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Poppe JA, Flint RB, Smits A, Willemsen SP, Storm KK, Nuytemans DH, Onland W, Poley MJ, de Boode WP, Carkeek K, Cassart V, Cornette L, Dijk PH, Hemels MAC, Hermans I, Hütten MC, Kelen D, de Kort EHM, Kroon AA, Lefevere J, Plaskie K, Stewart B, Voeten M, van Weissenbruch MM, Williams O, Zonnenberg IA, Lacaze-Masmonteil T, Pas ABT, Reiss IKM, van Kaam AH, Allegaert K, Hutten GJ, Simons SHP. Doxapram versus placebo in preterm newborns: a study protocol for an international double blinded multicentre randomized controlled trial (DOXA-trial). Trials 2023; 24:656. [PMID: 37817255 PMCID: PMC10566117 DOI: 10.1186/s13063-023-07683-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Apnoea of prematurity (AOP) is one of the most common diagnoses among preterm infants. AOP often leads to hypoxemia and bradycardia which are associated with an increased risk of death or disability. In addition to caffeine therapy and non-invasive respiratory support, doxapram might be used to reduce hypoxemic episodes and the need for invasive mechanical ventilation in preterm infants, thereby possibly improving their long-term outcome. However, high-quality trials on doxapram are lacking. The DOXA-trial therefore aims to investigate the safety and efficacy of doxapram compared to placebo in reducing the composite outcome of death or severe disability at 18 to 24 months corrected age. METHODS The DOXA-trial is a double blinded, multicentre, randomized, placebo-controlled trial conducted in the Netherlands, Belgium and Canada. A total of 396 preterm infants with a gestational age below 29 weeks, suffering from AOP unresponsive to non-invasive respiratory support and caffeine will be randomized to receive doxapram therapy or placebo. The primary outcome is death or severe disability, defined as cognitive delay, cerebral palsy, severe hearing loss, or bilateral blindness, at 18-24 months corrected age. Secondary outcomes are short-term neonatal morbidity, including duration of mechanical ventilation, bronchopulmonary dysplasia and necrotising enterocolitis, hospital mortality, adverse effects, pharmacokinetics and cost-effectiveness. Analysis will be on an intention-to-treat principle. DISCUSSION Doxapram has the potential to improve neonatal outcomes by improving respiration, but the safety concerns need to be weighed against the potential risks of invasive mechanical ventilation. It is unknown if the use of doxapram improves the long-term outcome. This forms the clinical equipoise of the current trial. This international, multicentre trial will provide the needed high-quality evidence on the efficacy and safety of doxapram in the treatment of AOP in preterm infants. TRIAL REGISTRATION ClinicalTrials.gov NCT04430790 and EUDRACT 2019-003666-41. Prospectively registered on respectively June and January 2020.
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Affiliation(s)
- Jarinda A Poppe
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Sten P Willemsen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kelly K Storm
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Debbie H Nuytemans
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Marten J Poley
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Katherine Carkeek
- Neonatal Intensive Care Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Vincent Cassart
- Department of Neonatology, Grand hôpital de Charleroi, Charleroi, Belgium
| | - Luc Cornette
- Department Neonatology, AZ St-Jan, Bruges, Belgium
| | - Peter H Dijk
- Division of Neonatology, Department of Paediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, the Netherlands
| | | | - Isabelle Hermans
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Matthias C Hütten
- Division of Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Dorottya Kelen
- Neonatal Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ellen H M de Kort
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - André A Kroon
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Julie Lefevere
- Neonatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Katleen Plaskie
- Department of Neonatology, GasthuisZusters Antwerpen, Antwerp, Belgium
| | - Breanne Stewart
- Quality Management in Clinical Research (QMCR), University of Alberta, Edmonton, AB, Canada
| | - Michiel Voeten
- Department of Neonatal Intensive Care, University Hospital Antwerp, Edegem, Belgium
| | - Mirjam M van Weissenbruch
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Olivia Williams
- Neonatology and Neonatal Intensive Care Unit, CHIREC-Delta Hospital, Brussels, Belgium
| | - Inge A Zonnenberg
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thierry Lacaze-Masmonteil
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Maternal Infant Child & Youth Research Network (MICYRN), Vancouver, Canada
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Irwin K M Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Sinno H P Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
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Wiedmann F, Beyersdorf C, Zhou XB, Kraft M, Paasche A, Jávorszky N, Rinné S, Sutanto H, Büscher A, Foerster KI, Blank A, El-Battrawy I, Li X, Lang S, Tochtermann U, Kremer J, Arif R, Karck M, Decher N, van Loon G, Akin I, Borggrefe M, Kallenberger S, Heijman J, Haefeli WE, Katus HA, Schmidt C. Treatment of atrial fibrillation with doxapram: TASK-1 potassium channel inhibition as a novel pharmacological strategy. Cardiovasc Res 2021; 118:1728-1741. [PMID: 34028533 DOI: 10.1093/cvr/cvab177] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS TASK-1 (K2P3.1) two-pore domain potassium channels are atrial-specific and significantly upregulated in atrial fibrillation (AF) patients, contributing to AF-related electrical remodelling. Inhibition of TASK-1 in cardiomyocytes of AF patients was shown to counteract AF-related action potential duration shortening. Doxapram was identified as a potent inhibitor of the TASK-1 channel. In the present study, we investigated the antiarrhythmic efficacy of doxapram in a porcine model of AF. METHODS AND RESULTS Doxapram successfully cardioverted pigs with artificially induced episodes of AF. We established a porcine model of persistent AF in domestic pigs via intermittent atrial burst stimulation using implanted pacemakers. All pigs underwent catheter-based electrophysiological investigations prior to and after 14 d of doxapram treatment. Pigs in the treatment group received intravenous administration of doxapram once per day. In doxapram-treated AF pigs, the AF burden was significantly reduced. After 14 d of treatment with doxapram, TASK-1 currents were still similar to values of sinus rhythm animals. Doxapram significantly suppressed AF episodes and normalized cellular electrophysiology by inhibition of the TASK-1 channel. Patch-clamp experiments on human atrial cardiomyocytes, isolated from patients with and without AF could reproduce the TASK-1 inhibitory effect of doxapram. CONCLUSIONS Repurposing doxapram might yield a promising new antiarrhythmic drug to treat AF in patients. TRANSLATIONAL PERSPECTIVE Pharmacological suppression of atrial TASK 1 potassium currents prolongs atrial refractoriness with no effects on ventricular repolarization, resulting in atrial-specific class III antiarrhythmic effects. In our preclinical pilot study the respiratory stimulant doxapram was successfully administered for cardioversion of acute AF as well as rhythm control of persistent AF in a clinically relevant porcine animal model.
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Affiliation(s)
- Felix Wiedmann
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Christoph Beyersdorf
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Xiao-Bo Zhou
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Manuel Kraft
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Amelie Paasche
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Natasa Jávorszky
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Susanne Rinné
- Institute for Physiology and Pathophysiology, Vegetative Physiology and Marburg Center for Mind, Brain and Behavior MCMBB, University of Marburg, Marburg, Germany
| | - Henry Sutanto
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Antonius Büscher
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ibrahim El-Battrawy
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Xin Li
- First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Siegfried Lang
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Ursula Tochtermann
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Niels Decher
- Institute for Physiology and Pathophysiology, Vegetative Physiology and Marburg Center for Mind, Brain and Behavior MCMBB, University of Marburg, Marburg, Germany
| | - Gunther van Loon
- Department of Large Animal Internal Medicine, Equine Cardioteam, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Ibrahim Akin
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Stefan Kallenberger
- Digital Health Center, Berlin Institute of Health (BIH) and Charité, Berlin, Germany and Health Data Science Unit, University Hospital Heidelberg, Heidelberg, Germany
| | - Jordi Heijman
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Constanze Schmidt
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.,HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
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The bioavailability and maturing clearance of doxapram in preterm infants. Pediatr Res 2021; 89:1268-1277. [PMID: 32698193 DOI: 10.1038/s41390-020-1037-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Doxapram is used for the treatment of apnea of prematurity in dosing regimens only based on bodyweight, as pharmacokinetic data are limited. This study describes the pharmacokinetics of doxapram and keto-doxapram in preterm infants. METHODS Data (302 samples) from 75 neonates were included with a median (range) gestational age (GA) 25.9 (23.9-29.4) weeks, bodyweight 0.95 (0.48-1.61) kg, and postnatal age (PNA) 17 (1-52) days at the start of continuous treatment. A population pharmacokinetic model was developed using non-linear mixed-effects modelling (NONMEM®). RESULTS A two-compartment model best described the pharmacokinetics of doxapram and keto-doxapram. PNA and GA affected the formation clearance of keto-doxapram (CLFORMATION KETO-DOXAPRAM) and clearance of doxapram via other routes (CLDOXAPRAM OTHER ROUTES). For a median individual of 0.95 kg, GA 25.6 weeks, and PNA 29 days, CLFORMATION KETO-DOXAPRAM was 0.115 L/h (relative standard error (RSE) 12%) and CLDOXAPRAM OTHER ROUTES was 0.645 L/h (RSE 9%). Oral bioavailability was estimated at 74% (RSE 10%). CONCLUSIONS Dosing of doxapram only based on bodyweight results in the highest exposure in preterm infants with the lowest PNA and GA. Therefore, dosing may need to be adjusted for GA and PNA to minimize the risk of accumulation and adverse events. For switching to oral therapy, a 33% dose increase is required to maintain exposure. IMPACT Current dosing regimens of doxapram in preterm infants only based on bodyweight result in the highest exposure in infants with the lowest PNA and GA. Dosing of doxapram may need to be adjusted for GA and PNA to minimize the risk of accumulation and adverse events. Describing the pharmacokinetics of doxapram and its active metabolite keto-doxapram following intravenous and gastroenteral administration enables to include drug exposure to the evaluation of treatment of AOP. The oral bioavailability of doxapram in preterm neonates is 74%, requiring a 33% higher dose via oral than intravenous administration to maintain exposure.
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Poppe JA, van Weteringen W, Sebek LLG, Knibbe CAJ, Reiss IKM, Simons SHP, Flint RB. Precision Dosing of Doxapram in Preterm Infants Using Continuous Pharmacodynamic Data and Model-Based Pharmacokinetics: An Illustrative Case Series. Front Pharmacol 2020; 11:665. [PMID: 32477133 PMCID: PMC7236770 DOI: 10.3389/fphar.2020.00665] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/23/2020] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Current drug dosing in preterm infants is standardized, mostly based on bodyweight. Still, covariates such as gestational and postnatal age may importantly alter pharmacokinetics and pharmacodynamics. Evaluation of drug therapy in these patients is very difficult because objective pharmacodynamic parameters are generally lacking. By integrating continuous physiological data with model-based drug exposure and data on adverse drug reactions (ADRs), we aimed to show the potential benefit for optimized individual pharmacotherapy. MATERIALS AND METHODS Continuous data on oxygen saturation (SpO2), fraction of inspired oxygen (FiO2) and composite parameters, including the SpO2/FiO2 ratio and the cumulative oxygen shortage under the 89% SpO2 limit, served as indicators for doxapram effectiveness. We analyzed these continuous effect data, integrated with doxapram exposure and ADR parameters, obtained in preterm infants around the start of doxapram therapy. The exposures to doxapram and the active metabolite keto-doxapram were simulated using a population pharmacokinetic model. Infants were selected and retrospectively compared on the indication to start doxapram, the first response to doxapram, a potential dose-response relationship, and the administered dosage over time. Recommendations were made for individual improvements of therapy. RESULTS We provide eight cases of continuous doxapram administration that illustrate a correct and incorrect indication to start doxapram, responders and non-responders to therapy, and unnecessary over-exposure with ADRs. Recommendations for improvement of therapy include: objective evaluation of added effect of doxapram after start, prevention of overdosing by earlier down-titration or termination of therapy, and the prevention of hypoxia and agitation by measuring specific parameters at strategical time-points. CONCLUSION Real-time and non-invasive effect monitoring of drug therapy combined with model-based exposure provides relevant information to clinicians and can importantly improve therapy. The variability between and within patients emphasizes the importance of individual, objective evaluation of pharmacotherapy. These measurements, together with data on ADRs, allow for precision medicine in neonatology that should be brought to the bedside.
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Affiliation(s)
- Jarinda A. Poppe
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Willem van Weteringen
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Pediatric Surgery, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lotte L. G. Sebek
- Department of Hospital Pharmacy, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Catherijne A. J. Knibbe
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Irwin K. M. Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sinno H. P. Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert B. Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
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