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

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 use in the neonatal intensive care unit and beyond: Single center report of 104 cases

BACKGROUND

We aimed to describe our experience with gabapentin use in infants admitted to our neonatal intensive care unit (NICU), including neurodevelopmental follow-up after discharge.

METHODS

We performed a retrospective medical record review of infants prescribed gabapentin during admission to the University of Virginia NICU from 01/01/2015 to 04/30/2021. We report clinical characteristics including gabapentin indication, dosing and side-effects while in the NICU, discharge data, and assessments in outpatient developmental follow-up clinic.

RESULTS

Gabapentin was prescribed to 104 infants (median gestational age 29 weeks, median postmenstrual age at initiation 41 weeks). Sixty-one percent of infants were male. The primary indication was irritability in 86%, and 67% were receiving at least one other neurosedative medication. Median maximum dose was 25 mg/kg/day (IQR 15-35 mg/kg/day) and 84% were discharged home on gabapentin. The majority required equipment at discharge (64% gastrostomy or nasogastric tube feeds, 54% supplemental oxygen or mechanical ventilation, and 40% both). At the first neurodevelopmental follow-up appointment, at least one area of delay was identified in 93% of infants and by 2 years corrected age 66% had a diagnosis of global developmental delay.

CONCLUSIONS

NICU patients treated with gabapentin often require complex post-discharge care and require close neurodevelopmental follow up.

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Gabapentin for pain, movement disorders, and irritability in neonates and infants

We aimed to report our institution's experience with gabapentin therapy to manage agitation and pain in the neonatal intensive care unit (NICU) setting. This was a retrospective, single-center study of NICU patients admitted between January 2015 and December 2017, who received gabapentin. Data on neonatal agitation, pain, Neonatal Pain, Agitation and Sedation Scale (N-PASS) scores, neurosedative medications, and adverse events were collected. Gabapentin was initiated in 16 patients at a corrected gestational age of 44 weeks (range 36.2-75wks) for agitation (n=9), pain (n=6), and movement disorders (n=1). A neurological diagnosis was present in 13 patients. Neonatal agitation, pain, and N-PASS scores and the need for other neurosedatives were significantly decreased 14 days after treatment initiation. Gabapentin is well tolerated in neonates and infants; it is associated with decreased pain scores and decreased need for multiple neurosedative medications 2 weeks after initiation. WHAT THIS PAPER ADDS: Gabapentin is well tolerated in neonates and infants. Gabapentin decreases pain scores and the need for other neurosedative medications in neonates and infants.