Efficacy of IV Valproic Acid and Oral Valproic Acid Tapers for the Treatment of Pediatric Headaches in the Emergency Department.

Background and Objectives: Pediatric headaches, including migraine, are a common reason for emergency department (ED) presentation. IV valproic acid (VPA) followed by oral VPA tapers are often used to abort pediatric headache and reduce recurrence, though limited data exist regarding this approach. This study evaluated the effectiveness of IV VPA and oral VPA tapers for the treatment of acute pediatric headaches in the ED in preventing return encounters. Methods: This is a retrospective cohort study of patients aged 5-21 years presenting to a tertiary-care pediatric ED from 2010 to 2016 who received IV VPA for headache or migraine. Primary outcomes were ED disposition, percent pain reduction (initial vs 2-hour patient-reported pain score [10-point scale]), and return for acute headache treatment within 1 month. Results: A total of 486 ED encounters were included with a median patient age of 15 years; most of them were females (76%, 369/486). Of available pain scores within 2 hours of IV VPA administration, 41% (173/425) had ≥50% pain reduction. Fifty-two percent (254/486) were discharged without additional treatment, 14% (69/486) were discharged after additional treatment, and 33% (163/486) were admitted to the hospital. Initial pain score, number of preceding home treatments, and number of preceding ED treatments were not associated with ED disposition. Oral VPA tapers were prescribed in 39% (94/253) of encounters when the patient was discharged after IV VPA. Oral VPA tapers produced a transient decrease in recurrence at 72 hours, which was no longer present at 1 week nor 1 month. There was no difference in the time to recurrence or total number of return visits within 1 month. Discussion: IV VPA was efficacious in treating pediatric headaches evaluated in the ED, with nearly two-thirds of patients discharged home after administration. Oral VPA tapers did not reduce total headache recurrence nor time to recurrence. Given the limited benefit of oral VPA tapers, this practice should be re-examined. Classification of Evidence: This study provides Class IV evidence that for children with headache seen in the ED, IV VPA reduces head pain and Class III evidence that following this with an oral VPA taper is of no benefit.

A Pilot Project: Improving the Transition Care Process for Neurosurgical Adolescent Patients with Indwelling Shunts to Adult Care.

BACKGROUND: A formal transition program has not been described for neurosurgical adolescent patients with an indwelling shunt device. Transitioning from pediatric neurosurgical care to adult care without transition guidance has caused abrupt transfer of care at this institution. The goal of this pilot transition program was to help patients and caregivers feel informed and prepared for transition. METHODS: The Got Transition®, Six Core Elements of Transition, were used to create this program. Both a policy and a registry to track and monitor patients were created. A validated questionnaire for transition readiness was measured. Education was provided based on the results of the questionnaire to prepare the adolescent for transfer of care. A smartphone application was used to promote health care independence. Transfer to adult neurosurgical care included hand-off between the pediatric and adult teams, child life and social work involvement, and scheduled follow up with an adult neurosurgical provider. FINDINGS: All patients 14 to 18 years with indwelling shunts were enrolled in the pilot program. Eight patients completed a baseline transition readiness assessment, received education and anticipatory guidance, and downloaded the smartphone application. At the end of the six month pilot, three patients were successfully transferred to adult care. DISCUSSION: The integration of a transition readiness questionnaire and smart phone application during this pilot program was feasible and continues to be used at this institution. Adolescent patients with shunts require gradual and carefully planned transition services.

Why the Maternal Medication List Matters: Neonatal Toxicity From Combined Serotonergic Exposures.

Serotonergic medications are used for the prevention and treatment of depression during pregnancy. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs) can cause poor neonatal adaptation, which has been attributed to withdrawal versus toxicity. Bupropion, a norepinephrine-dopamine reuptake inhibitor, is often used as an adjunctive agent to selective serotonin reuptake inhibitors or SNRIs for refractory depression. Quetiapine, an atypical antipsychotic, may also be used in more complex cases. When combined with serotonergic drugs, bupropion and quetiapine are associated with increased risk of serotonin syndrome in adults. We describe a neonate exposed to venlafaxine (an SNRI), bupropion, and quetiapine in utero who presented nearly immediately after birth with encephalopathy and abnormal movements. The severity and rapidity of symptoms may be attributable to potentiation of venlafaxine's serotonergic effects by bupropion and quetiapine. Neonatal providers should be aware of maternal medications and prepare for possible adverse effects, particularly from common psychotropic exposures.

Weaning nocturnal ventilation and decannulation in a pediatric ventilator care program.

INTRODUCTION: Children with chronic respiratory failure and upper airway disorders may require tracheostomy placement and long-term mechanical ventilation, yet many improve to permit ventilator weaning and decannulation. METHODS: As a quality improvement project, we conducted a chart review of patients followed by our Ventilator Care Program who underwent evaluation for weaning nocturnal ventilation (NV) and/or decannulation from 2007-2014. We collected patient demographics and characterized location, monitoring techniques, and outcomes for patients undergoing weaning NV or decannulation. We attempted to implement end tidal carbon dioxide (ETCO2 ) monitoring and used linear regression to compare ETCO2 with morning pCO2 . RESULTS: Weaning NV was successful in 20/21 patients. Decannulation was successful in 18/21 attempts. Once implemented, ETCO2 was piloted and successfully performed in 12 attempts (29%). Blood testing was performed in 24/42 trials (57%). When measured, the final ETCO2 result partially correlated with morning pCO2 (R(2) = 0.53, P < 0.02). Neither blood testing nor ETCO2 was performed for the four patients with unsuccessful attempts. CONCLUSIONS: Inpatient observation for weaning NV and decannulation is safe and, in most cases, successful. With close observation, weaning NV at home may also be safe. Blood testing and ETCO2 monitoring were frequently utilized, but rarely affected decision-making since signs of respiratory distress were observed clinically prior to testing. ETCO2 monitoring may provide reassurance without venipuncture. With our experience, we propose an algorithm for weaning NV and decannulation. Pediatr Pulmonol. 2016;51:825-829. © 2016 Wiley Periodicals, Inc.