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Zhang W, Zhang Q, Cao Z, Zheng L, Hu W. Physiologically Based Pharmacokinetic Modeling in Neonates: Current Status and Future Perspectives. Pharmaceutics 2023; 15:2765. [PMID: 38140105 PMCID: PMC10747965 DOI: 10.3390/pharmaceutics15122765] [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] [Received: 10/20/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Rational drug use in special populations is a clinical problem that doctors and pharma-cists must consider seriously. Neonates are the most physiologically immature and vulnerable to drug dosing. There is a pronounced difference in the anatomical and physiological profiles be-tween neonates and older people, affecting the absorption, distribution, metabolism, and excretion of drugs in vivo, ultimately leading to changes in drug concentration. Thus, dose adjustments in neonates are necessary to achieve adequate therapeutic concentrations and avoid drug toxicity. Over the past few decades, modeling and simulation techniques, especially physiologically based pharmacokinetic (PBPK) modeling, have been increasingly used in pediatric drug development and clinical therapy. This rigorously designed and verified model can effectively compensate for the deficiencies of clinical trials in neonates, provide a valuable reference for clinical research design, and even replace some clinical trials to predict drug plasma concentrations in newborns. This review introduces previous findings regarding age-dependent physiological changes and pathological factors affecting neonatal pharmacokinetics, along with their research means. The application of PBPK modeling in neonatal pharmacokinetic studies of various medications is also reviewed. Based on this, we propose future perspectives on neonatal PBPK modeling and hope for its broader application.
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Affiliation(s)
| | | | | | - Liang Zheng
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
| | - Wei Hu
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
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2
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Thibault C, Pelletier É, Nguyen C, Trottier ED, Doré-Bergeron MJ, DeKoven K, Roy AM, Piché N, Delisle JF, Morin C, Paquette J, Kleiber N. The Three W's of Acetaminophen In Children: Who, Why, and Which Administration Mode. J Pediatr Pharmacol Ther 2023; 28:20-28. [PMID: 36777982 PMCID: PMC9901322 DOI: 10.5863/1551-6776-28.1.20] [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: 01/10/2022] [Accepted: 04/25/2022] [Indexed: 02/05/2023]
Abstract
Acetaminophen is one of the oldest medications commonly administered in children. Its efficacy in treating fever and pain is well accepted among clinicians. However, the available evidence supporting the use of acetaminophen's different modes of administration remains relatively scarce and poorly known. This short report summarizes the available evidence and provides a framework to guide clinicians regarding a rational use of acetaminophen in children.
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Affiliation(s)
- Céline Thibault
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Élaine Pelletier
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Christina Nguyen
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Evelyne D. Trottier
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pediatric Emergency Medicine (EDT), CHU Sainte Justine, Montreal, QC, Canada
| | - Marie-Joëlle Doré-Bergeron
- Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Kathryn DeKoven
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Anesthesiology (KD), CHU Sainte-Justine, Montreal, QC, Canada
| | - Anne-Marie Roy
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Nelson Piché
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jean-Francois Delisle
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Caroline Morin
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Julie Paquette
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Niina Kleiber
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Surgery (NP), CHU Sainte-Justine, Montreal, QC, Canada
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3
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Shojaeian R, Alizadeh Ghamsari A, Mohammadipour A, Afshari R, Vakili R, Hiradfar M. Bioavailability of rectal acetaminophen in children following anorectal surgery. J Pediatr Surg 2021; 56:490-493. [PMID: 32732164 DOI: 10.1016/j.jpedsurg.2020.06.029] [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] [Received: 03/27/2020] [Revised: 06/07/2020] [Accepted: 06/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acetaminophen is widely used as an analgesic and antipyretic agent in pediatrics. Although bioavailability of rectal acetaminophen is unpredictable, rectal route is a usual and acceptable method of prescription. Major anorectal surgery may alter the normal structure of the surgical site, especially the vascular elements and the normal connections between port and systemic vessels. As a result the pharmacokinetics of rectal medications might also be altered. Based on this hypothesis, we decided to study acetaminophen plasma concentration among children who underwent these types of surgeries to determine the pharmacokinetic of absorption, plasma concentration, safety, and efficacy of rectal acetaminophen. MATERIALS AND METHODS The study included 20 cases with previous history of pull-through procedure owing to Hirschsprung's disease (HD), 20 cases with imperforate anus (IA) reconstructive surgeries who were admitted for colostomy closure, and 20 otherwise healthy cases of inguinal herniotomy. Venus blood sampling was done 4, 8 and 12 hrs after a single loading dose of rectal acetaminophen (40 mg/kg), and plasma acetaminophen concentration was compared between groups. RESULTS Mean serum acetaminophen levels of the HD group were significantly higher than those of the herniotomy group (36.3 ± 6.79, 27.4 ± 8.42, 16.8 ± 7.62 versus 25.9 ± 9.12, 16.7 ± 6.74, 8.1 ± 5.79 (μg/ml) at 4, 8 and 12 hrs after drug administration and P < 0.05). The IA group had higher concentrations of plasma acetaminophen compared to the herniotomy group; however, the p values were not statistically significant. (31.4 ± 10.39, 21.5 ± 9.12, 13.3 ± 6.79 versus 25.9 ± 9.12, 16.7 ± 6.74, 8.1 ± 5.79 (μg/ml) at 4, 8 and 12 hrs after drug administration). Serum concentrations of acetaminophen in IA and HD patients were above the therapeutic range four hours after administering the loading dose (31.4 ± 10.39 and 36.3 ± 6.79 versus 5-20 μg/ml). CONCLUSION Bioavailability of rectal acetaminophen might get altered after major anorectal surgery in children. Rectal acetaminophen should be administered with special caution among infants with history of anorectal operations. Repeated dose of rectal acetaminophen may cause the drug blood concentration to reach toxic levels in these patients. TYPE OF STUDY Prospective comparative study. LEVEL OF EVIDENCE Level II.
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4
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Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
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Chen L, Zhang M, Yung J, Chen J, McNair C, Lee KS. Safety of Rectal Administration of Acetaminophen in Neonates. Can J Hosp Pharm 2018; 71:364-369. [PMID: 30626982 PMCID: PMC6306189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND On the basis of pharmacokinetic modelling, high-dose acetaminophen by rectal administration has been recommended for neonates needing antipyretic or analgesic therapy, but the safety and efficacy of this approach have not been established in vivo. OBJECTIVES The primary objective was to assess the safety of rectal acetaminophen administration for neonates, as indicated by changes in the results of hepatic and renal function tests. The secondary objective was to assess the efficacy of rectal acetaminophen administration in terms of the Premature Infant Pain Profile-Revised (PIPP-R) score. METHODS This single-centre retrospective chart analysis was conducted in the neonatal intensive care unit at a quaternary care children's hospital. Neonates who received all prescribed doses of acetaminophen by continu - ous rectal administration for 24 h or more, from January 1, 2011, to December 31, 2012, were included. For the primary objective, hepatotoxicity was assessed in terms of changes in liver enzyme levels, and nephrotoxicity was assessed in terms of changes from baseline serum creatinine values. RESULTS Twenty-five patients, who received a total of 27 courses of acetaminophen by rectal administration, met the inclusion criteria. Median gestational age at initiation of acetaminophen was 37.0 weeks (interquartile range 35.0-39.8 weeks). Values of alanine aminotransferase remained within normal limits during acetaminophen therapy for all but 3 patients, for whom the changes were attributable to confounding factors. Renal function remained unchanged. The secondary outcome of efficacy (based on PIPP-R score) could not be evaluated because of concurrent use of opioids for most patients. CONCLUSIONS Continuous rectal administration of acetaminophen over a short period (< 48 h) appeared to be well tolerated. The conclusions that can be drawn from these results are limited because of small sample size, the prescribing of doses lower than those recommended by the hospital's formulary, and limited blood sampling. Further studies are required.
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Affiliation(s)
- Lori Chen
- RPh, BScPhm, ACPR, is with the Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario
| | - Monica Zhang
- PharmD, is with the Department of Pharmacy, Joseph Brant Hospital, Burlington, Ontario
| | - Jason Yung
- BMSc, PharmD, is with the Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario
| | - Jennifer Chen
- BScPhm, PharmD, is with the Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario
| | - Carol McNair
- RN(EC), MN, PhD(c), NNP-BC, NP-Peds, is with the Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario
| | - Kyong-Soon Lee
- MD, MSc, is with the Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario
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Aranda JV, Salomone F, Valencia GB, Beharry KD. Non-steroidal Anti-inflammatory Drugs in Newborns and Infants. Pediatr Clin North Am 2017; 64:1327-1340. [PMID: 29173788 DOI: 10.1016/j.pcl.2017.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen are used in young infants and newborns for pain and fever control, patent ductus closure, prevention of intraventricular hemorrhage, and potentially for prevention of retinopathy of prematurity. These drugs inhibit cyclooxygenase 1 (COX-1), COX-2, and peroxidases, thus, blocking prostaglandin (PG) synthesis. PGs are eicosanoids that regulate several physiologic, pathologic, and cellular processes, including vasomotor tone, platelet aggregation, sensitization of neurons to pain, and many molecular events critical to physiologic homeostasis. NSAIDs inhibit caspases and cell death. Increasing knowledge of these molecular entities may allow targeted drug development to prevent or minimize neonatal morbidities.
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Affiliation(s)
- Jacob V Aranda
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, USA.
| | - Fabrizio Salomone
- Neonatology and Pulmonary Rare Disease Unit, Corporate Pre-Clinical R and D, Chiesi Farmaceutici S.p.A, Largo Belloli 11/A, Parma IT-43122, Italy
| | - Gloria B Valencia
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, USA
| | - Kay D Beharry
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, USA
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7
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Abstract
A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.
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Affiliation(s)
- Paul C. Walker
- Departement of Pharmacy Services, University of Michigan Health System, College of Pharmacy at the University of Michigan,
| | - Deborah S. Wagner
- College of Pharmacy and Medical School, University of Michigan and Clinical Pharmacist, Department of Pharmacy Services, University of Michigan Health System
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Somani AA, Thelen K, Zheng S, Trame MN, Coboeken K, Meyer M, Schnizler K, Ince I, Willmann S, Schmidt S. Evaluation of changes in oral drug absorption in preterm and term neonates for Biopharmaceutics Classification System (BCS) class I and II compounds. Br J Clin Pharmacol 2015; 81:137-47. [PMID: 26302359 DOI: 10.1111/bcp.12752] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 08/11/2015] [Accepted: 08/17/2015] [Indexed: 12/24/2022] Open
Abstract
AIMS Evidence suggests that the rate of oral drug absorption changes during early childhood. Yet, respective clinical implications are currently unclear, particularly for preterm neonates. The objective of this study was to evaluate changes in oral drug absorption after birth for different Biopharmaceutics Classification System (BCS) class I and II compounds to better understand respective implications for paediatric pharmacotherapy. METHODS Two paradigm compounds were selected for BCS class I (paracetamol (acetaminophen) and theophylline) and II (indomethacin and ibuprofen), respectively, based on the availability of clinical literature data following intravenous and oral dosing. A comparative population pharmacokinetic analysis was performed in a step-wise manner in NONMEM® 7.2 to characterize and predict changes in oral drug absorption after birth for paracetamol, theophylline and indomethacin. RESULTS A one compartment model with an age-dependent maturation function for oral drug absorption was found appropriate to characterize the pharmacokinetics of paracetamol. Our findings indicate that the rate at which a drug is absorbed from the GI tract reaches adult levels within about 1 week after birth. The maturation function for paracetamol was found applicable to theophylline and indomethacin once solubility limitations were overcome via drug formulation. The influence of excipients on solubility and, hence, oral bioavailability was confirmed for ibuprofen, a second BCS class II compound. CONCLUSIONS The findings of our study suggest that the processes underlying changes in oral drug absorption after birth are drug-independent and that the maturation function identified for paracetamol may be generally applicable to other BCS class I and II compounds for characterizing drug absorption in preterm as well as term neonates.
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Affiliation(s)
- Amit A Somani
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Kirstin Thelen
- Computational Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany
| | - Songmao Zheng
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Mirjam N Trame
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Katrin Coboeken
- Computational Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany
| | - Michaela Meyer
- Computational Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany
| | - Katrin Schnizler
- Computational Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany
| | - Ibrahim Ince
- Computational Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany
| | - Stefan Willmann
- Computational Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
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Abstract
As a standard of care for preterm/term newborns effective pain management may improve their clinical and neurodevelopmental outcomes. Neonatal pain is assessed using context-specific, validated, and objective pain methods, despite the limitations of currently available tools. Therapeutic approaches reducing invasive procedures and using pharmacologic, behavioral, or environmental measures are used to manage neonatal pain. Nonpharmacologic approaches like kangaroo care, facilitated tucking, non-nutritive sucking, sucrose, and others can be used for procedural pain or adjunctive therapy. Local/topical anesthetics, opioids, NSAIDs/acetaminophen and other sedative/anesthetic agents can be incorporated into NICU protocols for managing moderate/severe pain or distress in all newborns.
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Harrison D, Loughnan P, Manias E, Johnston L. Utilization of analgesics, sedatives, and pain scores in infants with a prolonged hospitalization: A prospective descriptive cohort study. Int J Nurs Stud 2009; 46:624-32. [DOI: 10.1016/j.ijnurstu.2008.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 10/24/2008] [Accepted: 11/04/2008] [Indexed: 10/21/2022]
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Gharavi B, Schott C, Nelle M, Reiter G, Linderkamp O. Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland. Pediatr Int 2007; 49:652-8. [PMID: 17875094 DOI: 10.1111/j.1442-200x.2007.02453.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Painful invasive procedures are frequently performed on preterm infants admitted to a neonatal intensive care unit (NICU). The aim of the present study was to investigate current pain management in Austrian, German and Swiss NICU and to identify factors associated with improved pain management in preterm infants. METHODS A questionnaire was sent to all Austrian, German and Swiss pediatric hospitals with an NICU (n = 370). Pain assessment and documentation, use of analgesics for 13 painful procedures, presence of written guidelines for pain management and the use of 12 analgesics and sedatives were examined. RESULTS A total of 225 units responded (61%). Pain assessment and documentation and frequent analgesic therapy for painful procedures were performed more often in units using written guidelines for pain management and in those treating >50 preterm infants at <32 weeks of gestation per year. This was also the case for the use of opioid analgesics and sucrose solution. Non-opioid analgesics were used more often in smaller units and in units with written guidelines. There was a broad variation in dosage of analgesics and sedatives within all groups. CONCLUSION Pain assessment, documentation of pain and analgesic therapy are more frequently performed in NICU with written guidelines for pain management and in larger units with more than 50 preterm infants at <32 weeks of gestation per year.
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Affiliation(s)
- Bahman Gharavi
- Division of Neonatology, Department of Pediatrics, University of Bern, Bern, Switzerland.
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12
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Mercan A, Sayin MM, Saydam S, Ozmert S, Tiryaki T. When to add supplemental rectal paracetamol for postoperative analgesia with caudal bupivacaine in children? A prospective, double-blind, randomized study. Paediatr Anaesth 2007; 17:547-51. [PMID: 17498016 DOI: 10.1111/j.1460-9592.2006.02141.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether a supplemental dose of rectal paracetamol at the third or fourth hour would enhance the quality of analgesia provided by caudal epidural blockade in children. METHODS Two hundred and two ASA I patients aged 1-12 years undergoing inguinal surgery were randomized into three groups in the postanesthesia care unit by drawing lots. Patients in the control group did not receive any analgesic until they had a pain score of 5 or higher, patients in the group P3 received rectal paracetamol (20-25 mg x kg(-1)) at the third hour, and patients in the group P4 received the same dose of rectal paracetamol at the fourth hour after caudal epidural injection. Pain was assessed by VAS (Visual Analog Scale) and supplementary rescue analgesic need was recorded. RESULTS There was no difference between the demographic data or the duration and variety of surgery among the groups. A significantly lower number of patients required rescue analgesia at the sixth postoperative hour in group P3 and also lower pain scores were again obtained in group P3 at the sixth and eighth postoperative hours. CONCLUSIONS Supplemental rectal paracetamol at the third hour of caudal blockade enhances the quality of postoperative analgesia better than its addition at the fourth hour in children undergoing inguinal surgery.
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Affiliation(s)
- Arzu Mercan
- Department of Anesthesiology, SSK Ankara Training Hospital, Ankara, Turkey.
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Bertolini A, Ferrari A, Ottani A, Guerzoni S, Tacchi R, Leone S. Paracetamol: new vistas of an old drug. CNS DRUG REVIEWS 2007; 12:250-75. [PMID: 17227290 PMCID: PMC6506194 DOI: 10.1111/j.1527-3458.2006.00250.x] [Citation(s) in RCA: 348] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever. It occupies a unique position among analgesic drugs. Unlike NSAIDs it is almost unanimously considered to have no antiinflammatory activity and does not produce gastrointestinal damage or untoward cardiorenal effects. Unlike opiates it is almost ineffective in intense pain and has no depressant effect on respiration. Although paracetamol has been used clinically for more than a century, its mode of action has been a mystery until about one year ago, when two independent groups (Zygmunt and colleagues and Bertolini and colleagues) produced experimental data unequivocally demonstrating that the analgesic effect of paracetamol is due to the indirect activation of cannabinoid CB(1) receptors. In brain and spinal cord, paracetamol, following deacetylation to its primary amine (p-aminophenol), is conjugated with arachidonic acid to form N-arachidonoylphenolamine, a compound already known (AM404) as an endogenous cannabinoid. The involved enzyme is fatty acid amide hydrolase. N-arachidonoylphenolamine is an agonist at TRPV1 receptors and an inhibitor of cellular anandamide uptake, which leads to increased levels of endogenous cannabinoids; moreover, it inhibits cyclooxygenases in the brain, albeit at concentrations that are probably not attainable with analgesic doses of paracetamol. CB(1) receptor antagonist, at a dose level that completely prevents the analgesic activity of a selective CB(1) receptor agonist, completely prevents the analgesic activity of paracetamol. Thus, paracetamol acts as a pro-drug, the active one being a cannabinoid. These findings finally explain the mechanism of action of paracetamol and the peculiarity of its effects, including the behavioral ones. Curiously, just when the first CB(1) agonists are being introduced for pain treatment, it comes out that an indirect cannabino-mimetic had been extensively used (and sometimes overused) for more than a century.
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Affiliation(s)
- Alfio Bertolini
- Division of Toxicology and Clinical Pharmacology, University of Modena and Reggio Emilia, Modena, Italy.
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14
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Anand KJS, Johnston CC, Oberlander TF, Taddio A, Lehr VT, Walco GA. Analgesia and local anesthesia during invasive procedures in the neonate. Clin Ther 2006; 27:844-76. [PMID: 16117989 DOI: 10.1016/j.clinthera.2005.06.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area. OBJECTIVE The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates. METHODS Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded. RESULTS The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.
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Affiliation(s)
- K J S Anand
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.
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Berde CB, Jaksic T, Lynn AM, Maxwell LG, Soriano SG, Tibboel D. Anesthesia and analgesia during and after surgery in neonates. Clin Ther 2006; 27:900-21. [PMID: 16117991 DOI: 10.1016/j.clinthera.2005.06.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Historically, the use of anesthetics and analgesics in neonates and infants has been based on extrapolations from studies performed in adults and older children. Over the past 20 years, there has been a growing body of research on the clinical pharmacology and clinical outcomes of these agents in neonates and infants. OBJECTIVE This article summarizes clinical pharmacology and clinical outcomes studies of opioids, opioid antagonists, sedative-hypnotics, nonsteroidal anti-inflammatory drugs and acetaminophen, and local anesthetics in neonates and infants to highlight gaps in the available knowledge, review some concerns about study design, and identify drugs that should receive high priority for future study. METHODS Relevant studies were identified through a search of MEDLINE and a review of textbooks, conference proceedings, and abstracts. The available literature was subjected to expert committee-based review. CONCLUSIONS There is a growing body of information on analgesic and anesthetic pharmacokinetics, pharmacodynamics, and clinical outcomes in neonates and infants, permitting safe and effective use in some clinical settings. Major gaps in knowledge persist, however. Future research may involve a combination of clinical trials and preclinical studies in suitable infant animal surrogate models.
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Affiliation(s)
- Charles B Berde
- Department of Anaesthesia, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Affiliation(s)
- P-A Lönnqvist
- Astrid Lindgrens Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Allegaert K, Van der Marel CD, Debeer A, Pluim MAL, Van Lingen RA, Vanhole C, Tibboel D, Devlieger H. Pharmacokinetics of single dose intravenous propacetamol in neonates: effect of gestational age. Arch Dis Child Fetal Neonatal Ed 2004; 89:F25-8. [PMID: 14711849 PMCID: PMC1721651 DOI: 10.1136/fn.89.1.f25] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To investigate the pharmacokinetics and pharmacodynamics of single dose propacetamol in preterm and term infants on the first day of life. METHODS Neonates were stratified by gestational age. Preterm (< 37 weeks) and term (37-41 weeks) infants received a single dose of propacetamol in the first 24 hours of life when they had minor, painful procedures or as additional treatment in infants receiving opioids. Blood samples were taken from an arterial line, and pain was evaluated by a multidimensional pain scale. Results were reported as mean (SD). Student's t and Wilcoxon tests were used to compare the groups. RESULTS Thirty neonates were included, 10 of which were term infants. Serum half life was 277 (143) minutes in the preterm infants and 172 (59) minutes in the term infants (p < 0.05). Clearance was 0.116 (0.08) litre/kg/h in the preterm infants and 0.170 (0.06) litre/kg/h in the term infants (p < 0.05). Gestational age correlated with serum half life (r = -0.46). No effect of sex or administration of prenatal steroids was found on the pharmacokinetics of paracetamol. In neonates who only received propacetamol (n = 15), the level of analgesia seemed to be associated with the therapeutic (> 5 mg/l) level. CONCLUSIONS A correlation was found between gestational age and the serum half life of propacetamol. The maturational trend of clearance and half life in preterm and term neonates is in line with data on the pharmacokinetics of propacetamol beyond the newborn period.
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Affiliation(s)
- K Allegaert
- Neonatal Intensive Care Unit, Department of Paediatrics, University Hospitals, Gasthuisberg, Herestraat 49, Leuven, Belgium.
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18
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Affiliation(s)
- Charles B Berde
- Department of Anesthesia, Children's Hospital, Boston, MA 02115, USA
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Oliveira EJ, Watson DG, Morton NS. A simple microanalytical technique for the determination of paracetamol and its main metabolites in blood spots. J Pharm Biomed Anal 2002; 29:803-9. [PMID: 12093512 DOI: 10.1016/s0731-7085(02)00174-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The use of blood spot collection cards is a simple way to obtain specimens for analysis of drugs with a narrow therapeutic window. We describe the development and validation of a microanalytical technique for the determination of paracetamol and its glucuronide and sulphate metabolites from blood spots. The method is based on reversed phase high-performance liquid chromatography with ultraviolet detection. The limit of detection of the method is 600 pg on column for paracetamol. Intra- and inter-day precision of the determination of paracetamol was 7.1 and 3.2% respectively. The small volume of blood required (20 microl), combined with the simplicity of the analytical technique makes this a useful procedure for monitoring paracetamol concentrations. The method was applied to the analysis of blood spots taken from neonates being treated with paracetamol.
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Affiliation(s)
- E J Oliveira
- Department of Pharmaceutical Sciences, SIBS, University of Strathclyde, 27 Taylor Street, G4 0NR, Glasgow, UK
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Abstract
BACKGROUND Paracetamol (N-acetyl-p-amino-phenol) or acetaminophen has become the most widely used analgesic and antipyretic in children. However, there is a wide discrepancy between the extent to which paracetamol is used and the limited available pharmacological data in small infants. The purpose of this article is to present a review of the current literature regarding the use of paracetamol in neonates and infants with a particular emphasis on pharmacological issues. METHODS A MEDLINE search (up to March 2000) was conducted to identify relevant English-language publications using paracetamol, children, infants and neonates as search terms. Additional studies were identified from bibliographies of the reviewed literature. RESULTS Pharmacological studies on paracetamol in infants are few. Most studies have focused on the administration of one single paracetamol dose, and the problem of cumulative toxicity with repeated dosing has not been addressed. Plasma paracetamol concentration should be 10-20 mg ml(-1) to achieve antipyretic and analgesic effects. The bioavailability of the different formulations and routes of administration vary with age. Rectal absorption is slower and more erratic than the oral; however, in the very young, rectal bioavailability is higher than in older patients. Volume of distribution seems to be age-independent, whereas clearance is reduced in neonates and particularly in preterm babies. Neonates and infants are capable of forming the reactive intermediate metabolite that causes hepatocellular damage, particularly after multiple doses. They have an immature glucuronide conjugation system, but the rate constant for the sulphation metabolic pathway is larger than in older children, and this is the most important route of metabolism. CONCLUSIONS The pharmacokinetics and pharmacodynamics of paracetamol differ substantially in neonates and infants from those in older children and adults; hence, dosing should be adjusted accordingly.
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Affiliation(s)
- A Arana
- Department of Paediatric Anaesthesia, The Royal Hospital for Sick Children, Glasgow, Scotland, UK
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Hahn TW, Henneberg SW, Holm-Knudsen RJ, Eriksen K, Rasmussen SN, Rasmussen M. Pharmacokinetics of rectal paracetamol after repeated dosing in children. Br J Anaesth 2000; 85:512-9. [PMID: 11064607 DOI: 10.1093/bja/85.4.512] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Twenty-three children (aged between 9 weeks and 11 yr) were given paracetamol suppositories 25 mg kg-1 every 6 h (maximum 5 days) after major surgery and serum and saliva concentrations were measured. There was a good correlation (r = 0.91, P < 0.05) between saliva and serum concentrations. A one-compartment linear model with first-order elimination and absorption and lag-time was fitted to the data (ADAPT II). At steady state, the mean (SD) concentration was 15.2 (6.8) mg litre-1. Mean (SD) time to reach 90% of the steady state concentration was 11.4 (8.6) h. Body weight, age and body surface area were well correlated (P < 0.05) with clearance and apparent volume of distribution. There was no evidence of accumulation leading to supratherapeutic concentrations during this dosing schedule for a mean of approximately 2-3 days.
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Affiliation(s)
- T W Hahn
- Department of Pharmaceutics, Royal Danish School of Pharmacy, Universitetsparken, Copenhagen, Denmark
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Abstract
The past decade has brought about an explosion of knowledge about the physiology of nociception and many new techniques for pain relief, new analgesic drugs, and new applications of old analgesic drugs. These techniques include methods of opioid administration by transdermal and transmucosal absorption and the use of neuraxial analgesia for the management of pain in children. Interest in the use of regional anesthesia in children has been rekindled, and analgesic properties and pre-emptive analgesic properties of many agents not typically considered analgesics, such as clonidine and ketamine, have been recognized. Perhaps the greatest advance has been the paradigm shift in the recognition that pain not only exists in infants and children but also is a significant cause of morbidity and even mortality. Given the unprecedented interest in pain management in adults and children, physicians can now look forward to the development of new methods of drug delivery and of receptor-specific drugs that divorce analgesia from the untoward side effects of existing analgesics. Improvement in the quality of life of hospitalized children also will occur.
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Affiliation(s)
- B Golianu
- Department of Anesthesia, Stanford University Medical Center, California, USA
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Ward B, Alexander-Williams JM. Paracetamol revisited: A review of the pharmacokinetics and pharmacodynamics. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s1366-0071(99)80006-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Laboratory data, economic pressures, and the wish for humane treatment have been some of the driving forces behind improvements in paediatric pain management. Within the space of 10 years, there have been dramatic changes in the quality of treatment received by children undergoing surgical operations. Moreover, those receiving medical treatment, for example, sickle cell disease, have also benefited from increased experience in pain management. Children receiving care in specialised centres can now expect to benefit from up-to-date techniques of pain management, such as patient-controlled analgesia, nurse-controlled analgesia, and epidural infusions. They will be managed by ward nurses experienced and trained in paediatric pain relief, they will be attended by nurses whose special interest and training is the management of children's pain, and they will be provided with the techniques of analgesia by competent, trained anaesthetic staff. Improved care, with close attention to pain relief, is not only humane, but improves the patient turnaround by enhancing rapid discharge. Further education is required to spread these benefits to children being managed outside highly specialised centres. Not only education, but investment, is needed also to ensure that all children receive a standard of care second to none.
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Affiliation(s)
- A R Lloyd-Thomas
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Affiliation(s)
- B J Anderson
- Paediatric Intensive Care Unit, Auckland Children's Hospital, Grafton, New Zealand
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Abstract
There has been a steady advance in the understanding of pain measurement, prevention and treatment in children, and some of the recent progress is reviewed here. Important new discoveries in neonatal pain and pain assessment have overshadowed pharmacology in the past few years, although there has been good progress in the use of both opioid and non-opioid medications in children. The question of whether preemptive analgesia exists and can be utilized practically in children still puzzles us, but we are beginning to understand how to approach the problem, at least.
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Affiliation(s)
- G Allen Finley
- Dalhousie University, IWK Grace Health Centre, 5850 University Avenue, Halifax, Nova Scotia, Canada B3J 3G9.
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