Prescription drug dispensing profiles for one million children: a population-based analysis

Considerable paediatric drug dispensing - A nationwide study of more than 2 million Swedish children

AIM

The aim of the nationwide study was to describe paediatric drug utilisation in Sweden.

METHODS

Drug prescriptions dispensed to all children aged 0-17 years in 2019 were analysed using data from the Swedish National Prescribed Drug Register.

RESULTS

We retrieved data on 2 180 508 unique children. Nearly 4.6 million prescriptions were dispensed to children aged 0-17 years, and 52% of these were to boys. Just under half of the children (47%) were dispensed at least one drug: 48% of girls and 45% of boys (p < 0.01). More than a third (34%) were dispensed three or more different drugs during 2019. The number of dispensed prescriptions per 1000 children was higher in boys than girls up to 12 years of age (p < 0.01), and the opposite trend was observed from 13 years and above, even when we excluded contraceptives (p < 0.01). The most common therapeutic areas were drugs for the respiratory tract (25%), namely antihistamines, antiasthmatics and cough medication. These were followed by psychoanaleptics and melatonin for the nervous system (19%) and dermatologicals (16%), namely cortisone creams and emollients.

CONCLUSION

Paediatric drug use was common, and a considerable proportion of children were dispensed multiple drugs.

Urinary antibiotics concentrations, their related affecting factors and infant growth in the first 6 months of life: A prospective cohort study

Antibiotic exposure even in low-dose could have potential adverse health effects, especially during early life. There is a lack of data on antibiotic burdens in early infancy. We aim to assess antibiotic exposure in infants from birth to 6 months of age, their related affecting factors and the association between antibiotic exposure and infancy growth. Urine samples were collected at ages of 3 days, 42 days, 3 months and 6 months from 197 term-born Chinese infants. A total of 33 representative antibiotics were measured by high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Urinary antibiotics were detectable in 69.4%, 63.2%, 75.0% and 84.3% of infants at ages of 3 days, 42 days, 3 and 6 months, respectively. The dominant antibiotic categories detected were: Preferred as Veterinary Antibiotics (PVAs), Human Antibiotics (HAs), and Veterinary Antibiotics (VAs). The detectable rates were 30.6%, 45.8%, 58.9%, and 81.4% for PVAs, 34.1%, 20.8%, 28.6%, and 45.1% for HAs, and 36.5%, 12.5%, 6.3%, and 5.9% for VAs, at age 3 days, 42 days, 3 and 6 months, respectively. Urinary concentrations of HAs and preferred as human antibiotics (PHAs) in newborns at age 3 days were not associated with maternal intrapartum antibiotic prophylaxis. Similarly, no associations were observed between urinary antibiotics concentration and antibiotics use in infants at age 42 days or 6 months. The numbers and concentrations of urine detectable antibiotics were similar between infants with exclusive breastfeeding and infants fed with formula or mixed-feeding at all ages of 42 days, 3 and 6 months. At age of 42 days, infants in the low tertile of total antibiotics concentration or with one antibiotic detected had higher weight-for-length Z score and greater head circumference, compared to infants with no antibiotics detected. No associations were found between urinary antibiotics and any of the infant anthropometric measures at age 6 months. In conclusion, urinary antibiotics were detectable in most infants during the first 6 months of life, and PVAs, HAs and VAs were the most commonly detected antibiotics. This suggested the possibility of a foods-originated antibiotics exposure in children. No strong nor consistent associations were found between urinary antibiotic concentration and infant growth at the first six months of life. Still, attention is needed on the adverse health effect of early life exposure to antibiotics in future studies.

Antibiotics administration alleviates the high fat diet-induced obesity through altering the lipid metabolism in young mice

Currently, there is a global trend of rapid increase in obesity, especially among adolescents. The antibiotics cocktails (ABX) therapy is commonly used as an adjunctive treatment for gut microbiota related diseases, including obesity. However, the effects of broad-spectrum antibiotics alone on young obese hosts have rarely been reported. In the present study, the 3-week-old C57BL/6J male mice fed a high-fat diet (HFD) were intragastric administration with ampicillin, vancomycin, metronidazole or neomycin for 30 days. The lipid metabolites in plasma were assessed by biochemical assay kits, and genes related to lipid metabolite in the white adipose were assessed by qPCR. To further analyze the underlying mechanisms, the expression of genes related to lipid metabolism, inflammatory reactions and oxidative stress in the liver were determined by qPCR assay. In addition, the expression of oxidative damage-associated proteins in the liver were detected by western blot. The results showed that oral antibiotics exposure could reduce body weight and fat index in HFD-fed mice, concurrent with the increase of white adipose lipolysis genes and the decrease of hepatic lipogenic genes. Furthermore, antibiotics treatment could clearly reverse the HFD-induced elevation of oxidative damage-related proteins in the liver. Together, these findings will provide valuable clues into the effects of antibiotics on obesity.

Impact of antibiotics on off-target infant gut microbiota and resistance genes in cohort studies

BACKGROUND

Young children are frequently exposed to antibiotics, with the potential for collateral consequences to the gut microbiome. The impact of antibiotic exposures to off-target microbes (i.e., bacteria not targeted by treatment) and antibiotic resistance genes (ARGs) is poorly understood.

METHODS

We used metagenomic sequencing data from paired stool samples collected prior to antibiotic exposure and at 1 year from over 200 infants and a difference-in-differences approach to assess the relationship between subsequent exposures and the abundance or compositional diversity of microbes and ARGs while adjusting for covariates.

RESULTS

By 1 year, the abundance of multiple species and ARGs differed by antibiotic exposure. Compared to infants never exposed to antibiotics, Bacteroides vulgatus relative abundance increased by 1.72% (95% CI: 0.19, 3.24) while Bacteroides fragilis decreased by 1.56% (95% CI: -4.32, 1.21). Bifidobacterium species also exhibited opposing trends. ARGs associated with exposure included class A beta-lactamase gene CfxA6. Among infants attending day care, Escherichia coli and ARG abundance were both positively associated with antibiotic use.

CONCLUSION

Novel findings, including the importance of day care attendance, were identified through considering microbiome data at baseline and post-intervention. Thus, our study design and approach have important implications for future studies evaluating the unintended impacts of antibiotics.

IMPACT

The impact of antibiotic exposure to off-target microbes and antibiotic resistance genes in the gut is poorly defined. We quantified these impacts in two cohort studies using a difference-in-differences approach. Novel to microbiome studies, we used pre/post-antibiotic data to emulate a randomized controlled trial. Compared to infants unexposed to antibiotics between baseline and 1 year, the relative abundance of multiple off-target species and antibiotic resistance genes was altered. Infants who attended day care and were exposed to antibiotics within the first year had a higher abundance of Escherichia coli and antibiotic resistance genes; a novel finding warranting further investigation.

From Prescription Drugs to Natural Health Products: Medication Use in Canadian Infants

Limited data exist on pharmaceutical product use by infants, although available data suggests higher prevalence of use among children under 12 months of age. We conducted a descriptive study of 3050 infants recruited in the CHILD Cohort Study, a prospective, multicenter, longitudinal cohort following children from pregnancy through childhood. Parents were surveyed for use of prescription and over-the-counter drugs, and natural health products (NHPs, including homeopathic products and vitamins) at 3, 6, and 12 months after delivery. By one year of age, 96.0% of children had taken at least one pharmaceutical product. Among 307 reported products, 32 were given to at least 1% of cohort infants. Vitamin D, acetaminophen, ibuprofen, topical hydrocortisone, amoxicillin, and nystatin were the most common medications and natural health products (NHPs) received, with 8/32 of the most frequently used products being NHPs. Overall, 14.7% of pharmaceutical products administered to children were off-label and 35.8% were NHPs or products without a Drug Identification Number (DIN). The use of over-the-counter medications and NHPs is common and off-label use of drugs is frequent, even in the first year of life. This study highlights the importance of conducting studies on medication use in infants, and of infant medication use monitoring by healthcare providers.

Pediatric Outpatient Prescriptions in Countries With Advanced Economies in the 21st Century: A Systematic Review

Importance

An international comparison of pediatric outpatient prescriptions (POPs) is pivotal to investigate inadequate practices at the national scale and guide corrective actions.

Objective

To compare annual POP prevalence among Organisation for Economic Co-operation and Development (OECD) member countries.

Evidence Review

Two independent reviewers systematically searched PubMed, Embase, and institutes of public health or drug agency websites for studies published since 2000 and reporting POP prevalence (expressed as number of patients aged <20 years with ≥1 POP per 1000 pediatric patients per year) in OECD member countries or large geographic areas within them. Risk of bias was assessed for exhaustiveness and representativeness. Prevalence ratios (PRs) were used to compare the highest and lowest POP prevalence among countries overall, by levels of Anatomical Therapeutic Chemical (ATC) classification for the overall pediatric population, and by age group (ie, ages <5-6 vs ≥5-6 years), stratifying on prescription-only drug (POD) status.

Findings

Among 11 studies performed on 3 regional and 8 national medicoadministrative databases in 11 countries, 35 552 550 pediatric patients were included. The overall risk of bias was low (10 studies were representative [90.9%], and the prevalence denominator included nonusers of health care for 9 studies [81.8%]). Prevalence of 1 or more POP per year ranged from 480 to 857 pediatric patients per 1000 in Sweden and France, respectively (PR, 1.8 [95% CI, 1.8-1.8]). Overall, among 8 studies reporting ATC level 1 drugs, Denmark had the lowest POP prevalence (eg, systemic hormonal preparations: 9 pediatric patients per 1000 per year) and France the highest (eg, systemic hormonal preparation: 216 pediatric patients per 1000 per year). Among 8 studies reporting ATC level 2 drugs for PODs, the PR between France and Denmark was 108.2 (95% CI, 108.2-108.2) for systemic corticosteroids and 2.1 (95% CI, 2.1-2.1) for drugs for obstructive airway disease. The PR for antibiotics was 3.4 (95% CI, 3.4-3.4) between New Zealand and Sweden. For pediatric patients aged 5 to 6 years or older, the PR for sex hormones was 2.1 (95% CI, 2.1-2.1) between Denmark and France. Among 7 studies reporting ATC level 5 drugs, the prevalence of the 10 most prevalent PODs was less than 100 pediatric patients per 1000 per year in Scandinavian countries and the Netherlands and less than 300 pediatric patients per 1000 per year in France and New Zealand.

Conclusions and Relevance

This study found large between-country variations in POPs, which may suggest substantial inappropriate prescriptions. The findings may suggest guidance for educational campaigns and regulatory decisions in some OECD member countries.

Medicine and supplement use in infants, children, and adolescents depends on sex, age, and socioeconomic status: results of a German longitudinal population-based cohort study (LIFE Child)

Children and adolescents are exposed to medicines and supplements, but only a few studies have evaluated the actual intake in routine care. Thus, we performed a pharmacoepidemiological evaluation of a longitudinal population-based pediatric cohort study (LIFE Child) conducted at the University Hospital of Leipzig between 2014 and 2019. We analyzed all visits of the participants of the LIFE Child cohort between 1 January 2014 and 31 December 2019. Participants were asked to bring their medicines and supplements to their appointments at the study center. If they had not brought the preparations with them, attempts were made to obtain the relevant information during a telephone call after the visit to the study center. Furthermore, the participants and their parents were interviewed on medicine and supplement use and on sociodemographic and socioeconomic data during their visit to the study center. Associations of medicine and supplement use with age, sex, and socioeconomic status were analyzed using multivariate binary logistic regressions to obtain adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Furthermore, the number of the respective visit was included as possible confounder in the multivariate model. We included 3602 participants who visited the study center 11,906 times. The intake of 9759 medicines and supplements was recorded. Based on the evaluation of all study visits, 49% of the children and adolescents took at least one medicine or supplement. Self-medication accounted for 28% of the medicines and supplements. The prevalence of overall intake increased from 45% in 2014 to 53% in 2019 (aOR 2.63, 95% CI 2.23, 3.09). The prevalence was the highest (77%) in children aged 0- < 3 years, owing mainly to vitamin D. The prevalence of medicine use was higher in females (40%; aOR 1.18, 95% CI 1.10, 1.28) than in males (35%), owing mainly to the intake of ibuprofen and hormonal contraceptives in adolescent females. A high socioeconomic status was a predictor of lower medicine (aOR 0.80, 95% CI 0.68, 0.95) and higher supplement (aOR 1.47, 95% CI 1.09, 1.98) use.

CONCLUSION

Half of all children and adolescents took at least one medicine or supplement. The intake varied depending on age and sex. Furthermore, high socioeconomic status was associated with a decreased probability of medicine intake.

WHAT IS KNOWN

• Half of all children and adolescents in Germany are exposed to medicines and supplements. • Data on the actual intake are scarce as most studies focus on prescribed medicines.

WHAT IS NEW

• The prevalence of medicine/supplement use rose from 2014 (45%) to 2019 (53%). The prevalence was age-dependent: it was the highest in children aged < 3 years, and the lowest in children aged 6-< 9 years. Females took medicines more frequently than males. • High socioeconomic status was associated with lower medicine and higher supplement use. Self-medication accounted for 28% of all preparations.

The association between early life antibiotic exposure and the gut resistome of young children: a systematic review

Antimicrobial resistance is a growing public health burden, but little is known about the effects of antibiotic exposure on the gut resistome. As childhood (0-5 years) represents a sensitive window of microbiome development and a time of relatively high antibiotic use, the aims of this systematic review were to evaluate the effects of antibiotic exposure on the gut resistome of young children and identify knowledge gaps. We searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials. A PICO framework was developed to determine eligibility criteria. Our main outcomes were the mean or median difference in overall resistance gene load and resistome alpha diversity by antibiotic exposure groups. Bias assessment was completed using RoB 2 and ROBINS-I with quality of evidence assessed via the GRADE criteria. From 4885 records identified, 14 studies (3 randomized controlled trials and 11 observational studies) were included in the qualitative review. Eight studies that included information on antibiotic exposure and overall resistance gene load reported no or positive associations. Inconsistent associations were identified for the nine studies that assessed resistome alpha diversity. We identified three main groups of studies based on study design, location, participants, antibiotic exposures, and indication for antibiotics. Overall, the quality of evidence for our main outcomes was rated low or very low, mainly due to potential bias from the selective of reporting results and confounding. We found evidence that antibiotic exposure is associated with changes to the overall gut resistance gene load of children and may influence the diversity of antimicrobial resistance genes. Given the overall quality of the studies, more research is needed to assess how antibiotics impact the resistome of other populations. Nonetheless, this evidence indicates that the gut resistome is worthwhile to consider for antibiotic prescribing practices.

Understanding patient characteristics and medication prescriptions in children with mental health and neurodevelopmental disorders referred to a sleep clinic-A quality improvement/quality assurance analysis

INTRODUCTION

Motivated by challenges faced in outpatient sleep services for mental health and neurodevelopmental disorders (MHNDD) during the COVID-19 clinical shutdown, a pan-Canadian/international working group of clinicians and social scientists developed a concept for capturing challenging sleep and wake behaviours already at the referral stage in the community setting.

METHODS

In a quality improvement/quality assurance (QIQA) project, a visual logic model was the framework for identifying the multiple causes and possible interventions for sleep disturbances. Intake forms informed clinicians about situational experiences, goals/concerns, in addition to the questions from the Sleep Disturbances Scale for Children (SDSC), the ADHD Rating Scale-IV and medication history. Descriptive statistics were used to describe the sample.

RESULTS

66% of the pilot study patients (n = 41) scored in the SDSC red domains (highest scoring) with highest sub-scores for insomnia (falling asleep 73%; staying asleep: 51%) and daytime somnolence (27%). A total of 90% of patients were taking at least one medication; 59% sleep initiation/sleep medications, 41% in combination with further non-stimulant medications, 9% with stimulants, 27% with antidepressants and 18% with antipsychotics. Polypharmacy was observed in 62% of all patients and in 73% of the ones medicated for sleep disturbances. Qualitative information supported individualisation of assessments.

CONCLUSION

Our intake process enabled a comprehensive understanding of patients' sleep and wake profiles prior to assessment, at the referral stage. The high prevalence of insomnia in patients, combined with polypharmacy, requires special attention in the triaging process at the community level.

Disruptive Behaviors and Intellectual Disability: Creating a New Script

BACKGROUND

Terms currently used to describe the so-called challenging and disruptive behaviors (CBDs) of children with intellectual disabilities (ID) have different connotations depending on guiding contextual frameworks, such as academic and cultural settings in which they are used. A non-judgmental approach, which does not attempt to establish existing categorical diagnoses, but which describes in a neutral way, is missing in the literature. Therefore, we tried to describe CDBs in youth with ID in an explorative study.

METHODS

Interviews with families investigated the CDBs of five youth with Down syndrome. At home, families tracked youth's sleep/wake behaviors and physical activity. Youth were observed in a summer school classroom. The collected information and suggested explanatory models for observed CDBs were reviewed with the families.

RESULTS

We grouped CDBs as challenging, if they were considered to be reactive or triggered, or unspecified, if no such explanatory model was available. A third category was created for light-hearted CDBs: goofy, acknowledging the right to laugh together with peers. We found some relationships between sleep, physical activity, and CDBs and developed an explorative approach, supporting a child-centered perspective on CDBs.

CONCLUSION

The controversial discussions on terminology and management of CDBs in the literature demonstrate the need for a non-judgmental approach. Such an explorative approach, allowing non-professionals to not label, has been missing. The fact that, up to now, the light-hearted behaviors of an individual with ID have not been integrated in commonly-used behavioral checklists as their natural right, proves our concept and indicates that a paradigm change from judgment-based to exploratory-driven approaches is needed.

Analysis of the potential inappropriate use of medications in pediatric outpatients in China

Background

The appropriate use of medications is essential in children. Yet, detailed information on how drugs are being prescribed and dispensed to pediatric populations is not documented in China.

Aim

The study objective was to analyze the details of medicine use and categorize the types of inappropriate use of medications on children.

Methods

A retrospective cross-sectional study was conducted on the prescriptions of pediatric outpatients aged < 18 years from 2019 to 2020 at a major Chinese tertiary academic center. Each age group’s demographic and clinical characteristics were collected, and the ratios of inappropriate prescriptions were analyzed.

Results

The total number of pediatric outpatients was 652,152, and 49.37% (322000) were prescribed medications, in which the most widely used medicines were respiratory, anti-infectives, and Traditional Chinese Medicines (TCMs). The prevalence rate of inappropriate prescriptions reached 20.49%, and in 2019 it was higher (21.71%) than that in 2020 (18.36%). The top three common inappropriate categories were indication-related off-label drug use, improper administration frequency, and overdosing, accounting for 67.93, 17.80 and 11.06% of all inappropriate prescriptions, respectively. The inappropriate prescriptions were more likely seen in patients aged 2–5 years and respiratory medicines.

Conclusions

The study findings indicate that inappropriate drug use in pediatric outpatients is still common, and great attention needs to be paid. More prospective trials are required to identify the effectiveness, safety, and necessity of off-label drug use of medicines in children.

Paediatric outpatient prescriptions in France between 2010 and 2019: A nationwide population-based study: Paediatric outpatient prescriptions in France, 2010 to 2019

Background

Paediatric outpatient prescription (POP) monitoring is pivotal to identify inadequate prescriptions and optimize drug use. We aimed at describing recent trends in POPs in France.

Methods

All reimbursed dispensations of outpatient prescribed drugs (excluding vaccines) were prospectively collected for the paediatric population (<18 years old) in the French national health database in 2010-2011 and 2018-2019 (mean 117,356,938/year). POP prevalence (proportion of children receiving ≥1 drug prescriptions/year) was calculated by age groups and compared by prevalence rate ratios (PRRs). Given the large sample size, 95% confidence intervals of POP prevalences and PRRs did not differ from estimates.

Findings

Among the 14,510,023 children resident in France in 2018-2019, mean POP prevalence was 857‰ children. Most prescribed therapeutic classes were analgesics (643‰), antibiotics (405‰), nasal corticosteroids (328‰), nonsteroidal anti-inflammatory drugs (NSAIDs) (244‰), antihistamines (246‰) and systemic corticosteroids (210‰). POPs decreased with age from 976‰ for infants to 782‰ for adolescents. Children <6 years old were notably more exposed to inhaled corticosteroids (PRR=3.06), non-penicillin beta-lactam antibacterial agents (PRR=3.05) and systemic corticosteroids (PRR=2.11) than older ones. The POP prevalence was slightly higher (PRR=1.04) during 2018-2019 than 2010-2011, with marked increases for anti-emetics (PRR=1.84), vitamin D (PRR=1.49), proton pump inhibitors (PRR=1.42), systemic contraceptives (PRR=1.24) and nasal corticosteroids (PRR=1.21) and decreases for propulsive/prokinetic agents (PRR=0.09), NSAIDs (PRR=0.73) and systemic antibiotics (PRR=0.88).

Interpretation

POP remained highly prevalent in France throughout the 2010s, especially for children <6 years old, with only a few improvements for selected therapeutic classes. These findings should prompt clinical guidance campaigns and/or regulatory policies.

Funding

Internal funding.

Application of antibiotics before 3 years of age increases the risk of childhood overweight and obesity

Childhood obesity and antibiotics abuse have become global health problems. It is necessary to explore the correlation between application of antibiotics for children under 3 and the risk of overweight and obesity in children. In the present study, young children aged 3 (36-38 months) were investigated using a face-to-face questionnaire survey. These children were admitted to Dongying City Children's Hospital from December 2017 to May 2019, and the effective sample size was 4,258. According to the body mass index (BMI), young children were divided into two groups, including emaciation and normal group as well as overweight and obesity group. Univariate analysis was performed to identify the possible influencing factors between the two groups using chi-square test. A difference of P<0.05 indicated statistical significance of a certain factor between the two groups, which could be adopted as an influencing factor in Logistic regression analysis. In addition, odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) were employed to quantify the correlation of antibiotic application with the risk of overweight and obesity. A total of 3,322 young children (78.0%) were included in the antibiotic group while the remaining 936 (22.0%) were enrolled in the non-antibiotic group. Logistic regression analysis revealed that antibiotic application increased the risk of overweight and obesity among the 3-year-old young children (OR, 1.44; 95% CI, 1.03-2.01). In addition, application of antibiotics for five times or higher significantly increased the risk of overweight and obesity (OR, 1.73; 95% CI, 1.07-2.80), and such risks were more significant in children who were administered antibiotics for the first time within 6 months of age (OR, 1.71; 95% CI, 1.08-2.69). The application of antibiotics in infants and young children was thus revealed to increase the risk of overweight and obesity at the age of 3 in a frequency-dependent manner.

Antibiotic-induced dysbiosis of gut microbiota impairs corneal development in postnatal mice by affecting CCR2 negative macrophage distribution

Antibiotics are extremely useful, but they can cause adverse impacts on host bodies. We found that antibiotic treatment altered the composition of the gut microbiota and the gene expression profile in the corneal tissues of postnatal mice and decreased the corneal size and thickness, the angiogenesis of limbal blood vessels, and the neurogenesis of corneal nerve fibers. The reconstitution of the gut microbiota with fecal transplants in antibiotic-treated mice largely reversed these impairments in corneal development. Furthermore, C-C chemokine receptor type 2 negative (CCR2^-) macrophages were confirmed to participate in corneal development, and their distribution in the cornea was regulated by the gut microbiota. We propose that the CCR2^- macrophage population is a crucial mediator through which gut microbiota affect corneal development in postnatal mice. In addition, probiotics were shown to have the potential effect of restoring corneal development in antibiotic-treated mice. Abx-induced gut dysbiosis has significant, long-term effects on the development of the cornea, and reversal of these suppressive effects takes a long time.

Assessment Considerations in Pediatric Patients

Pharmacy assessment of pediatric patients is similar in many ways to that of adults; however there are many specific nuances that need to be considered in addition to the typical aspects included in an adult assessment. There is a lack of pediatric-specific medication research and a much higher rate of “off label” medication use, so children are at higher risk of medication errors and related harm. Pharmacokinetic differences and other age-related differences result in highly variable responses to medications throughout childhood. Pharmacists need to be aware of this variability and use every patient encounter as an opportunity for assessment of many aspects of medication including dose, formulation, administration, and indication. Infants and children also have physiological differences that need to be considered especially when assessing efficacy, toxicity, and the patient’s overall response to medications through physical exam or use of laboratory values. Lastly, a lack of appropriate medication formulations for children creates a requirement for pharmacists to specifically assess the formulations, measurement, and administration of pediatric medications. This chapter provides an approach to pediatric assessment, highlights common sources of error, and provides strategies for managing pediatric medications.

Trends in Outpatient Prescription Medicine Use in New Zealand Children 2010-2015: A National Population-Based Study

BACKGROUND

Research examining trends in the outpatient prescription medicine use of New Zealand children is limited.

OBJECTIVES

Our objective was to provide an overview of prescription medicine use in New Zealand children and assess changing patterns in use from 2010 to 2015.

METHODS

We conducted a retrospective cohort study including all New Zealand primary care-registered children aged < 18 years using data from the national pharmaceutical claims database. We calculated the prevalence of use within four age groups in each year by anatomical therapeutic class, therapeutic group and drug. Rate ratios were calculated to compare the prevalence of use in 2010 and 2015.

RESULTS

In total, 1,496,026 children with a mean of 2.7 years of potential drug exposure were included. The overall prevalence of drug use was 70% in 2010 and 73% in 2015. In 2015, medicine use was highest in children aged < 2 years (90%) and lowest in children aged 12-17 years (65%). Antibacterials, analgesics, topical corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs) and antihistamines were the most widely used medicines. The prevalence of use of systemic and topical antibiotics decreased by 2 and 10%, respectively, between 2010 and 2015, but there was increased use of analgesics (10%), NSAIDs (39%), antihistamines (15%) and antinausea and vertigo agents (306%).

CONCLUSIONS

Our findings indicate areas for further research focusing on inappropriate prescribing to children and safety issues in children's medicine use. Monitoring changing patterns of use over time is important for the evaluation of effective therapies in children and any potential harmful consequences of prescribing.

The association between early life antibiotic use and allergic disease in young children: recent insights and their implications

INTRODUCTION

Greater prescribing of antibiotics to infants has coincided with an epidemic of allergic disease. Through meta-analytic synthesis, accumulating evidence from prospective or database cohorts suggests a link between infant antibiotic treatment and the development of atopy. Stronger associations seen with multiple course and broad-spectrum antibiotic treatment add to biological plausibility. A major bias, confounding by indication, has been addressed in studies on antibiotic treatment of conditions which do not precede allergic disease. Areas covered: Our review provides an up-to-date synthesis of the current literature on associations between infant antibiotic exposure and future allergic disease. We discuss methods that assist in reducing study bias and look at new insights from studies of the infant gut microbiome. Expert commentary: Large-scale profiling of the gut microbiome provides a new tool for disentangling biases found in observational studies of infant antibiotic use. To date, microbial dysbiosis of the infant gut has been reported to predict allergic disease independent of antibiotic exposure up to 3 months after birth. However, these studies have not accounted for antibiotic treatment in later infancy. Continued study of the infant gut microbiome, mycobiome, or resistome will provide a closer link to antibiotic treatment or refute it as a cause of allergic disease.

Early microbiota, antibiotics and health

The colonization of the neonatal digestive tract provides a microbial stimulus required for an adequate maturation towards the physiological homeostasis of the host. This colonization, which is affected by several factors, begins with facultative anaerobes and continues with anaerobic genera. Accumulating evidence underlines the key role of the early neonatal period for this microbiota-induced maturation, being a key determinant factor for later health. Therefore, understanding the factors that determine the establishment of the microbiota in the infant is of critical importance. Exposure to antibiotics, either prenatally or postnatally, is common in early life mainly due to the use of intrapartum prophylaxis or to the administration of antibiotics in C-section deliveries. However, we are still far from understanding the impact of early antibiotics and their long-term effects. Increased risk of non-communicable diseases, such as allergies or obesity, has been observed in individuals exposed to antibiotics during early infancy. Moreover, the impact of antibiotics on the establishment of the infant gut resistome, and on the role of the microbiota as a reservoir of resistance genes, should be evaluated in the context of the problems associated with the increasing number of antibiotic resistant pathogenic strains. In this article, we review and discuss the above-mentioned issues with the aim of encouraging debate on the actions needed for understanding the impact of early life antibiotics upon human microbiota and health and for developing strategies aimed at minimizing this impact.

Stochastic Signatures of Involuntary Head Micro-movements Can Be Used to Classify Females of ABIDE into Different Subtypes of Neurodevelopmental Disorders

Background: The approximate 5:1 male to female ratio in clinical detection of Autism Spectrum Disorder (ASD) prevents research from characterizing the female phenotype. Current open access repositories [such as those in the Autism Brain Imaging Data Exchange (ABIDE I-II)] contain large numbers of females to help begin providing a new characterization of females on the autistic spectrum. Here we introduce new methods to integrate data in a scale-free manner from continuous biophysical rhythms of the nervous systems and discrete (ordinal) observational scores.

Methods: New data-types derived from image-based involuntary head motions and personalized statistical platform were combined with a data-driven approach to unveil sub-groups within the female cohort. Further, to help refine the clinical DSM-based ASD vs. Asperger's Syndrome (AS) criteria, distributional analyses of ordinal score data from Autism Diagnostic Observation Schedule (ADOS)-based criteria were used on both the female and male phenotypes.

Results: Separate clusters were automatically uncovered in the female cohort corresponding to differential levels of severity. Specifically, the AS-subgroup emerged as the most severely affected with an excess level of noise and randomness in the involuntary head micro-movements. Extending the methods to characterize males of ABIDE revealed ASD-males to be more affected than AS-males. A thorough study of ADOS-2 and ADOS-G scores provided confounding results regarding the ASD vs. AS male comparison, whereby the ADOS-2 rendered the AS-phenotype worse off than the ASD-phenotype, while ADOS-G flipped the results. Females with AS scored higher on severity than ASD-females in all ADOS test versions and their scores provided evidence for significantly higher severity than males. However, the statistical landscapes underlying female and male scores appeared disparate. As such, further interpretation of the ADOS data seems problematic, rather suggesting the critical need to develop an entirely new metric to measure social behavior in females.

Conclusions: According to the outcome of objective, data-driven analyses and subjective clinical observation, these results support the proposition that the female phenotype is different. Consequently the “social behavioral male ruler” will continue to mask the female autistic phenotype. It is our proposition that new observational behavioral tests ought to contain normative scales, be statistically sound and combined with objective data-driven approaches to better characterize the females across the human lifespan.

Association of Repeated Intravitreous Bevacizumab Injections With Risk for Glaucoma Surgery

Importance

Intravitreous injections of anti-vascular endothelial growth factor (VEGF) agents are associated with a sustained increase in intraocular pressure. This sustained elevated intraocular pressure could lead to higher rates of glaucoma surgery to lower this pressure.

Objective

To determine the risk of glaucoma surgery following repeated intravitreous bevacizumab injections.

Design, Setting, Participants

This nested, case-control study acquired and analyzed data from large, population-based, linked health databases supported by the British Columbia Ministry of Health in Canada. Study participants included all patients with ophthalmic issues in British Columbia, such as those of the Provincial Retinal Diseases Treatment Program, who had received intravitreous bevacizumab injections for exudative age-related macular degeneration between January 1, 2009, and December 31, 2013. Cases were identified using glaucoma surgical codes for trabeculectomy, complicated trabeculectomy, glaucoma drainage device, and cycloablative procedure. For each case, 10 controls were identified and matched for age, preexisting glaucoma, calendar time, and follow-up time. The number of intravitreous bevacizumab injections received per year-3 or fewer, 4 to 6, or 7 or more-was determined for both cases and controls. Data analysis was performed from February 23, 2016, to November 14, 2016.

Main Outcomes and Measures

Risk of glaucoma surgery compared with the number of intravitreous bevacizumab injections per year in cases and controls. Rate ratios were adjusted for covariates (diabetes mellitus, myocardial infarction, stroke, and verteporfin use).

Results

Seventy-four cases of glaucoma surgery and 740 controls were identified, with a mean (SD) age of 81.3 (8.4) years for cases and 81.4 (7.9) for controls. The case group had more males than the control group (38 [51.4%] vs 272 [36.8%]). The adjusted rate ratio of glaucoma surgery among those who received 7 or more injections per year was 2.48 (95% CI, 1.25-4.93). There was a 10.3% higher number of 7 or more injections among cases compared with controls. The adjusted rate ratio for those who received 4 to 6 injections per year compared with those who received 3 or fewer was 1.65% (95% CI, 0.84-3.23).

Conclusions and Relevance

Findings from this large, pharmacoepidemiologic study suggest that 7 or more intravitreous injections of bevacizumab annually is associated with a higher risk of glaucoma surgery and that 4 to 6 injections per year show a nonstatistically significant rate ratio in the same direction.

Oral Bisphosphonates and Risk of Wet Age-Related Macular Degeneration

PURPOSE

To examine the risk of age-related macular degeneration (AMD) with oral bisphosphonates.

DESIGN

Three study designs were used: (1) disproportionality analysis; (2) case-control study; (3) self-controlled case series (SCCS).

METHODS

setting: (1) Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) Database; (2) 2 patient cohorts from British Columbia, Canada.

STUDY POPULATION

(1) All reports of AMD to the FDA with oral bisphosphoantes; (2) patients with wet AMD in British Columbia (2009-2013) and 1 million controls (2000-2007).

INTERVENTION

Oral bisphosphonates.

MAIN OUTCOME MEASURES

(1) Reports of AMD to the FDA; (2) first diagnosis of wet AMD verified by a retina specialist in British Columbia.

RESULTS

In the disproportionality analysis there were 133 cases of AMD reported with alendronate, 20 with ibandronate, and 14 with risedronate. The reported odds ratios (RORs) for alendronate, ibandronate, and risedronate were 3.82 (95% CI: 2.94-4.96), 2.40 (95% CI: 1.49-3.86), and 2.87 (95% CI: 1.58-5.19), respectively. In the case-control analysis there were 6367 cases and 6370 corresponding controls. The adjusted OR for wet AMD among regular users of bisphosphonates in the 1, 2, and 3 years prior to the index date were 1.24 (1.12-1.38), 1.38 (1.22-1.56), and 1.59 (1.38-1.82), respectively. In the SCCS analysis there were 198 cases of wet AMD on continuous bisphosphonate therapy. The rate ratio for wet AMD for continuous bisphosphonate use was 1.99 (95% CI: 1.41-2.79). We did not have information on intravenous bisphosphonates.

CONCLUSIONS

Continuous users of oral bisphosphonates are at a higher risk of developing wet AMD. Given the observational nature of this study and limitation of the data, future studies are needed to confirm these findings.

Antibiotic perturbation of the preterm infant gut microbiome and resistome

The gut microbiota plays important roles in nutrient absorption, immune system development, and pathogen colonization resistance. Perturbations early in life may be detrimental to host health in the short and the long-term. Antibiotics are among the many factors that influence the development of the microbiota. Because antibiotics are heavily administered during the first critical years of gut microbiota development, it is important to understand the effects of these interventions. Infants, particularly those born prematurely, represent an interesting population because they receive early and often extensive antibiotic therapy in the first months after birth. Gibson et al. recently demonstrated that antibiotic therapy in preterm infants can dramatically affect the gut microbiome. While meropenem, ticarcillin-clavulanate, and cefotaxime treatments were associated with decreased species richness, gentamicin and vancomycin had variable effects on species richness. Interestingly, the direction of species richness response could be predicted based on the abundance of 2 species and 2 genes in the microbiome prior to gentamicin or vancomycin treatment. Nonetheless, all antibiotic treatments enriched the presence of resistance genes and multidrug resistant organisms. Treatment with different antibiotics further resulted in unique population shifts of abundant organisms and selection for different sets of resistance genes. In this addendum, we provide an extended discussion of these recent findings, and outline important future directions for elucidating the interplay between antibiotics and preterm infant gut microbiota development.

Risk of Myocardial Infarction and Stroke With Single or Repeated Doses of Intravitreal Bevacizumab in Age-Related Macular Degeneration

PURPOSE

To examine the risk of myocardial infarction and stroke with single and repeated doses of intravitreal bevacizumab in wet age-related macular degeneration (AMD).

DESIGN

Nested case-control study and retrospective cohort study.

METHODS

setting: Two patient cohorts from British Columbia, Canada.

STUDY POPULATION

Patients with wet AMD.

INTERVENTION

For the cohort study, patients who received the first intravitreal bevacizumab; for the nested case-control study, repeated injections of intravitreal bevacizumab.

MAIN OUTCOME MEASURES

Myocardial infarction for the retrospective cohort study; myocardial infarction and stroke for the nested case-control study.

RESULTS

In the cohort analysis, there were 2564 AMD subjects not on a vascular endothelial growth factor (VEGF) inhibitor and 5644 subjects receiving intravitreal bevacizumab. The rate of myocardial infarction (MI) among bevacizumab users was 11/1000 person-years, compared to 14.9/1000 person-years in nonusers. The adjusted rate ratio (RR) for MI was 0.70 (95% confidence interval [CI]: 0.50-1.00) and 0.74 (0.46-1.20) for the propensity score-adjusted analysis. In the nested case-control analysis there were 7452 new users of VEGF inhibitors, within which there were 313 cases of MI with 3130 matched controls. The adjusted RR for MI among those receiving 3 or more injections compared to those receiving fewer than 3 was 0.71 (95% CI: 0.41-1.22). Also in the nested case-control analysis, the adjusted RR for stroke was 0.81 (95% CI: 0.39-1.65) for those receiving ≥4 injections vs those receiving fewer than 4 injections.

CONCLUSION

Single or repeated doses of intravitreal bevacizumab were not shown to increase the risk of myocardial infarction or stroke in patients with wet AMD.

Ambulatory Care Visits to Pediatricians in Taiwan: A Nationwide Analysis

Pediatricians play a key role in the healthy development of children. Nevertheless, the practice patterns of pediatricians have seldom been investigated. The current study analyzed the nationwide profiles of ambulatory visits to pediatricians in Taiwan, using the National Health Insurance Research Database. From a dataset that was randomly sampled one out of every 500 records among a total of 309,880,000 visits in 2012 in the country, 9.8% (n = 60,717) of the visits were found paid to pediatricians. Children and adolescents accounted for only 69.3% of the visits to pediatricians. Male pediatricians provided 80.5% of the services and the main workforces were those aged 40-49 years. The most frequent diagnoses were respiratory tract diseases (64.7%) and anti-histamine agents were prescribed in 48.8% of the visits to pediatricians. Our detailed results could contribute to evidence-based discussions on health policymaking.

Drug use in French children: a population-based study

BACKGROUND AND OBJECTIVE

To provide an overview of drug use in outpatient children in France, a population-based study using a national reimbursement claims database representative of 90% of the French population was conducted.

DESIGN

Cross-sectional study performed between January and December 2011 using the EGB database (Echantillon Généraliste de Bénéficiaires), a 1/97th sample of the national healthcare insurance system beneficiaries. Drug use in children <18 years old was estimated through reimbursements for prescribed drugs excluding vaccines. Prevalences of use were calculated for different levels of the Anatomical Therapeutic Chemical classification by considering as users children who had at least one reimbursement during the study period.

RESULTS

In 2011, 133,800 children were included in the study. The overall prevalence of drug use was 84% and the median number of different drugs per child was 5. Drug use was greatest in children aged <2 years. The most widely used drugs were paracetamol, systemic anti-infectives, nasal corticosteroids and decongestants, and anti-histamines. 21% children <2 years received domperidone.

CONCLUSIONS

There is widespread use of medicines that are unlikely to be effective and may have significant toxicity in French children. Irrational use of medicines appears to be greatest in children aged 5 years and under.

Antibiotics and the developing infant gut microbiota and resistome

The microbial communities colonizing the human gut are tremendously diverse and highly personal. The composition and function of the microbiota play important roles in human health and disease, and considerable research has focused on understanding the ecological forces shaping these communities. While it is clear that factors such as diet, genotype of the host, and environment influence the adult gut microbiota community composition, recent work has emphasized the importance of early-life assembly dynamics in both the immediate and long-term personalized nature of the gut microbiota. While the mature adult gut microbiota is believed to be relatively stable, the developing infant gut microbiota (IGM) is highly dynamic and prone to disruption by external factors, including antibiotic exposure. Studies have revealed both transient and persistent alterations to the adult gut microbiota community resulting from antibiotic treatment later in life. As antibiotics are routinely prescribed at a greater rate in the first years of life, the impact of these interventions on the developing IGM is emerging as a key research priority. In addition to understanding the impact of these disruptions on the infant gut microbial architecture and related host diseases, we need to understand the contribution of early life antibiotics to the selection of antibiotic resistance gene reservoirs in the microbiota, and their threat to successful treatment of infectious disease. Here we review the current understanding of the developmental progression of the IGM and the impact of antibiotic therapies on its composition and encoded reservoir of antibiotic resistance genes.

Paediatric clinical pharmacology in the UK

Paediatric clinical pharmacology is the scientific study of medicines in children and is a relatively new subspecialty in paediatrics in the UK. Training encompasses both the study of the effectiveness of drugs in children (clinical trials) and aspects of drug toxicity (pharmacovigilance). Ethical issues in relation to clinical trials and also studies of the pharmacokinetics and drug metabolism in children are crucial. Paediatric patients require formulations that young children in particular are able to take. The scientific evidence generated from clinical trials, pharmacokinetic studies and studies of drug toxicity all need to be applied in order to ensure that medicines are used rationally in children.

Medication deserts: survey of neighborhood disparities in availability of prescription medications

Background

Only a small amount of research has focused on the relationship between socio-economic status (SES) and geographic access to prescription medications at community pharmacies in North America and Europe. To examine the relationship between a community’s socio-economic context and its residents’ geographic access to common medications in pharmacies, we hypothesized that differences are present in access to pharmacies across communities with different socio-economic environments, and in availability of commonly prescribed medications within pharmacies located in communities with different socio-economic status.

Methods

We visited 408 pharmacies located in 168 socio-economically diverse communities to assess the availability of commonly prescribed medications. We collected the following information at each pharmacy visited: hours of operation, pharmacy type, in-store medication availability, and the cash price of the 13 most commonly prescribed medications. We calculated descriptive statistics for the sample and fitted a series of hierarchical linear models to test our hypothesis that the in-stock availability of medications differs by the socio-economic conditions of the community. This was accomplished by modeling medication availability in pharmacies on the socio-economic factors operating at the community level in a socio-economically devise urban area.

Results

Pharmacies in poor communities had significantly higher odds of medications being out of stock, OR=1.24, 95% CI [1.02, 1.52]. There was also a significant difference in density of smaller, independent pharmacies with very limited stock and hours of operation, and larger, chain pharmacies in poor communities as compared to the middle and low-poverty communities.

Conclusions

The findings suggest that geographic access to a neighborhood pharmacy, the type of pharmacy, and availability of commonly prescribed medications varies significantly across communities. In extreme cases, entire communities could be deemed “medication deserts” because geographic access to pharmacies and the availability of the most prescribed medications within them were very poor. To our knowledge, this study is first to report on the relationship between SES and geographic access to medications using small area econometric analysis techniques. Our findings should be reasonably generalizable to other urban areas in North America and Europe and suggest that more research is required to better understand the relationship of socio-economic environments and access to medications to develop strategies to achieve equitable medication access.