Pediatric drug research--the road less traveled

Navigating monoclonal antibody use in breastfeeding women: Do no harm or do little good?

Many neurologic diseases disproportionately affect women, particularly during their reproductive years. For many of these diseases, monoclonal antibodies (mAbs) are becoming widely available as a treatment option, for example, in migraine, multiple sclerosis, and myasthenia gravis. Yet, despite how common pregnancy is (latest estimates suggest that 86% of US women ages 40-44 have given birth), there is a paucity of research on the safety of prescription medications, including mAbs, during the peripartum period. In this article, we focus on the safety of mAbs during breastfeeding. We summarize how pregnancy affects the trajectory of these diseases and explore the benefit derived from mAb therapies. We posit that as neurologists, we are uniquely poised to lead the study of peripartum safety for the mAbs now on the market and provide a framework for their future study.

An audit on parental attitudes towards medicines used in children

INTRODUCTION

There is growing concerns regarding the use of medicines in children. Therefore, many strategies were implemented to improve such use and make safe and effective medicines more available for children. Enhancing interaction between parents and health care providers plays an important role in insuring the proper use of medicines. In order to optimize such interaction, the attitudes, beliefs and practices of parents toward medicine use in children need to be explored.

METHODS

A validated questionnaire was administered via face to face interviews to 1000 parents attending pediatric outpatient clinics with their children in order to investigate their attitudes toward children's medicines.

RESULTS

The majority of respondents (83.2%) were mothers. The majority participants (84.4%) agreed that medicines are necessary in treating illnesses, 80% of the parents had worries about the side effects and interactions of medicines, and 60% of the parents said they try to avoid giving medicines to their children. Moreover, parents in this study varied considerably in their views toward prescription and over-the- counter medicines. More than half of the participants (55.2%) declared that doctors in Jordan prescribe antibiotics to children too easily.

CONCLUSION

Participants had positive attitudes toward the necessity of medicines for ill children. However, a considerable proportion of the parents had negative attitudes toward children's medicines with respect to their side effects and interactions, their capability of disturbing the body's own capability of healing illnesses, their unnatural characteristic and other aspects related to medicines.

Food and Drug Administration approval for medications used in the pediatric intensive care unit: a continuing conundrum

OBJECTIVES

Many drugs used in the pediatric intensive care unit are administered "off label," i.e., they have been neither thoroughly tested for efficacy and safety nor approved for use in children. The U.S. Congress has enacted legislation to promote standards and requirements for Food and Drug Administration labeling for drugs used in pediatrics. Nevertheless, we hypothesized that most medications used in our pediatric intensive care unit were not Food and Drug Administration approved for use in pediatric patients.

DESIGN

A list of medications dispensed in the pediatric intensive care unit from January through February 2008 was obtained from our pharmacy database. We then determined whether each medication had been granted Food and Drug Administration approval for use in children. Medications were divided into the following categories: not approved for use in any pediatric age group, approved for use in limited age groups only, and approved for use in all pediatric age groups.

SETTING

A pediatric intensive care unit at a tertiary care hospital with 26 beds and 1,500 admissions per year.

MEASUREMENTS AND MAIN RESULTS

In the 2-month period, 248 different medications were dispensed with a total of 49,707 medication orders. Sixty (24.2%) of the medications dispensed were not Food and Drug Administration approved for use in any pediatric age group, 106 (42.7%) were approved for use in limited age groups, and 82 (33%) were approved for use in all pediatric age groups. Eleven of the 25 most frequently dispensed medications were approved for use in limited age groups, but none of them was used for the indication or age group for which they were approved.

CONCLUSIONS

Despite the efforts of Congress, 67% of medications prescribed and administered in the pediatric intensive care unit did not have Food and Drug Administration approval or had only limited approval, underscoring the need for the medical community to demand oversight and research to improve drug labeling for our patient population.

Pediatric drug-trial recruitment: enticement without coercion

Despite federal initiatives to increase research and expand data about the effectiveness and safety of medications in children, data are still limited for this population. One of the most salient barriers to conducting pediatric clinical trials involves participant recruitment. In this article, we summarize recruitment challenges including a lack of research infrastructure, the need to properly define appropriate use of incentives and payments, and inconsistencies in the current use of payments and incentives. We also searched the Centerwatch.com and ClinicalTrials.gov databases for updated data on current practices in pediatric participant compensation/payment. We provide recommendations for tackling current barriers to recruiting and retaining children and families in clinical trials.

That sinking feeling, again? The state of National Institutes of Health pediatric research funding, fiscal year 1992-2010

This review article examines the National Institutes of Health's (NIH) overall budget and its pediatric research funding across three time periods: predoubling [fiscal year (FY) 1992-1997]; doubling (FY 1998-2003); and postdoubling (FY 2004-2009). The average annual NIH appropriations increased by 5.4%, 13.4%, and 1.3% in each period, respectively. The average annual pediatric research funding (actual grants, contracts, intramural research, and other mechanisms of support) increased much less, by 4.7%, 11.5%, and 0.3% in each period, respectively. Between FY 2004 and FY 2007, the average NIH budget increase has nearly flattened, to only 1.96%. During this period, average pediatric research funding has dropped markedly lower, to 0.57%; estimated FY 2008 pediatric funding is at negative 0.5%. Although pediatric research enjoyed significant benefits of the NIH doubling era, the proportion of the NIH budget devoted to the pediatric research portfolio has declined overall. The most recent period has wiped out the annual gains of the doubling era for both pediatric and overall NIH research funding. We offer recommendations to protect against further erosion of pediatric research funding and to implement several unfulfilled commitments to strengthen the federal pediatric research portfolio in the coming decade.

The premature demise of public child and adolescent inpatient psychiatric beds : Part II: challenges and implications

Psychiatric disorders are the leading reason for hospitalization among 5-19 year olds. Current data, however, suggest there are fewer than necessary available services for children and adolescents requiring intensive, inpatient psychiatric care. Children and adolescents with behavioral health problems, the majority of whom do not receive appropriate treatment, have increased risk of school failure, family disruption, out-of-home placements, poor employment opportunities, and poverty in adulthood. This paper will examine the challenges inherent in serving children and adolescents with serious emotional disturbances, avenues of financing for treatment and services, and various loci of intervention for high-risk children, including inpatient settings and systems of care. The goals of this paper are to illustrate the complexities of working with children and adolescents most in need of intensive psychiatric services, to explore how inpatient services "fit" into existing treatment approaches, and to discuss the efficacy of downsizing or closing inpatient psychiatric units for this population.

Pediatric pharmacotherapeutic education: current status and recommendations to fill the growing need

The Accreditation Council for Pharmacy Education and the Canadian Council for Accreditation of Pharmacy Programs state that their respective programs should provide a curriculum appropriate to produce general practitioners of pharmacy. Millions of prescriptions are written for infants and children each year, and relatively few pharmacists practice in environments devoid of pediatric patients. To fulfill the stated mandate, professional pharmacy curricula must include adequate content dedicated to pharmaceutical care of the pediatric patient. Current pediatric curricula are inadequate and must be improved. Pediatric topics should be introduced early in the curriculum to increase students' awareness of the special needs of this vulnerable population. Other recommendations include the provision at least 25 hours of didactic instruction in core pediatric areas and at least one pediatric clinical rotation to all students. Pharmaceutical care of pediatric patients can also be improved by offering pediatric rotations to all pharmacy practice residents and encouraging their participation. However, a change in attitude may be most important. The contention that pediatric pharmacy practice is an isolated subspecialty can no longer be supported.

Effect of the pediatric exclusivity provision on children's access to medicines

AIMS

To determine the paediatric licensing status in the USA, UK, Australia and New Zealand of the 79 medicines granted paediatric exclusivity in the USA, and to assess the importance of those medicines to paediatric practice.

METHODS

The medicines granted a patent extension in the USA as of 10 November 2003 were identified from the FDA website. Data on paediatric licensing were obtained from the Physicians Desk Reference (USA), the Electronic Medicines Compendium (UK), the Australian Prescription Products Guide (Australia) and the MedSafe website (New Zealand). A questionnaire was administered to seven paediatric consultants to assess the importance of the 79 PEMs for use in children. The questionnaire sought opinions on each drug, by age grouping, regarding: usefulness in patients with the condition, number of patients likely to be treated with each drug in a year, and acceptable therapeutic alternatives.

RESULTS

Fifty-eight (73%) of the medicines had attained paediatric licensing in the USA. Sixty were licensed for adults in all four countries and of these 45 (75%) were licensed for children under 12 years in the USA compared with 31 (52%) to 33 (55%) for the other three countries. The proportion of these medicines licensed for children under 1 month, under 2 years and under 6 years of age ranged from 10% to 58% and there were no significant differences between the countries. For all four countries perceived usefulness and predicted numbers of patients both had some influence on the odds of a medicine having paediatric licensing.

CONCLUSIONS

Improvements in licensing of some medicines for children have occurred in the USA, relative to the UK, Australia and New Zealand, subsequent to the Paediatric Exclusivity Provision. Improvements occurred for children over the age of six, but not for younger children.