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Medical cannabis (MC) may offer therapeutic benefits for children with complex neurological conditions and chronic diseases. In Canada, parents, and caregivers frequently report encountering barriers when accessing MC for their children. These include negative preconceived notions about risks and benefits, challenges connecting with a knowledgeable healthcare provider (HCP), the high cost of MC products, and navigating MC product shortages. In this manuscript, we explore several of these barriers and provide recommendations to decision-makers to enable a family-centered and evidence-based approach to MC medicine and research for children.

ObjectiveExploration of a novel therapeutic drug monitoring (TDM) strategy to personalise use of ibuprofen for closure of patent ductus arteriosus (PDA) in preterm neonates.DesignProspective, single-centre, open-label, pharmacokinetics study in preterm neonates.SettingNeonatal intensive care unit at McMaster Children’s Hospital.PatientsNeonates with a gestational age ≤28+6 weeks treated with oral ibuprofen for closure of a PDA.MethodsPopulation pharmacokinetic parameters, concentration-time profiles and exposure metrics were obtained using pharmacometric modelling and simulation.Main outcome measureAssociation between ibuprofen plasma concentrations measured at various sampling time points on the first day of treatment and attainment of the target exposure over the first 3 days of treatment (AUC0–72h >900 mg·hour/L).ResultsTwenty-three preterm neonates (median birth weight 780 g and gestational age 25.9 weeks) were included, yielding 155 plasma ibuprofen plasma samples. Starting from 8 hours’ postdose on the first day, a strong correlation between ibuprofen concentrations and AUC0–72h was observed. At 8 hours after the first dose, an ibuprofen concentration >20.5 mg/L was associated with a 90% probability of reaching the target exposure.ConclusionWe designed a novel and practical TDM strategy and have shown that the chance of reaching the target exposure (AUC0–72h >900 mg·hour/L) can be predicted with a single sample collection on the first day of treatment. This newly acquired knowledge can be leveraged to personalise ibuprofen dosing regimens and improve the efficacy of ibuprofen use for pharmacological closure of a PDA.

Résumé La douleur est un problème courant chez les enfants. Des mesures pharmacologiques et non pharmacologiques sont utilisées pour la prendre en charge. Depuis quelques décennies, les opioïdes par voie orale sont populaires pour soulager la douleur modérée à grave. La codéine a longtemps été l’opioïde par voie orale le plus connu pour les enfants. Pour des raisons de sécurité, elle est désormais nettement moins accessible et moins employée. Divers autres opioïdes la remplacent, mais les données sur leur efficacité et leur sécurité sont limitées chez les enfants. L’oxycodone par voie orale emprunte les mêmes voies métaboliques que la codéine, mais sa pharmacocinétique est très variable. Les données sur la sécurité et l’efficacité de l’hydromorphone et du tramadol par voie orale chez les enfants sont également limitées. Lorsqu’on y recourt au lieu de la codéine, la morphine par voie orale est l’opiacé dont la sécurité et l’efficacité sont les mieux démontrées chez les enfants. Des recherches devront être réalisées pour explorer d’autres approches relatives aux médicaments opioïdes et non opioïdes, afin d’orienter les traitements analgésiques fondés sur des données probantes qui soulageront la douleur modérée à grave chez les enfants.

Pain is a common problem for children, and pain management comprises both pharmacologic and nonpharmacologic measures. For moderate to severe pain, oral opioids have been a popular choice for the last few decades. Codeine has historically been the best-known oral opioid for use in children. However, availability and use of codeine have sharply declined due to safety concerns. A variety of other opioids have been used in place of codeine, but data are limited regarding their efficacy and safety in children. While the same pathways metabolize oral oxycodone as codeine, oxycodone’s pharmacokinetics varies widely. There are also limited data on the safety and efficacy of oral hydromorphone and tramadol use for children. Oral morphine is the opiate alternative to codeine for which there is the most evidence of safety and efficacy in children. Research is needed to investigate both other opioids and non-opioid approaches to guide evidence-based analgesic therapy and treatment for moderate-to-severe pain in children.

BackgroundSerum sickness-like reaction (SSLR) is an acute inflammatory condition affecting predominantly children. The pathophysiology remains unclear, but drugs are considered the main trigger.ObjectiveThe aim of this study was to describe the clinical and laboratory features, triggers, and treatment modalities in children diagnosed with SSLR.MethodsWe conducted a 10-year retrospective cohort study including all paediatric patients (0 to 18 years old) with query SSLR referred to the Adverse Drug Reactions Clinic at the Children’s Hospital of Western Ontario. Diagnostic criteria included acute skin rash plus joint inflammation with or without fever.ResultsWe included 83 patients (47 females). Age ranged from 11 months to 12 years (mean 3.2 years). Amoxicillin was the trigger in 82.7% of patients. The mean time between the exposure to the triggering drug and the development of the symptoms was 8.5 days. Urticaria-like and Erythema multiforme-like lesions were present in 35% and 38.5% of the cases, respectively. Joint inflammation affecting hands/feet was present in 60%. Pruritus, lip/eye swelling, and fever were reported in 33, 31, and 45% of patients, respectively. The lymphocyte toxicity assay (LTA) showed incremental T-cell toxicity in 32 of 34 patients. Children that received treatment with antihistamines/nonsteroidal anti-inflammatory drugs (NSAIDs) plus oral steroids had a mean recovery time shorter than those treated only with antihistamines/NSAIDs (6 versus 8 days; P=0.09).ConclusionsIn our study, SSLR was mostly triggered by amoxicillin and had a mean time presentation of 8.5 days. Further prospective and well-conducted studies are needed.

Primary Subject area Rheumatology Background Prednisone is a glucocorticoid (GC) medication commonly used in moderate (>7.5 mg/day) to high doses (≥ 1 mg/kg/day to maximum 60 mg/day) for children with moderate to severe presentations of rheumatic disease, including systemic lupus erythematosus (SLE), juvenile idiopathic arthritis (JIA), and juvenile dermatomyositis (JDM). Adverse effects (AE) to GCs impose a significant burden on health and quality of life including frequent development of weight gain, mood changes, sleep difficulties, osteoporosis, and Cushingoid features, amongst others. Objectives We sought to evaluate a possible relationship between baseline patient body-mass-index (BMI) measure and development of select GC-mediated toxicity within the first 12 months of starting moderate or high-dose prednisone therapy using conventional weight-based dosing of prednisone. Secondary outcomes were to examine rates of GC-mediated hypertension, osteopenia, and osteoporosis. Design/Methods We performed a retrospective chart review on children with rheumatic disease aged ≤ 17 years treated with moderate and high-dose prednisone therapy at a single Canadian academic hospital between January 1, 2010 and December 31, 2019. Demographic variables collected included diagnosis, age, sex, ethnicity. Clinical variables collected include weight, height, and body-mass-index (BMI), hepatitis (AST>41 U/L, ALT>40 U/L, or GGT>60 U/L), proteinuria (>0.1 g/L), and presence of hypoalbuminemia ( Baseline characteristics, which were significant for the subsequent development of obesity during the first 12 months at the bivariate level (p < 0 .05), were included as predictors of obesity in separate logistic regression analyses. In each regression analysis, we also adjusted for baseline BMI, and for confounding variables of hepatitis, hypoalbuminemia (albumin less than 38 grams per litre), proteinuria and prednisone dose. We conducted a complete case analysis, and all analyses were performed using SPSS v.26 (IBM Corp., Armonk, NY, USA), and p-values < 0 .05 were considered statistically significant. Results Seventy-four charts were reviewed, and 72 patients met criteria for analysis. The median prednisone dose was 35 mg per day (IQR 20 to 60 mg), and median duration of therapy was 302 days (IQR 126.75 to 581.25). Thirty-five (48.6%) patients developed obesity, 33 (45.8%) hypertension, five (7.0%) osteopenia, and three (4.2%) osteoporosis. Greater BMI at baseline was associated with greater total weight gain (OR 4.04, 95% CI = [1.98-8.33], p < 0 .001). Conclusion Greater baseline patient BMI may be a predictor of weight gain on high-dose prednisone therapy in children with rheumatic disease requiring high-dose therapy. Further work is required to determine methods for individualized prednisone dosing and counseling and behavioral interventions to mitigate risk for weight gain.

Objective We compared pain and degree of disability in patients with acute ankle sprains receiving regular scheduled ibuprofen versus pro re nata (PRN). Methods This study is a randomized single-blinded controlled trial of children aged 7 to 17 years presenting with acute ankle sprain to an emergency department. Patients were randomized to receive 10 mg/kg of ibuprofen per dose (maximum 600 mg) every 6 hours regular scheduled versus PRN. Outcome measures included a 100-mm visual analog scale pain and degree of disability at day 4. A sample size of 72 children had a power of 80% to detect a clinically meaningful difference of 20 mm between the regular and PRN group. Results We randomly assigned 99 patients to receive regular scheduled (n = 50) or PRN (n = 49) ibuprofen. Pain scores and degree of disability at day 4 showed no significant differences between groups. The rate of reported adverse effects was higher in the regular scheduled group (11.4% vs 9.5%) versus the PRN group. Conclusions Our study suggests that there is little benefit from routinely using a regular scheduled ibuprofen regimen for acute pediatric ankle sprains.

Ukraineis a republic formed from someof the former Soviet Union's territory. Primary care for children in Ukraine is delivered by paediatricians in polyclinics. Specialty and tertiary care for children is based at children's hospitals, as is postgraduate training in paediatrics. Many challenges to child health care in Ukraine accompanied the collapse of the Soviet Union, includinga lack of resources devoted topublic health and community care, environmental contamination and a system of medical education and delivery of care that is not suited to meet evolving changes in medical care.L'Ukraine est une république formée d'une partie du territoire de l'ancienne Union soviétique. Dans ce pays, les soins de premier recours aux enfants sont assurés par des pédiatres situés dans des polycliniques. Les soins spécialisés et tertiaires sont offerts dans des hôpitaux pour enfants, de même que la formation surspécialisée en pédiatrie. De nombreux défis aux soins infantiles ont émergé en Ukraine par suite du démantèlement de l'Union soviétique, dont le manque de ressources vouées à la santé publique et aux soins communautaires, la contamination de l'environnement et un systême d’éducation médicale et de prestation des soins mal adapté pour répondre à l’évolution constante des soins médicaux.

Résumé L’organisme a besoin de très petites quantités de sodium alimentaire pour soutenir le volume sanguin et la tension artérielle. Selon les données de surveillance nutritionnelle disponibles, la plupart des enfants canadiens consomment une quantité de sodium supérieure à leurs besoins nutritionnels. Environ 80 % du sodium que consomment les Canadiens proviennent d’aliments transformés et emballés. Chez les enfants, un fort apport en sodium peut être indicateur d’un régime alimentaire de piètre qualité. Les résultats d’analyses systématiques et de méta-analyses démontrent que la diminution du sodium alimentaire chez les enfants entraîne une réduction modeste, mais cliniquement non significative, de la tension artérielle. Les stratégies en population pour limiter la consommation de sodium, telles que la reformulation des produits alimentaires, la modification des processus d’approvisionnement alimentaire et les politiques fédérales de saine alimentation, sont d’importantes initiatives en santé publique qui peuvent réduire considérablement la consommation de sodium et contribuer à prévenir des maladies chroniques à l’âge adulte.

Contains fulltext : 193438.pdf (Publisher’s version ) (Open Access) Optimising the dosing of medicines for neonates and children remains a challenge. The importance of pharmacokinetic (PK) and pharmacodynamic (PD) research is recognised both in medicines regulation and paediatric clinical pharmacology, yet there remain barriers to undertaking high-quality PK and PD studies. While these studies are essential in understanding the dose-concentration-effect relationship and should underpin dosing recommendations, this review examines how challenges affecting the design and conduct of paediatric pharmacological studies can be overcome using targeted pharmacometric strategies. Model-based approaches confer benefits at all stages of the drug life-cycle, from identifying the first dose to be used in children, to clinical trial design, and optimising the dosing regimens of older, off-patent medications. To benefit patients, strategies to ensure that new PK, PD and trial data are incorporated into evidence-based dosing recommendations are needed. This review summarises practical strategies to address current challenges, particularly the use of model-based (pharmacometric) approaches in study design and analysis. Recommendations for practice and directions for future paediatric pharmacological research are given, based on current literature and our joint international experience. Success of PK research in children requires a robust infrastructure, with sustainable funding mechanisms at its core, supported by political and regulatory initiatives, and international collaborations. There is a unique opportunity to advance paediatric medicines research at an unprecedented pace, bringing the age of evidence-based paediatric pharmacotherapy into sight.

OBJECTIVES: Proton pump inhibitors (PPIs) are often used in pediatrics to treat common gastrointestinal disorders, and there are growing concerns for infectious adverse events. Because CYP2C19 inactivates PPIs, genetic variants that increase CYP2C19 function may decrease PPI exposure and infections. We tested the hypothesis that CYP2C19 metabolizer phenotypes are associated with infection event rates in children exposed to PPIs. METHODS: This retrospective biorepository cohort study included individuals aged 0 to 36 months at the time of PPI exposure. Respiratory tract and gastrointestinal tract infection events were identified by using International Classification of Diseases codes in the year after the first PPI mention. Variants defining CYP2C19 *2, *3, *4, *8, *9, and *17 were genotyped, and all individuals were classified as CYP2C19 poor or intermediate, normal metabolizers (NMs), or rapid or ultrarapid metabolizers (RM/UMs). Infection rates were compared by using univariate and multivariate analyses. RESULTS: In all, 670 individuals were included (median age 7 months; 44% girls). CYP2C19 NMs (n = 267; 40%) had a higher infection rate than RM/UMs (n = 220; 33%; median 2 vs 1 infections per person per year; P = .03). There was no difference between poor or intermediate (n = 183; 27%) and NMs. In multivariable analysis of NMs and RM/UMs adjusting for age, sex, PPI dose, and comorbidities, CYP2C19 metabolizer status remained a significant risk factor for infection events (odds ratio 0.70 [95% confidence interval 0.50–0.97] for RM/UMs versus NMs). CONCLUSIONS: PPI therapy is associated with higher infection rates in children with normal CYP2C19 function than in those with increased CYP2C19 function, highlighting this adverse effect of PPI therapy and the relevance of CYP2C19 genotypes to PPI therapeutic decision-making.

BACKGROUND: Over the past decade a number of highly promising new therapeutic entities have become available. Many of these new treatments are biologicals or antibodies rather than conventional small molecules. These drugs offer great promise but come with the potential for potent adverse effects as well as creating challenges for access. Many of these new treatments are very expensive and are frequently not on hospital formularies. There is no comprehensive pan-Canadian strategy on how to best provide access to these drugs for the children at most need and how to address the rapidly evolving world of novel therapeutics for children. To evaluate how this issue is being addressed nationally we conducted a survey among the 17 Departments of Paediatrics across Canada. OBJECTIVES: In Paediatrics high cost drugs are most commonly used in academic child health care centres. Our objectives were to; I) Determine what the policies as to provision of high cost drugs in Canada’s academic child health care centres, ii) Determine what the challenges facing Canada’s academic health care centres were in providing access to novel therapies to children at most need and iii) Explore possible solutions to these challenges. DESIGN/METHODS: To explore these questions we conducted a survey of the 17 Departments of Paediatrics across Canada through the Paediatric Chairs of Canada and faciliated through Childrens Healthcare Canada. A questionnaire was sent to all Department Chairs asking the following four questions; 1) Does your hospital have a policy for how to deal with high cost drugs that are not covered by provincial health insurance or are not on the hospital formulary? 2) If so, how does this policy work? 3) If not, how are these therapies addressed? 4) What do you think is the best approach to provide access to high cost drugs for children? Department Chairs agreed to voluntarily participate in the survey. After completion of the survey areas of uncertainty were followed up by interviews with the respective Department Chairs. RESULTS: The issue of high cost drugs for children was noted to be a growing issue by all Departments of Paediatrics across Canada. There was a wide variability in how requests for high cost drugs were dealt with, ranging from a somewhat ad hoc case-specific response to a formal process involving decision making groups representing physicians, hospital administration and hospital pharmacy. No single best practice was identified. There was a concensus that this has emerged as a major problem in terms of access having a significant impact on hospital budgets with no end in sight as the therapeutic revolution in biological, factor and molecular therapy continued. It was acknowledged that traditional payment measures have failed to address this and some changes in provincial policy towards drugs for children may have negatively impacted access to these therapies. There was also a wide concensus that a pan-Canadian approach was needed, with suggestions including a national formulary for drugs for children that could provide evidence and recommendations to provincial funders as well as the suggestion of a pan-Canadian pharmacare plan for children. An urgent need for national leadership on this issue was also identified. CONCLUSION: Historically the per capita expenditure for pharmaceuticals for a Canadian child was in the range of $450. With the advent of new therapies that cost in the tens of thousands of dollars new approaches to drug evaluation and drug access for Canada’s children are urgently needed. This is a concern for all Departments of Paediatrics across Canada and pan-Canadian solutions are needed to address how to best treat Canada’s children at highest need.

Many paediatric patients require sedation and analgesia for diagnostic testing and therapeutic procedures outside the operating room. This statement reviews the literature on procedural sedation, focusing on the prevention of adverse events through the selection of appropriate patients, advance preparation for emergency situations, and adequate monitoring during and after the administration of pharmacologic agents. Procedural sedation should only be performed by clinicians who are competent in airway management and resuscitation, as part of a hospital program with active and engaged quality assurance and safety initiatives. Recommendations include the development of institutional policies and procedures for the safe delivery of procedural sedation in infants, children, and adolescents.

De nombreux patients pédiatriques ont besoin de sédation et d’analgésie lors de tests diagnostiques et d’actes thérapeutiques hors de la salle d’opération. Le présent document de principes contient une analyse bibliographique de la sédation interventionnelle (qu’on appelle aussi sédation procédurale), axée sur la prévention des événements indésirables grâce à la sélection des patients appropriés, à la préparation aux situations d’urgence et à la surveillance nécessaire pendant et après l’administration des agents pharmacologiques. Seuls des cliniciens formés en assistance respiratoire et en réanimation devraient être autorisés à l’effectuer, dans le cadre d’un programme hospitalier comportant des initiatives à la fois dynamiques et soutenues en matière de sécurité et d’assurance de la qualité. La rédaction de politiques et de protocoles sur la sédation interventionnelle sécuritaire chez les nourrissons, les enfants et les adolescents fait partie des recommandations.

Background Oral morphine has been proposed as an effective and safe alternative to codeine for after-discharge pain in children following surgery but there are few data guiding an optimum safe oral dose. Aims The aim of this study was to characterize the absorption pharmacokinetics of enteral morphine in order to simulate time–concentration profiles in children given common oral morphine dose regimens. Methods Children (2–6 years, n = 34) undergoing elective surgery and requiring opioid analgesia were randomized to receive preoperative oral morphine (100 mcg·kg−1, 200 mcg·kg−1, 300 mcg·kg−1). Blood sampling for morphine assay was performed at 30, 60, 90, 120, 180, and 240 min. Morphine serum concentrations were determined by liquid chromatography–mass spectroscopy and pharmacokinetic parameters were calculated using nonlinear mixed effects models. Current data were pooled with published time–concentration profiles from children (n = 1059, age 23 weeks postmenstrual age – 3 years) administered intravenous morphine, to determine oral bioavailability (F), absorption lag time (TLAG), and absorption half-time (TABS). These parameter estimates were used to predict concentrations in children given oral morphine (100, 200, 300, 400, 500 mcg·kg−1) at different dosing intervals (3, 4, 5, 6, 8, 12 h). Results The oral morphine formulation had F 0.298 (CV 36.5%), TLAG 0.45 (CV 63.6%) h and TABS 0.71 (CV 55%) h. A single-dose morphine 100 mcg·kg−1 achieved a mean CMAX 10 mcg·l−1. Repeat 4-hourly dosing achieved mean steady-state concentration 13–18 mcg·l−1; concentrations associated with good analgesia after intravenous administration. Serum concentration variability was large ranging from 5 to 55 mcg·l−1 at steady state. Conclusions Oral morphine 200 mcg·kg−1 then 100 mcg·kg−1 4 h or 150 mcg·kg−1 6 h achieves mean concentrations associated with analgesia. There was high serum concentration variability suggesting that respiration may be compromised in some children given these doses.

L’acide folique (vitamine B9) est une vitamine hydrosoluble du groupe B. On le trouve dans les aliments sous forme de folate et dans les supplements sous forme d’acide folique, dont la biodisponibilite est plus importante. Le folate joue un role essentiel dans la synthese et la reparation de l’ADN, ainsi que dans la croissance et la division cellulaires. Il contribue egalement a la methylation de l’ADN et est donc important pour la regulation epigenomique.

Periconceptional folic acid significantly reduces the risk of neural tube defects. It is difficult to achieve optimal levels of folate by diet alone, even with fortification of flour, especially because flour consumption in Canada is slightly decreasing. Intermittent concerns have been raised concerning possible deleterious effects of folate supplementation, including the masking of symptoms of vitamin B12 deficiency and an association with cancer, especially colorectal cancer. Both concerns have been disproved. The Canadian Paediatric Society endorses the following steps to enhance folate intake in women of child-bearing age: encouraging the consumption of folate-rich foods such as leafy vegetables, increasing the level of folate food fortification, taking a supplement containing folate and B12, and providing free folate supplementation to disadvantaged women of child-bearing age. These recommendations are consistent with those of the Society of Obstetricians and Gynaecologists of Canada.La consommation d’acide folique pendant la période périconcep- tionnelle réduit considérablement le risque d’anomalie du tube neural. Il est difficile d’atteindre un taux optimal de folate à partir du seul régime alimentaire, malgré l’enrichissement de la farine, surtout que la consommation de ce produit diminue légèrement au Canada. Les effets délétères possibles des suppléments de folate ont suscité sporadiquement des inquiétudes, y compris le camouflage des symptômes de carence en vitamine B

Cannabis is a psychoactive compound with a long history of recreational and therapeutic use. Current considerations regarding cannabis use for medical purposes in children have been stimulated by recent case reports describing its beneficial effect with refractory epilepsy. Overall, there are insufficient data to support either the efficacy or safety of cannabis use for any indications in children, and an increasing body of data suggests possible harm, most importantly in specific conditions. The potential for cannabis as a therapeutic agent must be evaluated carefully for both efficacy and safety in treating specific paediatric health conditions. Smoking is not an acceptable mode of drug delivery for children. The use of cannabis for medical purposes in specific cases should not be construed as a justification for recreational cannabis use by adolescents. Recommendations for therapeutic use in exceptional paediatric cases are offered, always providing that this treatment course is carefully evaluated in individuals and in ongoing, well-designed research studies to determine safety and efficacy.Le cannabis est une substance psychoactive utilisée depuis très longtemps dans un cadre récréatif et thérapeutique. Les considérations actuelles à l’égard de l’utilisation du cannabis à des fins médicales en pédiatrie découlent de récents rapports de cas sur son effet bénéfique lors d’une épilepsie réfractaire. Dans l’ensemble, les données sont insuffisantes pour en corroborer l’efficacité ou l’innocuité pour quelque indication que ce soit au sein de cette population, mais les données s’accumulent sur son potentiel néfaste, particulièrement pour traiter certaines affections. Il faut en évaluer soigneusement l’efficacité et l’innocuité comme agent thérapeutique contre certaines affections infantiles. L’inhalation sous forme de cigarette n’est pas un mode d’administration acceptable chez les enfants. L’utilisation de cannabis à des fins médicales dans des situations particulières ne doit pas en justifier l’utilisation à des fins récréatives chez les adolescents. Des recommandations sont formulées quant à son utilisation à des fins thérapeutiques dans des cas exceptionnels en pédiatrie, à condition d’assurer une évaluation étroite des sujets traités et de poursuivre des recherches bien conçues pour en déterminer l’innocuité et l’efficacité.

Beta-lactam allergy is commonly diagnosed in paediatric patients, but over 90% of individuals reporting this allergy are able to tolerate the medications prescribed after evaluation by an allergist. Beta-lactam allergy labels are associated with negative clinical and administrative outcomes, including use of less desirable alternative antibiotics, longer hospitalizations, increasing antibiotic-resistant infections, and greater medical costs. Also, children with true IgE-mediated allergy to penicillin medications are often advised to avoid all beta-lactam antibiotics, including cephalosporins, which is likely unnecessary in greater than 97% of those reporting penicillin allergies. Most patients can be safely treated with penicillin or amoxicillin if they do not have a history compatible with IgE-mediated or systemic, delayed reactions such as Stevens-Johnson syndrome (SJS), serum sickness-like reactions, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, or acute generalized exanthematous pustulosis (AGEP). Guidance is provided on how to stratify risk of beta-lactam allergy, and on test dosing and monitoring in the outpatient setting for patients deemed low risk. Guidance for patients at higher risk of beta-lactam allergy includes criteria for appropriate referral to allergists and the use of alternative antimicrobials, such as cephalosporins, while awaiting specialist assessment.

L’allergie aux bêta-lactamines est souvent diagnostiquée chez les patients pédiatriques, mais plus de 90 % de ceux qui déclarent en être victimes peuvent tolérer les médicaments prescrits après avoir été évalués par un allergologue. Une « étiquette » d’allergie aux bêta-lactamines est liée à des résultats cliniques et administratifs négatifs, y compris l’utilisation d’autres antibiotiques moins indiqués, des hospitalisations plus longues, une augmentation des infections antibiorésistantes et des coûts médicaux plus élevés. De plus, pour les enfants ayant une véritable allergie à médiation IgE aux pénicillines, on conseille souvent d’éviter toutes les bêta-lactamines, y compris les céphalosporines, ce qui n’est probablement pas nécessaire chez plus de 97 % de ceux qui déclarent être allergiques à la pénicilline. La plupart des patients peuvent recevoir un traitement à la pénicilline ou à l’amoxicilline en toute sécurité s’ils n’ont pas d’antécédents compatibles avec des réactions à médiation IgE ni avec des réactions systémiques tardives comme le syndrome de Stevens-Johnson, une réaction de type maladie sérique, le syndrome d’éruption médicamenteuse avec éosinophilie et manifestations systémiques ou la pustulose exanthématique aiguë généralisée. Des directives sont proposées pour stratifier le risque d’allergie aux bêta-lactamines ainsi que pour administrer des doses tests aux patients considérés comme à faible risque et les surveiller en milieu ambulatoire. Les directives sur les patients à plus haut risque d’allergie aux bêta-lactamines comprennent les critères pour les diriger vers des allergologues et l’utilisation d’autres antimicrobiens tels que les céphalosporines, en attendant l’évaluation par un spécialiste.

Purpose: Ketamine is the most commonly used agent for procedural sedation in children in the emergency department. Evidence suggests ketamine can be administered intranasally, obviating the need for intravenous access. However, studies are conflicting with regards to dosing and indications, limiting the ability of clinicians to extrapolate findings to practice. We sought to summarize the pediatric literature on the effectiveness of intranasal (IN) ketamine for sedation, analgesia, and adverse effects. Methods: Trials were identified through electronic searches of MEDLINE (1946-2015), EMBASE (1980-2015), Google Scholar (2015), CINAHL (1981-2015), Cochrane Central Register …

BACKGROUND: Since the removal of codeine from hospital formularies, clinicians have increasingly turned to oral morphine to manage acute pain in children. However, recent evidence highlights a high prevalence of adverse effects and variable efficacy. Characterization of oral morphine pharmacokinetics and pharmacogenomics is necessary to guide the safe and effective use of oral morphine. OBJECTIVES: We sought to explore the pharmacokinetics and pharmacogenomics of oral morphine in otherwise healthy children with fractures. DESIGN/METHODS: We included a convenience sample of children age 5–17 years in the Paediatric Emergency Department with a deformed extremity fracture. Repeated blood samples were taken from an intravenous (IV) line for 120 minutes. Key pharmacokinetic parameters included time to maximum concentration (Tmax), peak serum concentration (Cmax), half-life, and area under the curve (AUC) for morphine and its metabolites: morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G). Concentrations were determined by ultra performance liquid chromatography (UPLC) coupled to quadrupole time of flight (QTOF) mass spectrometry. Genotyping of single nucleotide polymorphisms (SNPs) was performed by TaqMan assay. Pain scores were collected using the Faces Pain Scale – Revised. RESULTS: We recruited 13 children (11 males) ranging from 4–16 (median 11.6) years. All participants received a single dose of oral morphine 0.5 mg/kg (maximum 20 mg). For morphine, M6G, and M3G, Tmax ranged from 30–120 minutes, 60–180 minutes, and 60–180 minutes, respectively; Cmax ranged from ranged from 6.2–52.6 ng/mL, 14.7–86 ng/mL, and 89.3–483.4 ng/mL, respectively; half-life ranged from 47.9–271.5 minutes, 71.2–400.5 minutes, and 94.7–278.3 minutes, respectively; AUC ranged from 250.1–6760.1 ng/mL*hr, 1129.4–9893.2 ng/mL*hr, and 8030.6–56246.5 ng/mL*hr, respectively. In one patient who reported no reduction from a pain score of 6, a SNP (RS563649) on the OPRMIgene locus previously shown to confer reduced receptor efficiency (less analgesia) was identified. In two patients, we identified a SNP (RS1799971) on the OPRMIgene locus previously shown to confer reduced metabolism, blood-brain barrier penetration, and receptor activity (less analgesia but fewer adverse effects). In 11 patients, we identified a SNP (RS1045642) on the ABCB1 gene locus previously shown to confer reduced intestinal p-glycoprotein expression (greater analgesia). Five patients were homozygous for a SNP (RS7439366) on the UGT2B7*2gene locus previously shown to confer reduced metabolism of M6G, an active metabolite (greater analgesia and nausea). CONCLUSION: Several SNPs confer variability in oral morphine’s pharmacokinetic and pharmacodynamic profile and may explain the wide variability in analgesic efficacy and adverse effects in children.

OBJECTIVES:To determine whether lidocaine is superior to nonanesthetic lubricant (NAL) for relieving pain in children undergoing urethral catheterization (UC).METHODS:Children 0 to 24 months requiring UC were randomized to NAL or topical and intraurethral 2% lidocaine gel. Primary outcome was facial grimacing in the pre to during drug administration and catheterization phases. Secondary outcome was caregiver satisfaction by using a Visual Analog Scale.RESULTS:There were 133 participants (n = 68 lidocaine, n = 65 NAL). There were no significant differences in mean (SD) scores during UC between lidocaine and NAL (86.4% [121.5%] vs 85.2% [126.6%]), respectively (Δ [confidence interval (CI)] = −1.2 [−21.0 to 49.0], P = .4). There was a significantly greater difference in mean (SD) scores during instillation of lidocaine versus NAL (61.8% [105.6%] vs 3.2% [84.9%]), respectively (Δ [CI] –58.6 [–95.0 to –32.0], P < .001). There were no significant differences in mean (SD) parental satisfaction scores between lidocaine and NAL (4.8 [3.2] vs 5.9 [2.9]), respectively (CI–0.1 to 2.2; P = .06). In the subgroup analysis, age, gender, and positive urine culture did not significantly influence between-group differences in facial grimacing.CONCLUSIONS:Compared with NAL, topical and intraurethral lidocaine is not associated with significant pain reduction during UC, but significantly greater pain during instillation. Therefore, clinicians may consider using noninvasive pain-reducing strategies for young children who require UC.

Adverse drug reactions (ADRs) are a common problem in children. Health-related quality of life in patients with such conditions has not been well studied. In this study we found that health-related quality of life is adversely affected in children who developed ADRs with cutaneous manifestations.

Objectives Dexamethasone is associated with adrenal insufficiency in adults and children with chronic disease. This association has not been studied after single-dose oral dexamethasone, the standard of care for children with croup. We hypothesized that single-dose oral dexamethasone in children with croup is associated with a transient decrease in endogenous glucocorticoids. Methods We conducted a prospective, 2-arm, pharmacodynamic study of single-dose oral dexamethasone 0.6 mg/kg (maximum, 12 mg) in children older than 2 years with croup compared with controls (children with febrile upper respiratory tract infections who did not receive dexamethasone). Primary outcome was urinary 6β-hydroxycortisol-cortisol ratio. Results Twenty-seven children were analyzed (22 with croup and 5 with upper respiratory tract infections). Median 6β-hydroxycortisol-cortisol ratios before dexamethasone, the following morning, and on days 1, 3, and 7 were 2.8, 2.2, 2.0, 2.8, and 2.6, respectively. Among controls, the median 6β-hydroxycortisol-cortisol ratios at the same time intervals was 1.9, 1.5, 1.8, 2.5, and 1.7, respectively. There were no significant differences in the change from time 0 between groups at any time point. There were no serious adverse events or infectious complications. Conclusions Single-dose oral dexamethasone is not associated with decreased endogenous corticosteroid levels in children with croup. Future studies should use criterion standard tests to rule out suppression of the hypothalamic-pituitary-adrenal axis and be powered sufficiently to identify adverse clinical outcomes.

Bronchiolitis is the most common reason for admission to hospital in the first year of life. There is tremendous variation in the clinical management of this condition across Canada and around the world, including significant use of unnecessary tests and ineffective therapies. This statement pertains to generally healthy children ≤2 years of age with bronchiolitis. The diagnosis of bronchiolitis is based primarily on the history of illness and physical examination findings. Laboratory investigations are generally unhelpful. Bronchiolitis is a self-limiting disease, usually managed with supportive care at home. Groups at high risk for severe disease are described and guidelines for admission to hospital are presented. Evidence for the efficacy of various therapies is discussed and recommendations are made for management. Monitoring requirements and discharge readiness from hospital are also discussed.La bronchiolite est la principale cause d’hospitalisation avant l’âge de un an. La prise en charge clinique de cette maladie varie considérablement selon les régions du Canada et du monde, y compris une grande utilisation de tests inutiles et de thérapies inefficaces. Le présent document de principes porte sur des enfants en santé de deux ans ou moins qui sont atteints d’une bronchiolite. Le diagnostic de bronchiolite repose d’abord sur l’anamnèse de la maladie et sur les résultats de l’examen physique. En général, les examens de laboratoire sont inutiles. La bronchiolite est une maladie spontanément résolutive, qui est généralement prise en charge par des soins de soutien à domicile. Par ailleurs, les groupes très vulnérables à une bronchiolite grave sont décrits, et les indications d’admission à l’hôpital sont présentées. Les données probantes sur l’efficacité des diverses thérapies et les recommandations de prise en charge sont exposées. La surveillance requise et le moment du congé de l’hôpital sont également abordés.

BACKGROUND AND OBJECTIVES: Pharmacogenetics (PGx) promises to optimize patient response to therapy. However, the public’s acceptance of PGx is not well known, notably when this applies to children. Our objective was to explore perceptions of PGx testing among individuals, who differ from each other by either parental status or educational exposure to PGx, and to explore parents’ views between PGx testing for oneself and PGx testing for their children. METHODS: An exploratory survey was conducted among parents and other adults. Surveys P and C were completed by parents, survey NP by middle-aged nonparents, and survey MS by medical students. RESULTS: Proper explanation before PGx testing appeared to be the most important issue to the respondents (eg, P = 1.55 × 10−38 for survey NP). Respondents who were more knowledgeable about PGx were also more comfortable with PGx testing (eg, P = 2.53 × 10−7 in case of mild disease). When PGx testing was for one’s child, parents valued their own understanding more than their child’s assent (P = 1.57 × 10−17). CONCLUSIONS: The acceptability of PGx testing, either for oneself or for one’s child, seemed to depend on baseline PGx knowledge, but not on parenthood.

BACKGROUND Cannabis use for medical purposes has gathered growing interest from the public through its purported benefits. Since 2001, Health Canada has authorized availability from health practitioners, even for paediatric patients, despite concerns regarding efficacy and adverse effects among children and adolescents. It is likely that a lack of knowledge regarding the substance and indications for use, tempered by known and unknown side effects, dictate paediatricians’ practice toward cannabis. OBJECTIVES This study examines the views and knowledge of Canadian paediatricians regarding the use of cannabis for medical purposes among children and adolescents. Differences between general paediatricians and sub-specialists were explored. DESIGN/METHODS Data was collected using a Canadian Paediatric Surveillance Program (CPSP) one-time survey performed in 2017. A total of 864 paediatric physicians (33% participation rate) were asked about medical use of cannabis. They were also asked personal and professional characteristics. Descriptive statistics regarding their views and knowledge towards cannabis use for medical purposes are reported, as well as significant differences (p RESULTS General paediatricians represented 55.4% of the analyzed sample, with 36.7% having ≥ 20 years of practice. Half (50.4%) of all surveyed paediatricians had encountered in the past year patients who used cannabis for medical purposes (authorized or not). Half (50.6%) were also aware that Canadian physicians could authorize cannabis to children for medical purposes. More (61.3%) knew they could authorize it to adolescents (significantly more among sub-specialists, p=0.03). Nearly half (46.5%) believed that there are appropriate indications to support the authorization of cannabis for medical reasons to the paediatric population (significantly more among sub-specialists, p CONCLUSION Cannabis use for medical purposes is a situation frequently encountered by paediatricians. While they are generally supportive of certain medical indications for its authorization, most have minimal knowledge on its use and, report concerns about efficacy and safety. Differences between general paediatricians and sub-specialists probably emerge from conditions treated by these two groups. Our study highlights the need for timely continuing education for all paediatricians on this topic.

BackgroundReported allergy to penicillins is a major clinical problem. Over 10% of parents report drug allergy resulting in higher cost and less than optimum management of infectious diseases.ObjectivesTo determine the relative likelihood of true allergy in patients suspected to have a penicillin allergy and to investigate the risk factors involved. We hypothesized that the vast majority of self-reported penicillin allergies are less likely to be true allergies when proper immunological work up is performed.MethodsPaediatric patients aged 0–18 years presenting to the ADR clinic at the Children Hospital of Western Ontario (CHWO) with suspected antibiotic allergies were included. A retrospective review of charts was conducted to obtain demographic information and results from allergological and in vitro testing. Subjects were evaluated with a radioallergosorbent test (RAST) or the lymphocyte toxicity assay (LTA)/the invitro platelet toxicity assay (iPTA) depending on whether the history was most consistent with an immediate allergy or a delayed hypersensitivity, respectively. Patients with negative RAST or LTA/iPTA were recommended to undergo confirmatory oral challenge test (OCT).ResultsNinety subjects were identified including 75 with possible penicillin allergy and 10 with suspected allergy to a non-penicillin antibiotic. Five subjects presented with a mixed allergy. Based on the results from RAST, in vitro testing and OCTs, the prevalence of a true allergy in the penicillin group was 6.25% vs. 66.67% in the non-penicillin group (p< 0.001). Patients presenting with severe reactions were more likely to be truly allergic (p< 0.01). In-patients were more likely to present with non-penicillin allergies and were subsequently more likely to have a true allergy (p< 0.001).ConclusionsTrue allergy is very rare in patients with suspected penicillin allergies and can be determined with a proper work-up including OCT. Shorter protocols for the evaluation of these patients would be beneficial.Disclosure(s)Nothing to disclose

Background . The use of anthracyclines as effective antineoplastic drugs is limited by the occurrence of cardiotoxicity. Multiple genetic variants predictive of anthracycline-induced cardiotoxicity (ACT) in children were recently identified. The current study was aimed to assess replication of these findings in an independent cohort of children. Procedure . Twenty-three variants were tested for association with ACT in an independent cohort of 218 patients. Predictive models including genetic and clinical risk factors were constructed in the original cohort and assessed in the current replication cohort. Results . We confirmed the association of rs17863783 in UGT1A6 and ACT in the replication cohort (P = 0.0062, odds ratio (OR) 7.98). Additional evidence for association of rs7853758 (P = 0.058, OR 0.46) and rs885004 (P = 0.058, OR 0.42) in SLC28A3 was found (combined P = 1.6 × 10−5 and P = 3.0 × 10−5, respectively). A previously constructed prediction model did not significantly improve risk prediction in the replication cohort over clinical factors alone. However, an improved prediction model constructed using replicated genetic variants as well as clinical factors discriminated significantly better between cases and controls than clinical factors alone in both original (AUC 0.77 vs. 0.68, P = 0.0031) and replication cohort (AUC 0.77 vs. 0.69, P = 0.060). Conclusions . We validated genetic variants in two genes predictive of ACT in an independent cohort. A prediction model combining replicated genetic variants as well as clinical risk factors might be able to identify high- and low-risk patients who could benefit from alternative treatment options. Pediatr Blood Cancer 2013;601375-1381. © 2013 Wiley Periodicals, Inc.

Dietary sodium is required in very small amounts to support circulating blood volume and blood pressure (BP). Available nutritional surveillance data suggest that most Canadian children consume sodium in excess of their dietary requirements. Approximately 80% of the sodium Canadians consume comes from processed and packaged foods. High sodium intakes in children may be an indicator of poor diet quality. Results from systematic reviews and meta-analyses have demonstrated that decreasing dietary sodium in children leads to small but clinically insignificant decreases in BP. However, population-level strategies to reduce sodium consumption, such as food product reformulation, modifying food procurement processes, and federal healthy eating policies, are important public health initiatives that can produce meaningful reductions in sodium consumption and help to prevent chronic disease in adulthood.

Adverse drug reactions (ADRs) complicate at least 5% of all courses of therapy for children. Dealing with an ADR requires a stepwise approach in appreciation of the possibility of an ADR, assessment of whether the adverse event in question is drug-related, assessment of causality, assistance in treating the symptoms of the ADR, and dealing with the aftermath of the event. Several new developments likely will improve the ability to assess, evaluate, treat, and prevent ADRs in children. These developments include tools to evaluate causality, laboratory tests to diagnose ADRs, pharmacogenomic approaches to prevent ADRs, and new insights into treating serious ADRs.

Background: Asthma is the most common chronic condition in childhood, and the recommended pharmacotherapy for long-term control includes the use of inhaled corticosteroids (ICS). ICS were designed to act at the site of inflammation in the lung, thus decreasing systemic absorption and reducing the risk of adverse effects associated with corticosteroid use (e.g., HPA suppression and its consequent effects). Available data show that measurement of hair cortisol successfully reflects endogenous cortisol levels. We sought to examine whether hair cortisol measurements can be used to identify HPA suppression surrounding ICS therapy in children with asthma.Methods:Hair samples were collected from the vertex posterior region of the head of 18 asthmatic children. We compared their hair cortisol concentration during ICS use with the concentration prior to ICS use.Results:During ICS therapy, median hair cortisol levels were twofold lower compared with the period of no ICS use (median 89.8 ng/g vs. 198.2 ng/g, P = 0.0015).Conclusion:Hair cortisol is an effective biomarker of the HPA suppression associated with ICS therapy and can be a sensitive tool for determining systemic effects of ICS use and monitoring adherence. Future research is needed to characterize the effect of untreated asthma on hair cortisol concentrations, if any.

Drug therapy is one of the cornerstones of care for many common and important child health problems worldwide, as safe and effective pharmacotherapy has been one of the key strategies in improving child health over the past century alongside vaccination, public sanitation and child protection. They are also commonly used—for most children, as monotherapy for acute problems but for children with chronic disease ongoing and frequently complex pharmacotherapy is the rule.1 Prescription drugs are also costly—in 2014 the NHS spent £14 billion on prescription drugs, 40% being in-hospital.2 As well, adverse drug reactions are one of the top four causes of death.1 Consequently, it would be prudent to consider that, when we prescribe medications for children, it is done rationally. An important question in child healthcare and in public policy for children is––Is this true? Dr Benard-Laribiere et al 3 describe drug use among a sample of 133 800 children selected from a reimbursement claims database representing 90% of the French population. This is the first study to systematically look at drug use in children in France. Over a 1 year period, 84% of French children had a prescription for at least one drug; drug use was age-dependent, with 97% of children under the age of 2 years having at least one prescription and with the rate of drug use declining significantly with age. The median number of drugs prescribed per child over this year was 5. …

Division of Clinical Pharmacology, Departments of Paediatrics, Physiology & Pharmacology, and Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario Correspondence: Dr Michael Rieder, e-mail mrieder@uwo.ca Accepted for publication January 7, 2015 In the current issue of Paediatrics & Child Health, Beringer et al (pages 23-29) report the results of a review of medical records investigating the use of natural health products (NHPs) by children in a hospice in Ontario between 2008 and 2013. The authors have demonstrated a very high rate of use of NHPs, with three-quarters of the children receiving at least one NHP in addition to conventional therapy. This finding is higher than in previous studies investigating NHP use in Canadian children; for example, the work of Adams et al (1) which demonstrated a rate of 37% among children with chronic health problems attending specialty clinics in Ontario and Alberta. The reasons for this may lie in the nature of the patients; as the authors note, the children in this study have complex disease with limited life expectancy. These figures are also closer to those observed among adult patients with cancer, in whom up to 60% use some type of NHP (2). An additional important finding in this study is that there were a number of potential drug-NHP or NHP-NHP interactions, which were present among 66% of all patients. Of interest, there were no clinically relevant drug-NHP interactions reported during the study period. This observation should be interpreted with some caution because under-reporting of adverse events is common in records reviews, and adverse events may not have been as well appreciated in the setting of hospice care. What is the take-home message of this article for the clinician? First, that use of NHPs is likely to be common among children, especially among children with complex and serious disease. Second, that some of this NHP use may have the potential for producing interactions not only with concurrent drug therapy but also with other NHPs. This highlights the importance of a careful history, with clinicians being nonjudgemental with regard to NHP use to encourage candor on the part of children and their parents. In this respect, pharmacy team members can be a vital resource, particularly with respect to medication history at the time of hospital admission or clinic visit. In addition, clinicians need to take advantage of drug information resources to ensure that they have timely and accurate information with regard to potential drug-NHP and NHP-NHP interactions. editorial

Drug toxicity in association with adverse drug reactions is common in hospitalisedchildren. The toxicity of medicines in children is different to that seen in adults.There are also differences between different age groups of paediatric patientswith neonates being generally at greater risk for experiencing a drug-associatedadverse event. The major examples of drug toxicity that have occurred inpaediatric patients are reviewed ranging from percutaneous toxicity over 100years ago to formulation errors and toxicity associated with normal,developmental alterations in drug metabolism . The need to learn from previouscases of drug toxicity to prevent future cases is paramount. Paed Perinatal Drug Ther 2002; 5: 12– 18 Key words: Drug toxicity – drug metabolism – children Introduction Adverse drug reactions ( ADRs ) are commonclinical problems in both paediatric and adultmedicine. Over 9% of hospitalised children haveadverse reactions to therapy and up to 4% of allhospital admissions are the consequence of ADRs

La bronchiolite est une infection virale des voies respiratoires inferieures caracterisee par l’obstruction des petites voies respiratoires, causee par une inflammation aigue, un œdeme et une necrose des cellules epitheliales qui recouvrent les petites voies respiratoires, de meme que par une augmentation de la production de mucus.(1) Le virus respiratoire syncytial (VRS) est responsable de la plupart des cas.(2,3) Cependant, d’autres virus, y compris le metapneumovirus humain (MPVH), l’influenza, le rhinovirus, l’adenovirus et le parainfluenza, peuvent tous donner un meme portrait clinique.(4) Une co-infection par de multiples virus se produit chez 10 % a 30 % des enfants et adolescents hospitalises. (5) L’infection primaire ne confere pas d’immunite protectrice, et les reinfections continuent de se repeter jusqu’a l’âge adulte, meme si elles sont generalement plus legeres. Au Canada, la saison du VRS debute habituellement entre novembre et janvier et persiste pendant quatre a cinq mois.(6) La bronchiolite, qui touche plus du tiers des enfants avant deux ans, est la principale cause d’hospitalisation avant un an. Depuis 30 ans, les taux d’hospitalisation sont passes de 1 % a 3 % chez l’ensemble des nourrissons.(1,7,8) La hausse des hospitalisations est couteuse pour le systeme de sante,(9) reflete une importante morbidite(10) et a des repercussions sur les familles. Malgre l’existence de nombreux guides de pratique clinique, y compris celui de l’American Academy of Pediatrics (AAP) publie en 2006 et souvent cite,(1) on constate d’importantes variations(11) dans les approches du diagnostic, de la surveillance et de la prise en charge. Les initiatives pour standardiser les soins de la bronchiolite(12) demontrent une diminution des tests et des ressources diagnostiques, de meme qu’une reduction des couts et de meilleurs resultats.(7,13) Toutefois, meme si le nombre de tests et de traitements a diminue depuis la publication des recommandations de l’AAP,(14) son implantation n’est pas generalisee. Le present document de principes s’appuie sur le document de principes detaille et revise par les pairs produit par l’AAP(1) et y integre les nouvelles donnees probantes publiees depuis huit ans, tout en fournissant au clinicien des recommandations pour contribuer a orienter le diagnostic, la surveillance et la prise en charge d’enfants de un a 24 mois auparavant en sante qui consultent en raison de signes de bronchiolite (figure 1). Ces recommandations sont concues pour appuyer une moindre utilisation des epreuves diagnostiques inutiles et des medicaments et interventions inefficaces. Le present document de principes ne s’applique pas aux enfants ayant des maladies pulmonaires chroniques, une immunodeficience ou d’autres maladies chroniques graves. La prevention et les effets potentiels a long terme de la bronchiolite depassent la portee du present document, mais sont bien decrits dans les publications scientifiques et dans d’autres documents de principes de la Societe canadienne de pediatrie.(4,6) Figure 1) Algorithme pour la prise en charge medicale de la bronchiolite. IV voie intraveineuse; NG voie nasogastrique; O2 oxygene; SaO2 saturation en oxygene. Traduit et adapte avec l’autorisation de la reference ...

The objective of this observational study was to evaluate the safety and effectiveness of discharging stabilized neonates to complete their oral morphine weaning at home. This retrospective cohort study evaluated neonates treated with oral morphine at two hospitals in London, Ontario, Canada. Neonates who completed their morphine wean in hospital were compared with neonates who completed their morphine wean following discharge from hospital (at home). There were 80 neonates treated with oral morphine at two hospitals from 2006 to 2010. The majority (65 %, 52/80) of neonates completed their morphine weaning after hospital discharge and were significantly less likely to return to hospital for further withdrawal treatment (1/52 vs 4/28, p

Ondansetron is a useful adjunct for the treatment of acute gastroenteritis in the paediatric ED. The use of ondansetron is associated with many benefits including decreased emesis, decreased need for intravenous fluids, decreased rate of admission, decreased length of stay, decreased revisit rates and increased cost savings (15-18). There may be value in giving patients a second as-needed home dose of ondansetron as part of ED discharge planning, with the appropriate patient education, in anticipation of recurrent emesis. This practice may further reduce ED revisit rates and also prevent morbidity and hospitalization associated with severe dehydration for patients who do eventually return to the ED, especially those in rural communities where timely treatment and access to an ED is difficult. The decision to dispense ondansetron should be made clinically by the ED physician for patients who have failed ORT whose symptoms are predominantly emesis as opposed to diarrhea, and when the discharging physician is reasonably certain of a diagnosis of acute gastroenteritis and not something more sinister. There is currently no consensus on the role of ED-provided ondansetron for out-of-hospital use for paediatric patients with acute gastroenteritis. Future studies are needed to determine the potential impact on morbidity and the health care economy. ©2014 Pulsus Group Inc. All rights reserved.