Hospital, Hollywood, FL Kimberley W. Benner, PharmD, BCPS, FASHP, FPPAG, Professor and Vice-chair, Department of Pharmacy Practice, Samford University McWhorter School of Pharmacy, and PediatricSPECIALTY COUNCIL ON PEDIATRIC PHARMACY