Multisystem Inflammatory Syndrome in Children (MIS-C) was first recognized as a novel illness in 2020 with manifestations similar to other hyperinflammatory syndromes, such as Kawasaki disease or macrophage activation syndrome. Severity varies from a self-limited febrile illness to shock requiring inotropes and mechanical ventilation. Gastrointestinal symptoms and persistent fevers are the most common clinical symptoms, with the addition of cardiac manifestations inclusive of ventricular dysfunction and coronary artery aneurysms. With no controlled trials or comparative effectiveness studies evaluating treatment of MIS-C to date, current treatment with immunomodulatory agents has mainly been derived from previous experience treating Kawasaki disease. This article provides a comprehensive review summarizing published data for the evaluation and management of MIS-C, with a focus on pharmacotherapy treatment considerations.
With significant increases noted in adolescent marijuana use across the United States, perhaps as a result of legislative changes over the past half-decade, clinicians must be increasingly aware of the potential negative health effects. One such effect that warrants concern is cannabinoid hyperemesis syndrome (CHS) in the pediatric population. A systematic review of the literature was performed to determine the safety and efficacy of management strategies for CHS using PubMed, Scopus, the Cumulative Index of Nursing and Allied Health (CINAHL), Web of Science, and Cochrane Library databases. Search terms used in each database were “pediatric OR child OR children OR adolescent” AND “cannabinoid OR marijuana” AND “hyperemesis OR cyclic vomiting OR vomiting” NOT “seizure OR chemotherapy OR pregnancy OR cancer OR AIDS OR HIV.” Fourteen pieces of literature that described either effective, ineffective, or supportive management strategies for pediatric CHS were included in this review. Benzodiazepines were the most reported efficacious agents, followed by topical capsaicin cream and haloperidol. A total of 9 of the 14 studies described intravenous fluid resuscitation and hot bathing rituals as supportive measures, and 7 cases reported traditional antiemetics were ineffective for CHS. The heterogenicity of reported data, combined with the limited number of encounters, make it difficult to ascertain whether a definitive treatment strategy exists. Clinicians should be cognizant of pharmacotherapy agents that are efficacious, and perhaps more importantly, avoid using traditional antiemetic therapies that do not provide benefit.
A venous thromboembolism (VTE) is a blood clot that occurs secondary to vessel wall injury often from a central line insertion. Enoxaparin is often considered a first-line treatment in pediatrics for VTE due to its favorable kinetic profile. Enoxaparin monitoring for pediatric patients is accomplished through anti-Xa monitoring in which monitoring practices may vary between institutions. The objective of this study is to evaluate covariates in pediatric patients to determine which variables are most likely to be associated with enoxaparin dose changes as a result of anti-Xa monitoring. A single center, retrospective chart review was conducted in pediatric patients treated with enoxaparin for VTE over a 10-year period and who were assessed to determine covariates that lead to dose changes based on anti-Xa levels. Secondary outcomes described monitoring patterns at the University of New Mexico Children's Hospital. Sixty-eight patients met inclusion criteria in which results showed that patients aged 2 to 5.9 months (p = 0.026), who had critical care status (p = 0.009), and who were of Native American ethnicity (p = 0.016) were likely to have an enoxaparin dose change at least once during their treatment regimen. The mean number of levels drawn were 7.5 per patient over a 6- to 12-week period, and doses were not frequently changed based on a confirmatory lab draw. However, many doses were adjusted based on the week 1 post-therapeutic level. Patients of Native American ethnicity, younger than 6 months, and those admitted to the PICU were likely to have dose changes based on anti-Xa levels.OBJECTIVES
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Safety information regarding the use of medication, over-the-counter drugs, and supplements for Japanese children is scarce. The aim of this study was to clarify adverse drug reaction (ADR) experiences in children and consider the method to collect ADRs efficiently. We conducted a questionnaire survey regarding the ADR experiences of 20,412 children who were attending a preschool or kindergarten in the cities of Warabi and Toda, Saitama Prefecture, in May 2013. Responses were received from the guardians of 15,076 children (49.5% girls; 8.2 ± 3.5 yr). A total of 196 guardians (1.3%) responded that their children had experienced ADRs. Among them, a total of 243 suspected drugs and 284 ADRs were reported. Of the 243 suspected drugs, 2.5% were associated with a vaccine. The most frequently reported medication, reaction, and “medication–reaction pair” were antibacterials for systemic use, rash, and “antibacterials for systemic use and rash,” respectively. In this study, we clarified that there were many potential ADRs among children, but all “medication–reaction pairs” reported were consistent with adverse events reported in the clinical trials available in the prescribing information of each medication. This study provides data respective to the frequency of these adverse events in the general pediatric population. Additional education is needed to enlighten guardians of the importance to report ADRs through the Direct Patient Reporting System.OBJECTIVE
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To determine the use of melatonin and its role in therapy for pediatric delirium (as either prophylaxis or treatment for delirium) in an academic medical center's PICU. This retrospective, single-center study reviewed patients between 1 and 18 years of age admitted to the PICU between April 1, 2014, and February 29, 2019. Patients were included if they were admitted for greater than 48 hours and received melatonin for the indication of “delirium.” Patients were excluded if melatonin was a home medication. Data collected included baseline characteristics, sedation and antipsychotic usage, assessment scores, and admission overview data. Descriptive statistics were used to report categorical data as percentages. A total of 63 patients were included. Thirty-nine patients (62%) required antipsychotics post–melatonin exposure, with risperidone being the most frequently used agent. The average cumulative antipsychotic exposure pre– and post–melatonin initiation was 2 versus 13 days. The average cumulative exposure to sedating agents, including opioids, benzodiazepines, ketamine, dexmedetomidine, and propofol, pre– and post–melatonin initiation was 13 versus 10 days. The average hospital and PICU lengths of stay were 54 and 39 days, respectively. The initiation of melatonin was also associated with lighter levels of sedation and decreased pain scores. Although the initiation of melatonin does not appear to decrease antipsychotic use, the results of this study may suggest a potential prophylactic effect in reducing the days of sedation the patient receives while inpatient.OBJECTIVE
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We assessed the impact of acid suppression therapy (i.e., ranitidine or proton pump inhibitors) on iron supplementation and its ability to maintain or alter laboratory values that are commonly associated with anemia. This was a prospective, observational trial. The primary outcome was changes in serum iron levels from baseline. Secondary outcomes were changes in hemoglobin (Hgb) and hematocrit (Hct), transfusions, and maintenance of an alkalotic gastric pH. Thirty-four patients (mean 24 ± 43 months) met inclusion criteria. The serum iron levels increased to 50.9 ± 24.6 mcg/dL by day 3. The mean difference from baseline was 1.5 mcg/dL (95% CI, 1.14–1.98, p = 0.0056). Gastric pH increased to 4.68 ± 1.49 on day 5. The mean Hgb and Hct increased on day 5 to 10 ± 1.06 g/dL and 29.6% ± 3.27%, respectively. The mean difference of Hgb was 1.15 g/dL (95% CI, 0.51–1.78, p = 0.0009). The mean difference of Hct was 3.04% (95% CI, 1.11–4.97, p = 0.0032). The use of antacids along with oral ferrous sulfate supplementation did not affect the absorption of iron. Serum iron, Hgb, and Hct all showed statistically significant increases despite combined antacid and iron therapy. Thus, despite use of antacids, combination use showed increases in iron absorption.OBJECTIVE
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The primary objective was to compare the volume of distribution (Vd), clearance (CL), elimination rate (Ke), and half-life (t½) of amikacin in neonates with cyanotic defects, acyanotic defects, and controls, adjusted for gestational and postnatal age. Secondary objectives were to compare the incidence of acute kidney injury (AKI) between controls and the congenital heart disease (CHD) group and to identify potential risk factors. This retrospective cohort study included neonates receiving amikacin from January 1, 2013 to August 31, 2016. Patients were excluded if concentrations were not appropriately obtained or if AKI or renal anomalies were identified prior to amikacin initiation. Congenital heart disease was classified as acyanotic or cyanotic. Patients with CHD were matched 1:1 with non-CHD controls according to postmenstrual age. Bivariate analyses were performed using Wilcoxon-Mann-Whitney test, Pearson χ2 tests, or Fisher exact as appropriate with a p value <0.05. Regression analyses included logistic and analysis of covariance. Fifty-four patients with CHD were matched with 54 controls. Median (IQR) postnatal age (days) at amikacin initiation significantly differed between CHD and controls, 3.0 (1.0–16.0) versus 1.0 (1.0–3.0), p = 0.016. After adjusting for gestational and postnatal age, there was no difference in the mean (95% CI) Vd (L/kg) and CL (L/kg/hr) between CHD and controls, 0.47 (0.44–0.50) versus 0.46 (0.43–0.49), p = 0.548 and 0.05 (0.05–0.05) versus 0.05 (0.05–0.05), p = 0.481, respectively. There was no difference in Ke or t½ between groups. There was no difference in AKI between the CHD and controls, 18.5% versus 9.3%, p = 0.16. Clinicians should consider using standard amikacin dosing for neonates with CHD and monitor renal function, since they may have greater AKI risk factors.OBJECTIVES
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This study aims to use and evaluate the Nephrotoxic Injury Negated by Just-in-time Action (NINJA) program in hospitalized patients with cystic fibrosis (CF) at Children's Healthcare of Atlanta. This was a single-center study evaluating patients with CF who were hospitalized and admitted to the pulmonary service 4 months pre- and post-NINJA implementation. Postimplementation patients with high nephrotoxic medication (NTMx) exposure were identified using an electronic reporting tool that triggered the pharmacist to alert the medical team and recommend Monday/Wednesday/Friday serum creatinine (SCr) monitoring. High NTMx exposure was defined as 3 or more NTMxs given concurrently, or at least 3 consecutive days of IV aminoglycosides or vancomycin. Outcomes assessed were rate of SCr monitoring, NTMx exposure, and days of acute kidney injury (AKI) pre- and post-NINJA implementation. A total of 19 patients and 25 high-NTMx exposures were identified both pre- and post-NINJA implementation. The SCr monitoring increased from 13% to 50% of NTMx exposure days in the pre- versus post-NINJA time frame. More NTMx exposure days occurred in the post-NINJA time frame, from 250 exposure days per 1000 patient days pre-NINJA to 521 post-NINJA. An increased incidence of AKI events and AKI days were noted post-implementation; however, these differences were not significantly different between the 2 groups. Increased SCr monitoring for patients with NTMx exposure using NINJA uncovered more episodes of AKI. Increased prevalence of NTMx use was associated with increased rates of AKI. Increased SCr monitoring as a result of NINJA implementation may allow for earlier detection of AKI.OBJECTIVE
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Children with epilepsy are at increased risk of medication errors due to disease complexity and administration of time-sensitive medication. Errors frequently occur during transitions of care between home and hospital, a time when accuracy of medication history lists is difficult to ascertain. Adverse events likely from medication discrepancies underscore the importance of improving medication reconciliation upon inpatient intake. This quality improvement project was designed to evaluate and optimize the current medication history process in epileptic patients upon hospital admission at a pediatric academic hospital. A retrospective chart review was conducted on 30 patients with epilepsy admitted in during April, July, and October 2018 to identify unintentional medication discrepancies among 6 sources: documented medication history, inpatient orders from the electronic medical record, outpatient clinic notes, inpatient history and admission document, phone message records, and external insurance claims. A total of 63% percent of patients had at least 1 unintentional medication discrepancy. Most discrepancies occurred with daily maintenance anticonvulsants (63%). The most common types were omission of medication history (31%) and inpatient order omissions (27%). The number of medication histories completed with at least 1 discrepancy varied across pharmacists, nurses, and physicians, yet differences were not statistically significant. Our study found a higher incidence of anticonvulsant discrepancies compared with previous studies. This quality improvement initiative identified the absence of a standardized process as the root cause for the high incidence of anticonvulsant discrepancies in pediatric patients with epilepsy at hospital admission.BACKGROUND
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In the hospital settings, buprenorphine is used for the treatment of patients with neonatal abstinence syndrome. It is extemporaneously compounded and stored in oral plastic syringes. However, limited information exists about the stability of buprenorphine and its compounded formulations when stored under specific conditions. Hence, we developed a stability-indicating high-performance liquid chromatography–mass spectrometry (LC-MS) method to analyze the stability of buprenorphine over time. A stability-indicating LC-MS method was developed to map the potential degradation peaks of buprenorphine when exposed to acidic, basic, and oxidative conditions. This method was used to study the stability of compounded buprenorphine oral syringes stored under refrigeration (2°C–8°C) and room temperature (25°C ± 2°C with 60% relative humidity). Syringes from each storage condition were assessed for stability using pH meter and stability-indicating LC-MS assay for 30 days. Buprenorphine gets completely degraded in the presence of acid at the end of 1 hour of exposure. Various degradation peaks were identified using LC-MS assay for buprenorphine under acidic, basic, and peroxide conditions. Stability study of oral buprenorphine syringes showed no precipitation, cloudiness, or color change during this study at all storage conditions. The LC-MS assay revealed that buprenorphine oral syringes retained greater than 90% of the initial concentrations for 30 days. Highly sensitive stability-indicating LC-MS method was developed for studying the stability of extemporaneously compounded buprenorphine oral syringes. This study demonstrates that buprenorphine extemporaneous formulation prepared according to the manufacturers' recommendations is stable under refrigerated or room temperature conditions for 30 days in oral plastic syringes.OBJECTIVE
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This case report evaluates the potential benefit of pitolisant in a 15-year-old female with Prader-Willi syndrome, obsessive-compulsive disorder, autism spectrum disorder, and mild intellectual disability. Due to its action on the H3 receptor, it enhances central activity of histaminergic neurons resulting in increased alertness, irrespective of the loss of orexin neurons seen in narcolepsy. Additionally, it is thought to modulate various other neurotransmitter systems including acetylcholine, norepinephrine, and dopamine. Pitolisant has the potential to improve many symptoms in patients with Prader-Willi syndrome and it appears to be well tolerated with minimal side effects observed. Therefore, the use of pitolisant should be considered in patients with Prader-Willi syndrome who fail a psychostimulant trial.
Renal toxicity has been described with tramadol overdoses; however, it is typically associated with rhabdomyolysis, multiorgan failure and/or mortality. Our patient was a 16-year-old female who was evaluated following an intentional tramadol ingestion, estimated 27.8 to 37 mg/kg, and had a seizure prior to arriving at our health care facility. Her symptoms were consistent with a tramadol ingestion; however, she developed transient acute renal impairment (peak serum creatinine, 4.04 mg/dL), which improved over 6 days with minimal intervention. No other causes were identified to explain her acute renal impairment thus it was attributed to the tramadol overdose. Providers should be aware that transient acute renal impairment could occur with an intentional tramadol ingestion and may not require aggressive intervention.
Congenital junctional ectopic tachycardia is a rare and special type of supraventricular arrhythmia. Junctional ectopic tachycardia is characterized by persistently elevated heart rates that may cause an impairment in cardiac function. Junctional ectopic tachycardia is considered one of the most difficult-to-treat conditions even with a combination of antiarrhythmic medications. Ivabradine is a novel antiarrhythmic medication used to decrease the heart rate in adults with angina pectoris. We report a first case of a premature neonate with a normal heart structure who developed junctional ectopic tachycardia and was subsequently treated successfully with ivabradine.
Vaccination efforts against COVID-19 must include the pediatric population, not only to protect children and their families from the virus, but also to support a safe return to in-person schooling. Given the novel methodologies and targets used in the COVID-19 vaccines and the potential for multisystem inflammatory syndrome-children, it is insufficient to extrapolate safety and efficacy data between different vaccine candidates or from adult studies. Adequate enrollment in pediatric studies for COVID-19 vaccines is crucial. The Pediatric Pharmacy Association supports continued research, surveillance, and transparency for COVID-19 vaccines in the pediatric population, including those younger than 12 years of age.