Treatment with Gabapentin Associated with Resolution of Apnea in Two Infants with Neurologic Impairment

Evaluating Gabapentin Dosing, Efficacy and Safety in Infants

OBJECTIVE

Gabapentin for management of neuropathic pain, irritability, neonatal abstinence syndrome, rescue sedation, feeding intolerance and visceral hyperalgesia in infants has grown over the past decade. There remains little guidance for indications, initiation, titration and maintenance dosing trends and assessment of outcomes. The primary objective was to describe gabapentin dosing, and the secondary objectives were to identify outcomes to assess efficacy and describe weaning practices.

METHODS

A retrospective single-center study was performed in infants younger than 1 year who received gabapentin at Boston Children's Hospital between 2015 and 2021. The primary outcome was indication, initiation and maximum gabapentin dose. Secondary outcomes included mortality, adverse reactions and impact on feeding volumes, weight-for-age Z-scores and face, legs, activity, cry, consolability (FLACC) scores. Descriptive statistics were utilized.

RESULTS

Sixty-six infants received gabapentin at a mean ± SD age of 5.5 ± 2.7 months (range of 0-11 months). The mean ± SD initiation dose of gabapentin was 8.6 ± 5.4 mg/kg/day with a median interval of 24 hours (8-24 hours). The maximum mean dose was 23.2 ± 14.4 mg/kg/day at a median interval of every 8 hours (8 hours). The most common indications for initiation were irritability, rescue sedation, and visceral hyperalgesia. There was a statistical improvement in weight-for-age Z scores from 24 hours prior to gabapentin initiation to 2 weeks after the maximum dose of gabapentin (-2.23 ± 1.78 to -1.66 ± 1.91, p < 0.001) and a reduction in FLACC scores (2.29 ± 1.64 to 1.52 ± 1.76, p = 0.007) from 24 hours prior to gabapentin initiation to 3 days after the maximum dose of gabapentin. Three patients experienced minor adverse events.

CONCLUSIONS

Gabapentin was well tolerated in infants. Initial gabapentin dosing of 5 mg/kg/dose every 24 hours appears safe and consistent with other published studies in infants. The improvement in outcomes with few adverse events suggests a beneficial role for gabapentin.

Gabapentin for Pain in Pediatric Palliative Care

OBJECTIVE

Gabapentin is commonly used to treat pain in children receiving pediatric palliative care. This study describes the real-world use of gabapentin and the associated benefits and adverse effects/events (AEs).

METHODS

A prospective, multicenter cohort of standardized data collection after a clinical decision was made to use gabapentin for managing neuropathic or nociplastic pain in children attended on by a pediatric palliative care service. It was conducted across 11 sites in seven countries including hospital, inpatient, and outpatient services. Clinical outcomes were graded using pain scales validated for age and cognitive ability and the National Cancer Institute Common Terminology Criteria for Adverse Events (NCICTCAE) at baseline, 14 days, 28 days, six weeks and 12 weeks after initiation of gabapentin. Ad-hoc safety reporting continued throughout the study.

RESULTS

Data were collected from 127 children with a median age of 4.7 years (IQR 0.1-17.9); 61% had a neurological disorder, 21% advanced cancer and the cohort had a high level of disability (Lansky/Karnofsky performance score 37.1). Gabapentin was prescribed at standard pediatric doses. On average, 76% of children had a reduction in pain and 42% experienced a potential AE. The mean pain score decreased from 6.0 (SD 2.6) at baseline to 3.3 (SD 2.4) at 14 days and 1.8 (SD 1.8) after 12-weeks of gabapentin therapy. Ten percent had increased pain at each time point. AEs did not increase when individual changes over time were accounted for except for somnolence (7%). Serious AEs attributable to gabapentin were possible or probable in 3% of children.

CONCLUSIONS

Gabapentin prescribed at standard doses for advanced cancer and severe neurological injury in children under a pediatric palliative care service was associated with generally improved pain intensity at previously described levels of adverse effects.

Gabapentin in Infants: Critical Evaluation of a Novel Sedative/Analgesic Medication

Chronic pain and agitation can complicate the clinical course of critically ill infants. Randomized controlled trials of analgesia and sedation in neonatal intensive care have focused on relatively short durations of exposure. To date, clinicians have few options to treat chronic visceral pain and hyperalgesia. Gabapentin has emerged as a common therapy for a diverse group of pain syndromes and neurologic conditions in adults. In neonates, case reports and series describe the successful treatment of visceral hyperalgesia arising from gastrointestinal insults with or without concomitant neurologic morbidities. Additionally, a case report and series describe the utility of gabapentin for neonatal abstinence syndrome refractory to standard pharmacotherapy. The adverse effect profile of gabapentin, most notably bradycardia and sedation, compares favorably to alternative analgesics and sedatives. However, the long-term impacts of prolonged gabapentin therapy have not been studied. Therefore, candidates for therapy must be selected carefully, and response must be assessed objectively. Future studies must assess the short-term and long-term benefits and risks of gabapentin compared to standard therapies for chronic pain and agitation in infants and refractory neonatal abstinence syndrome.

Gabapentin Use for Hospitalized Neonates

BACKGROUND

Despite some clinician advocacy for the use of gabapentin to treat neonatal irritability of presumed neurological origin, the extent of gabapentin administration to hospitalized neonates is unknown. We aimed to identify trends in gabapentin utilization among infants hospitalized in neonatal intensive care units (NICUs) across the United States and to evaluate the associations between clinical diagnoses and gabapentin treatment.

METHODS

We analyzed neonates admitted to the NICU using the Pediatric Health Information System (2005 to 2016) to measure treatment timing, duration, and frequency. We used modified Poisson regression with a robust between-cluster variance estimator to calculate a probability (adjusted relative risk) for gabapentin administration.

RESULTS

Of 278,403 neonates, 374 were administered gabapentin (0.13%). The median treatment duration was 16 days (25th to 75th percentile: 8; 40). Gabapentin use increased from 0% in 2005 to 0.39% in 2016. Treatment was prescribed to neonates at 31 of 48 studied hospitals; 73% of total treated infants localized to five neonatal intensive care units. Term (0.16%) and ≤28 weeks' gestation preterm infants (0.22%) were most likely to receive gabapentin. Varying by gestational age, a diagnosis of chromosomal abnormalities, severe bronchopulmonary dysplasia, hemorrhagic stroke, and neonatal abstinence syndrome were associated with higher treatment with gabapentin. The majority (88.8%) of treated infants did not have a seizure diagnosis.

CONCLUSION

Gabapentin use in NICU in the United States increased in recent years and varies markedly between institutions. Term infants, ≤28 weeks' gestation preterm infants, and neonates with chronic genetic, neurological, and gastrointestinal diagnoses were more likely to receive gabapentin.

Gabapentin Improves Oral Feeding in Neurologically Intact Infants With Abdominal Disorders

Feeding intolerance, poor oral feeding skills, and retching are common symptoms seen in medically complex infants with a history of abdominal disorders and surgical interventions, such as gastrostomy tube placement and Nissen fundoplication. Visceral hyperalgesia may play a role in the underlying pathophysiology. We report the use of orally administered gabapentin in 3 infants with presumed visceral hyperalgesia presenting as poor tolerance of enteral and oral feeds. Retching and outward discomfort associated with feeds was resolved within 2 to 3 days of initiation of therapy. Full oral feeds were obtained in all 3 patients within 3 to 4 months of starting gabapentin without changing adjunctive medications or therapies. After attainment of full oral feeds, all patients were successfully weaned off gabapentin over a month, with no notable side effects, signs of withdrawal, or impact on ability to feed by mouth.

Defining pain in newborns: need for a uniform taxonomy?

A framework for defining pain terms such as acute, persistent, prolonged or chronic pain to newborns was derived from the scientific literature on neonatal pain assessments, previous attempts to define chronic pain and the clinical and neurophysiological features of neonatal pain. This novel framework incorporates the temporal features, localising characteristics, and secondary effects of the pain experienced, as well as the behavioural and physiological response patterns of newborns.

CONCLUSION

Although not evidence-based, this framework provides an initial starting point for defining commonly used neonatal pain terms. It will require future revision/refinement based on the accumulating evidence for non-acute pain.

Visceral Hyperalgesia: When to Consider Gabapentin Use in Neonates-Case Study and Review

Visceral hyperalgesia refers to increased pain sensation in response to gastrointestinal sensory stimulus. In neonates with neurological impairments, gabapentin has been successfully used as a treatment for visceral hyperalgesia in neonates. The authors describe a preterm infant with myelomeningocele and persistent neuropathic pain that manifested as irritability, hypertonicity, poor weight gain, and feeding intolerance. After exclusion of other etiologies, the diagnosis of visceral hyperalgesia was suspected and the infant was treated with gabapentin. Following appropriate titration to effect and close monitoring of side effects of gabapentin, he subsequently demonstrated improved tone, decreased irritability with feedings, and appropriate weight gain. In addition, the authors provide a review of the available literature of gabapentin use in neonates and offer suggestions on when to consider starting gabapentin in a neonate with neurological impairment and chronic unexplained gastrointestinal manifestations.

Gabapentin Use in the Neonatal Intensive Care Unit

Gabapentin was used for the treatment of term and preterm infants with suspected visceral hyperalgesia caused by a variety of neurologic and gastrointestinal morbidities. Improved feeding tolerance and decreased irritability were seen, as well as decreased usage of opioids and benzodiazepines. Adverse events occurred with abrupt discontinuation of this medication.

Medication Repurposing in Pediatric Patients: Teaching Old Drugs New Tricks

OBJECTIVES

Gaps in pediatric therapeutics often result in off-label use and specifically, novel uses for existing medications, termed "drug repurposing." Drug Information (DI) queries to a Pediatric Medication Resource Center of a large metropolitan pediatric hospital in New York and inherent difficulties in retrieving evidence-based information prompted a review of current medication repurposing for pediatric patients. The objective included characterization of innovative off-label use of medications Food and Drug Administration (FDA)-approved for 1 or more indications to treat a totally different disorder or indication in pediatric patients.

METHODS

A systematic literature review was conducted to retrieve publications describing repurposed medications in pediatric patients. Excluded was FDA-approved indications used off-label in pediatric patients (e.g., different dose), preclinical data, adult use only, and experimental use. Evidence quality was classified using a modified American Academy of Neurology Level of Evidence. Results were analyzed using χ(2) at p < 0.05.

RESULTS

Over 2000 references were retrieved and reviewed. A total of 101 medications repurposed for novel off-label uses for pediatric patients were identified: 38 for neonates, 74 for children, and 52 for adolescents. Neonates and infants were least likely to receive a medication for a repurposed use. Strong or intermediate evidence existed in 80.2% of cases. The evidence was weak in 19.8%. No significant relationship was observed between the pediatric age group and strength of the literature. Most repurposed uses pertained to generic or widely used medications. Less than 5% of medications were first marketed after 2011.

CONCLUSIONS

While not exhaustive, the present study represents the most comprehensive listing of novel uses exclusive to pediatric patients. Further research is needed to identify the frequency of repurposed uses. The valuable DI role of pharmacists in assessing repurposed uses is of expanding and increasing importance to ensure such uses are evidence-based.

Neonatal Gabapentin Withdrawal Syndrome

INTRODUCTION

Gabapentin, an anticonvulsant, neuroleptic, and pain medication, is widely used in both adults and children for management of epilepsy, bipolar illness, and neuropathic pain. Gabapentin use has also been recommended for hyperemesis gravidarum and restless leg syndrome in pregnant mothers.

OBJECTIVE

Although gabapentin use is deemed safe during pregnancy, no clinical reports of gabapentin withdrawal syndrome in a neonate have been described.

RESULTS

We present a newborn who showed signs of withdrawal after prolonged in utero exposure to gabapentin.

CLINICAL IMPLICATIONS

Clinicians should be aware of possible withdrawal symptoms from drugs such as gabapentin, administered to mothers during pregnancy. We also encourage the gradual tapering of gabapentin in neonates over weeks to months similar to the adult population.