Treatment for Migraines in Pediatric Patients

Migraines often bring pediatric patients into the emergency department and can continue on for 2 to 3 days. One study conducted a systematic review to determine what treatments are best to use in pediatric patients. The therapies included antiemetics, fluids, opioids, NSAIDS, acetaminophen, 5HT receptor agonists, DA receptor antagonists, and anesthetics.

Fluids were determined to be more beneficial for those prone to emesis symptoms due to dehydration. Ibuprofen and acetaminophen to a lesser degree may be effective in preventing migraine worsening to avoid the need for other aggressive therapies. DA receptor antagonists are effective in treating migraines; prochlorperazine patients had a lower chance of returning to the emergency department than patients on metoclopramide. Propofol reduced patients’ pain greatly and shortened their emergency department stay.

Magnesium improved pain by a decrease of 3 or more points on a 10 point pain scale. Opioids are not part of the American Academy of Neurology practice for pediatric patients. Triptans are effective in the treatment of adult migraines in adolescents and there are a variety of formulations.

In conclusion, ibuprofen, prochlorperazine, and triptans are the most effective and safe medications to use in pediatric patients for the treatment of acute migraines. This is important because many pediatric patients come into the emergency department with migraines. If the escalation of migraines can be prevented with the use of these medications, the amount of time the patient spends in the emergency department will greatly be reduced. Pharmacists play a key role in making recommendations for these pediatrics therapies. How does the treatment for pediatric migraines differ than that for adult migraines?

Headache. doi: 10.1111/head.12746 (published 21 January 2016). 

 

Pediatric Weight-based Dosing in Outpatient Pharmacies

A retrospective outpatient prescription record review was conducted for 6 months to determine the percentage of outpatient pediatric prescriptions with errors. Johns Hopkins Outpatient Pharmacy fills about 450 prescriptions daily with 30% for pediatric patients. Weight-based checking includes having 2 pharmacists complete a dosing calculation and cite an appropriate reference. The final verification pharmacist then double checks the calculation before dispensing to the patient. Any discrepancies are sent to the problem queue for further investigation.

For the 6 month study, 5,010 pediatric prescriptions were filled, 1,448 were sent to the problem queue and 156 required a pharmacist intervention. 50% of those prescriptions (78) were changed. The majority of prescribing errors included dose too high, incomplete or illegible prescription, inappropriate dosing interval, and dose too low.

There were several limitations to the study because pharmacists could call the physician directly and change the prescription without documenting it in the problem queue. Additionally, the majority of prescribers were from a teaching hospital where errors may have been higher.

Although the numbers seem small, I think that any reduction in error is significant. Since pediatric patients require very specific doses, it is so critical to check and double check the prescribed dosing. I wonder how many less errors are given to the patients due to weight-based dosing. This study showed that many errors were caught by pharmacists but did not compare it to other outpatient pharmacies. What other factors should the pharmacist consider when filling pediatric prescriptions?

J Am Pharm Assoc. 2016;56(1):54-57. 

iCat in Pediatric Extracranial Solid Tumors

We hear about cancer related news almost every day, but pediatric cancer is unique because its targeted therapies are less available. Harris and colleagues just this past month studied the effects of individualized cancer therapy (iCat) recommendations and the feasibility of determining alterations in genomic sequences that can be targeted for treatment of pediatric extracranial (out side of the skull) solid tumors. The study was done from September 5, 2012 to November 19th, 2013 in 4 academic medical centers. There was also a one-year follow-up from the time of the visit. In order to be included in the study the patient criteria was 30 years of age or younger and with high risk, recurrent, or refractory extracranial solid tumors. Once selected, the tumors were profiled for their genetic sequencing. If an actionable alteration in the sequence was in fact present and iCat recommendation was made as long as an appropriate drug was available. Of the 100 participants it was found that 43 had results of potential clinical significance. They came to the conclusion that a clinical genomics study in pediatric oncology is feasible. It was also concluded that a large portion of pediatric solid tumors have actionable alterations in their genome.

Each case of cancer is different, especially in children. With new knowledge of certain places that we can begin treatment, such as an iCat, we are coming closer to an increase in survival rates. In my opinion there is still an immense amount of research that needs to be done, especially with pediatric cancer and stopping it from relapsing later in the child’s life. The use of genomics in this study really interested me because it is exactly what we talked about in class, targeted drug therapy. With the use of this I think we as the science community need to continue on looking at cancer and discovering drugs and therapies to overcome it. I believe that any tool that can help a health care professional make an informed decision on treatments is well worth it.

 

JAMA Oncol. http://oncology.jamanetwork.com/article.aspx?articleid=2484355 (published online January 28, 2016)

Weight-Based Dosing in Pediatric Patients

Inappropriate prescribing is a medication error found in almost 15% of pediatric outpatient prescriptions. With more significant pharmacokinetic and pharmacodynamic differences than adults, as well as a greater variation in height and weight, children are more susceptible to prescribing errors. Although many inpatient pharmacies have procedures and safeguards to protect children from these errors, outpatient pharmacies lack these procedures and error prevention strategies in the outpatient setting remain relatively unstudied.

This study was performed in outpatient pharmacy located in an academic teaching hospital. All pediatric prescriptions were reviewed for a six month period. Over five thousand prescripts were reviewed during the sixth month period and of these prescriptions, around 156 of those prescriptions required pharmacist intervention. The majority of those prescriptions needing pharmacist intervention had to be changed because dose too high. This study demonstrated the need for weight-based dosing procedures in outpatients pharmacies as way to proactively reduce medication errors for children. Although this procedure adds time, it’s an important safeguard for children using prescription medications.

Link

Grant JJ. Adams Mb. Decker K et al. Evaluating the impact of a pediatric weight-based dosing procedure in outpatient pharmacy. J Am Pharm Assoc. 2016; 56.1: 54-57.

Neonatal Pharmacist to the Rescue: Caring for the Hospital’s Most Vulnerable Participants

This article discusses a clinical pharmacist, Dr. Keliana O’Mara, who works in the neonatal ICU at the University of Florida Health Shands Hospital. She is the only pharmacist in this unit, and her role there is incredibly important.

One of the sickest patients that O’Mara had to work with was a baby girl who was born at 28 weeks gestation. This baby had a congenital diaphragmatic hernia and cardiac defect. Because her diaphragm did not develop completely, her abdominal contents were pushed into her chest cavity, and as a result she only had the functionality of 1.5 of her lungs.

O’Mara did a significant amount to save this baby’s life while the baby was in the neonatal ICU. She was in charge of the pain and sedation management for the infant as she went in and out of several surgeries for developmental defects. After all of the infant’s surgeries, O’Mara realized that the infant had developed a fungus in her blood. As a pharmacist, she was able to notice that the antifungal that the infant was to be started on would most likely not work because the infant had been on it previously, and the fungus in the infant’s blood was most likely resistant to the medication as a result. O’Mara was able to collaborate with the primary physician and get the medication changed to a broader spectrum antifungal medication. This was beneficial because a later culture showed that the fungus in the infant’s blood would have indeed been resistant to the original medication.

Another role that O’Mara has in the neonatal ICU is to help implement better treatment methods there. For example, by looking at 2 years of vancomycin dosing data, O’Mara realized that half of the infants in the NICU never reached a therapeutic level of this antibiotic in their blood. As a result, she got permission to begin individualized pharmacokinetic/pharmacodynamic dosing for vancomycin. This is when a pharmacist evaluates serial blood concentrations of a drug after patients receive the first dose. The pharmacist then creates an appropriate dosing regiment personalized for each patient based on these values. Doing this for vancomycin ultimately led to a quicker clearance of bacterial infections in infants in this NICU, and therefore a shorter amount of time that they needed to be on the antibiotic.

Pharmacists who work in the neonatal ICU are additionally crucial because of how small the doses are for babies. Pharmacists must make sure that an infant is never getting too much medication and that mixtures of medications are always made properly. Adding more fluid to a dose to dilute it is not possible for a 500 mg infant because this could lead to fluid overload in the baby. As a result, pharmacists working in this unit have to be extra precise and careful. They also need to make sure the team they are working with understands the latest drug data. It is their job to show physicians when a medication should not be used in an infant, for example if scientific data shows that the treatment and placebo yields the same response from a drug.

I overall found this article very interesting. It is incredible how different one’s experience can be as a pharmacist just by working in one unit of a hospital over another. It also is crazy to think how easy and life threatening it can be to mess up one small part of an infant’s medication regimen. It is clear that a pharmacist is crucial in the NICU of every hospital, and it amazes me how much of an impact one pharmacist can have on saving someone’s life and allowing a premature baby to one day make it home.

Pharmacy Today. 2015;Health-System Edition:2-3.

http://pharmacytoday.org.marlin-prod.literatumonline.com/article/S1042-0991(15)30102-X/pdf

 

Pharmacist-led screening program for an inner-city pediatric population

This study was conducted to see how inner city children are affected by asthma, hypertension, obesity, and environmental tobacco smoke (ETS) exposure. This study took place in lower socioeconomic communities throughout Pittsburgh and pharmacists and student pharmacists ran 12 health screenings on 144 children over the course of 2 years.

The study found that 16% of the children were already diagnosed with asthma before the screenings, and 18% had potential asthma. More than half of the children were not at a healthy weight (0.7% were underweight and the remaining were either overweight or obese), and 24% had abnormal blood pressure. 26% of the children had exposure to ETS comparable to that of smokers.

Over the course of this study, nearly 200 referrals were made by the pharmacists. This study is important because it shows how at risk the children in our own community are for conditions that could greatly affect their health outcomes. It also shows how critical of a role pharmacists could play in screening and preventing diseases among children who face numerous health disparities. Screening programs such as this can be implemented by pharmacists in other communities, especially those of even lower socioeconomic status than the one studied, to help lower health disparities among inner city populations of children.

Elliott JP, Harrison C, Konopka C, et al. Pharmacist-led screening program for an inner-city pediatric population. J Am Pharm Assoc. 2003;55:413-8.

Use of Stimulants in Children of Mentally Ill, Increased Risk of Psychotic Symptoms

This article concerned a study showing that children aged 6-21 with one or more parents with a severe mental illness had a higher likelihood of experiencing psychotic symptoms when taking stimulants.  It was once thought that psychotic symptoms, including hallucinations, delusions, and psychotic-like experiences, were rare side effects of stimulants in children.  This study demonstrated that it might not be the case that they are such rare side effects, especially in children of one or more parent with a severe mental illness.  In the study, the children of parents with mental illnesses including major depressive disorder, bipolar disorder, and schizophrenia were tested for ADHD, a common indication for use of stimulants in children.  Of the children with ADHD, those that had taken stimulants had a much higher rate of experiencing psychotic symptoms than those who had not taken stimulants.  The study showed that there was a temporal relationship between taking stimulants and experiencing psychotic symptoms.  It also ruled out the possibility that the real cause of the psychotic symptoms was ADHD and not the use of stimulants.  The study used multiple sophisticated instruments for assessing psychotic symptoms, and the results were statistically significant.  Additional studies are necessary to confirm that there is indeed a causal relationship between stimulants and psychotic symptoms in children of parents with mental illnesses.  Further studies will also be necessary to determine of the stimulant methylphenidate, the most frequently seen in the study, produces results that can be generalized to other stimulants.  However, the results of this study alone are enough to encourage doctors and psychiatrists to consider familial history of severe mental illnesses when considering prescribing stimulants for children with ADHD.

I was happy to see this article because I think it is important to continue testing in the field of mental illnesses and medications for learning disabilities and mental illnesses.  There has always been a stigma attached to mental illness, and it is possible that this stigma has affected how mental illness and medications for mental problems have been studied and presented to the public.  Further studies in this area will help to clear any misconceptions that have formed and to improve medical practice in this area.

MacKenzie LE, Abidi S, Fisher HL, et al. Stimulant Medication and Psychotic Symptoms in Offspring of Parents With Mental Illness. Pediatrics. 2016;137:1-10.

Link to Article

Pediatrics: Synbiotics for Prevention and Treatment of Atopic Dermatitis

Chang and colleagues conducted a meta-analysis of all published randomized clinical control trials that have been reviewed to study the use of synbiotics in the prevention/treatment of atopic dermatitis (AD) in pediatric patients. AD is a common condition in children and is more commonly referred to as eczema. It is characterized by dry and scaly red patches, usually occurring on the face of children. Chang and colleagues also describe AD as creating an environment that increases a child’s susceptibility to allergic diseases. Synbiotics are OTC medications that are a mixture of both prebiotics and probiotics. The clinical control trials must have met certain criteria in order to be included in the analysis. 8 of the 257 studies met the criteria of an oral administration intervention of synbiotics, and included the severity of the AD in the children within the trial. Of the studies used, 6 were for treatment of AD and 2 were the prevention. After a complete analysis of the 8 studies, evidence was found that synbiotics can be used to treat AD for children 1 year and older, but no significant evidence was found to support the use of synbiotics for AD primary prevention.

JAMA Pediatr. doi:10.1001/jamapediatrics.2015.3943 (published online 25 January 2016).

Parents have the most concern about newborns and what medications that they are receiving. They are also concerned about any disease that may affect their young children, and are willing to do anything in order to treat their children. This analysis shows that there is an effective oral treatment for AD in children, but do you think that this analysis alone is enough for a parent to agree to use as a treatment for their child’s AD? Pediatric medication use also has very strict guidelines in order to ensure the safety of children. In my opinion, I would be more inclined to give a child a topical medication that only interacts with the affected area before I would suggest an over the counter oral medication.