A look at the highlights from the 30th annual Pediatric Pharmacy Association meeting.
The Pediatric Pharmacy Association (PPA) is the leading pharmacy association dedicated to pediatric pharmacy practice. Due to the COVID-19 pandemic, its annual conference was held virtually. Below is a brief synopsis of some of the pertinent presentations.
The KIDs list: Key potentially inappropriate drugs in pediatrics
The KIDs List (key potentially inappropriate drugs in pediatrics) was published in 2020 by a panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association to raise awareness of medications and excipients that should be used cautiously, monitored, or avoided altogether in specific pediatric age groups. Primary, secondary, and tertiary literature; US Food & Drug Administration (FDA) Pediatric Safety Communications; electronic drug reference databases, and product information was evaluated and rated using predefined criteria. This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or a select subgroup of pediatric patients.
Seerat Kapoor, PharmD and her colleague’s Kelly Bobo, PharmD; William Mabry, PharmD; and Dhyana Naik, PharmD from Le Bonheur Children's Hospital in Memphis, Tennessee, were awarded the PPA Best Practice Award for their work on integration of the KIDs List with formulary management and clinical decision support in a freestanding children’s hospital. The purpose of their project was to review existing alerts for congruency with the recommendations in the KIDs list and identify changes that needed to occur to maximize patient safety. Using the Plan, Do, Study, Act process, the team evaluated current practices and worked with their institution's medication committees to make inventory modifications, modify dose ranges, and develop pharmacy and provider alerts within their electronic medical record system. Ultimately, 23 interventions were made to reduce potential for patient harm.
Vaccine recommendations and updates for 2021
Vaccine recommendations are reviewed by the Advisory Committee on Immunization Practices (ACIP) annually; however, in 2020, ACIP met 14 times due to the continuous changes with the COVID-19 pandemic. This year, Lea Eiland, PharmD, from the Harrison School of Pharmacy at Auburn University presented the changes most likely to affect providers and pharmacists caring for pediatric patients.
HPV vaccine updates
This year, special comments were added to state that if the human papillomavirus (HPV) series is interrupted, the series does not need to be restarted.
Flu vaccine updates
The live attenuated influenza vaccine (LAIV) abbreviation was changed to LAIV4.
Special situations were also updated to include guidance for administering the flu vaccine in patients with egg allergy who have symptoms other than hives and information on severe allergic reactions.
Hepatitis B vaccine updates
Clarification was provided on when to administer the Hepatitis B vaccine in infants < 2kg. Instructions now state to give 1 dose of the Hepatitis B vaccine at chronological age of 1 month or upon hospital discharge (whichever is earlier and even if < 2kg).
In addition to these updates, Dr Eiland discussed vaccines on the horizon, including the PCV-15, PCV-20, and the much-anticipated pediatric data on administration of the COVID-19 vaccine in children as young as 6 months of age that are expected to be reviewed and disseminated in Fall 2021.
To combat the impact of moving many ambulatory care services to telehealth in 2020 for social distancing, the Public Readiness and Emergency Preparedness Act (Prep Act) has also been amended to allow more individuals to be vaccinated by pharmacists. As of September 2020, pharmacists and pharmacy interns (depending on state law) can administer FDA-approved vaccines to children aged 3 years and older per ACIP recommendations, with some states allowing vaccine administration by pharmacists to patients as young as 6 months.
Shortening duration of therapy for pediatric infections
Antimicrobials are the most common class of medications prescribed to pediatric patients. A common question prescribers face is how long to treat various infections. Antimicrobial stewardship efforts within pediatrics often focus on appropriate short courses of antibiotic therapy which are crucial to reducing antimicrobial overuse in these patients. Current literature has evaluated short-course antibiotics for the treatment of many pediatric infections, including community acquired pneumonia (CAP), urinary tract infections (UTI), skin and soft tissue infections (SSTI), ventilator-associated tracheitis (VAT), and uncomplicated bacteremia. In their presentation, Aimee Dassner, PharmD, Children's National Hospital in Washington, DC; and Karisma Patel, PharmD, Children's Medical Center, Dallas, Texas, reviewed the many benefits of shortening antimicrobial courses while providing an overview of the recent literature examining antimicrobial duration in common pediatric infections.
Compared to recently published literature, most of the current Infectious Diseases Society of America (IDSA) and American Academy of Pediatrics (AAP) guidelines for common pediatric infections recommend longer durations. For example, recent literature suggests clinicians may successfully treat CAP with 5 days of antibiotic therapy and complicated UTIs with 7 days of therapy as compared to guideline recommendations of 10 and 14 days, respectively. For VAT, prolonged courses have not been shown to reduce development of hospital-acquired pneumonia/ventilator-associated pneumonia (HAP/VAP), and thus, prescribers are encouraged to use shorter durations in these patients. When evaluating patients with uncomplicated bacteremia, the consensus is shorter durations will mitigate the need for central lines which introduce another risk of infection. An exception to this is with SSTI, where antibiotic durations tend to exceed that of what guidelines recommend.
Don’t take the risk, learn about MIS-C: Pharmacologic treatment strategies for MIS-C
Baby it’s COVID outside: don’t MIS-C it
The COVID-19 pandemic has been a constant factor in the healthcare setting and the world over. Thanks to global collaborations, evidence has been shared and disseminated, though there are frequent updates and changes as more data are collected and reported. Sarah Parsons, PharmD, Children's Hospital of The King's Daughters, Norfolk, Virginia; Van Tran, PharmD, Inova Children’s Hospital; Kelli Crowley, PharmD, UPMC Children's Hospital of Pittsburgh, Pennsylvania; and Alexandra Kibler, PharmD, UPMC Children's Hospital of Pittsburgh, Pennsylvania, provided a comprehensive review of the coronavirus diagnosis, pathways, and pharmacologic management of this viral disease. Identified mainstays of therapy include dexamethasone and remdesivir. Interestingly, remdesivir powder should be utilized (versus the solution) in patients weighing less than 40kg due to the amount of sulfobutylether-β cyclodextrin (SBECD) in the solution. This compound can accumulate in patients with impaired renal function of < 50 mL/min, which can cause liver necrosis and obstruct renal tubules. Regrettably, the level and quality of evidence to support these treatments, as well as other therapies such as tocilizumab are weak and limited, and many other medications are not recommended due to a lack of perceived benefit.
Multi-Inflammatory Syndrome in Children (MIS-C) has been reported since April of 2020 with 99% of cases testing positive for the COVID-19 virus and is often diagnosed between 1 and 6 weeks post-acute COVID-19 infection. More than 3100 cases have been tracked by the CDC as of April 2021, with 63% of MIS-C diagnosed patients described as Black or Hispanic race, and ages ranging from infants through adults (median age: 9 years). Treatment options that have reasonable evidential support include immune globulin (up to 2g/kg), low-dose (1-2mg/kg/day) and high-dose (30mg/kg/day) methylprednisolone, with consideration given to high-dose anakinra (> 4mg/kg/day) for high-dose steroid-refractive MIS-C. Low-dose aspirin is also indicated in these patients for cardiac considerations, while enoxaparin or heparin should be administered in patients who meet specific anticoagulant requirements.
Caring for the chronically critically ill child: A new conundrum
Dr Katie Hughes, PharmD at Riley Children’s Hospital at Indiana University Health in Indianapolis; and Pete Johnson, PharmD from the University of Oklahoma Health Sciences Center College of Pharmacy, Oklahoma City, closed out the meeting with some key insights into this challenging patient dynamic. Chronic critical illness in pediatrics lends itself to unique and often complex situations where competing interests frequently occur. A prime example of this is incorporating preventative medicine while managing a myriad of multifaceted medical and pharmacologic interventions. One commonly forgotten area of care is addressing vaccinations in these children as they are likely to have fallen behind on their vaccine schedule. Fortunately, the ACIP has a catch-up schedule for patients with evidence-based accelerated timelines for multiple vaccines, including the common ones administered in the first year of life as well as live vaccines. It is important to remember that some medical interventions require a particular period of time to elapse before vaccinating in order to achieve optimal antibody development. Corticosteroids administered at prednisone-equivalent doses of ≥2mg/kg or ≥20mg/day, IVIG administration, and blood transfusions require adjustments to vaccination schedules as they can all decrease the immunologic response and result in reduced coverage of preventable diseases.
A second key point involved the management of iatrogenic withdrawal symptoms (IWS). It’s likely that chronic critically ill patients will receive extensive pain and sedation medications over the course of their stay. Once they are stable enough to reduce and eventually stop these agents, the optimal method for weaning and discontinuation remains elusive. Many factors, including duration of therapy, cumulative doses, use of neuromuscular blockade, and younger age, need to be considered when developing tapering plans. Appropriately identifying withdrawal in infants and younger patients can be difficult to separate from what would be normal functions, such as irritability or short gut syndrome and diarrhea. Regardless, standardized protocols are recommended to both reduce exposure to and time on these therapies.