Archive | Pediatric Medication Use

Pain meds used by children while in the hospital

Pediatric pain medications

When children are in the hospital, they often need pain relief or sedation, yet most drugs used for pain relief or sedation in children have not been studied in children. A first step in understanding the overall use of pain medications is to document the medications used and their frequency of use. Our publication, “Use of Analgesic, Anesthetic, and Sedative Medications During Pediatric Hospitalizations in the United States 2008”, published in the journal, Anesthesia and Analgesia in  2012, describes medications used in over 800,000 hospitalizations.

We describe use of analgesics, anesthetics, and sedatives in pediatric inpatients by conducting a statistical analysis of medication data from the Premier database. We identified all uses of a given medication, selected the first use for each child, and calculated the prevalence of use of specific medications among hospitalized children in 2008 as the number of hospitalizations in which the drug was used per 100 hospitalizations. Dose and number of doses were not considered in these analyses.

The dataset contained records for 877,201 hospitalizations of children younger than 18 years of age at the time of admission. Thirty-three medications and an additional 11 combinations were administered in this population, including nonsteroidal antiinflammatory drugs, local and regional anesthetics, opioids, benzodiazepines, sedative-hypnotics, barbiturates, and others. The 10 most frequently administered analgesic, anesthetic, or sedative medications used in this population were acetaminophen (14.7%), lidocaine (11.0%), fentanyl (6.6%), ibuprofen (6.3%), morphine (6.2%), midazolam (4.5%), propofol (4.1%), lidocaine/ prilocaine (2.5%), hydrocodone/acetaminophen (2.1%), and acetaminophen/codeine (2.0%).

Use changed with age, and the direction of change (increases and decreases) and the type of change (linear, u-shaped, or other) appeared to be specific to each drug.

Figure 1 shows the number and percentage of pediatric hospitalizations with nonsteroidal antiinflammatory drug (NSAID) use, by age group. Bars indicate number of hospitalizations. Lines indicate percentage of hospitalizations. Acetaminophen was considered in these analyses as an NSAID for the sake of categorical simplicity; however, pharmacologically, the antiinflammatory activity of acetaminophen is minimal, such that some do not consider it a true NSAID.

Pediatric pain medications by age group.

Figure 1. Number and percentage of pediatric hospitalizations with non steroidal anti-inflammatory drug (NSAID) use, by age group.

Figure 2 shows the number and percentage of pediatric hospitalizations with opioid use, by age group. Bars indicate number of hospitalizations. Lines indicate percentage of hospitalizations.

hospitalizations with use of pediatric pain medications (opioids), by age group.

Figure 2. Number and percentage of pediatric hospitalizations with opioid use, by age group.

See the accompanying editorial by Joseph Tobin, MD, “Pediatric Drug Labeling: Still an Unfinished Need”. As he says,

Chronic pain in children is seriously underrecognized in comparison with the prevalence of chronic pain in adults. This is one more circumstance in which labeling in children would be very beneficial to anesthesiologists and their patients.

Variation in Vancomycin Use in Pediatric Hospitalizations in the 2008 Premier Database

How much variation in use is too much?

Vancomycin is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (beta-lactam-resistant) staphylococci.  Because of concerns about the development of drug-resistant bacteria, recommendations to prevent the spread of vancomycin resistance have been in place since 1995 and include guidelines for inpatient pediatric use of vancomycin.  With such guidelines in place, it is of special interest to compare inpatient pediatric vancomycin administration across hospitals.

Our recent publication, “Pediatric Vancomycin Use in 421 Hospitals in the United States 2008” published in PLOS ONE on 8/16/2012 (Lasky T, Greenspan J, Ernst FR, and Gonzalez L), compares vancomycin use in all pediatric hospitalizations (hospitalizations of children under age 18) in 421 hospitals in the Premier database.

Key Findings

  • Vancomycin was administered to children at 374 hospitals in the Premier hospital database.
  • Another 47 hospitals with 17,271 pediatric hospitalizations (13,233 under age 2) reported no vancomycin use during 2008.
  • The number of pediatric hospitalizations with vancomycin use ranged from 0 to 1225 at individual hospitals.
  • Most hospitals (221) had fewer than 10 pediatric hospitalizations with vancomycin use in the study period.
  • 21 hospitals (5.6% of hospitals) each had over 200 hospitalizations with vancomycin use, and together, accounted for more than 50% of the pediatric hospitalizations with vancomycin use.
  • Percentage of hospitalizations with vancomycin use ranged up to 33.3% when hospitals with few pediatric hospitalizations were kept in the sample, the high percenetages being an artifact of the small number of hospitalizations in the denominator. For this reason, percentage, by itself, may not be a useful indicator in small hospitals.
  • In hospitals with more than 100 pediatric hospitalizations with vancomycin use, the percentage with vancomycin use ranged from 1.26 to 12.90, a 10 fold range in the prevalence of vancomycin use.
  • Our stratified analyses and logistic modeling showed variation in vancomycin use by individual hospital that was not explained by hospital or patient characteristics including: bed size, teaching status, region of the country, rural or urban geography, and patient sex, race, APR-DRG risk of mortality and APR-DRG severity of illness.

For Discussion and Further Investigation

Until recently, few studies have compared pediatric antibiotic use across large numbers of hospitals or geography, and it was not possible to assess variation in use across institutions. Hospital variation in care of adults has been studied for several decades, much of it made possible by large Medicare claims databases. With the availability of aggregated data for pediatric hospitalizations we can begin describing and attempting to understand variation in pediatric practice. This first study of hospital variation in pediatric vancomycin use raises questions for further research.

Morphine Use in Pediatric Inpatients

Pediatric morphine use in the hospital

As with so many medications used widely to treat children, morphine is not labeled for pediatric use. Describing patterns of use helps us understand how many children are receiving a drug that is not approved for pediatric use by the FDA.

A statistical analysis of 877,201 pediatric hospitalizations in the United States in 2008 estimated that morphine was used in 54,613 (6.2%) hospitalizations in the database. If this percentage is applied to the total number of children’s hospitalizations in the US in 2008, as many as 476,205 children will have received morphine during their hospital stay that year. Fractures and appendicitis were two of the diagnoses most frequently listed for children receiving morphine.

While morphine can be used safely for pain management during hospital procedures, and has been used for this purpose for several decades, the lack of pediatric labeling is undesirable. In a discussion about whether the off-label use of a drug constitutes experimentation and research, the American Academy of Pediatrics Committee on Drugs noted that “discussion about the off-label status of a drug may, as a matter of professional judgment, be part of the information provided to the patient or parents.”

The article reporting statistical analysis on morphine use in pediatric inpatients can be found here:”Morphine Use in Hospitalized Children in the United States: A Descriptive Analysis of Data From Pediatric Hospitalizations in 2008″Lasky T, Greenspan J, Ernst FR, and Gonzalez L Clinical Therapeutics 2012, 34(3): pp.720-727.

The American Academy of Pediatrics discussion on “Uses of drugs not described in the package insert (off-label uses)” can be found here. Pediatrics. 2002;110: 181–183.

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