Polypharmacy Among Hospitalized Children

Abstract

Source: Feudtner C, Dingwei D, Hexem KR, et al. Prevalence of polypharmacy exposure among hospitalized children in the United States. Arch Pediatr Adolesc Med. 2012; 166(1): 9– 16; doi: 10.1001/archpediatrics.2011.161Investigators at the Children’s Hospital of Philadelphia and the University of Pennsylvania examined the pattern of exposure to drugs and therapeutic agents among children hospitalized in 2006, excluding healthy newborns. The goals of the study were to determine the most commonly used drugs and therapeutic agents, measure the daily and cumulative medication exposures during a hospital stay, and identify potential differences in the use of drugs and therapeutic agents in children’s hospitals versus general hospitals based on patient characteristics such as age, gender, diagnosis, and length of stay. Data were extracted from two databases, the Pediatric Health Information System and the Perspective Data Warehouse, which provided detailed information on pharmacy activity on each day of hospitalization.Data collected from 52 children’s hospitals and 411 general hospitals on 587,427 children younger than 18 years (equivalent to 20% of pediatric admissions across the country in 2006) were analyzed. The most prevalent drugs and therapeutic agents to which hospitalized children were exposed were intravenous fluids, analgesics, anti-infectives, anesthetics, and gastrointestinal drugs. Stratified by age, heparin and ampicillin were the most common drug exposures in children younger than 1 year in children’s and general hospitals, respectively; acetaminophen was the most common exposure in children 1 to 9 years old in both children’s and general hospitals; and ondansetron and fentanyl were the most common in children aged 10 to 17 years in children’s and general hospitals, respectively. On day 1 of hospitalization, the median level of exposure was four distinct medications for children younger than 1 year in children’s hospitals and three distinct medications at general hospitals. For children 1 year or older, the median level of first-day exposure was five distinct medications in both children’s and general hospitals. In children’s hospitals, the cumulative number of medications received for the median patient younger than 1 year was 25 by hospital day 30, and for the patient 1 year or older was 42 by hospital day 30. In general hospitals, the cumulative number of medications received increased to 21 and 25, respectively, for children younger than 1 year and those 1 year or older. Patients in children’s hospitals were estimated to be exposed to 1.34 times more medications than patients in general hospitals, but after adjusting for patient characteristics, this was not a significant difference.The authors conclude that a large number of hospitalized children are exposed to polypharmacy, raising patient safety concerns.Dr Riedmann has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.There are limitations to this study, many identified by the authors, which potentially bias its findings. First, the retrospective nature of the study eliminated the ability to verify that the patients actually received the medications that were prescribed and billed. Second, the data sources used were also limited because PRN medications may have been inaccurately billed for but not received. Third, unaccounted-for confounding may have skewed the comparisons of medications used for pediatric patients admitted to children’s hospitals versus the general hospitals. For example, adolescent females who were admitted for childbirth rather than an acute illness/ injury would be found exclusively in general hospitals, as evidenced by the amount of oxytocin administered at general hospitals versus children’s hospitals. In addition, children needing specialists for more complex medical conditions would more likely be admitted to a children’s hospital, as evidenced by the finding of a higher percentage of disease-specific medications (cardiovascular, neoplastic, etc.) prescribed at children’s hospitals.However, the results of this study are important. There is a clear association between polypharmacy and the risk of adverse drug effects in adults.1 Previous studies of the risk of adverse drug reactions in hospitalized children, particularly children admitted to intensive care units, suggest similar risks.2 In addition, many medications have not been thoroughly studied in the pediatric population for their safety.3 Since the amount of polypharmacy increases with the length of hospitalization, patients with complex medical problems requiring a prolonged hospital stay are at a greater risk for adverse effects. Studies dedicated to the effects of polypharmacy in children would be beneficial to establishing goals to limit adverse effects and create standards of care for pediatric patients admitted to the hospital. Finally, as pointed out in an editorial accompanying the main study,4 polypharmacy in children is an increasing problem in the outpatient setting as well, with a different set of issues requiring further study.