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Serotonin discontinuation syndrome (SDS) can result in a constellation of symptoms exhibited by infants exposed to selective serotonin reuptake inhibitors or other psychotropic drugs during pregnancy. Currently, there is no consensus regarding the pharmacologic management of SDS. We report our experience with clonidine for the management of a term infant with poor neonatal adaption. The infant exhibited biphasic symptoms of acute toxicity at birth and a plateauing of symptoms, followed by subsequent withdrawal symptomatology requiring the use of clonidine in doses up to 4 mcg/kg/dose every 3 hours for control of symptoms. The 38-week gestation Caucasian male infant was born to a mother with major depressive disorder, which was managed with sertraline, trazodone, venlafaxine, and buspirone throughout her pregnancy. The infant exhibited severe hypertonia at delivery and continued to have hypertonia, tremors, hypoglycemia, and feeding issues upon admission to the NICU. The initial Modified Finnegan Neonatal Abstinence scores were extremely elevated, and clonidine was started at 1 mcg/kg/dose every 3 hours and then the dose was titrated up to 4 mcg/kg/dose. This is the first report documenting the use of clonidine to manage serotonin toxicity at birth followed by subsequent neonatal withdrawal associated with maternal antidepressant drug use during pregnancy.

This case report describes an extremely low birth weight infant, born at 26-week gestational age, who developed hypertrophic cardiomyopathy (HCM) and cardiogenic shock a few hours after administration of a small dose of dexamethasone. Although cases of steroid-induced cardiomyopathy in preterm neonates are known in literature, their adverse effects are insidious and are transient in occurrence. This is the first report of HCM and cardiogenic shock occurring acutely after administration of small-dose dexamethasone. This neonate received small-dose dexamethasone initially to prevent reintubation, and again to facilitate successful extubation. Both occurrences were associated with acute cardiac decompensation with reduction in ejection fraction within hours of administration. Cardiac function subsequently improved with discontinuation of drug and use of inotropic pharmacotherapy. Studies outlined in this report show that steroid-induced HCM is known and not isolated to dexamethasone alone; however, little is known on the adverse effect of small-dose steroid in resulting acute cardiac decompensation. This case is of educational value in clinical practice by highlighting the potential adverse effects even at the smaller doses of dexamethasone currently recommended in extremely low birth weight infants.

Objective The objective of this study was to evaluate iron deficiency in preterm infants and determine impact of blood transfusions on serum iron (SI) and ferritin (FTN). Study Design A prospective evaluation of baseline and weekly hemoglobin (Hgb), hematocrit (Hct), SI, FTN levels in premature infants with birth weights (BWs) Results In 125 preterm infants, the mean Hgb, Hct, and SI levels at birth were lower for infants Conclusion Infants

Necrotizing enterocolitis (NEC) is one of the leading causes of death in the neonatal intensive care unit. Morbidity and mortality rates significantly increase with decreases in gestational age and birth weight. Strong evidence suggests probiotic prophylaxis may significantly decrease the incidence of NEC and should therefore be incorporated into the standard of care for preterm infants. However, debate still remains because of limitations of completed studies. The purpose of this review was to provide an overview of the controversies regarding probiotic use in preterm infants and to shed light on the practical considerations for implementation of probiotic supplementation.

ABBREVIATIONS ACIP, Advisory Committee on Immunization Practices; AAP, American Academy of Pediatrics; CDC, Centers for Disease Control and Prevention; HPV, human papillomavirus; PPAG, Pediatric Pharmacy Advocacy Group; STD, sexually transmitted disease; Tdap; tetanus, diphtheria and reduced acellular pertussis The human papillomavirus (HPV) is the most common sexually transmitted disease in the United States, affecting greater than 6 million people annually. The majority of newly infected individuals are between the ages of 15 and 24 years. Although the vaccine may be administered from 9 to 26 years of age, the Centers for Disease Control and Prevention (CDC) currently recommends routine vaccination with the HPV vaccine for females at 11-12 years of age. The Pediatric Pharmacy Advocacy Group endorses the safety and efficacy of the quadrivalent HPV vaccine and agrees that the vaccine should be recommended for all adolescent girls, preferably prior to their “sexual debut.” Furthermore, we support the recommendation that young women through the age of 26 years should be vaccinated in order to decrease the risk of contracting a cancer-causing strain of HPV, even if they are already sexually active.

Selective serotonin reuptake inhibitor (SSRI) exposure during pregnancy can result in symptoms of serotonin syndrome or serotonin withdrawal. In contrast to other SSRIs, reports of serotonin behavioral syndrome following in utero exposure to escitalopram and citalopram are limited. We describe a case of suspected toxicity following in utero exposure to 20 mg escitalopram throughout pregnancy. The infant was transferred to our neonatal intensive unit at 9 hours of life for further evaluation of lethargy, weak cry, bradycardia, and non-reactive pupils. Hypoxic ischemic encephalopathy was suspected upon presentation, despite APGAR scores of 8 and 9. Upon admission, symptoms progressed to signs of hypertonia, irritability, high-pitched cry, and posturing. The patient was loaded with phenobarbital for empiric management of suspected seizures versus drug withdrawal. Both electroencephalogram and computed tomography scan results were normal; however, an electrocardiogram revealed a prolonged QTc interval of 531 milliseconds. Signs of irritability and QTc prolongation continued through day of life (DOL) 5. The infant was discharged on DOL 10 with no further symptoms. We hypothesize that this represented a case of serotonin toxicity due to in utero exposure to escitalopram and recommend close monitoring for neonatal behavioral syndrome symptoms and QTc prolongation in infants exposed to escitalopram during pregnancy.

Objective:To provide commentary and reviews and brief discussions in controversial or innovative recent advances in neonatal pharmacotherapy. To discuss cutting edge drug delivery systems that may become useful in neonatal drug delivery in the future.Data Sources:Articles were identified through searches of MEDLINE (1990–October 2005), key articles in the authors' files, and in some cases, through data generated and/or published by the author of a particular topic.Data Selection:Article selection and relevance to the topics under discussion was determined by individual authors.Data Synthesis:Therapeutic strategies addressed in this review include the use of hematopoietic growth factors including a simulated amniotic fluid preparation containing these growth factors for neonates with selected gastrointestinal problems, erythropoietin for neuroprotection following perinatal asphyxia, drug therapy advances in treatment of patent ductus arteriosus (PDA), evaluation of advances in transdermal drug delivery, and its potential application to neonates and advances in the treatment of persistent pulmonary hypertension (PPHN) of the newborn.Conclusions:Despite being over 30 years old, the practice of neonatology is as much of an art as a science. Advances in the basic science research have improved our understanding of use of pharmacologic agents in the premature and full-term neonate including drug disposition pathways. Expanding our knowledge on issues such as physiology of hematopoietic factors, the pharmacologic responses of conditions such as PDA and PPHN, and newer technologies for drug administration, as well as other pharmacologic reponses in the neonate are vital in the development of safe and efficacious treatments for neonates. Many questions remain unanswered, and every clinician must make an effort to contribute to the knowledge and understanding of pharmacotherapy in this patient population.

BACKGROUNDPharmacy school faculty, residents, and students have been shown to positively impact patient care in multiple settings. However, their potential role in the care of pediatric patients has not been described.OBJECTIVETo document the contribution of pharmacy school faculty, residents, and students to the optimization of medical care for pediatric patients.METHODSAll clinical interventions performed by faculty, residents, and students for pediatric patients seen from January through December 2002 were recorded and analyzed. The interventions were concurrently recorded using a handheld and desktop computer-based documentation system, the Pharmacist's Electronic Database for Interventions, developed by the pediatric practice team. Practice sites included general pediatrics, pediatric intensive care, neonatal intensive care, and ambulatory clinics.RESULTSFour faculty members, 5 residents, and 44 students collected intervention data. A total of 4605 interventions were performed for 3978 patients. The most common interventions performed were drug therapy change, pharmacokinetic monitoring, drug information, and medication histories/patient education. Drug added and drug deleted were the most frequent interventions performed in the drug therapy change category. The most common indications for which interventions were made were infectious (39.6%) and respiratory (23.3%) diseases. A total of 223 adverse drug events or medication errors were prevented or detected during the study period. Errors in dosing (overdose or underdose) were the most commonly encountered adverse events.CONCLUSIONSPharmacy school faculty, residents, and students perform numerous clinical activities that play a significant role in the multidisciplinary care of pediatric patients.

A 38-week postconceptional age (29-week gestational age) infant required the placement of an Ommaya reservoir following a grade IV intraventricular hemorrhage and progressive hydrocephalus. At 70 days of age, a cerebrospinal fluid (CSF) culture was positive for Pseudomonas aeruginosa and the infant was empirically treated with age-appropriate parenteral doses of ceftazidime and gentamicin. This antibiotic regimen was changed to meropenem and tobramycin following the results of sensitivity reports. The infection failed to respond despite aggressive systemic dosing of antibiotics and removal of the Ommaya reservoir. Intraventricular injections of tobramycin were added to the systemic antibiotic regimen at a dose of 2 mg daily with subsequent doses adjusted to maintain trough concentrations in the CSF of 20–30 μg/mL. The CSF was sterilized after three days of intraventricular injections. The infant completed seven days of intraventricular tobramycin plus a 24-day regimen of systemic antibiotics. No acute complications were noted with the addition of intraventricular injections.

Few data exist in the literature to support the use of high dosages of oral baclofen and clonidine that are frequently required to treat children with spasticity. This study was a retrospective chart review of baclofen and clonidine dosages used in children diagnosed with cerebral palsy or traumatic brain injury. The primary objective was to calculate the mean dosages of baclofen and clonidine based on the duration of spasticity postinjury. Secondary objectives included determining correlations between dosage and age, injury type, location of spasticity, comorbid seizures, or concomitant antispasticity medications. Eighty-seven children receiving baclofen and/or clonidine were included in this study. Mean dosages of 40 mg/day ( n = 86) and 0.4 mg/day ( n = 31) were required for baclofen and clonidine, respectively. The maximum dosage was 240 mg/day for baclofen and 3.6 mg/day for clonidine. Duration postinjury, age, and concomitant antispasticity medications were the most predictive variables for baclofen dosage as a model ( r = .522; P = .000). Duration postinjury and location of spasticity were the most predictive variables for clonidine dosage as a model ( r = .523; P = .000). The average dosages of baclofen and clonidine used in this population of children with cerebral palsy or traumatic brain injury were similar to those reported in the literature, with higher maximum dosages found in this investigation.

This report is the first to replicate the earlier findings of Standing et al and validates the inadequacy of reporting of dosage forms used in pediatric drug trials. Journal authors should provide and journal editors should require adequate dosage form information for published reports of pediatric drug trials. We also recommend that compounding pharmacists provide detailed compounding instructions to assure that extemporaneously compounded formulations can be reliably reproduced, and that quality-control data be provided to support formulation stability. Until the problem of insufficient information is addressed, replication of many pediatric drug trials is impossible, calling into question their reliability and validity.

Significant controversy and debate continue to surround the issue of mandatory immunization requirements with the human papillomavirus (HPV) vaccine in adolescent females. Much of the attention in the media has been directed to one extreme or the other and oftentimes used to support the agendas of