The Efficacy of Neutral Position Beractant Administration in Neonates.

OBJECTIVE: The objective was to compare the efficacy and adverse effects of beractant administration in neonates via a single aliquot in a neutral position versus positioning the neonates on their left then right side and two aliquots administration. STUDY DESIGN: This was a retrospective cohort chart review of neonates who were diagnosed with respiratory distress syndrome and received beractant during two 15-month periods between 2013 and 2015 and 2015 and 2016 to compare the change in the fraction of inspired oxygen (FiO2) 1 hour after beractant administration. RESULTS: There were no differences in FiO2 1 hour after beractant between groups (p = 0.617). Adverse events and other comorbidities did not differ between the groups. CONCLUSION: Changing administration of beractant from two aliquots and positions to a neutral position resulted in no significant change in FiO2 and may be considered as an option for administration in neonates.

Intravenous Ferumoxytol in Pediatric Patients With Iron Deficiency Anemia.

BACKGROUND: Iron deficiency anemia (IDA) is common in children. Limited data exist on the efficacy and safety of ferumoxytol in children. OBJECTIVE: To assess the efficacy of 10 mg/kg dose given over 15-60 minutes in correcting IDA and report any adverse drug reactions (ADRs). METHODS: We conducted a retrospective review of all patients who received ferumoxytol infusions for the management of IDA by the Pediatric Blood Management Program between October 2010 and March 2015. RESULTS: A total of 110 infusions were given to 54 patients. Compared with baseline preinfusion hemoglobin (Hb; 9.2 ± 1.9 g/dL), a significant rise was seen at 1 week and 4 weeks postinfusion (11.5 ± 1.5 and 11.8 ± 1.7 g/dL, respectively, P < 0.001). Also, a significant rise in serum ferritin at 1 week and 4 weeks postinfusion was seen (51 ± 71 vs 192 ± 148 and 89 ± 135 ng/mL, P < 0.001 and <0.035, respectively). Patients who concomitantly received erythropoietin had a significantly larger Hb rise from baseline than those who did not at 4 weeks (2.7 ± 2.2 vs 1.6 ± 1.1 g/dL, P < 0.017). ADRs included pruritus (n = 1), urticaria (n = 1), and multisymptom episodes (n = 3) that included shortness of breath, chest tightness, back pain, and epigastric cramping that responded to therapy with IV diphenhydramine and methylprednisolone. CONCLUSION: Ferumoxytol was effective in treating IDA in our small study. Slow infusion rate and close monitoring allowed early detection of the infrequent ADRs.

Therapeutic role of anakinra, an interleukin-1 receptor antagonist, in the management of secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction/macrophage activating syndrome in critically ill children*.

OBJECTIVES: Secondary hemophagocytic lymphohistiocytosis, macrophage activating syndrome, and sepsis share the same inflammatory phenotype leading often to multiple organ dysfunction syndrome needing intensive care. The goal of this article is to describe our experience with anakinra (Kineret), a recombinant interleukin-1 receptor antagonist, in decreasing the systemic inflammation. DESIGN: Retrospective case series. SETTING: The PICU at the Helen DeVos Children's Hospital (Grand Rapids, MI). PATIENTS: The records of eight critically ill children presumed to have secondary hemophagocytic lymphohistiocytosis at our institution between January 1, 2011, and July 31, 2012, were reviewed. INTERVENTIONS: All of the patients were treated with anakinra (Kineret) and in some cases systemic corticosteroids as first-line therapy for secondary hemophagocytic lymphohistiocytosis. MEASUREMENTS AND MAIN RESULTS: Patients had a median age of 14 years and a median Pediatric Risk of Mortality score of 11.5. Four were previously healthy and four had underlying diseases that could have made them susceptible to secondary hemophagocytic lymphohistiocytosis. Indications for PICU transfer were respiratory distress 50% (4 of 8), cardiovascular instability 37.5% (3 of 8), and chest pain (1 of 8). Five of the patients (62.5%) were mechanically ventilated and 62.5% (5 of 8) received vasoactive infusions. Inflammatory markers were assessed linearly at the start of therapy and 7 days later. Baseline C-reactive protein was 206 ± 50 mg/L (mean ± SEM) at the start of anakinra and decreased by 67.1% to 68 ± 36 mg/L (p = 0.03). Ferritin decreased by 63.8% to 3,210 ± 1,178 ng/mL (p = 0.30), and fibrinogen decreased by 42% to 158 ± 41 mg/dL (p = 0.03). Absolute neutrophil count (p = 0.38) and absolute lymphocyte count (p = 0.69) did not change significantly. No infections were attributed to anakinra therapy. One patient died long after treatment with anakinra while receiving pre-hematopoietic stem cell transplant chemotherapy. CONCLUSIONS: Anakinra could represent a promising therapeutic approach in these life-threatening disorders that are likely underdiagnosed and often difficult to treat.

Ferumoxytol infusion in pediatric patients with gastrointestinal disorders: first case series.

OBJECTIVE: To report our preliminary experience using ferumoxytol as intravenous iron therapy for treating iron deficiency anemia in 6 pediatric patients with underlying gastrointestinal disease. CASE SUMMARY: Between October 2010 and February 2011, 6 patients aged 6 months to 16 years who had malabsorption and/or ongoing gastrointestinal blood loss were given ferumoxytol infusions at a dose of 5.8-12 mg elemental iron/kg over 15-60 minutes, followed by 1 hour of observation to monitor for adverse effects. DISCUSSION: Thirteen separate ferumoxytol administrations were given to 6 pediatric patients with various gastrointestinal diseases, including inflammatory bowel disease and short bowel syndrome, and/or chronic parenteral nutrition dependence. Twelve of 13 infusions were well tolerated at 5.8-12 mg elemental iron/kg/dose. No patient experienced adverse events that required clinical intervention. One patient developed mild pruritus that resolved spontaneously. CONCLUSIONS: Ferumoxytol doses of up to 12 mg elemental iron/kg administered over 15-60 minutes seem to be well tolerated in pediatric patients. Larger prospective studies are needed to determine the incidence and severity of adverse effects associated with ferumoxytol, both during administration and immediately after. Long-term studies will be required to assess to risk for iron overload toxicity.

An Evaluation of Twice-Daily Dosing of Caffeine for Apnea of Prematurity.

OBJECTIVE: Preterm infants often require caffeine for the treatment of apnea. While the maintenance dose of caffeine citrate is usually administered once daily per FDA labeling, many providers administer the maintenance dose in two divided doses. This study evaluated the effectiveness of a twice daily dosing regimen of caffeine for apnea of prematurity. METHODS: This was a retrospective analysis conducted from 2013-2018 that included preterm infants who received caffeine that was dosed both once and twice daily respectively. The primary outcome of our study was a composite of the number of apneic and bradycardic events for five 24-hour periods prior to switching to twice daily dosing of caffeine and five 24-hour periods after switching to twice daily dosing of caffeine. RESULTS: The median five-day average incidence of apnea and bradycardia during the once and twice daily dosing periods was 6.2 events and 6.4 events respectively (p=0.09). CONCLUSIONS: There is little benefit of twice daily dosing of caffeine for apnea of prematurity.

Implementation of a Pediatric Pharmacy Education Program at a Community Regional Medical Center.

OBJECTIVES: This study aimed to implement a web-based pediatric education program designed for pharmacists who participate in neonatal and pediatric order verification at a community-based health system and to evaluate the success through measuring outcomes related to both comfort and competence of pharmacists in pediatric and neonatal pharmacotherapy. METHODS: This prospective quality improvement study assessed changes in confidence and competence from before to after education. Eight educational modules were designed to provide education based on the needs of this institution. All pharmacists who participate in neonatal and pediatric order verification were eligible for inclusion throughout the health system. Time in the verification queue for pediatric and neonatal medication orders was compared for before to after education as an objective surrogate marker for comfort and competence. A provider survey was conducted before and after education to assess the providers' perspective of the quality and necessity of pharmacist-provider interactions. RESULTS: All confidence scores showed statistical improvement from before to after education (p < 0.001). Before to after education competency scores significantly improved (median 77% [IQR, 69%-85%] to 100% [IQR, 92%-100%]; p < 0.01). The module with the lowest mean score (87%) was module 4 (Antibiotics Part 1), and the one with highest number of retakes (24 retakes from 16 different pharmacists) was module 5 (Antibiotics Part 2). CONCLUSIONS: Targeted web-based education effectively improved both confidence and competence among health-system pharmacists to provide pediatric and neonatal care in a community hospital.