1
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Boonrit N, Klaidokchan N, Niyomdecha A, Noppamas J, Suknuntha K, Prasertsan P, Thaworncheep S, Ruanglertboon W. Development and Evaluation of a Prototype Mobile Application for Intravenous Drug Dose Calculation in Overweight and Obese Thai Children: Precision Dosing in Practice. Hosp Pharm 2024; 59:453-459. [PMID: 38919757 PMCID: PMC11195842 DOI: 10.1177/00185787241229141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Background: Medication dosing in overweight and obese children often involves complex weight-based calculations, leading to higher dosing errors, particularly with intravenous drugs. Currently, tools to aid in dosage calculations are lacking for these patients, especially in Thai population. Objective: This study aimed to develop a mobile application with the intent of utilizing it as a tool to enhance the efficiency and accuracy of dosing calculations required for obese and overweight Thai children. Methods: The performance of the application was assessed in 3 key aspects using a sample of 30 healthcare professionals. These key aspects included: 1) the accuracy of dosage calculations, assessed through pre- and posttests comparing manual calculations to app-based calculations using a 10-item questionnaire, 2) the time taken for calculations before and after app usage, 3) user satisfaction, which was measured through a questionnaire. Results: The integration of applications into the calculation demonstrated a significant improvement when compared to the manual calculation in both accuracy (6.10 vs 9.33 out of 10, P < .001) and efficiency (10.40 vs 8.53 minutes per 10 questions, P = .008). Also, the application elicited high levels of satisfaction among users, as reflected by an overall mean satisfaction score of 4.57 on a 5-point scale. Conclusion: The integration of this application to assist in dosage calculations for overweight and obese pediatric Thai patients has yielded favorable outcomes concerning accuracy, efficiency, and user satisfaction. Further development should be pursued within a larger cohort, with an emphasis on real-world implementation in clinical settings.
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Affiliation(s)
| | | | | | | | - Krit Suknuntha
- Prince of Songkla University, Hatyai, Songkhla, Thailand
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2
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Cloyd CP, Macedone D, Merandi J, Pierson S, Sellas Wcislo M, Lutmer J, MacDonald J, Ayad O, Kalata L, Thompson RZ. A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity. Pediatr Qual Saf 2024; 9:e741. [PMID: 38868757 PMCID: PMC11167219 DOI: 10.1097/pq9.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/17/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year. Methods The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department. Results Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months. Conclusions Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.
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Affiliation(s)
- Colleen P. Cloyd
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Danielle Macedone
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Nationwide Children’s Hospital Center for Clinical Excellence, Columbus, Ohio
| | - Jenna Merandi
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Shawn Pierson
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Maria Sellas Wcislo
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Jeffrey Lutmer
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Jennifer MacDonald
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Onsy Ayad
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Lindsay Kalata
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - R. Zachary Thompson
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
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3
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Burhanuddin K, Mohammed A, Badhan RKS. The Impact of Paediatric Obesity on Drug Pharmacokinetics: A Virtual Clinical Trials Case Study with Amlodipine. Pharmaceutics 2024; 16:489. [PMID: 38675150 PMCID: PMC11053426 DOI: 10.3390/pharmaceutics16040489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
The incidence of paediatric obesity continues to rise worldwide and contributes to a range of diseases including cardiovascular disease. Obesity in children has been shown to impact upon the plasma concentrations of various compounds, including amlodipine. Nonetheless, information on the influence of obesity on amlodipine pharmacokinetics and the need for dose adjustment has not been studied previously. This study applied the physiologically based pharmacokinetic modelling and established a paediatric obesity population to assess the impact of obesity on amlodipine pharmacokinetics in children and explore the possible dose adjustments required to reach the same plasma concentration as non-obese paediatrics. The difference in predicted maximum concentration (Cmax) and area under the curve (AUC) were significant between children with and without obesity across the age group 2 to 18 years old when a fixed-dose regimen was used. On the contrary, a weight-based dose regimen showed no difference in Cmax between obese and non-obese from 2 to 9 years old. Thus, when a fixed-dose regimen is to be administered, a 1.25- to 1.5-fold increase in dose is required in obese children to achieve the same Cmax concentration as non-obese children, specifically for children aged 5 years and above.
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Affiliation(s)
| | | | - Raj K. S. Badhan
- School of Pharmacy, College of Health and Life Science, Aston University, Birmingham B4 7ET, UK; (K.B.); (A.M.)
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4
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Walton M, Wagner JB. Pediatric Beta Blocker Therapy: A Comprehensive Review of Development and Genetic Variation to Guide Precision-Based Therapy in Children, Adolescents, and Young Adults. Genes (Basel) 2024; 15:379. [PMID: 38540438 PMCID: PMC10969836 DOI: 10.3390/genes15030379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 06/14/2024] Open
Abstract
Beta adrenergic receptor antagonists, known as beta blockers, are one of the most prescribed medications in both pediatric and adult cardiology. Unfortunately, most of these agents utilized in the pediatric clinical setting are prescribed off-label. Despite regulatory efforts aimed at increasing pediatric drug labeling, a majority of pediatric cardiovascular drug agents continue to lack pediatric-specific data to inform precision dosing for children, adolescents, and young adults. Adding to this complexity is the contribution of development (ontogeny) and genetic variation towards the variability in drug disposition and response. In the absence of current prospective trials, the purpose of this comprehensive review is to illustrate the current knowledge gaps regarding the key drivers of variability in beta blocker drug disposition and response and the opportunities for investigations that will lead to changes in pediatric drug labeling.
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Affiliation(s)
- Mollie Walton
- Ward Family Heart Center, Kansas City, MO 64108, USA
| | - Jonathan B. Wagner
- Ward Family Heart Center, Kansas City, MO 64108, USA
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy, 2401 Gillham Road, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64108, USA
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5
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Kyler KE, Houtrow A, Hall M. Prevalence and Severity of Chronic Conditions Among Adolescents With Obesity. Child Obes 2024; 20:68-71. [PMID: 36594991 DOI: 10.1089/chi.2022.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Childhood obesity prevalence continues to increase, and may be coupled with a rise in rates of chronic conditions tied to obesity. We compared the prevalence and severity of 14 chronic conditions between adolescents aged 10-17 years with and without obesity using the 2018-2019 National Survey of Children's Health (NSCH). Chi square tests assessed differences in chronic condition prevalence across weight groups, and logistic regression determined the odds of having chronic conditions in adolescents with versus without obesity. We found adolescents with obesity had higher prevalence of >85% of included chronic conditions. Those with obesity had higher odds of moderate/severe depression [adjusted odds ratio (aOR) 1.41, 95% confidence interval (CI) 1.01-1.96], autism spectrum disorder (aOR 2.07, 95% CI 1.2-3.57), and developmental delay (aOR 1.77, 95% CI 1.15-2.73). Awareness of the ties between having a chronic condition among adolescents with obesity may help providers in assessing risk of morbidity among this at-risk group of children.
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Affiliation(s)
- Kathryn E Kyler
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amy Houtrow
- Departments of Physical Medicine and Rehabilitation and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Children's Hospital Association, Lenexa, KS, USA
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6
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Leung AKC, Wong AHC, Hon KL. Childhood Obesity: An Updated Review. Curr Pediatr Rev 2024; 20:2-26. [PMID: 35927921 DOI: 10.2174/1573396318666220801093225] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/05/2022] [Accepted: 05/19/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Childhood obesity is an important and serious public health problem worldwide. OBJECTIVE This article aims to familiarize physicians with the evaluation, management, and prevention of childhood. METHODS A PubMed search was conducted in May, 2021, in Clinical Queries using the key terms "obesity" OR "obese". The search included clinical trials, randomized controlled trials, case-control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to English literature and children. The information retrieved from the above search was used in the compilation of the present article. RESULTS Most obese children have exogenous obesity characterized by a growth rate for height above the 50th percentile, normal intelligence, normal genitalia, and lack of historical or physical evidence of an endocrine abnormality or a congenital syndrome. Obese children are at risk for dyslipidemia, hypertension, diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, psychosocial disturbances, impaired quality of life, and shorter life expectancy. The multitude of serious comorbidities necessitates effective treatment modalities. Dietary modification, therapeutic exercise, and behavioral modification are the fundamentals of treatment. Pharmacotherapy and/or bariatric surgery should be considered for obese individuals who do not respond to the above measures and suffer from a serious comorbid condition. CONCLUSION Childhood obesity, once established, is often refractory to treatment. Most treatment programs lead to a brief period of weight loss, followed by rapid re-accumulation of the lost weight after the termination of therapy. As such, preventive activity is the key to solving the problem of childhood obesity. Childhood obesity can be prevented by promoting a healthy diet, regular physical activity, and lifestyle modification. Parents should be encouraged to get involved in school and community programs that improve their children's nutritional status and physical activity.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong, China
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong, China
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7
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Kyler KE, Hall M, Antoon JW, Goldman J, Grijalva CG, Shah SS, Tang Girdwood S, Williams DJ, Feinstein JA. Polypharmacy among medicaid-insured children with and without documented obesity. Pharmacotherapy 2023; 43:588-595. [PMID: 36564960 PMCID: PMC10287842 DOI: 10.1002/phar.2755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/08/2022] [Accepted: 11/30/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Polypharmacy increases the risk of drug-drug interactions and adverse drug events. As obesity and rates of obesity-associated comorbid chronic conditions continue to rise, an improved understanding of whether children with obesity experience higher risk of polypharmacy is needed. This study aimed to compare chronic medication polypharmacy prevalence among children with and without a diagnosis of obesity. METHODS We performed a cross-sectional examination of prescription data for children aged 2-18 years prescribed ≥1 chronic medication using the 2019 Marketscan Medicaid database. Children with documented obesity were identified using medical visit diagnosis codes. Chronic medications included any ≥30-day prescription with ≥2 dispensed refills. Polypharmacy was defined as the prescription of ≥2 chronic medications for ≥1 overlapping days. Chi-squared tests compared polypharmacy prevalence and the distribution of chronic medication classes between children with and without obesity. Logistic regression determined the adjusted odds ratio (aOR) of polypharmacy for children with obesity, adjusting for relevant demographic and clinical differences. RESULTS Of 634,671 included children, 12.2% had documented obesity. More than one-half (52.7%) of children with obesity experienced polypharmacy compared with 47.6% of children without obesity (aOR 1.06 [95% confidence interval 1.04-1.08]). Chronic medication prescriptions, particularly for psychiatric and asthma medications, were more commonly prescribed among children with obesity than those without obesity. CONCLUSIONS Children with documented obesity have higher polypharmacy prevalence than children without obesity. Clinicians must be aware of this risk and minimize inappropriate polypharmacy whenever possible. Future work should examine the consequences of polypharmacy, including drug-drug interactions and adverse drug events in children with obesity.
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Affiliation(s)
- Kathryn E. Kyler
- Division of Hospital Medicine, Children’s Mercy Kansas City, Kansas City, MO
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Matt Hall
- Division of Hospital Medicine, Children’s Mercy Kansas City, Kansas City, MO
- Children’s Hospital Association, Lenexa, KS
| | - James W. Antoon
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer Goldman
- Division of Clinical Pharmacology, Children’s Mercy Hospitals and Clinics, Kansas City, Mo; Division of Infectious Diseases, Children’s Mercy Hospitals and Clinics, Kansas City, Mo
| | - Carlos G. Grijalva
- Division of Pharmacoepidemiology, Departments of Health Policy and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center & Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sonya Tang Girdwood
- Divisions of Hospital Medicine and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center & Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Derek J. Williams
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center, Nashville, TN
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research & Delivery Science, Children’s Hospital Colorado, University of Colorado, Aurora
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8
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Elrggal ME, Haseeb A, AlGethamy M, Ahsan U, Saleem Z, Althaqafi AS, Alshuail SS, Alsiddiqi ZA, Iqbal MS, Alzahrani AF, AlQarni A, Radwan RM, Qul AKS, Mahrous AJ, Alsharif JM, Alqurashi MK, Faidah HS, Aldurdunji M. Dose optimization of vancomycin in obese patients: A systematic review. Front Pharmacol 2023; 14:965284. [PMID: 37033643 PMCID: PMC10081578 DOI: 10.3389/fphar.2023.965284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background: Dose optimization of vancomycin plays a substantial role in drug pharmacokinetics because of the increased incidence of obesity worldwide. This systematic review was aimed to highlight the current dosing strategy of vancomycin among obese patients. Methods: This systematic review was in concordance with Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was carried out on various databases such as Scopus, PubMed/MEDLINE, ScienceDirect and EMBASE using Keywords and MeSH terms related to vancomycin dosing among obese patients. Google Scholar was also searched for additional articles. The English language articles published after January, 2000 were included in this study. The quality of the study was assessed using different assessment tools for cohort, and case reports. Results: A total of 1,029 records were identified. After screening, 18 studies were included for the final review. Of total, twelve studies are retrospective and remaining six are case-control studies. A total of eight studies were conducted in pediatrics while remaining studies were conducted in adult population. Most of the studies reported the dosing interval every 6-8 h. Differences in target trough concentration exist with respect to target ranges. The administration of loading dose (20-25 mg/kg) followed by maintenance dose (15-25 mg/kg) of vancomycin is recommended in adult patients to target therapeutic outcomes. Moreover, a dose of 40-60 mg/kg/day appears appropriate for pediatric patients. Conclusion: The initial dosing of vancomycin based on TBW could be better predictor of vancomycin trough concentration. However, the clinical significance is uncertain. Therefore, more studies are needed to evaluate the dosing strategy of vancomycin in overweight or obese patients.
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Affiliation(s)
- Mahmoud E. Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
- *Correspondence: Abdul Haseeb,
| | - Manal AlGethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Umar Ahsan
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Areej Sultan Althaqafi
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Sattam Saad Alshuail
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zohair Ahmad Alsiddiqi
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Albaraa Faraj Alzahrani
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdullmoin AlQarni
- Alnoor Specialist Hospital Makkah, Department of Infectious Diseases, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ameer Khalid Saab Qul
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ahmad Jamal Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Jumana Majdi Alsharif
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | | | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Mohammed Aldurdunji
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
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9
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Goldman VE, Espinoza JC, Vidmar AP. Inpatient medical management of severe pediatric obesity: Literature review and case reports. Front Pediatr 2023; 11:1095144. [PMID: 36861081 PMCID: PMC9970259 DOI: 10.3389/fped.2023.1095144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023] Open
Abstract
Pediatric obesity rates continue to rise steeply with significant adverse effects on health outcomes across the lifespan. Significant obesity can affect the efficacy, side effects, and ability to use certain treatment, medication, or imaging modalities needed in the evaluation and management of acute pediatric conditions. Inpatient settings are rarely used as an opportunity for weight counseling and thus there is a paucity of clinical guidelines on how to manage severe obesity in the inpatient setting. We present a literature review and three patient cases with single-center protocol for non-surgical management of severe obesity in children admitted for other acute medical reasons. We performed a PubMed review from January 2002 to February 2022 utilizing keywords: "inpatient," "obesity," and "intervention." For our cases, we identified three patients with severe obesity acutely impacting their health while admitted for medical treatment who concurrently underwent acute, inpatient, weight loss regimens at a single children's hospital. The literature search yielded 33 articles describing inpatient weight loss treatments. Three patients met case criteria, all three of which demonstrated a decrease in their weight in excess percent of the 95th percentile after inpatient weight-management protocol implementation (% reduction BMIp95: 16%-30%). This highlights obesity acutely limits or impacts specific medical care required during inpatient admissions in pediatric patients. It also suggests that implementation of an inpatient weight-management protocol during admission may provide an opportune setting to support acute weight loss and overall improved health outcomes in this high-risk cohort.
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Affiliation(s)
- Victoria E Goldman
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Juan C Espinoza
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Alaina P Vidmar
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine of University of Southern California, Los Angeles, CA, United States.,Department of Pediatrics, Endocrinology and Metabolism, Children's Hospital Los Angeles Center for Diabetes, Los Angeles, CA, United States
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10
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Gaeta F, Conti V, Pepe A, Vajro P, Filippelli A, Mandato C. Drug dosing in children with obesity: a narrative updated review. Ital J Pediatr 2022; 48:168. [PMID: 36076248 PMCID: PMC9454408 DOI: 10.1186/s13052-022-01361-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Childhood obesity and its associated comorbidities are highly prevalent diseases that may add to any other possible health problem commonly affecting the pediatric age. Uncertainties may arise concerning drug dosing when children with obesity need pharmacologic therapies. In general, in pediatric practice, there is a tendency to adapt drug doses to a child’s total body weight. However, this method does not consider the pharmacological impact that a specific drug can have under a two-fold point of view, that is, across various age and size groups as well. Moreover, there is a need for a therapeutic approach, as much as possible tailored considering relevant interacting aspects, such as modification in metabolomic profile, drug pharmacokinetics and pharmacodynamics. Taking into account the peculiar differences between children with overweight/obesity and those who are normal weight, the drug dosage in the case of obesity, cannot be empirically determined solely by the per kg criterion. In this narrative review, we examine the pros and cons of several drug dosing methods used when dealing with children who are affected also by obesity, focusing on specific aspects of some of the drugs most frequently prescribed in real-world practice by general pediatricians and pediatric subspecialists.
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Affiliation(s)
- Francesca Gaeta
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Valeria Conti
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Angela Pepe
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Pietro Vajro
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Amelia Filippelli
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Claudia Mandato
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy.
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11
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Kyler KE, Lee BR, Glynn EF, Waddell JP, Hoffman MA, Goldman JL. Clinical Outcome and Antibiotic Dosing Differences by Weight in Children With Acute Osteomyelitis. Hosp Pediatr 2021; 11:1112-1120. [PMID: 34593567 DOI: 10.1542/hpeds.2021-005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate for weight-based differences in clinical outcomes and antibiotic dosing variability for children hospitalized with acute hematogenous osteomyelitis (AHO). METHODS We performed a retrospective cohort study of children aged 2 to 17 years and hospitalized with a primary AHO International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision diagnosis code between 2010 and 2017 using the Cerner Health Facts database. Weight categories (healthy, overweight, obesity) were determined by using Centers for Disease Control and Prevention age- and sex-specific BMI percentiles. Rates of procedures, complications, and length of stay (LOS) were compared between groups. Dosing variability between groups was assessed by comparing the initial milligrams per kilogram per day of prescribed antibiotics. RESULTS We identified 755 children with AHO for inclusion. Children with overweight and obesity were more likely to undergo surgical procedures (19% and 17%, respectively) compared with children with a healthy weight (10%; P = .009). They also had a longer LOS (5.7 and 5.8 days) than children with a healthy weight (4.9 days; P = .03). There were no differences in complication rates between weight categories. Mean weight-adjusted daily dose for the most frequently prescribed antibiotics was different by weight category, with children in higher weight categories more likely to receive lower weight-based doses. CONCLUSIONS Children with overweight and obesity hospitalized for AHO were more likely to undergo procedures, have longer LOS, and receive lower weight-based antibiotic dosing compared with children with a healthy weight. Our findings suggest that weight should be carefully considered when treating children with AHO.
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Affiliation(s)
- Kathryn E Kyler
- Children's Mercy Kansas City, Kansas City, Missouri .,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Brian R Lee
- Children's Mercy Kansas City, Kansas City, Missouri
| | - Earl F Glynn
- Children's Mercy Kansas City, Kansas City, Missouri
| | | | - Mark A Hoffman
- Children's Mercy Kansas City, Kansas City, Missouri.,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,University of Kansas Medical Center, Kansas City, Kansas
| | - Jennifer L Goldman
- Children's Mercy Kansas City, Kansas City, Missouri.,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
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12
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Stancil SL, Abdel-Rahman S, Wagner J. Developmental Considerations for the Use of Naltrexone in Children and Adolescents. J Pediatr Pharmacol Ther 2021; 26:675-695. [PMID: 34588931 DOI: 10.5863/1551-6776-26.7.675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/27/2021] [Indexed: 11/11/2022]
Abstract
Naltrexone (NTX) is a well-tolerated drug with a wide safety margin and mechanism of action that affords use across a wide variety of indications in adults and children. By antagonizing the opioid reward system, NTX can modulate behaviors that involve compulsivity or impulsivity, such as substance use, obesity, and eating disorders. Evidence regarding the disposition and efficacy of NTX is mainly derived from adult studies of substance use disorders and considerable variability exists. Developmental changes, plausible disease-specific alterations and genetic polymorphisms in NTX disposition, and pharmacodynamic pathways should be taken into consideration when optimizing the use of NTX in the pediatric population. This review highlights the current state of the evidence and gaps in knowledge regarding NTX to facilitate evidence-based pharmacotherapy of mental health conditions, for which few pharmacologic options exist.
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Roy H, Bertoldi C, Farrell C, Rousseau E. Prescribing drugs to overweight and obese children: Balancing efficacy and safety. Paediatr Child Health 2021; 26:e236-e239. [PMID: 34552680 DOI: 10.1093/pch/pxaa108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 09/05/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Helene Roy
- CHU Sainte Justine/University of Montreal, Montreal, Quebec
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14
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Cignarella A, Busetto L, Vettor R. Pharmacotherapy of obesity: An update. Pharmacol Res 2021; 169:105649. [PMID: 33962014 DOI: 10.1016/j.phrs.2021.105649] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/14/2021] [Accepted: 04/25/2021] [Indexed: 12/12/2022]
Abstract
Several pharmacological approaches to controlling body weight have been developed over the last decades, albeit with limited success. Currently available agents include centrally acting appetite suppressants and peripherally acting compounds. Efficacy and safety of these agents in the clinical setting require a difficult balance. Further strategies including multiagonists able to simultaneously target multiple actors involved in obesity initiation and expansion such as the glucagon receptor family are under investigation. The results of recent clinical trials are encouraging and highlight emerging compounds as potential game changers. In view of the rising prevalence of obesity and the associated burden of comorbidities worldwide, and compared with other areas of pharmacological intervention, we feel that the field of obesity has been affected by therapeutic inertia. Of note, obesity may also affect the response to concomitant medications such as low-dose aspirin. Lessons from withdrawn agents such as the cannabinoid receptor antagonist rimonabant include developing compounds with a more targeted action profile (i.e., central vs peripheral, or antagonist versus inverse agonist) as well as careful selection of patients based on individual risk factors. We anticipate that the expanding knowledge base and clinical testing will result in improved outcomes for patients with obesity in the near future.
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Affiliation(s)
- Andrea Cignarella
- Department of Medicine, University of Padova Medical School, Via Giustiniani 2, 35128 Padova, Italy.
| | - Luca Busetto
- Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; Department of Medicine, Internal Medicine 3,University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Roberto Vettor
- Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; Department of Medicine, Internal Medicine 3,University of Padova, Via Giustiniani 2, 35128 Padova, Italy
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15
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Kyler KE, Bettenhausen JL, Hall M, Glynn EF, Hoffman MA, Shakhnovich V, Smolderen K, Davis AM. Obesity and Corticosteroid Dosing Guideline Adherence in Children Hospitalized With Asthma. Hosp Pediatr 2021; 11:380-388. [PMID: 33664119 DOI: 10.1542/hpeds.2020-001420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Drug dosing recommendations for children with obesity remain limited. This may lead to variability in medication dosing among children with obesity. Therefore, our objective was to determine differences in the prevalence of guideline-nonadherent systemic corticosteroid orders by weight category in children hospitalized for asthma. METHODS We performed a retrospective cross-sectional study of children aged 2 to 17 years hospitalized with asthma and prescribed systemic corticosteroids between January 1, 2010, and December 31, 2017, using the Cerner Health Facts deidentified database. Weight categories ranging from underweight to class III obesity were defined on the basis of BMI percentiles by using CDC guidelines. Corticosteroid orders were categorized as guideline adherent or nonadherent on the basis of total body weight-based dosing guidelines from the National Heart, Lung, and Blood Institute. χ2 test and multivariable logistic regression models were used to determine differences in guideline adherence between weight categories. RESULTS We identified 21 488 children prescribed systemic corticosteroids during asthma hospitalizations. Most (54.2%) had a healthy weight, and 23.8% had obesity. Almost one-quarter received guideline-nonadherent orders (22.2%), with increasing prevalence among higher weight categories (19.4% of healthy weight children versus 36.0% of those with class III obesity; P < .001). After controlling for demographic and clinical covariates, weight category remained significantly associated with receiving a guideline-nonadherent order (P < .001). CONCLUSIONS The prevalence of guideline-nonadherent corticosteroid orders for children hospitalized with asthma increases linearly with weight category, disproportionately affecting children with severe obesity. Standardization of drug dosing guidelines for children with obesity may help reduce variability in drug doses prescribed that may increase risk of harm.
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Affiliation(s)
- Kathryn E Kyler
- Children's Mercy Hospital, Kansas City, Missouri; .,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Bettenhausen
- Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Matt Hall
- Children's Mercy Hospital, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | - Earl F Glynn
- Children's Mercy Hospital, Kansas City, Missouri
| | - Mark A Hoffman
- Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Valentina Shakhnovich
- Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Center for Children's Healthy Lifestyles and Nutrition, Kansas City, Missouri; and
| | - Kim Smolderen
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Ann M Davis
- Center for Children's Healthy Lifestyles and Nutrition, Kansas City, Missouri; and.,University of Kansas Medical Center, Kansas City, Kansas
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16
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Zempsky WT, Bhagat PK, Siddiqui K. Practical Challenges-Use of Paracetamol in Children and Youth Who are Overweight or Obese: A Narrative Review. Paediatr Drugs 2020; 22:525-534. [PMID: 32918268 PMCID: PMC7529628 DOI: 10.1007/s40272-020-00417-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Worldwide, > 380 million children and adolescents are overweight or obese, including 41 million children aged < 5 years. Obesity can change the pharmacokinetic properties of drugs by altering their distribution, metabolism, and elimination. Thus, children who are overweight or obese are at increased risk for receiving inappropriate doses of commonly used drugs, which can result in treatment failure, adverse events, and/or drug toxicity. This review analyzes available data on paracetamol dosing for pain and fever in children and adolescents who are overweight or obese to identify gaps and challenges in optimal dosing strategies. Literature searches using Medline, Embase, and ClinicalTrials.gov were conducted to identify English-language articles reporting paracetamol pharmacokinetics, dosing practices, and guidelines in children and adolescents who are overweight or obese. Of 24 relevant studies identified, 20 were specific to overweight/obese individuals and 15 were specific to children and/or adolescents. Data on paracetamol pharmacokinetics in children and adolescents who are overweight or obese are lacking, and there is no high-quality evidence to guide paracetamol prescribing practices in these patients. Adult data have been extrapolated to pediatric populations; however, extrapolation does not address differences in paracetamol metabolism in adults versus children; the efficacy and safety effects of such differences are unknown. Given the growing worldwide prevalence of obesity in children and adolescents and the likelihood that paracetamol use in this population will increase accordingly, obesity-specific pediatric dosing guidelines for paracetamol are urgently needed. High-quality research is necessary to inform such guidelines.
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Affiliation(s)
- William T Zempsky
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, 282 Washington St, Hartford, CT, 06106, USA.
| | - Preeti K Bhagat
- Consumer Healthcare R & D, GlaxoSmithKline Consumer Healthcare, Singapore, Singapore
| | - Kamran Siddiqui
- Consumer Healthcare R & D, GlaxoSmithKline Consumer Healthcare, Singapore, Singapore
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Dosage adjustment in obese children, even for common drugs, is largely unclear and a treat-to-effect approach may work best. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00734-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Ameer B, Weintraub MA. Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review. Obesity (Silver Spring) 2020; 28:1013-1022. [PMID: 32441477 DOI: 10.1002/oby.22739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022]
Abstract
Medication management in children and adolescents with obesity is challenging because both developmental and pathophysiological changes may impact drug disposition and response. Evidence to date indicates an effect of obesity on drug disposition for certain drugs used in this population. This work identified published studies evaluating drug dosing, pharmacokinetics (PK), and effect in pediatric patients with obesity, focusing on 70 common medications used in a pediatric network of 42 US medical centers. A PubMed search revealed 33 studies providing PK and/or effectiveness data for 23% (16 of 70) of medications, 44% of which have just one study and can be considered exploratory. This work appraising 4 decades of literature shows several promising approaches: greater use of PK models applied to prospective clinical studies, dosing recommendations derived from both PK and safety, and multiyear effectiveness data on drugs for chronic conditions (e.g., asthma). Most studies make dose recommendations but are weakened by retrospective study design, small study populations, and no controls or historic controls. Dosing decisions continue to rely on extrapolating knowledge, including targeting systemic drug exposure typically achieved in adults. Optimal weight-based dosing strategies vary by drug and warrant prospective, controlled studies incorporating PK and modeling and simulation to complement clinical assessment.
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Affiliation(s)
- Barbara Ameer
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Michael A Weintraub
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Shakhnovich V, Kyler KE. Filling the Gap in Knowledge for Drug Dose Individualization in Pediatric Obesity. Obesity (Silver Spring) 2020; 28:1003. [PMID: 32441475 PMCID: PMC7713700 DOI: 10.1002/oby.22823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Valentina Shakhnovich
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- The Center for Children’s Healthy Lifestyles & Nutrition, Kansas City, Missouri, USA
| | - Kathryn E. Kyler
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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