Medication Use In Children Research Articles

Evaluating the off-label use of medications in children

Medications are sometimes prescribed for indications not included in the product insert (i.e., off-label indications).[1][1] Pediatric patients are frequently administered medications for off-label indications. It has been estimated that only 20–30% of medications with labeling approved by the

Effect of Particulate Air Pollution on Lung Function in Adult and Pediatric Subjects in a Seattle Panel Study

To determine whether increased exposure to particulate matter air pollution (PM), measured with personal, residential, or central site monitoring, was associated with pulmonary function decrements in either adults with COPD or children with asthma. We studied 57 adults with or without COPD and 17 children aged 6 to 13 years with physician-diagnosed asthma in Seattle during a 3-year panel study. Indoor and outdoor PM measurements were made at subjects' homes. The subjects wore personal exposure monitors for 10 consecutive 24-h periods, and PM was also measured at a central outdoor location. We assessed the within-subject effect of particulate exposure on FEV(1) and peak expiratory flow (PEF) in adults, and maximal midexpiratory flow (MMEF), PEF, FEV(1), and symptoms in children. FEV(1) decrements were associated with 1-day lagged central site PM </= 2.5 microm in diameter (PM(2.5)) in adult subjects with COPD. In children not receiving antiinflammatory medication, same day indoor, outdoor, and central site exposures to PM(2.5) were associated with decrements in MMEF, PEF, and FEV(1). Associations with PM(2.5) and lung function decrements were also observed for 1-day lagged indoor (MMEF, PEF, FEV(1)) and personal (PEF only) exposures. Antiinflammatory medication use in children significantly attenuated the PM effect on airflow rates and volumes. This study found consistent decrements in MMEF in children with asthma who were not receiving medications. It is notable that effects were observed even though PM exposures were low for an urban area. These findings suggest the need for future larger studies of PM effects in this susceptible population that repeatedly measure spirometry to include MMEF and potentially more sensitive markers of airway inflammation such as exhaled breath condensate and exhaled nitric oxide.

The medical effects of mold exposure

Exposure to molds can cause human disease through several well-defined mechanisms. In addition, many new mold-related illnesses have been hypothesized in recent years that remain largely or completely unproved. Concerns about mold exposure and its effects are so common that all health care providers, particularly allergists and immunologists, are frequently faced with issues regarding these real and asserted mold-related illnesses. The purpose of this position paper is to provide a state-of-the-art review of the role that molds are known to play in human disease, including asthma, allergic rhinitis, allergic bronchopulmonary aspergillosis, sinusitis, and hypersensitivity pneumonitis. In addition, other purported mold-related illnesses and the data that currently exist to support them are carefully reviewed, as are the currently available approaches for the evaluation of both patients and the environment.

Association of Atopy to Asthma Severity and Medication Use in Children

The importance of aeroallergens as triggers for asthma is well recognized, but the relationship between asthma severity and atopic profiles in childhood has not been elucidated. This study assessed the relationship of allergen sensitization to asthma severity in a study of 114 asthmatic children followed for 8 weeks in three Southern California areas. Increased controller medication and β-agonist use were positively associated with number of positive skin tests and allergy to mold and pollens. Mold was associated with increased asthma symptoms. Degree of atopy and reactivity to mold and pollens plays a significant role in asthma severity in asthmatic children.

Habit Reversal Training for Tic Disorders in Children and Adolescents

Chronic tic disorders, including Tourette's syndrome (TS), affect approximately .5% of children and adolescents. Although strong evidence exists supporting a neurobiological etiology, operant factors may play a role in the maintenance of tic behaviors. Pharmacological approaches remain the most commonly used intervention for chronic tic disorder in children and adults. Nevertheless, the unpredictable efficacy and serious side effects associated with medication along with parental concerns about long-term medication use in children underlie the need for nonpharmacological interventions for tics in this age group. This article reviews the rationale and evidence base for the use of habit reversal training (HRT), a multicomponent behavioral treatment package, as a treatment for childhood tics. Each of the primary treatment components of HRT is described and implementation is illustrated in case report format. A growing body of data suggests that HRT is a well-tolerated and efficacious intervention for tic disorders in this age group.

New Data Show Declines In Antidepressant Prescribing

New Data Show Declines In Antidepressant Prescribing

My 15 Minutes of Fame

My 15 Minutes of Fame

Home‐Based Asthma Self‐Management Education for Inner City Children

Optimal home self-management in young children with asthma includes accurate symptom identification followed by timely and appropriate treatment. The objective of this study was to evaluate a home-based asthma educational intervention targeting symptom identification for parents of children with asthma. Two hundred twenty-one children with asthma were enrolled into an ongoing home-based clinical trial and randomized into either a standard asthma education (SAE) or a symptom/nebulizer education intervention (SNEI). Data included home visit records and parent's self-report on questionnaires. Symptom identification and self-management skills significantly improved from preintervention to postintervention for parents in both groups with the exception of checking medications for expiration dates and the frequency of cleaning nebulizer device and equipment. However, significantly more parents of children in the SNEI group reported treating cough symptoms as compared with the SAE group (p = 0.05). Of concern is that only 38% of all parents reported having an asthma action plan in the home. A targeted home-based asthma education intervention can be effective for improving symptom identification and appropriate use of medications in children with asthma. Home asthma educational programs should address accurate symptom identification and a demonstration of asthma medication delivery devices.

Pharmacological Management of Treatment-Resistant Pediatric Depression

‘‘Psychopharmacology Perspectives,’’ a new feature in the Clinical Perspectives section of the Journal, aims to discuss practical approaches to everyday issues in pediatric pharmacotherapy. ‘‘Psychopharmacology Perspectives’’ will provide clinicianswith a quarterly case vignette followed by commentary from three or four experts in pediatric psychopharmacology. The cases and discussions will specifically target aspects of clinical care related to psychopharmacology for which we do not have applicable controlled trials. Given the need to address symptoms in youths with complex, severe, and comorbid disorders, recommendations are likely to be ‘‘off label,’’ from the perspective of the U.S. Food and Drug Administration (FDA). While it is important that clinicians address psychosocial issues in the evaluation and treatment of their patients, such discussion is beyond the specific scope of this feature. I hope you find these case examples and the clinical experience of our respondents to be practical and helpful in your use of medications for children with psychiatric disorders.

Patterns of quick-relief and long-term controller medication use in pediatric asthma

To simultaneously examine adherence to long-term controller and quick-relief medications and to contrast patterns of medication use in children with asthma. Cross-sectional, 1-month follow-up study conducted with 75 children ages 8 to 16 years diagnosed with persistent asthma and prescribed quick-relief and long-term controller medications by metered dose inhaler. Participants were a subsample of a larger adherence study. The primary outcome measure was adherence to both medications as measured by electronic monitoring devices. A classification framework for contrasting adherence patterns between medication classes was developed to identify cases for individual analysis. High levels of nonadherence to long-term controller medications (median = 46% of prescribed doses taken) and variable patterns of quick-relief medication use (range = 0 to 251 doses over the month) were documented, whereas consistent relationships between patterns of medication use across both classes were not found. Individual cases identified by the classification scheme illustrated the complexity and clinical utility of contrasting adherence patterns. Monitoring long-term controller medication adherence may be more predictive of morbidity than quick-relief medication use, except in outlier cases in which monitoring both medication types may be valuable for clinical and empirical purposes.

Differences in asthma diagnosis and medication use in children living in Germany and the Netherlands

To compare diagnosis and treatment between German and Dutch children with asthmatic symptoms at the age of 5-6 and 7-8 years, and the use of anti-asthma medication at 7-8 years of age. Parents of 4462 children participated in two surveys, in 1995 and 1997. All 465 children identified with current asthmatic symptoms at the age of 5-6 (May 1995) or at 7-8 years of age (May 1997) were sent a third more detailed questionnaire (October 1997). Asthma diagnosis was more prevalent in Dutch children with current asthmatic complaints (50-60%), whereas over 90% of the German children with current asthmatic complaints had been diagnosed with bronchitis. Inhaled beta(2)-agonists were more frequently used by Dutch children compared to German children (67.3% vs. 45.6% p < 0.01) as were inhaled steroids (38.9% vs. 7.0% p < 0.01). Instead, German children more often used sodium cromoglycate or nedocromil as anti-inflammatory medication as compared with Dutch children (42.1% vs. 11.5% p < 0.01). Differences in diagnosis rates for asthma and bronchitis between German and Dutch children most likely result from differential labelling of complaints, and probably lead to differences in treatment practice, indicating possible undertreatment of German children with inhaled steroids.

Rapid Rise in Psychotropic Use Becomes Global Phenomenon

Back to table of contents Previous article Next article International NewsFull AccessRapid Rise in Psychotropic Use Becomes Global PhenomenonJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:17 Dec 2004https://doi.org/10.1176/pn.39.24.00390001bPsychotropic drug prescribing for American youth has soared over the past several decades (Psychiatric News, February 7, 2003), and now it looks as though the same trend may be occurring in other countries, a new study indicates.The study was headed by Ian Wong, Ph.D., director of the Center for Pediatric Pharmacy Research at the University of London. Results appeared in the December Archives of Disease in Childhood.Wong and his coworkers obtained data about psychotropic prescribing for youth under 18 years of age in nine countries between 2000 and 2002. The countries included France, Germany, Spain, and the United Kingdom—the four European countries with the largest markets for these medications; Argentina, Brazil, and Mexico—the three Latin-American countries with the largest markets for these medications; and Canada and the United States.Results indicated that the number of psychotropics prescribed for youth in all nine countries rose between the years 2000 and 2002, and seven of the nine countries showed a significant increase. The United Kingdom had the largest percentage increase at 68 percent, while Germany had the smallest, 13 percent.Wong told Psychiatric News that the results did not surprise him.“ American data showed a similar trend a few years ago.”He also indicated that he was not surprised to find that the United Kingdom is outpacing the United States in psychotropic prescribing for youth.“The U.S. already had a high baseline, so it can't really grow as fast as the United Kingdom. There is no doubt, however, that we are catching up.”Psychiatric News likewise asked Wong whether there was more of an increase in one category of psychotropic prescribing for youth in the countries of interest than in another category—say, more SSRI antidepressant prescribing than antipsychotic prescribing. Wong said that he and his coworkers have already learned that both SSRI and stimulant prescribing for youth increased significantly in the United Kingdom from 2000 to 2002, and that his team will now analyze more data from the United Kingdom and the other countries to further answer this question.Why psychotropic prescribing is surging not just in the United States, but also in numerous other countries is not known. Wong and his colleagues, however, offer several possible explanations in their study report: “The increase probably represents the improved recognition of pediatric psychopathology; there is also a concern that drugs are being used to replace nondrug treatments.”In any event, they pointed out, “The observed increase in so many countries should raise concern, as little research has been conducted in children to study the effects of most psychotropic medications” and because of the brouhaha about antidepressants' possibly increasing suicide risk in children (Psychiatric News, November 5).“The use of psychotropic medications in children is a global public health issue,” Wong and his colleagues concluded, “which should be studied in partnership with pharmaceutical companies, governments, and researchers to grow and expand the evidence base for their use in children.”“The problem with this type of psychotropic medication market research is that it contains no information about quality of the clinical treatment that is associated with the use of these medications,” Darrel Regier, M.D., executive director of the American Psychiatric Institute for Research and Education and director of APA's Division of Research, told Psychiatric News. “In the absence of associated data on the prevalence of treated and untreated mental disorders, and the degree to which use of these medications follow established treatment guidelines, the author is free to speculate about the implications of the increase in medication use in children.“If one starts from a public health perspective that there is well-documented evidence of undertreatment of child and adolescent mental disorders in all countries and that there is an attendant high level of disability and waste of human potential because of the absence of treatment, then the evidence of increased use of psychotropic medications could be seen in very positive terms.“If, on the other hand, one starts from a perspective that mental disorders don't exist and that medications are a means whereby poor parenting is being supported by inappropriate use of psychotropic medications, then there is a very negative spin for this information.“My concern is that the author adds a negative spin with an incomplete reporting on the effectiveness data for psychotropic medications in children and adolescents.”The study was funded by the Department of Health in England.An abstract of the study, “Increased Prescribing Trends of Pediatric Psychotropic Medications,” is posted online at<http://adc.bmjjournals.com/cgi/content/abstract/89/12/1131?>.▪ Arch Dis Child 2004 89 1131 ISSUES NewArchived

Medication errors in pediatrics—the octopus evading defeat

Medication errors have come to the forefront in healthcare and oversight organizations as well as to the public over the past several years. There has been an increasing focus on this area of patient care requiring more intensive evaluation and intervention to prevent these errors. Although it is difficult to ascertain the true occurrence of medication errors, they may occur as frequently as once in every 20 orders. Children are at higher risk for medication errors and adverse drug events for numerous reasons. Not only is there great variability in weight and body surface area in this population, there is also significant differences in the pharmacokinetics and pharmacodynamics of many medications when compared to adults. In addition, our knowledge of pharmacogenetics and phenotypic ontogeny must be applied. Sources of medication errors are identified, and specific examples and solutions to improve medication use in children are provided. It is critical to have 1) personnel trained in pediatrics to prescribe, prepare, dispense and administer medications, 2) a quality review system in place to review drug use and medication errors, and 3) to implement computerized physician order entry with decision support and other tools in the next decade to improve pharmacologic therapy for pediatric patients.

Medication use in children and adolescents treated in the community for bipolar disorder.

We assessed the use of mood stabilizers, stimulants, antipsychotic medication, and selective serotonin reuptake inhibitors in children being treated in the community for bipolar disorder (BPD). One hundred eleven patients were screened via parent phone interview for possible inclusion in a phenomenological study of BPD. Data were obtained on the patients' medication trials and side effects. The results of the study indicated that children and adolescents who carry a diagnosis of BPD are treated with a mean of 3.40 +/- 1.48 medications and have had a mean of 6.32 +/- 3.67 trials of psychotropic medication in the past. Ninety-eight percent have had a trial of a mood stabilizer or anticonvulsant, with the most common being valproate (79%), lithium (51%), and gabapentin (29%).

Effects of ambient air pollution on symptom severity and medication use in children with asthma

Exposure to air pollutants has been investigated as a possible cause of asthma attacks in children. To investigate the short-term effects of air pollutants on a panel of 133 children with asthma who enrolled in the Childhood Asthma Management Program. During screening, the children completed daily diary cards for an average of 58 days to indicate their medication use and asthma severity. We used ordinal logistic regression to compare the odds of a more serious relative to a less serious asthma attack, and we used a Poisson model to analyze medication use. In both analyses we accommodate dependence in the data and different periods of observation for study subjects. Our results indicate that a 10-microg/m3 increase in particulate matter less than or equal to 2.5 microm (PM2.5) lagged 1 day was associated with a 1.20 times increased odds of having a more serious asthma attack [95% confidence interval (CI), 1.05 to 1.37] and a 1.08-fold increase in medication use (95% CI, 1.01 to 1.15). A 10-microg/m3 increase in particulate matter less than or equal to 10 microm (PM10) increased the odds of a more serious asthma attack (odds ratio = 1.12; 95% CI, 1.04 to 1.22) and also increased medication use (relative risk = 1.05; 95% CI, 1.00 to 1.09). Increases in PM2.5 and PM10 are significantly associated with an increased risk of more severe asthma attacks and medication use in Seattle area children with asthma. We also found associations with carbon monoxide, but we believe that carbon monoxide is a marker for exposure to combustion byproducts.

Principles of Clinical Pharmacology

Editors A. J. Atkinson, C. E. Daniels, R. L. Dedrick, C. V. Grudzinskas, S. P. Markey. Academic Press, San Diego, 2001 460 pages, price £53.95, ISBN 0120660601 This is a somewhat unusual book. While there are a number of texts on clinical pharmacology and therapeutics for undergraduates, this aims at a different audience, postgraduates with an academic or more likely an industrial interest in the principles of clinical pharmacology. The book arose from a course run for some years by the National Institutes of Health and which they have made largely accessible on the Internet without charge (http:www.cc.nih.govcccprinciples). The book deals with the same topics in much greater depth and detail. After an introductory chapter it is divided into five parts: pharmacokinetics; drug metabolism and transport; assessment of drug effects; optimizing and evaluating patient therapy; and drug discovery and development. The section on pharmacokinetics provides a very thorough comprehensive account of the general principles of the subject, including a detailed description of compartmental and noncompartmental models. It also discusses the alterations in pharmacokinetics seen in liver and renal disease. Some of the material requires more than elementary mathematics, but overall it provides an excellent overview of the subject even for the mathematically naive. The second section describes drug metabolism and some of the mechanisms of drug interactions and toxicity, as well as outlines of analytical methods for assaying drugs. Pharmacogenetics is also discussed in a pharmacokinetics context. Next, several chapters in section three deal with qualitative and quantitative aspects of the assessment of drug effects, including an introduction to pharmacodynamic and pharmacokinetic modelling. The fourth part of the book discusses special issues concerning gender differences in drug therapy, as well as the use of medication in children, the elderly and in pregnant and nursing women. There are also chapters on the clinical analysis of adverse drug reactions and on quality assessment in drug therapy. Finally, the last section describes the processes of drug development from discovery to clinical trials, with the regulatory aspects obviously having an almost exclusively US perspective. This is then a comprehensive book, and also a very well-produced (and probably expensive) one, as one might expect from its publishers. It assembles a huge amount of information difficult to find elsewhere in a single source at this level. The main drawback of the book is a certain lack of coherence in approach and style that is inevitable with five co-editors and more authors. On the whole this does not detract from its usefulness for specialist registrars in clinical pharmacology and those in training in pharmaceutical medicine in industry, perhaps also for the shrinking band who teach clinical pharmacology in medical schools. Compared with a book with its main focus on therapeutics, it should have a relatively long life, since it deals with largely unchanging principles.

Judicious use of medication in children

To perform a bibliographic review on criterion-based use of drugs by children. Articles were searched through Medline database using the terms: acute respiratory diseases, asthma, antibiotics, treatment and children. There is an excessive use of drugs to treat acute respiratory diseases and asthma. Drugs with unproved action are frequently prescribed. Considering the toxicity of many drugs used in children and the emergency of bacterial strains resistant to antibiotics, it is essential to develop new methods of diagnosing bacterial infections, as well as to educate both physicians and the general public on the judicious use of drugs.

Fluocinolone acetonide 0.01% in peanut oil: Therapy for childhood atopic dermatitis, even in patients who are peanut sensitive

Background: Fluocinolone acetonide 0.01% in a blend of refined peanut and mineral oils has been used as treatment for scalp psoriasis for several years, but only more recently for atopic dermatitis. Objective: We sought to study the effectiveness for atopic dermatitis, potential for adrenal axis suppression, and safety of the fluocinolone acetonide 0.01% in oil in children with atopic dermatitis, including children with atopic dermatitis and peanut allergic sensitivity. Methods: Three separate studies were performed in children aged 2 to 12 years with atopic dermatitis: multicenter double-blind, randomized, and vehicle-controlled trial; cortisol stimulation testing; and prick testing, patch testing, and monitored medication use in children with peanut allergic sensitivity. Results: Improvement of ≥50% was demonstrated within 2 weeks in 81% to 87% of 81 patients treated with active medication versus 39% of 45 children treated with vehicle oil alone. No adrenal suppression occurred after 4 weeks of therapy in 32 patients. None of 9 patients who were peanut sensitive reacted to either the full formulation or vehicle in prick or patch testing; 20 children who were peanut sensitive showed no allergic reactions after application of the medication. Conclusion: Fluocinolone 0.01% in peanut oil is an effective alternative to the use of topical corticosteroid agents in ointment, cream, and lotion forms in children. No evidence of adrenal suppression or adverse local effects were demonstrated in these studies. The medication was well tolerated in patients with peanut allergic sensitivity. (J Am Acad Dermatol 2003;48:569-77.)

Budesonide Inhalation Suspension Reduces the Need for Emergency Intervention in Pediatric Asthma: A Named‐Patient Case Series

This report describes 15 children aged 10–35 months frequently hospitalized with uncontrolled asthma who were monitored for a mean of 26.9 months to assess the efficacy of budesonide inhalation suspension (AstraZeneca LP, Wilmington, DE) in reducing emergency interventions. Budesonide inhalation suspension was previously shown to relieve asthma symptoms, improve pulmonary function, and reduce rescue medication use in children as young as 6 months with mild to severe persistent asthma. We now show that ≥ 1 year of treatment with Budesonide inhalation suspension at doses between 0.25 and 1.5 mg/d decreased the burden of asthma. The mean number of hospitalizations caused by asthma or respiratory illness decreased from 1.8 ± 1.37 in the period before initiation of treatment with Budesonide inhalation suspension to 0.33 ± 0.62 during treatment. Likewise, the mean number of oral prednisone courses decreased from 8.1 ± 13.7 to 1.8 ± 2.1, and the mean number of acute respiratory illnesses requiring additional therapy decreased from 2.7 ± 2.3 before treatment with Budesonide inhalation suspension to 0.87 ± 0.74 during treatment. Numbers of emergency department visits decreased or remained the same after initiation of Budesonide inhalation suspension treatment in all but two children. There was no effect on growth rate in this group of children with moderate to severe asthma. In this case series, Budesonide inhalation suspension represents a safe, effective treatment option to prevent recurrent emergency intervention for patients < 3 years of age with poorly controlled asthma.

Psychotropic prescribing practices of paediatricians in the UK.

This study examines the prescribing practices and attitudes to psychotropic medication by paediatricians in the UK. Questionnaires were sent to 100 randomly chosen paediatricians in the UK to assess their prescribing practices of psychotropic medication in children. Paediatricians see and treat many children with a wide variety of psychotropic medications on a regular basis. However, few of them feel competent, and most requested regular psychopharmacology seminars. In the US, primary care physicians and paediatricians are recognized as primarily responsible for the continuing increase in psychotropic prescriptions in children. This study shows that, in the UK, paediatricians also contribute to such prescribing and need to be taken into account when estimating the prevalence and appropriateness of such medication use in children.