Published reports on placebo-controlled clinical trials and other studies investigating the use of pure opioid antagonists for the prevention and treatment of opioid-induced pruritus (OIP) were evaluated. OIP is a common adverse effect of therapeutic use of opioid medications that can have a major impact on patients' comfort, quality of life, and willingness to continue opioid therapy. A literature search identified more than a dozen published reports on the use of pure opioid antagonists (naloxone, naltrexone, methylnaltrexone) for the management of OIP in pediatric and adult patients. Of the studies included in this review, most investigated the effects of naloxone administered by various parenteral routes for the prevention of OIP. Some of those studies indicated a significant reduction in the frequency or severity of pruritus with use of naloxone (a low-dose, continuous i.v. infusion of naloxone appeared to be the most effective treatment). A significant diminution of analgesia requiring increased cumulative doses of morphine was also observed in some studies. A number of studies evaluating the use of orally administered naltrexone for the management of OIP yielded generally less favorable results. Evidence from one small study suggested a potential role for orally administered methylnaltrexone in the prevention of OIP. Based on the existing data, a low-dose, continuous i.v. infusion of naloxone has the largest body of evidence supporting its use for prevention of OIP in adult and pediatric patients.

Refeeding syndrome (RS) has not been well defined in the neonatal population, although hypophosphatemia is identified as the most common manifestation. The American Society for Parenteral and Enteral Nutrition recently provided recommendations for the prevention and management of RS in children and adults; however, specific neonatal recommendations were not provided. In an effort to provide an overview of the incidence of RS or hypophosphatemia in the neonatal population and the impact of patient-specific and nutrition factors, a review of the literature was conducted. The literature search included articles published in the English language in Medline, PubMed, and EPub between 1946 and December 2020. Relevant citations within identified articles were also reviewed. Sixteen studies representing 3688 neonates were included. There was variation in the incidence of hypophosphatemia (20%–90%), hypokalemia (8.8%–66.7%), and hypomagnesemia (1%–8.3%) between studies. There was significant variability in definitions of hypophosphatemia, patient populations (e.g., gestational age, small for gestational age status, intrauterine growth restriction), and initial nutrition between studies (i.e., initial amino acid intake, calcium and phosphate ratio), proving it difficult to identify the overall incidence of neonatal RS. Clinical outcomes associated with hypophosphatemia identified in the studies included increased duration of mechanical ventilation, development of bronchopulmonary dysplasia, and increased mortality. Vigilant monitoring of serum phosphate, potassium, and magnesium is required in the first week of life. In addition, early addition of phosphate in a 1:1 molar ratio with calcium is recommended in the first week of life for patients who are at greatest risk for RS.

BACKGROUND: The prevalence of overweight/obesity in US children has increased over the past several decades. Routine use of weight-based dosing of medications could potentially result in over- or underdosing in these children. OBJECTIVE: To determine the percentage of admissions of children with a body mass index (BMI) greater than or equal to the 85th percentile for age and sex and the mean error rate per admission in the overweight versus control group. METHODS: We performed a retrospective, preliminary study of children aged 5–12 years who were admitted to a children's hospital over a period of 6 months. The overweight group included children with a BMI greater than or equal to the 85th percentile; the control group included children with a BMI less than the 85th percentile. Dose appropriateness was assessed, using 2 references. An overdose was defined as: (1) total mg/kg/day or mg/kg/dose greater than or equal to 110% of the maximum recommended pediatric dose, (2) total mg/day greater than the adult maximum recommended dose, or (3) greater than the recommended number of doses per day. An underdose was defined as: (1) total mg/kg/day or mg/kg/dose less than or equal to 90% of the minimum recommended pediatric dose, or (2) fewer than the recommended number of doses per day. Baseline comparisons between groups were done via Student's t-tests and χ ² analysis, when appropriate, with an a priori α of p less than or equal to 0.05. RESULTS: A total of 839 admissions representing 699 patients were included. The overweight group included 278 (33.1%) admissions. Comparison of overall mean error rate per admission revealed a statistically significant increase in dosing errors for overweight patients (0.4 ± 0.6 vs 0.3 ± 0.6; p = 0.030), with underdose errors occurring more frequently than overdose errors (0.3 ± 0.6 vs 0.2 ± 0.5; p = 0.010). CONCLUSIONS: Overweight children accounted for one-third of admissions, and the results of this study suggest that these patients are at greater risk for errors in dosing than are children of age- and sex-appropriate weight. This study did not assess clinical outcomes; however, overweight children could be at increased risk for therapeutic failures or adverse effects.

The association of disulfiram-like reaction with concomitant use of metronidazole and alcohol has been reported in the literature; however, alcohol containing oral liquids may not always be identified as a culprit. A case of a 14-year-old patient who experienced a possible disulfiram-like interaction while receiving metronidazole and Prednisone Intensol solution is reported. Metronidazole oral suspension was initiated for treatment of Clostridium difficile-associated diarrhea. Later, a 5-day course of oral Prednisone Intensol solution was initiated. On day 2 of concomitant metronidazole and steroid therapy, the patient experienced severe discomfort and abdominal distention accompanied by new onset tachycardia. A disulfiram-like reaction between the steroid solution and metronidazole was suspected; therefore, the Prednisone Intensol was discontinued. The patient's mother reported that, following discontinuation, the patient slept well for the first time in 2 days. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a possible relationship (score of 4) between the concomitant medication use and the gastrointestinal discomfort and tachycardia. If this interaction between metronidazole and alcohol containing medications occurs, it may be initially unrecognized, potentially resulting in patient discomfort or harm. It is important for healthcare professionals to identify these potential drug-drug interactions so that alternative medications may be utilized and offending agents can be avoided or replaced.

OBJECTIVES To describe the method of delivery, dosage regimens, and outcomes of sedatives and analgesics administered via the extravascular route for laceration repair in children METHODS Medline, Embase, and International Pharmaceutical Abstracts were searched using the keywords “child,” “midazolam,” “ketamine,” dexmedetomidine,” “fentanyl,” “nitrous oxide” (N₂O), and “laceration repair.” Articles evaluating the use of extravascular sedation in children for laceration repair published in the English language between 1946 and June 2017 were included. Two authors independently screened each article for inclusion. Reports were excluded if they did not contain sufficient details on dosage regimen and outcomes. RESULTS A total of 16 reports representing 953 children receiving sedatives and analgesics via the extravascular route were included for analyses. A statistical analysis was not performed because of heterogeneity in dosing and types of analyses conducted. Midazolam and N₂O were the most common agents, with oral (PO) midazolam being the most common agent. Other agents that have supporting data were intranasal (IN) dexmedetomidine, IN ketamine, IN midazolam, PO diazepam, PO ketamine, transmucosal (TM) midazolam, and TM fentanyl. CONCLUSIONS Most of the agents administered through the extravascular route were efficacious. Selection of the agents should be based on perceived need for analgesia versus sedation, patient accessibility, and adverse drug events. Future research is needed to determine the optimal agent and route for laceration repair.