1
|
Iijima S. Clinical Dilemma Involving Treatments for Very Low-Birth-Weight Infants and the Potential Risk of Necrotizing Enterocolitis: A Narrative Literature Review. J Clin Med 2023; 13:62. [PMID: 38202069 PMCID: PMC10780023 DOI: 10.3390/jcm13010062] [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: 11/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Necrotizing enterocolitis (NEC) is a critical gastrointestinal emergency with substantial morbidity and mortality risks, especially for very low-birth-weight (VLBW) infants, and unclear multifactorial pathophysiology. Whether common treatments for VLBW infants increase the NEC risk remains controversial. Indomethacin (utilized for patent ductus arteriosus) offers benefits but is concerning because of its vasoconstrictive impact on NEC susceptibility. Similarly, corticosteroids used to treat bronchopulmonary dysplasia may increase vulnerability to NEC by compromising immunity and altering the mesenteric blood flow. Histamine-2 receptor blockers (used to treat gastric bleeding) may inadvertently promote NEC by affecting bacterial colonization and translocation. Doxapram (used to treat apnea) poses a risk of gastrointestinal disturbance via gastric acid hypersecretion and circulatory changes. Glycerin enemas aid meconium evacuation but disrupt microbial equilibrium and trigger stress-related effects associated with the NEC risk. Prolonged antibiotic use may unintentionally increase the NEC risk. Blood transfusions for anemia can promote NEC via interactions between the immune response and ischemia-reperfusion injury. Probiotics for NEC prevention are associated with concerns regarding sepsis and bacteremia. Amid conflicting evidence, this review unveils NEC risk factors related to treatments for VLBW infants, offers a comprehensive overview of the current research, and guides personalized management strategies, thereby elucidating this clinical dilemma.
Collapse
Affiliation(s)
- Shigeo Iijima
- Department of Regional Neonatal-Perinatal Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| |
Collapse
|
2
|
Sultana Z, Hasenstab KA, Moore RK, Osborn EK, Yildiz VO, Wei L, Slaughter JL, Jadcherla SR. Symptom Scores and pH-Impedance: Secondary Analysis of a Randomized Controlled Trial in Infants Treated for Gastroesophageal Reflux. GASTRO HEP ADVANCES 2022; 1:869-881. [PMID: 36310566 PMCID: PMC9615096 DOI: 10.1016/j.gastha.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS To evaluate and compare gastro-esophageal reflux (GER) symptom scores with pH-impedance and test the effects of acid-suppressive medications with or without feeding modifications on pH-impedance in high-risk infants. METHODS Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and 24-hour pH-impedance data were analyzed from 94 infants evaluated in a tertiary care setting for GER disease. Longitudinal data from 40 infants that received randomized GER therapy (proton pump inhibitor [PPI] with or without feeding modifications) for 4 weeks followed by 1-week washout were analyzed. Relationships between I-GERQ-R and pH-impedance metrics (acid reflux index, acid and bolus GER events, distal baseline impedance, and symptoms) were examined and effects of treatments compared. RESULTS (A) Correlations between I-GERQ-R and pH-impedance metrics were weak. (B) I-GERQ-R sensitivity, specificity, and positive predictive values were suboptimal when correlated with pH-impedance metrics. I-GERQ-R negative predictive value (NPV) was high for acid symptom-association probability (NPV = 84%) and distal baseline impedence (NPV = 86%) thresholds. (C) PPI with feeding modifications (vs PPI alone) did not alter pH-impedance metrics or symptom scores (P > .05); however, bolus clearance metrics worsened for both treatment groups (P < .05). CONCLUSIONS In high-risk infants (1) I-GERQ-R may be a helpful clinical screening tool to exclude acid-GER disease diagnosis and minimize unnecessary acid-suppressive treatment, but further testing is needed for diagnosis. (2) Acid-suppressive therapy with feeding modifications has no effect on symptom scores or pH-impedance metrics. Clearance of refluxate worsened despite PPI therapy, which may signal development of pharyngoesophageal dysmotility and persistence of symptoms. (3) Placebo-controlled trials are needed in high-risk infants with objective pH-impedance criteria to determine efficacy, safety, and underlying mechanisms. Clinicaltrials.gov ID: NCT02486263.
Collapse
Affiliation(s)
- Zakia Sultana
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Rebecca K. Moore
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Erika K. Osborn
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Vedat O. Yildiz
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lai Wei
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan L. Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, The Ohio State University College of Medicine, Columbus, Ohio
| |
Collapse
|
3
|
Gilna GP, Saberi RA, Baez AC, Ribieras AJ, Cioci AC, Urrechaga EM, Parreco JP, Perez EA, Sola JE, Thorson CM. Nationwide Outcomes and Readmission After Pediatric Laparoscopic and Open Fundoplication. J Laparoendosc Adv Surg Tech A 2021; 31:1389-1396. [PMID: 34851741 DOI: 10.1089/lap.2021.0345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Fundoplications are a common operation in the pediatric population. This study aims to explore outcomes comparing laparoscopic versus open operative techniques. Methods: From 2010 to 2014 the Nationwide Readmissions Database was used to identify patients aged 0-18 years who underwent a fundoplication. Propensity score matched analysis was performed based on 87 covariates. Demographics, hospital factors, readmissions, and complications were compared by surgical technique (laparoscopic versus open). Results: There were 4411 patients (47% female) who underwent fundoplication via laparoscopic (69%) versus open (31%) technique. Gastrostomy tubes were placed in 75% of patients also undergoing fundoplication. Newborn made up 64% of the cohort, with 47% of newborns having cardiac anomalies and 96% being premature. Open fundoplications were more likely to be performed in newborns (72% versus 61%) and those in the lowest income quartile compared to laparoscopic (41% versus 31% P < .001), both P < .001. The readmission rate was 20% within 30 days and 38% within the year, with 15% admitted to a different hospital. Only 14% of readmissions were elective. Open fundoplication was associated with more unplanned readmissions (94% versus 84%), conversion to gastrojejunostomy tube (11% versus 5%) along with major (5% versus 3%) and minor (8% versus 2%) complications compared to the laparoscopic approach, all P < 0.001. Conclusion: The majority of fundoplications are being performed in newborns and are being done laparoscopically, which are associated with lower complication and postoperative readmission rates compared to open fundoplications.
Collapse
Affiliation(s)
- Gareth P Gilna
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rebecca A Saberi
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Adriana C Baez
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Antoine J Ribieras
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Alessia C Cioci
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eva M Urrechaga
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joshua P Parreco
- Division of Trauma and Surgical Critical Care, Memorial Regional Hospital, Hollywood, Florida, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chad M Thorson
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
4
|
Sanchez JB, Jadcherla SR. Gastroesophageal Reflux Disease in Neonates: Facts and Figures. Neoreviews 2021; 22:e104-e117. [PMID: 33526640 DOI: 10.1542/neo.22-2-e104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jenny Bellodas Sanchez
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Sudarshan R Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
5
|
Role of feeding strategy bundle with acid-suppressive therapy in infants with esophageal acid reflux exposure: a randomized controlled trial. Pediatr Res 2021; 89:645-652. [PMID: 32380509 PMCID: PMC7647955 DOI: 10.1038/s41390-020-0932-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To test the hypothesis that a feeding bundle concurrent with acid suppression is superior to acid suppression alone in improving gastroesophageal reflux disease (GERD) attributed-symptom scores and feeding outcomes in neonatal ICU infants. METHODS Infants (N = 76) between 34 and 60 weeks' postmenstrual age with acid reflux index > 3% were randomly allocated to study (acid-suppressive therapy + feeding bundle) or conventional (acid-suppressive therapy only) arms for 4 weeks. Feeding bundle included: total fluid volume < 140 mL/kg/day, fed over 30 min in right lateral position, and supine postprandial position. Primary outcome was independent oral feeding and/or ≥6-point decrease in symptom score (I-GERQ-R). Secondary outcomes included growth (weight, length, head circumference), length of hospital stay (LOHS, days), airway (oxygen at discharge), and developmental (Bayley scores) milestones. RESULTS Of 688 screened: 76 infants were randomized and used for the primary outcome as intent-to-treat, and secondary outcomes analyzed for 72 infants (N = 35 conventional, N = 37 study). For study vs. conventional groups, respectively: (a) 33% (95% CI, 19-49%) vs. 44% (95% CI, 28-62%), P = 0.28 achieved primary outcome success, and (b) secondary outcomes did not significantly differ (P > 0.05). CONCLUSIONS Feeding strategy modifications concurrent with acid suppression are not superior to PPI alone in improving GERD symptoms or discharge feeding, short-term and long-term outcomes. IMPACT Conservative feeding therapies are thought to modify GERD symptoms and its consequences. However, in this randomized controlled trial in convalescing neonatal ICU infants with GERD symptoms, when controlling for preterm or full-term birth and severity of esophageal acid reflux index, the effectiveness of acid suppression plus a feeding modification bundle (volume restriction, intra- and postprandial body positions, and prolonged feeding periods) vs. acid suppression alone, administered over a 4-week period was not superior in improving symptom scores or feeding outcomes. Restrictive feeding strategies are of no impact in modifying GERD symptoms or clinically meaningful outcomes. Further studies are needed to define true GERD and to identify effective therapies in modifying pathophysiology and outcomes. The improvement in symptoms and feeding outcomes over time irrespective of feeding modifications may suggest a maturational effect. This study justifies the use of placebo-controlled randomized clinical trial among NICU infants with objectively defined GERD.
Collapse
|
6
|
Santos VS, Freire MS, Santana RNS, Martins-Filho PRS, Cuevas LE, Gurgel RQ. Association between histamine-2 receptor antagonists and adverse outcomes in neonates: A systematic review and meta-analysis. PLoS One 2019; 14:e0214135. [PMID: 30947259 PMCID: PMC6448909 DOI: 10.1371/journal.pone.0214135] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/07/2019] [Indexed: 12/25/2022] Open
Abstract
Background The use of histamine-2 receptor antagonists (H2RA) in neonates is still debated because of possible risk of infection, necrotizing enterocolitis (NEC) and increased mortality. Aim To review whether the use of H2RA in neonates admitted to neonatal intensive care units (NICU) is associated with infection, NEC or mortality. Materials and method We performed a systematic search in PubMed, Web of Science and SCOPUS databases using the terms “histamine-2 receptor antagonists”, “infection”, “necrotizing enterocolitis”, “mortality”, “neonates” and related terms to identify studies published up to April 30, 2017. We included studies conducted in hospitalized neonates and exposed to H2RA. The primary outcomes were infection, NEC and mortality. We included reports of infections with clinical signs and positive culture, and NEC according to Bell stages (stage ≥II) based on standardised clinical and radiologic criteria. Among 1,144 studies identified, 10 fulfilled the selection criteria. Information extracted included study design, sample size and number of participants, along with the outcomes of interest. We conducted a meta-analysis of adjusted data and pooled estimates of infection, NEC and mortality are reported as odds ratios (OR) and 95% confidence intervals (95%CI). Results Ten studies were analysed. There were substantial associations between H2RA and infection (pooled OR: 2.09; 95%CI: 1.35–3.24; P = 0.001) and NEC (pooled OR: 2.81, 95%CI: 1.19–6.64; P = 0.02) but not with the mortality risk (pooled OR: 1.76; 95%CI: 0.50–6.16; P: 0.38). Conclusion Current evidence suggests that H2RA is associated with an increased risk of infection and NEC, but not with mortality in neonates admitted to NICU. The use of H2RA in neonates must be stringently considered when necessary.
Collapse
Affiliation(s)
- Victor S. Santos
- Centre for Epidemiology and Public Health. Federal University of Alagoas, Arapiraca, Brazil
| | - Marina S. Freire
- Department of Medicine. Federal University of Sergipe, Aracaju, Brazil
| | | | - Paulo R. S. Martins-Filho
- Postgraduate Programme in Health Science. Federal University of Sergipe, Aracaju, Brazil
- Investigative Pathology Laboratory, Federal University of Sergipe, Brazil
| | - Luis E. Cuevas
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ricardo Q. Gurgel
- Department of Medicine. Federal University of Sergipe, Aracaju, Brazil
- Postgraduate Programme in Health Science. Federal University of Sergipe, Aracaju, Brazil
- * E-mail:
| |
Collapse
|
7
|
Gulati IK, Jadcherla SR. Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Infant: Who Needs to Be Treated and What Approach Is Beneficial? Pediatr Clin North Am 2019; 66:461-473. [PMID: 30819348 PMCID: PMC6400306 DOI: 10.1016/j.pcl.2018.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastroesophageal reflux (GER) and GER disease (GERD) pertaining to infants in the neonatal intensive care unit (NICU) are reviewed, based on research in this specific population. The developmental biology of the gastroesophageal junction, physiology of GER, and pathophysiology of GERD in this setting are summarized, and risk factors for GER and GERD identified. The epidemiology, economic burden, and controversies surrounding GERD in NICU infants are addressed, and an approach to GER and GERD in these patients formulated. Recent advancements in individual assessment of GER and GERD in the NICU infant are examined, and evidence-based guidelines for their adoption provided.
Collapse
Affiliation(s)
- Ish K Gulati
- Innovative Research Program in Neonatal Feeding Disorders; The Neonatal and Infant Feeding Disorders Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Research Program in Neonatal Feeding Disorders; The Neonatal and Infant Feeding Disorders Program, Nationwide Children's Hospital, Columbus, OH, USA; Division of Neonatology, Department of Pediatrics, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 575 Children's Cross Roads, Columbus, OH 43215, USA; Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 575 Children's Cross Roads, Columbus, OH 43215, USA.
| |
Collapse
|
8
|
Patil UP, Bailey SM, Wachtel EV, Orosz E, Zarchin R, Mally PV. Efficacy of and potential morbidities associated with the use of antacid medications in preterm neonates. J Perinat Med 2017; 45:947-952. [PMID: 28141547 DOI: 10.1515/jpm-2016-0285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 12/05/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Antacid medications are frequently administered to preterm infants. These medications can change gastric pH levels and can affect regular gastrointestinal function and gut micro-bacterial flora. We hypothesized that preterm infants exposed to antacid medications are at a greater risk of necrotizing enterocolitis (NEC) and sepsis, and set out to determine any association, as well as to assess the clinical efficacy of these medications. MATERIALS AND METHODS Retrospective chart review of preterm infants ≤30 weeks' gestational age or birth weight ≤1250 g over a 2-year period at New York University Langone Medical Center. Subjects were divided into two groups: those who had been treated with antacid medications and those who had not. We then examined for any difference in NEC (≥Bell stage 2) or culture proven sepsis. RESULTS The study comprised 65 eligible neonates, 28 in antacid treatment group and 37 in control. The incidence of NEC (21.4% vs. 2.7%, P=0.04) was significantly higher in the antacid group, but these infants tended to be born more prematurely than control subjects. There was a trend toward more culture proven sepsis cases in the antacid group. We found no difference in signs generally associated with neonatal reflux (apnea, bradycardia, and desaturation events) in subjects treated with antacid medications after treatment began. CONCLUSIONS Treatment of preterm infants with antacid medications is potentially associated with a higher risk of NEC, and possibly sepsis, while appearing to provide little benefit.
Collapse
|
9
|
Belik J. IN TIME: NUTRIÇÃO ENTERAL EM RECÉM-NASCIDOS PRÉ-TERMO: MUITO FOI APRENDIDO, MAS AINDA NÃO SABEMOS COMO MELHOR ALIMENTÁ-LOS. REVISTA PAULISTA DE PEDIATRIA 2017; 35:242-243. [PMID: 28977302 PMCID: PMC5606185 DOI: 10.1590/1984-0462/;2017;35;3;00018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Indexed: 11/23/2022]
|
10
|
Santana RNS, Santos VS, Ribeiro-Júnior RF, Freire MS, Menezes MAS, Cipolotti R, Gurgel RQ. Use of ranitidine is associated with infections in newborns hospitalized in a neonatal intensive care unit: a cohort study. BMC Infect Dis 2017; 17:375. [PMID: 28558748 PMCID: PMC5450121 DOI: 10.1186/s12879-017-2482-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 05/22/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The inhibition of gastric acid secretion with ranitidine is frequently prescribed off-label to newborns admitted to neonatal intensive care units (NICU). Some studies show that the use of inhibitors of gastric acid secretion (IGAS) may predispose to infections and necrotising enterocolitis (NEC), but there are few data to confirm this association. This study aimed to compare the rates of neonatal infections and NEC among preterm infants (<37 weeks gestation) hospitalised in a NICU exposed or not to treatment with ranitidine. METHODS A retrospective cohort study was conducted with all consecutive preterm newborns admitted to a NICU between August-2014 and October-2015. The rates of infection, NEC, and death of newborns exposed or not to ranitidine were recorded. RESULTS A total of 300 newborns were enrolled, of which 115 had received ranitidine and 185 had not. The two groups were similar with regard to the main demographic and clinical characteristics. Forty-eight (41.7%) of the 115 infants exposed to ranitidine and 49 (26.5%) of the 185 infants not exposed were infected (RR = 1.6, 95%CI 1.1-2.2, p = 0.006). The late onset (>48 h) blood culture positive infection rate was higher in the group exposed to ranitidine than in the untreated group (13.0% vs. 3.8%, p = 0.001). There was no significant association between the use of ranitidine and NEC (Bell stage >II) (p = 0.36). The mortality rate risk was 4-fold higher in infants receiving ranitidine (16.5% vs. 8.6%, p < 0.001). CONCLUSION Ranitidine use in neonates was associated with an increased risk of infections and mortality, but not with NEC.
Collapse
Affiliation(s)
- Ruth N S Santana
- Department of Medicine, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil
| | - Victor S Santos
- Postgraduate Program in Health Sciences, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil
| | - Ruy F Ribeiro-Júnior
- Department of Medicine, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil
| | - Marina S Freire
- Department of Medicine, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil
| | - Maria A S Menezes
- Postgraduate Program in Health Sciences, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil
| | - Rosana Cipolotti
- Department of Medicine, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil.,Postgraduate Program in Health Sciences, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil
| | - Ricardo Q Gurgel
- Department of Medicine, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil. .,Postgraduate Program in Health Sciences, Federal University of Sergipe, R. Cláudio Batista, s/n - Cidade Nova, Aracaju, 49060-108, Brazil.
| |
Collapse
|
11
|
D’Agostino JA, Passarella M, Martin AE, Lorch SA. Use of Gastroesophageal Reflux Medications in Premature Infants After NICU Discharge. Pediatrics 2016; 138:peds.2016-1977. [PMID: 27940703 PMCID: PMC5127072 DOI: 10.1542/peds.2016-1977] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To describe the epidemiology and management of gastroesophageal reflux (GER) medications started in the first year of life for premature infants. METHODS Retrospective review of a cohort of infants ≤35 weeks' gestation presenting for care by 168 days of age to a 30-site network between 2005 and 2009 (n = 2217) and followed to 3 years of age. Medication frequency, types, and duration of use were assessed. Logistic regression identified factors associated with treatment. RESULTS Thirty-seven percent (812) were prescribed GER medications with 77% begun after NICU discharge. Ninety percent (727) received histamine-2 receptor antagonists, 33% (269) proton pump inhibitors, 22% (182) prokinetics; 40% (325) received >1 medication. Outpatient medication was initiated at 95 ± 69 days of life for total of 294 ± 249 days (interquartile ratio: 117-359). Feeding issues (adjusted odds ratio [aOR] 2.05, 95% confidence interval [CI]: 1.24-3.39) were associated with outpatient initiation. Forty-three percent (322) of infants started before 6 months were still on at 1 year of age associated with gestational age <32 weeks (aOR 1.76, 95% CI: 1.16-2.67), chronic lung disease (aOR 2.59, 95% CI: 1.29-5.22), and reactive airways disease (aOR 1.67, 95% CI: 1.05-2.65). CONCLUSIONS Of the 37% of the cohort on GER medications, 77% were started after NICU discharge with prolonged use of medications. Feeding difficulties were associated with starting medication and markers of chronic lung disease with continuation of treatment. With uncertain evidence of efficacy, use of these medications in a high-risk population should be carefully evaluated.
Collapse
Affiliation(s)
- Jo Ann D’Agostino
- Department of Pediatrics,,Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Molly Passarella
- Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Ashley E. Martin
- Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Scott A. Lorch
- Department of Pediatrics,,Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,The University of Pennsylvania School of Medicine and,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Abstract
Comprehensive guidelines for the diagnosis and management of gastro-esophageal reflux (GER) and GER disease (GERD) were developed by the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. GERD is reflux associated with troublesome symptoms or complications. The recognition of GER and GERD is relevant to implement best management practices. A conservative management is indicated in infants with uncomplicated physiologic reflux. Children with GERD may benefit from further evaluation and treatment. Since the publications of the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition guidelines in 2009, no important novelties in drug treatment have been reported. Innovations are mainly restricted to the management of regurgitation in infants. During the last 5 years, pros and cons of multichannel intraluminal impedance have been highlighted. However, overall 'not much has changed' in the diagnosis and management of GER and GERD in infants and children.
Collapse
Affiliation(s)
| | - Bruno Hauser
- a Department of Pediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| |
Collapse
|
13
|
Romaine A, Ye D, Ao Z, Fang F, Johnson O, Blake T, Benjamin DK, Cotten CM, Testoni D, Clark RH, Chu VH, Smith PB, Hornik CP. Safety of histamine-2 receptor blockers in hospitalized VLBW infants. Early Hum Dev 2016; 99:27-30. [PMID: 27390109 PMCID: PMC4969147 DOI: 10.1016/j.earlhumdev.2016.05.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/20/2016] [Accepted: 05/24/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Histamine-2 receptor (H2) blockers are often used in very low birth weight infants despite lack of population specific efficacy and safety data. AIMS We sought to describe safety and temporal trends in histamine-2 receptor (H2) blocker use in hospitalized very low birth weight (VLBW) infants. STUDY DESIGN We conducted a retrospective cohort study using a clinical database populated by an electronic health record shared by 348 neonatal intensive care units in the United States. SUBJECTS We included all VLBW infants without major congenital anomalies. OUTCOME MEASURES We used multivariable logistic regression with generalizing estimating equations to evaluate the association between days of H2 blocker exposure and risk of: 1) death or necrotizing enterocolitis (NEC); 2) death or sepsis; and 3) death, NEC, or sepsis. RESULTS Of 127,707 infants, 20,288 (16%) were exposed to H2 blockers for a total of 6,422,352days. Median gestational age for infants exposed to H2 blockers was 27weeks (25th 75th percentile 26, 29). H2 blocker use decreased from 18% of infants in 1997 to 8% in 2012 (p<0.001). On multivariable analysis, infants were at increased risk of the combined outcome of death, NEC, or sepsis on days exposed to H2 blockers (odds ratio=1.14) (95% confidence interval 1.08, 1.19). CONCLUSIONS H2 blocker use is associated with increased risk of the combined outcome of death, NEC, or sepsis in hospitalized VLBW infants.
Collapse
Affiliation(s)
| | - Daniel Ye
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Zachary Ao
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Francia Fang
- Duke Clinical Research Institute, Durham, NC, USA.
| | | | - Taylor Blake
- Duke Clinical Research Institute, Durham, NC, USA.
| | | | | | | | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL,USA.
| | - Vivian H Chu
- Duke Clinical Research Institute, Durham, NC, USA.
| | | | | |
Collapse
|
14
|
de Souza AS, Dos Santos DB, Rey LC, Medeiros MG, Vieira MG, Coelho HLL. Off-label use and harmful potential of drugs in a NICU in Brazil: A descriptive study. BMC Pediatr 2016; 16:13. [PMID: 26795213 PMCID: PMC4722776 DOI: 10.1186/s12887-016-0551-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 01/13/2016] [Indexed: 11/26/2022] Open
Abstract
Background Neonates admitted to neonatal intensive care units (NICU) are exposed to a wide variety of drugs, most without any data on safety and efficacy. Objective: To describe the drugs prescribed to different groups of neonates hospitalized in a NICU, and to analyze off-label use and harmful potential of drugs, in terms of the potential risks. Methods This was a six-month retrospective cohort study of drug use in a NICU, with neonates who were inpatients for a period of over 24 hours, and using prescription data from electronic medical records. Drug information found in the package leaflets, in the British National Formulary for Children 2012–2013, and in the Thomson Micromedex database were compared. Drugs and excipients considered potentially harmful were evaluated according to the literature. Results One hundred ninety-two neonates were included in the study, with a mean gestational age (GA) of 33.3 weeks (SD ± 4.3), 75.0 % were preterm, with an average of 18.8 days of hospitalization (SD ± 18.1), and a total of 3617 neonates-day. 3290 prescriptions were registered, on average 17.1 prescriptions/neonate (SD ± 17.9) and 8.8 drugs/neonate (SD ± 5.9). The number of prescriptions and drugs was higher in neonates with GA <31 weeks (p <0.05). Anti-infectives for systemic use, blood, alimentary tract and metabolism drug groups were more frequent, varying according to the GA. Neonates (99.5 %) were exposed to unlicensed drugs (UL) and off label use (OL), more frequently in GA <28 weeks (p <0.05). Most OL drugs used were indicated for newborns. 15 potentially harmful drugs were used in more than 70 % of the neonates, and most were OL; exposure to harmful excipients occurred in 91.6 % of the neonates, a percentage even higher when considering immature neonates. Conclusions Immature neonates in a Brazilian NICU are exposed to a variety of OL, UL and potentially harmful drugs and excipients.
Collapse
Affiliation(s)
- Alcidésio Sales de Souza
- Pharmacy Department, Mother and Child Hospital of Brasilia, Brasília, Federal District, Brazil. .,Doctoral Program in Development and Technological Innovation in Drugs, Federal University of Ceará, Fortaleza, Ceará, Brazil. .,Mother and Child Hospital of Brasilia, SGAS, Av. L2 Sul, Quadra608, Módulo A, Asa Sul, Brasília, CEP 70203-900, DF, Brazil.
| | - Djanilson Barbosa Dos Santos
- Postgraduate Programme in Pharmaceutical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Federal University of Recôncavo da Bahia, Santo Antônio de Jesus, Bahia, Brazil
| | - Luís Carlos Rey
- Mother and Child Health Department, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Marina Garruti Medeiros
- Postgraduate Programme in Pharmaceutical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Marta Gonçalves Vieira
- Neonatology Department, Mother and Child Hospital of Brasilia, Brasília, Federal District, Brazil
| | - Helena Lutéscia Luna Coelho
- Doctoral Program in Development and Technological Innovation in Drugs, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Postgraduate Programme in Pharmaceutical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil
| |
Collapse
|
15
|
Off-label and unlicensed drug treatments in Neonatal Intensive Care Units: an Italian multicentre study. Eur J Clin Pharmacol 2015; 72:117-23. [DOI: 10.1007/s00228-015-1962-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/02/2015] [Indexed: 01/20/2023]
|
16
|
The Role of Sleep in the Modulation of Gastroesophageal Reflux and Symptoms in NICU Neonates. Pediatr Neurol 2015; 53:226-32. [PMID: 26149107 PMCID: PMC4590781 DOI: 10.1016/j.pediatrneurol.2015.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/22/2015] [Accepted: 05/23/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Newborns sleep about 80% of the time. Gastroesophageal reflux disease is prevalent in about 10% of neonatal intensive care unit infants. Concurrent polysomnography and pH-impedance studies clarify the relationship of gastroesophageal reflux with sleep. AIMS To characterize spatiotemporal and chemical characteristics of impedance-positive gastroesophageal reflux and define symptom associations in sleep and wake states in symptomatic neonates. We hypothesized that frequency of impedance-positive gastroesophageal reflux events and their association with cardiorespiratory symptoms is greater during sleep. METHODS Eighteen neonates underwent concurrent polysomnography with a pH-impedance study. Impedance-positive gastroesophageal reflux events (weakly acidic or acidic) were categorized between sleep versus wake states: Symptom Index = number of symptoms with gastroesophageal reflux/total symptoms*100; Symptom Sensitivity Index = number of gastroesophageal reflux with symptoms/total gastroesophageal reflux*100; Symptom Association Probability = [(1 - probability of observed association between reflux and symptoms)*100]). RESULTS We analyzed 317 gastroesophageal reflux events during 116 hours of polysomnography. During wake versus sleep, respectively, the median (interquartile range) frequency of impedance-positive gastroesophageal reflux was 4.9 (3.1-5.8) versus 1.4 (0.7-1.7) events/hour (P < 0.001) and the proximal migration was 2.6 (0.8-3.3) versus 0.2 (0.0-0.9) events/hour (P < 0.001). The Symptom Index for cardiorespiratory symptoms for impedance-positive events was 22.5 (0-55.3) versus 6.1 (0-13), P = 0.04, whereas the Symptom Sensitivity Index was 9.1 (0-23.1) versus 18.4 (0-50), P = 0.04, although Symptom Association Probability was similar (P = 0.68). CONCLUSIONS Contrary to our hypothesis, frequency of gastroesophageal reflux in sleep is lower; however, spatiotemporal and chemical characteristics of gastroesophageal reflux and symptom-generation mechanisms are distinct. For cardiorespiratory symptoms during sleep, a lower Symptom Index entails evaluation for etiologies other than gastroesophageal reflux disease, a higher Symptom Sensitivity Index implies heightened esophageal sensitivity, and similar Symptom Association Probability indicates other mechanistic possibilities.
Collapse
|
17
|
Toxic excipients in medications for neonates in Brazil. Eur J Pediatr 2014; 173:935-45. [PMID: 24500397 DOI: 10.1007/s00431-014-2272-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/08/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED The aim was to describe the exposure to excipients among neonates hospitalised in the neonatal intensive care unit (NICU) of a public hospital in Brasilia, Brazil. This was a retrospective study based on medicines that were prescribed electronically to neonates (≤28 days) who were admitted to the NICU of a hospital in Brasilia between January 1 and March 31, 2012. Excipients were identified from the medicine package leaflets and were classified according to toxicity. Seventy-nine infants received a total of 1,303 prescriptions comprising 77 formulations and 70 active drugs. Eighty-six excipients were identified, of which, 9 were harmful excipients (HE) and 48 were potentially harmful excipients (PHE). Almost all the neonates (98.7 %) were exposed to at least one HE and PHE. Preterm neonates (n = 64; 1,502 neonate days) presented high risk of exposure to polysorbate 80 (3.26/100 neonate days), sodium hydroxide (3.39), PG (3.19) and propylparaben (3.06). Full-term neonates (n = 15; 289 neonate days) presented risks in relation to phenol (4.84), ethanol (3.8) and sodium citrate (3.46). CONCLUSION Neonates in NICUs in Brazil are exposed to a wide variety of HE and PHE with unpredictable results. Safer alternatives are needed, as well as further studies on the subject.
Collapse
|
18
|
Abstract
Paediatric GERD is complicated to manage, as symptoms are diverse and often difficult to interpret. In infants, regurgitation is a common physiological condition. Nevertheless, when it occurs frequently (>4 times per day) and causes the infant distress, parents often seek medical help. In children 2-10 years of age, GERD is often considered to cause extra-oesophageal symptoms, despite the absence of hard evidence. Diagnostic investigations often lack solid validation and the signs and symptoms of GERD overlap with those of cow's milk protein allergy and eosinophillic oesophagitis. Reassurance, dietary treatment and positional adaptations are recommended for troublesome infant reflux. Anti-acid medication, mainly PPIs, is over-used in infants even though, in many children, reflux is not an acid-related condition. Moreover, evidence is increasing that PPIs cause adverse events such as gastroenteritis and respiratory tract infections. Management in children older than 10 years is similar to that in adults. Using prokinetics to treat nonerosive reflux disease remains only a promising theoretical concept, as no such molecule is currently available. Today, the adverse effects of each prokinetic molecule largely outweigh its potential benefit. Laparoscopic surgery is indicated in children who have life-threatening symptoms or in cases of drug dependence.
Collapse
Affiliation(s)
- Yvan Vandenplas
- Department of Pediatrics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| |
Collapse
|
19
|
Kasirer MY, Welsh C, Pan J, Shifrin Y, Belik J. Metoclopramide does not increase gastric muscle contractility in newborn rats. Am J Physiol Gastrointest Liver Physiol 2014; 306:G439-44. [PMID: 24407589 DOI: 10.1152/ajpgi.00242.2013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Feeding intolerance resulting from delayed gastric emptying is common in premature neonates. Metoclopramide (MCP), the most frequently used prokinetic drug in neonates, enhances gastric muscle contractility through inhibition of dopamine receptors. Although its therapeutic benefit is established in adults, limited data are available to support its clinical use in infants. Hypothesizing that developmentally dependent differences are present, we comparatively evaluated the effect of MCP on fundus muscle contractility in newborn, juvenile, and adult rats. The muscle strips were either contracted with electrical field stimulation (EFS) to induce cholinergic nerve-mediated acetylcholine release or carbachol, a cholinergic agonist acting directly on the muscarinic receptor. Although in adult rats MCP increased EFS-induced contraction by 294 ± 122% of control (P < 0.01), no significant effect was observed in newborn fundic muscle. MCP had no effect on the magnitude of the carbachol-induced and/or bethanechol-induced gastric muscle contraction at any age. In response to dopamine, an 80.7 ± 5.3% relaxation of adult fundic muscle was observed, compared with only a 8.4 ± 8.7% response in newborn tissue (P < 0.01). Dopamine D2 receptor expression was scant in neonates and significantly increased in adult gastric tissue (P < 0.01). In conclusion, the lack of MCP effect on the newborn fundic muscle contraction potential relates to developmental differences in dopamine D2 receptor expression. To the extent that these novel data can be extrapolated to neonates, the therapeutic value of MCP as a prokinetic agent early in life requires further evaluation.
Collapse
Affiliation(s)
- Moshe Yair Kasirer
- Physiology and Experimental Medicine Program, Hospital for Sick Children Research Institute
| | | | | | | | | |
Collapse
|
20
|
Laughon MM, Avant D, Tripathi N, Hornik CP, Cohen-Wolkowiez M, Clark RH, Smith PB, Rodriguez W. Drug labeling and exposure in neonates. JAMA Pediatr 2014; 168:130-6. [PMID: 24322269 PMCID: PMC3927948 DOI: 10.1001/jamapediatrics.2013.4208] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Federal legislation has led to a notable increase in pediatric studies submitted to the Food and Drug Administration (FDA), resulting in new pediatric information in product labeling. However, approximately 50% of drug labels still have insufficient information on safety, efficacy, or dosing in children. Neonatal information in labeling is even scarcer because neonates comprise a vulnerable subpopulation for which end-point development is lagging and studies are more challenging. OBJECTIVE To quantify progress made in neonatal studies and neonatal information in product labeling as a result of recent legislation. DESIGN, SETTING, AND PARTICIPANTS We identified a cohort of drug studies between 1997 and 2010 that included neonates as a result of pediatric legislation using information available on the FDA website. We determined what studies were published in the medical literature, the legislation responsible for the studies, and the resulting neonatal labeling changes. We then examined the use of these drugs in a cohort of neonates admitted to 290 neonatal intensive care units (NICUs) (the Pediatrix Data Warehouse) in the United States from 2005 to 2010. EXPOSURE Infants exposed to a drug studied in neonates as identified by the FDA website. MAIN OUTCOMES AND MEASURES Number of drug studies with neonates and rate of exposure per 1000 admissions among infants admitted to an NICU. RESULTS In a review of the FDA databases, we identified 28 drugs studied in neonates and 24 related labeling changes. Forty-one studies encompassed the 28 drugs, and 31 (76%) of these were published. Eleven (46%) of the 24 neonatal labeling changes established safety and effectiveness. In a review of a cohort of 446,335 hospitalized infants, we identified 399 drugs used and 1,525,739 drug exposures in the first 28 postnatal days. Thirteen (46%) of the 28 drugs studied in neonates were not used in NICUs; 8 (29%) were used in fewer than 60 neonates. Of the drugs studied, ranitidine was used most often (15,627 neonates, 35 exposures per 1000 admissions). CONCLUSIONS AND RELEVANCE Few drug labeling changes made under pediatric legislation include neonates. Most drugs studied are either not used or rarely used in US NICUs. Strategies to increase the study of safe and effective drugs for neonates are needed.
Collapse
Affiliation(s)
- Matthew M. Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill
| | - Debbie Avant
- Food and Drug Administration, Rockville, Maryland
| | - Nidhi Tripathi
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Christoph P. Hornik
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | | | - Reese H. Clark
- Pediatrix Center for Research and Education, Sunrise, Florida
| | - P. Brian Smith
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | | |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW To provide current information on off-label medication use in pediatric gastroenterology, including a discussion on US legislative efforts to address the issue. RECENT FINDINGS Medications used to treat pediatric gastrointestinal illnesses are frequently prescribed off-label. Acid suppressors, antiemetics, laxatives, and antitumor necrosis factor therapies are types of medications frequently used off-label in the pediatric gastroenterology arena. Pediatric studies conducted under US Federal laws are generating much-needed data on the safety and effectiveness of medications used to treat pediatric patients. Moreover, a new US law, the Food and Drug Administration Safety and Innovation Act, may further the development of pediatric medications in part by requiring pediatric-specific study plans earlier in the overall drug development process. As of today, there still are gaps in our knowledge about these medications, including for the treatment of pediatric gastroenterology diseases. SUMMARY Medications are widely used off-label in pediatrics, including medications intended to treat gastrointestinal diseases, such as antitumor necrosis factor and laxatives. Although legislation is helping to generate and make available important information about pediatric medications, most still do not contain pediatric data. Therefore, providers need to understand the potential risks and benefits of prescribing off-label products to pediatric patients.
Collapse
|
22
|
Fang H, Jin L, Huang N, Wang J, Zou K, Luo Z. Synthesis, Structure and H+/K+-ATPase Inhibitory Activity of Novel Triazolyl Substituted Tetrahydrobenzofuran Derivatives via One-pot Three-component Click Reaction. CHINESE J CHEM 2013. [DOI: 10.1002/cjoc.201300119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
23
|
Allegaert K. Clinical pharmacological studies in children: From exploratory towards confirmation driven methodology. World J Clin Pediatr 2012; 1:3-7. [PMID: 25254160 PMCID: PMC4145636 DOI: 10.5409/wjcp.v1.i2.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 07/31/2012] [Accepted: 08/05/2012] [Indexed: 02/06/2023] Open
Abstract
Just like children are not small adults, pediatric studies are not just subgroup-adult studies. Clinical pharmacology aims to predict these effects based on drug, population and/or patient-specific pharmacokinetics (concentration-time profiles) and -dynamics (concentration-effect profile). The most essential characteristics of childhood are growth and maturation. Both phenomena are most prominent during infancy making the claim that “an infant is not just a small child” as relevant compared to the paradigm that “a child is not just a small adult”. From a clinical pharmacology perspective, the consequence of such a dynamic setting is extensive variability throughout childhood in both the pharmacokinetics and pharmacodynamics. Trial design probably has impact on recruitment to an even greater extent compared to adult studies. In general, if a study is designed well, with a clear clinical question with which parents and children can identify, they are likely to consider participation. Open communication with all stakeholders involved will most likely result in ethically correct, practically feasible, scientifically sound, and economical reasonable studies to provide children with the appropriate treatment. From an academic perspective, feasibility, relevance, applicability and costs of clinical pharmacological studies in children can be significantly improved by new sampling concepts (e.g., saliva, urine, dried spot blood) and the systematic introduction of already known information into the trial design through model based pediatric drug development, that mainly affect feasibility of pharmacokinetic studies. In contrast, for the pharmacodynamic part of pediatric studies, development and validation of population specific biomarkers or robust outcome variables is urgently needed.
Collapse
Affiliation(s)
- Karel Allegaert
- Karel Allegaert, Division of Woman and Child, Neonatal Intensive Care Unit, University Hospital, 3000 Leuven, Belgium
| |
Collapse
|