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Sansone L, Gentile C, Grasso EA, Di Ludovico A, La Bella S, Chiarelli F, Breda L. Pain Evaluation and Treatment in Children: A Practical Approach. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1212. [PMID: 37508709 PMCID: PMC10378137 DOI: 10.3390/children10071212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Pain is the most common complaint reported by children who access the emergency departments, but despite its frequency and the availability of many international guidelines, it often remains underreported and undertreated. Recently, the American Academy of Pediatrics and the American Pain Society have reiterated the importance of a multidisciplinary approach in order to eliminate pain in children. In all pediatric settings, an adequate assessment is the initial stage in a proper clinical approach to pain, especially in the emergency departments; therefore, an increasing number of age-related tools have been validated. A wide range of analgesic agents are currently available for pain management, and they should be tailored according to the patient's age, the drug's pharmacokinetics and the intensity of pain. In order to facilitate the choice of the appropriate drug, a treatment algorithm based on a ladder approach can be used. Moreover, non-pharmacological techniques should be considered to alleviate anxiety and distress in pediatric age. This review aims to offer a simple but intuitive description of the best strategies for pain relief in children, starting with the prompt recognition and quantification of pain through adequate assessment scales, and following with the identification of the most appropriate therapeutic choice among the ones available for pediatric age.
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Affiliation(s)
- Lorenzo Sansone
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Cristina Gentile
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Eleonora Agata Grasso
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Armando Di Ludovico
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Saverio La Bella
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Luciana Breda
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C Ziesenitz
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.
| | - Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Patrick Saur
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Gorenflo
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Johannes N van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Division of Clinical Pharmacology, Children's National Hospital, Washington DC, USA
- Intensive Care and Department of Pediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands
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Crews KR, Monte AA, Huddart R, Caudle KE, Kharasch ED, Gaedigk A, Dunnenberger HM, Leeder JS, Callaghan JT, Samer CF, Klein TE, Haidar CE, Van Driest SL, Ruano G, Sangkuhl K, Cavallari LH, Müller DJ, Prows CA, Nagy M, Somogyi AA, Skaar TC. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2D6, OPRM1, and COMT Genotypes and Select Opioid Therapy. Clin Pharmacol Ther 2021; 110:888-896. [PMID: 33387367 PMCID: PMC8249478 DOI: 10.1002/cpt.2149] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/02/2020] [Indexed: 11/08/2022]
Abstract
Opioids are mainly used to treat both acute and chronic pain. Several opioids are metabolized to some extent by CYP2D6 (codeine, tramadol, hydrocodone, oxycodone, and methadone). Polymorphisms in CYP2D6 have been studied for an association with the clinical effect and safety of these drugs. Other genes that have been studied for their association with opioid clinical effect or adverse events include OPRM1 (mu receptor) and COMT (catechol-O-methyltransferase). This guideline updates and expands the 2014 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 genotype and codeine therapy and includes a summation of the evidence describing the impact of CYP2D6, OPRM1, and COMT on opioid analgesia and adverse events. We provide therapeutic recommendations for the use of CYP2D6 genotype results for prescribing codeine and tramadol and describe the limited and/or weak data for CYP2D6 and hydrocodone, oxycodone, and methadone, and for OPRM1 and COMT for clinical use.
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Affiliation(s)
- Kristine R. Crews
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Andrew A. Monte
- University of Colorado School of Medicine, Department of Emergency Medicine & Colorado Center for Personalized Medicine, Aurora, CO, USA
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Kelly E. Caudle
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Evan D. Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kanas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Henry M. Dunnenberger
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - J. Steven Leeder
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kanas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - John T. Callaghan
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Caroline Flora Samer
- Clinical Pharmacology and Toxicology Department, Geneva University Hospitals, Switzerland
| | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Cyrine E. Haidar
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Sara L. Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gualberto Ruano
- Institute of Living Hartford Hospital, Genomas Lab of Personalized Health; University of Connecticut School of Medicine and University of Puerto Rico Medical Sciences, Hartford, CT, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Daniel J. Müller
- Campbell Family Mental Health Research Institute of CAMH, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Cynthia A. Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mohamed Nagy
- Department of Pharmaceutical Services, Children’s Cancer Hospital Egypt 57357, Cairo, Egypt
| | - Andrew A. Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Todd C. Skaar
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
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Arbaeen A, Wheate NJ, Cairns R. Opioid exposures in children under 5 years of age (2004-2019): A retrospective study of calls to Australia's largest poisons information centre. J Paediatr Child Health 2021; 57:883-887. [PMID: 33460248 DOI: 10.1111/jpc.15348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/11/2020] [Accepted: 12/28/2020] [Indexed: 11/29/2022]
Abstract
AIM To describe time trends in opioid exposures in children under 5 years, and to describe patient demographics, the medicines involved, the reasons for exposure and disposition. METHODS A retrospective analysis of paediatric (<5 years of age) opioid exposure calls to the New South Wales Poisons Information Centre (NSWPIC, Australia's largest poison centre), 2004-2019. Joinpoint regression analysis was used to examine temporal trends. RESULTS There were 4807 cases of paediatric opioid exposure during the 16 year study period, with an average of 300 exposures per year. Exposures increased, 2004-2007, with an annual percentage change (APC) of 14.6% (95% CI = 4.3 to 26.0%), then decreased, 2007-2016, APC -3.4% (95% CI = -5.3 to -1.3%). A steeper decrease was observed after 2016, APC -14.1% (95% CI = -21.8 to -5.6%). The overall APC was -2.3% (95% CI = -4.7 to 0.2%), 2004-2019. Accidental exposures accounted for 86% of calls (4137). The majority of calls were from family members regarding exposures that happened at home, highlighting the need for safety initiatives. The preparations most frequently involved were paracetamol/opioid combination products (primarily codeine), 53% (2566) and ibuprofen/opioid combinations 14% (650). Twenty-two percent of cases were referred to a hospital (1062), and a further 15% (719) of calls originated from hospital staff. CONCLUSION Opioid exposures in young Australian children continue to occur; however, the rate has declined since 2007. Safe storage and parent education initiatives could further reduce the burden of paediatric opioid poisoning in Australia.
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Affiliation(s)
- Abrar Arbaeen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nial J Wheate
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rose Cairns
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Park YR, Kim H, Park JA, Ahn SH, Chang S, Shin JW, Kim M, Lee JH. Comparative Analysis of Single and Combined Antipyretics Using Patient-Generated Health Data: Retrospective Observational Study. JMIR Mhealth Uhealth 2021; 9:e21668. [PMID: 34037528 PMCID: PMC8190646 DOI: 10.2196/21668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 01/27/2021] [Accepted: 04/11/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fever is one of the most common symptoms in children and is the physiological response of the human immune system to external pathogens. However, effectiveness studies of single and combined antipyretic therapy are relatively few due to lack of data. In this study, we used large-scale patient-generated health data from mobile apps to compare antipyretic affects between single and combination antipyretics. OBJECTIVE We aimed to establish combination patterns of antipyretics and compare antipyretic affects between single and combination antipyretics using large-scale patient-generated health data from mobile apps. METHODS This study was conducted using medical records of feverish children from July 2015 to June 2017 using the Fever Coach mobile app. In total, 3,584,748 temperature records and 1,076,002 antipyretic records of 104,337 children were analyzed. Antipyretic efficacy was measured by the mean difference in the area under the temperature change curve from baseline for 6 hours, 8 hours, 10 hours, and 12 hours after antipyretic administration in children with a body temperature of ≥38.0 ℃ between single and combination groups. RESULTS The single antipyretic and combination groups comprised 152,017 and 54,842 cases, respectively. Acetaminophen was the most commonly used single agent (60,929/152,017, 40.08%), and acetaminophen plus dexibuprofen was the most common combination (28,065/54,842, 51.17%). We observed inappropriate use, including triple combination (1205/206,859, 0.58%) and use under 38 ℃ (11,361/206,859, 5.50%). Combination antipyretic use increased with temperature; 23.82% (33,379/140,160) of cases were given a combination treatment when 38 ℃ ≤ temperature < 39 ℃, while 41.40% (1517/3664) were given a combination treatment when 40 ℃ ≤ temperature. The absolute value of the area under the curve at each hour was significantly higher in the single group than in the combination group; this trend was consistently observed, regardless of the type of antipyretics. In particular, the delta fever during the first 6 hours between the two groups showed the highest difference. The combination showed the lowest delta fever among all cases. CONCLUSIONS Antipyretics combination patterns were analyzed using large-scale data. Approximately 75% of febrile cases used single antipyretics, mostly acetaminophen, but combination usage became more frequent as temperature increased. However, combination antipyretics did not show definite advantages over single antipyretics in defervescence, regardless of the combination. Single antipyretics are effective in reducing fever and relieving discomfort in febrile children.
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Affiliation(s)
- Yu Rang Park
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyery Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Ji Ae Park
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hyun Ahn
- Korea Human Resource Development Institute for Health & Welfare, Cheongju, Republic of Korea
| | - Seyun Chang
- Mobile Doctor Co, Ltd, Seoul, Republic of Korea
| | | | | | - Jae-Ho Lee
- Department of Information Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea.,Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
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Gude P, Gustedt F, Bellgardt M, Vogelsang H, Herzog-Niescery J, Dazert S, Weber TP, Volkenstein S. High dose ibuprofen as a monotherapy on an around-the-clock basis fails to control pain in children undergoing tonsil surgery: a prospective observational cohort study. Eur Arch Otorhinolaryngol 2020; 277:2115-2124. [DOI: 10.1007/s00405-020-05929-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
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Cascorbi I. Challenges in Neuropharmacology. Clin Pharmacol Ther 2019; 105:1050-1053. [DOI: 10.1002/cpt.1407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ingolf Cascorbi
- Institute of Experimental and Clinical PharmacologyUniversity Hospital Schleswig‐Holstein Campus Kiel Germany
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