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Cunico D, Rossi A, Verdesca M, Principi N, Esposito S. Pain Management in Children Admitted to the Emergency Room: A Narrative Review. Pharmaceuticals (Basel) 2023; 16:1178. [PMID: 37631093 PMCID: PMC10459115 DOI: 10.3390/ph16081178] [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: 06/30/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.
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Affiliation(s)
- Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Arianna Rossi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Matteo Verdesca
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
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Anderson BJ, Cortinez LI. Perioperative Acetaminophen Dosing in Obese Children. CHILDREN 2023; 10:children10040625. [PMID: 37189874 DOI: 10.3390/children10040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Acetaminophen is a commonly used perioperative analgesic drug in children. The use of a preoperative loading dose achieves a target concentration of 10 mg/L associated with a target analgesic effect that is 2.6 pain units (visual analogue scale 1–10). Postoperative maintenance dosing is used to keep this effect at a steady-state concentration. The loading dose in children is commonly prescribed per kilogram. That dose is consistent with the linear relationship between the volume of distribution and total body weight. Total body weight is made up of both fat and fat-free mass. The fat mass has little influence on the volume of distribution of acetaminophen but fat mass should be considered for maintenance dosing that is determined by clearance. The relationship between the pharmacokinetic parameter, clearance, and size is not linear. A number of size metrics (e.g., fat-free and normal fat mass, ideal body weight and lean body weight) have been proposed to scale clearance and all consequent dosing schedules recognize curvilinear relationships between clearance and size. This relationship can be described using allometric theory. Fat mass also has an indirect influence on clearance that is independent of its effects due to increased body mass. Normal fat mass, used in conjunction with allometry, has proven a useful size metric for acetaminophen; it is calculated using fat-free mass and a fraction (Ffat) of the additional mass contributing to total body weight. However, the Ffat for acetaminophen is large (Ffat = 0.82), pharmacokinetic and pharmacodynamic parameter variability high, and the concentration–response slope gentle at the target concentration. Consequently, total body weight with allometry is acceptable for the calculation of maintenance dose. The dose of acetaminophen is tempered by concerns about adverse effects, notably hepatotoxicity associated with use after 2–3 days at doses greater than 90 mg/kg/day.
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Zempsky W, Bell J, Mossali VM, Kachroo P, Siddiqui K. Common Selfcare Indications of Pain Medications in Children. Paediatr Drugs 2023; 25:321-341. [PMID: 36928608 PMCID: PMC10019440 DOI: 10.1007/s40272-023-00562-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/17/2023]
Abstract
Pain has a multifaceted impact on individuals worldwide, affecting their physical functioning, emotional well-being, and quality of life. Children (age < 18 years) have a high prevalence of conditions associated with pain, such as toothache, headache, earache, sore throat, and respiratory tract infections, many of which may be accompanied by fever. Globally, the pharmacologic treatment of pain in pediatric patients is limited largely to nonopioid analgesics, and dosing must account for differences in age, weight, metabolism, and risk of adverse effects. This narrative review summarizes the findings of a literature search on the pediatric indications, dosing approaches, dosing guidelines, and pharmacokinetics of paracetamol and ibuprofen, which are common pain medications available globally for self-care use in children. The review also discusses the risks and benefits associated with these agents. The current roles of paracetamol and ibuprofen in the symptomatic management of coronavirus disease 2019 (COVID-19) infection and in the management of post-COVID-19 immunization symptoms in children are also discussed. Therefore, while a very large amount of data over several decades is available for paracetamol and ibuprofen, an urgent need exists for well-designed studies of these medications for the management of pain and fever in pediatric patients with COVID-19 to ensure optimal relief with minimal toxicity.
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Affiliation(s)
- William Zempsky
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, 06106, USA. .,University of Connecticut School of Medicine, Farmington, CT, USA.
| | - John Bell
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
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Neonatal pharmacology. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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5
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Engbers AGJ, Völler S, Flint RB, Goulooze SC, de Klerk J, Krekels EHJ, van Dijk M, Willemsen SP, Reiss IKM, Knibbe CAJ, Simons SHP. The Effect of Ibuprofen Exposure and Patient Characteristics on the Closure of the Patent Ductus Arteriosus in Preterm Infants. Clin Pharmacol Ther 2022; 112:307-315. [PMID: 35429165 PMCID: PMC9540485 DOI: 10.1002/cpt.2616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/09/2022] [Indexed: 12/25/2022]
Abstract
Spontaneous closure of the ductus arteriosus depends on gestational age (GA) and might be delayed in preterm infants, resulting in patent ductus arteriosus (PDA). Ibuprofen can be administered to enhance closure, but the exposure‐response relationship between ibuprofen and the closure of PDA remains uncertain. We investigated the influence of patient characteristics and ibuprofen exposure on ductus closure. A cohort of preterm infants with PDA and treated with ibuprofen was analyzed. Ibuprofen exposure was based on a previously developed population pharmacokinetic study that was in part based on the same study population. Logistic regression analyses were performed with ductus closure (yes/no) as outcome, to analyze the contribution of ibuprofen exposure and patient characteristics. In our cohort of 263 preterm infants (median GA 26.1 (range: 23.7–30.0) weeks, birthweight 840 (365–1,470) g) receiving ibuprofen treatment consisting of 3 doses that was initiated at a median postnatal age (PNAstart) of 5 (1–32) days, PDA was closed in 55 (21%) patients. Exposure to ibuprofen strongly decreased with PNAstart. Overall, the probability of ductus closure decreased with PNAstart (odds ratio (OR): 0.7, 95% CI: 0.6–0.8) and Z‐score for birthweight (ZBirthweight‐for‐GA; OR: 0.8, 95% CI: 0.6‐1.0), and increased with GA (OR: 1.5, 95% CI: 1.1–1.9). For patients with PNAstart < 1 week, concentrations of ibuprofen, GA, and ZBirthweight‐for‐GA predicted probability of ductus closure. During a window of opportunity for ductus closure within the first days of life, probability of closure depends on GA, ZBirthweight‐for‐GA, and ibuprofen exposure. Increased, yet unstudied dosages might increase the effectivity of ibuprofen beyond the first week of life.
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Affiliation(s)
- Aline G J Engbers
- Division of Systems Biomedicine and Pharmacology, LACDR, Leiden University, Leiden, The Netherlands.,Division of Neonatology, Department of Paediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Swantje Völler
- Division of Systems Biomedicine and Pharmacology, LACDR, Leiden University, Leiden, The Netherlands.,Pharmacy, LACDR, Leiden University, Leiden, The Netherlands
| | - Robert B Flint
- Division of Neonatology, Department of Paediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sebastiaan C Goulooze
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Johan de Klerk
- Division of Neonatology, Department of Paediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, LACDR, Leiden University, Leiden, The Netherlands
| | - Monique van Dijk
- Department of Pediatric Surgery, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sten P Willemsen
- Division of Neonatology, Department of Biostatistics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, LACDR, Leiden University, Leiden, The Netherlands.,Division of Neonatology, Department of Paediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Paediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, The Netherlands
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Metamizole Use in Children: Analysis of Drug Utilisation and Adverse Drug Reactions at a German University Hospital between 2015 and 2020. Paediatr Drugs 2022; 24:45-56. [PMID: 34877625 PMCID: PMC8651268 DOI: 10.1007/s40272-021-00481-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Metamizole use is controversially discussed due to its potentially serious adverse drug reactions (ADRs). In Germany, however, it remains a popular analgesic and antipyretic drug. OBJECTIVE The aim of this study was to discuss the safety profile of metamizole in children by analysing the inpatient prescription patterns and presenting the metamizole-related ADRs at a paediatric hospital between 2015 and 2020. METHODS Metamizole utilisation data were retrospectively analysed from electronic medical records. ADRs were prospectively recorded via the hospital's stimulated reporting system and analysed accordingly. Patients aged < 18 years admitted to one of the general wards of the department of paediatrics and adolescent medicine of a German university hospital between June 2015 and May 2020 who received at least one drug therapy within their inpatient stay were included in the analysis. Causality of ADRs was rated according to the World Health Organisation causality assessment. RESULTS In 31.7% (3759/11,857) of the inpatient stays of 7809 patients, metamizole was administered. Metamizole exposure was highest in adolescents (37.9%) and lowest in newborns (9.9%). Overall, metamizole was administered parenterally in about 90%. Three cases of agranulocytosis, one allergic shock and one rash with possible or higher causality to metamizole treatment were reported. Three of these occurred prior to hospitalisation. All patients recovered without remaining harm. DISCUSSION Metamizole is commonly used in paediatric inpatients in Germany. Serious ADRs occur but rarely. Continuous monitoring of drug therapy through, for example, stimulated reporting systems ensures that serious ADRs are detected, and appropriate interventions can be introduced.
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Chakkarapani AA, Aly H, Benders M, Cotten CM, El-Dib M, Gressens P, Hagberg H, Sabir H, Wintermark P, Robertson NJ. Therapies for neonatal encephalopathy: Targeting the latent, secondary and tertiary phases of evolving brain injury. Semin Fetal Neonatal Med 2021; 26:101256. [PMID: 34154945 DOI: 10.1016/j.siny.2021.101256] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In term and near-term neonates with neonatal encephalopathy, therapeutic hypothermia protocols are well established. The current focus is on how to improve outcomes further and the challenge is to find safe and complementary therapies that confer additional protection, regeneration or repair in addition to cooling. Following hypoxia-ischemia, brain injury evolves over three main phases (latent, secondary and tertiary), each with a different brain energy, perfusion, neurochemical and inflammatory milieu. While therapeutic hypothermia has targeted the latent and secondary phase, we now need therapies that cover the continuum of brain injury that spans hours, days, weeks and months after the initial event. Most agents have several therapeutic actions but can be broadly classified under a predominant action (e.g., free radical scavenging, anti-apoptotic, anti-inflammatory, neuroregeneration, and vascular effects). Promising early/secondary phase therapies include Allopurinol, Azithromycin, Exendin-4, Magnesium, Melatonin, Noble gases and Sildenafil. Tertiary phase agents include Erythropoietin, Stem cells and others. We review a selection of promising therapeutic agents on the translational pipeline and suggest a framework for neuroprotection and neurorestoration that targets the evolving injury.
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Affiliation(s)
| | - Hany Aly
- Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Manon Benders
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Pierre Gressens
- Université de Paris, NeuroDiderot, Inserm, Paris, France; Centre for the Developing Brain, Department of Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, SE1 7EH, United Kingdom.
| | - Henrik Hagberg
- Centre for the Developing Brain, Department of Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, SE1 7EH, United Kingdom; Centre of Perinatal Medicine & Health, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital University of Bonn, Bonn, Germany; German Centre for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | - Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
| | - Nicola J Robertson
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, Edinburgh BioQuarter, Edinburgh, United Kingdom; Institute for Women's Health, University College London, London, United Kingdom.
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8
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Grundzüge des perioperativen Schmerzmanagements bei Säuglingen, Kindern und Jugendlichen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01045-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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9
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Engbers AGJ, Flint RB, Völler S, de Klerk JCA, Reiss IKM, Andriessen P, Liem KD, Degraeuwe PLJ, Croubels S, Millecam J, Allegaert K, Simons SHP, Knibbe CAJ. Enantiomer specific pharmacokinetics of ibuprofen in preterm neonates with patent ductus arteriosus. Br J Clin Pharmacol 2020; 86:2028-2039. [PMID: 32250464 PMCID: PMC7495289 DOI: 10.1111/bcp.14298] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/11/2020] [Accepted: 03/21/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Racemic ibuprofen is widely used for the treatment of preterm neonates with patent ductus arteriosus. Currently used bodyweight‐based dosing guidelines are based on total ibuprofen, while only the S‐enantiomer of ibuprofen is pharmacologically active. We aimed to optimize ibuprofen dosing for preterm neonates of different ages based on an enantiomer‐specific population pharmacokinetic model. Methods We prospectively collected 210 plasma samples of 67 preterm neonates treated with ibuprofen for patent ductus arteriosus (median gestational age [GA] 26 [range 24–30] weeks, median body weight 0.83 [0.45–1.59] kg, median postnatal age [PNA] 3 [1–12] days), and developed a population pharmacokinetic model for S‐ and R‐ibuprofen. Results We found that S‐ibuprofen clearance (CLS, 3.98 mL/h [relative standard error {RSE} 8%]) increases with PNA and GA, with exponents of 2.25 (RSE 6%) and 5.81 (RSE 15%), respectively. Additionally, a 3.11‐fold higher CLS was estimated for preterm neonates born small for GA (RSE 34%). Clearance of R‐ibuprofen was found to be high compared to CLS (18 mL/h [RSE 24%]), resulting in a low contribution of R‐ibuprofen to total ibuprofen exposure. Current body weight was identified as covariate on both volume of distribution of S‐ibuprofen and R‐ibuprofen. Conclusion S‐ibuprofen clearance shows important maturation, especially with PNA, resulting in an up to 3‐fold increase in CLS during a 3‐day treatment regimen. This rapid increase in clearance needs to be incorporated in dosing guidelines by adjusting the dose for every day after birth to achieve equal ibuprofen exposure.
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Affiliation(s)
- Aline G J Engbers
- Division of Systems Biomedicine & Pharmacology, LACDR, Leiden University, Leiden, the Netherlands.,Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department of Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Swantje Völler
- Division of Systems Biomedicine & Pharmacology, LACDR, Leiden University, Leiden, the Netherlands.,Division of BioTherapeutics, LACDR, Leiden University, Leiden, the Netherlands
| | - Johan C A de Klerk
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Kian D Liem
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pieter L J Degraeuwe
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre, the Netherlands
| | - Siska Croubels
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Belgium
| | - Joske Millecam
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Belgium
| | - Karel Allegaert
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Development and Regeneration, KU Leuven, Belgium
| | - Sinno H P Simons
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine & Pharmacology, LACDR, Leiden University, Leiden, the Netherlands.,Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
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Anderson BJ, Morse JD, Hannam JA, Cortinez LI. Pharmacokinetic and pharmacodynamic considerations of general anesthesia in pediatric subjects. Expert Opin Drug Metab Toxicol 2020; 16:279-295. [PMID: 32148110 DOI: 10.1080/17425255.2020.1739648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Introduction: The target concentration strategy uses PKPD information for dose determination. Models have also quantified exposure-response relationships, improved understanding of developmental pharmacokinetics, rationalized dose prescription, provided insight into the importance of covariate information, explained drug interactions and driven decision-making and learning during drug development.Areas covered: The prime PKPD consideration is parameter estimation and quantification of variability. The main sources of variability in children are age (maturation) and weight (size). Model use is mostly confined to pharmacokinetics, partly because anesthesia effect models in the young are imprecise. Exploration of PK and PD covariates and their variability hold potential to better individualize treatment.Expert opinion: The ability to model drugs using computer-based technology is hindered because covariate data required to individualize treatment using these programs remain lacking. Target concentration intervention strategies remain incomplete because covariate information that might better predict individualization of dose is absent. Pharmacogenomics appear a valuable area for investigation for pharmacodynamics and pharmacodynamics. Effect measures in the very young are imprecise. Assessment of the analgesic component of anesthesia is crude. While neuromuscular monitoring is satisfactory, depth of anaesthesia EEG interpretation is inadequate. Closed loop anesthesia is possible with better understanding of EEG changes.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - James D Morse
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - L Ignacio Cortinez
- División Anestesiología, Pontificia Universidad Católica De Chile, Santiago De Chile, Chile
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