Pregnancy outcome following in utero exposure to bisphosphonates

BACKGROUND AND AIM

The safety of bisphosphonates in human pregnancy has not been well established. To characterize pregnancy outcome in women receiving bisphosphonates, we conducted a multi-centre, prospective cohort study with a comparison group.

METHODS

Patients were recruited through 3 teratogen information centres in Canada and South Korea. We followed 21 women exposed to bisphosphonates during or <3 months before pregnancy, and 21 matched-comparison group women without exposure to known teratogens. Pregnancy/neonatal outcome data were collected by interview. The primary endpoint was neonatal outcome including major birth defects. The secondary endpoints included other pregnancy outcomes such as spontaneous abortions.

RESULTS

Indication of the therapy was osteoporosis in all patients. There was no difference in the maternal demographics between the 2 groups. In the bisphosphonate group, there were 18 live births, 2 spontaneous abortions and 1 therapeutic abortion, which were not significantly different from the comparison group. The mean gestational age (mean+/-SD) of the bisphosphonate group was 38.7+/-1.9 weeks (comparison group: 39.3+/-1.9 weeks; P=0.42), and the mean birth weight was 3.1+/-0.3 kg (comparison group: 3.3+/-0.5 kg; P=0.11). In the bisphosphonate group, there was a child diagnosed with Apert syndrome, an autosomal dominant acrocephalosyndactyly, with a fibroblast growth factor 2 mutation.

CONCLUSION

Coupled with existing data in the literature, our findings suggest that preconceptional and first-trimester use of bisphosphonates may not pose substantial fetal risks.

A palatability study of a flavored dexamethasone preparation versus prednisolone liquid in children

BACKGROUND

Palatability is an important factor in medication compliance for children where the acceptability of a liquid medication and its ease of administration will be greatly affected by its taste.

OBJECTIVES

The objective of this study was to determine which, if any of two steroid preparations, oral dexamethasone or oral prednisolone, was more palatable to children requiring steroid treatment for asthma.

METHODS

A single-blind taste test of 2 different steroid suspensions, liquid prednisolone (1mg/ml) versus liquid dexamethasone (1mg/ml), was conducted in children aged 5-12 years, presenting to the pediatric emergency department with an exacerbation of asthma requiring steroid treatment. Children received 2.5mls of either prednisolone or dexamethasone and were asked to score their impression of taste on a 10 cm visual analog scale. After cleansing of the palate they were given the other steroid and scored its taste.

RESULTS

Thirty-nine children (54% male) were enrolled in the study. The mean age was 7.1 years (SD=2.0). The median visual analog scale measurement for dexamethasone was 8.2 cm (IQR= 5.2) whilst the median measurement for prednisolone was 5.0 cm (IQR= 7.3), p=0.03. Male children were more likely to prefer dexamethasone than females with a median score of 9.9 cm (IQR=3.8) for males vs. 5.9 cm (IQR=9.3) for females, p=0.005. There was no gender preference for prednisolone.

CONCLUSIONS

There was a statistically significant difference between the taste of dexamethasone and prednisolone, with dexamethasone being the preferred steroid among pediatric patients with asthma. Males were much more likely to prefer dexamethasone than females.

Current issues in pediatric medication adherence

With the recent emphasis on investigating the efficacy of medication in children, it is also important to assess what determines whether pediatric patients do or do not take their medication. In general, children are no better at adhering to drug therapy than older individuals. Dealing with medication nonadherence is essential given its association with a failure to achieve the desired treatment goal. In addition to the many factors that influence adherence in adults, there are some unique challenges faced in the pediatric age group including the role of family (and its dysfunction), the changes of adolescence, and the lack of appropriate drug formulations. Intervention strategies to improve adherence include behavioral and educational strategies. Although there is no consensus as to what is the best approach to promote adherence with therapy, attention should be given to determining what barriers exist and trying to overcome them by involving children and their parents in the treatment planning process. If possible, the medication regimen, taking into account the frequency and timing of administration, should be tailored to the child and family's lifestyle and daily routine. Consideration should be given to the palatability and formulations of medications prescribed for young children. The use of simplified regimens of better tasting medications and age-appropriate delivery mechanisms may enhance the ability of pediatric patients to adhere to their drug therapy.

Rural women and pharmacologic therapy: needs and issues in rural Canada

INTRODUCTION

The needs and issues of rural women regarding pharmacologic information and therapy are rarely explored. We sought to explore the needs and issues of rural women in Canada regarding drug-related information and prescription and nonprescription pharmaceuticals.

METHODS

We used the qualitative methodology of interpretive description. In-depth semistructured face-to-face interviews were conducted with 20 women aged 17-88 years who lived in rural southwestern Ontario.

RESULTS

Although rural women accessed prescription medications, complementary and alternative medicine (CAM) was highly favoured, and alcohol and illicit drugs such as marijuana, crystal meth and cocaine were prevalent in rural communities. Factors that affected rural women's decisions about which medications to use included access to health care practitioners, costs of medications, experiences of family members and friends with prescribed and alternative medications, attitudes and approaches of health care providers and health store employees, and the women's own expectations and desires. Factors that affected the use of illicit drugs included availability, boredom, peer pressure and cultural norms. Rural factors that influenced access to drug information and use included presence or lack of confidential care, distance to resources, and presence, accessibility and acceptability of rural resources.

CONCLUSION

Rural women use a variety of drug therapies and sources of information, and experience unique socioeconomic and environmental issues that affect access to appropriate drug-related information and therapies. Further research is needed to clarify and articulate pharmacologic needs, issues and solutions for women in diverse rural settings.

Screening for iron deficiency anemia in at risk children in the pediatric emergency department: a survey of Canadian pediatric emergency department physicians

OBJECTIVE

To determine the attitudes and reported practices of physicians regarding screening for iron deficiency anemia in at-risk children in pediatric emergency departments (PEDs) across Canada.

METHODS

A standardized survey was mailed to 183 PED physicians at 10 tertiary care PED across Canada. The practices and attitudes regarding screening for iron deficiency anemia were collected via a questionnaire consisting of single select closed-ended items and items which required ranking in order of importance.

RESULTS

Sixty-one percent (111/183) of physicians responded to the survey. Ninety-six percent of respondents do not routinely screen for iron deficiency anemia. One third of respondents believed that screening for iron deficiency anemia in the PED is possible. The remaining stated lack of time, difficulty with follow-up, it not being an emergent issue and cost as prohibitive factors. One third of participants stated that 21% to 40% of the pediatric patients seen in their PED did not have a primary care physician. The main considerations in deciding on whom to perform venipuncture were based on dietary history and physical examination with a history of consumption of milk greater than 24 ounces per day (94%) and conjunctival or skin pallor (97%, 94%, respectively) selected as the most important items.

CONCLUSION

The results of this study indicate that Canadian PED physicians are not routinely screening for iron deficiency anemia, although they demonstrate knowledge of the risk factors for iron deficiency anemia and recognize the importance of diagnosis and treatment to prevent long-term morbidity.

British and Canadian views on the ethics of paediatric clinical trials

BACKGROUND

Ethical problems are quoted as a reason not to perform clinical trials in children. Little is known about the views of researchers regarding ethics.

OBJECTIVES

A pilot study was conducted to assess the applicability of a questionnaire design containing trial scenarios to examine views regarding the use of children in drug trials and to elicit possible international differences.

SETTING

Paediatricians and researchers in the United Kingdom and Canada.

METHODS

Responders were presented with a questionnaire containing direct questions and six trial scenarios, each containing an ethical dilemma. Responders were asked regarding their own approval and their perceived opinion of whether an ethical review board (ERB) would approve.

RESULTS

One hundred questionnaires (50 each country) were received. Few responders had research ethics training (14% United Kingdom and 8% Canada). Most (80 and 88%) felt children could be harmed by participation in trials and half (47 and 59%) felt children should only participate if they receive direct benefit. Many (58 and 61%) disagreed with payments beyond travel expenses. In the trial scenarios, 34% of responders were willing to enter healthy children in a pharmacokinetics study of an antibiotic for cystic fibrosis and 22% considered their ERBs would approve. Only a third (33%) would enter children in an analgesia trial that was placebo-controlled.

CONCLUSION

Using healthy children and placebos in trials caused concern. Similar views were found between the two countries. The majority had no training in research ethics. The study highlights the usefulness of a questionnaire with clinical trial scenarios to try to elicit views on the ethics of conducting research in children.

Counseling regarding pregnancy--related drug exposures by family physicians in Ontario

BACKGROUND

Family physicians may play a significant role in providing information to their patients on the effects of medication exposure during pregnancy. Women must receive accurate information, as unrealistic perception of teratogenic risk may lead to inadequate treatment of maternal disease or termination of otherwise wanted pregnancies.

OBJECTIVES

To collect data on the current practices of family physicians in providing information regarding pregnancy-related drug exposures, in particular, their confidence in providing counseling and their sources of information.

METHODS

A mailed survey was sent to a random sample of family physicians in Ontario. Outcome measures included the proportion of family physicians that feel confident in providing counseling regarding drugs in pregnancy, most common resources, barriers to counseling and preferences for future educational programs.

RESULTS

Of the 756 surveys, 400 (53%) were returned, 265 (66%) by practicing physicians caring for women of childbearing age. Most (80.3%) felt confident in providing counseling, though a majority (56%) stated that available sources of information are not adequate. The most commonly consulted source was the Motherisk Program (62%). Lack of evidence-based information was cited as the major barrier.

CONCLUSIONS

Although family physicians were confident in providing counseling to pregnant patients with regards to drug use, more than one-half thought that the available sources of information are not adequate. The dissemination of more evidence-based information in this field is needed.

Young children's perceptions of physicians wearing standard precautions versus customary attire

OBJECTIVE

The aim of the study was to determine if young children have a preference regarding whether physicians wear standard precautions attire.

METHODS

One hundred ninety-seven children, aged 4 to 8 years, and their parents were recruited from the pediatric emergency department of a tertiary care center. Two sets of 4 photographs-the same man in formal attire, a white coat, greens, and severe acute respiratory syndrome (SARS) standard precautions attire, and the same woman in formal attire, a white coat, greens, and SARS standard precautions attire-were shown to the children and their caregiver. Both were asked which physician's attire he or she liked the most and which he or she liked the least. Parents filled out a questionnaire regarding their experiences in the pediatric emergency department during the SARS epidemic.

RESULTS

The children selected the physician in SARS standard precautions attire as most liked 17.5% of the time and least liked 53.3% of the time. The parents selected the physician in SARS standard precautions attire as most liked 0% of the time and least liked 94.8% of the time.

CONCLUSIONS

Physicians wearing standard precautions attire while working in the pediatric emergency department need to be aware that this attire may negatively impact their relationship with pediatric patients 4 to 8 years of age.

Comparison of verbal claims for natural health products made by health food stores staff versus pharmacists in Ontario, Canada

BACKGROUND

This study tested the hypothesis that while there are no written medical claims existing for many NHP, such claims are made verbally, giving a false impression that these are proven medical products.

OBJECTIVE

To compare the number and type of verbal claims for NHP made by pharmacists to those made by health food stores personnel.

METHODS

Randomly selected Canadian pharmacies selling NHP and health food stores were visited and the staff was asked to recommend natural health products for the treatment of hypertension.

RESULTS

All health food stores (n=20) but only 4 out of 38 pharmacies (p< 0.001) recommended NHP for the treatment of hypertension. A majority of health food store staff (70%) stated that NHP are superior or equal to medicinal drugs in treating hypertension based on efficacy.

CONCLUSION

Unlike pharmacy practice, verbal claims are common practice in health food stores, despite the lack of either written claims and/or proof of efficacy for most of them. These may be a very effective approach given that 30-40% of North American adults are functionally illiterate. These verbal claims are often inappropriate and not evidence-based.

DEET-based insect repellents: safety implications for children and pregnant and lactating women

Reducing the risk of mosquito bites is currently the only way to reduce the risk of West Nile virus infection. Methods for avoiding mosquito bites include limiting the time spent outdoors at dawn and dusk, wearing protective clothing and using an insect repellent. Repellents containing DEET (N,N-diethyl-m-toluamide, also known as N,N-diethyl-3-methylbenzamide) are the most effective and most widely used. However, concerns have been raised over the risk of adverse toxic effects, especially in young children and pregnant and lactating women. In this article, we review the available evidence on the effectiveness and safety of DEET-based products. The evidence does not support increased risk in young children.

Complementary and alternative medicine: how do we know if it works? Time to find out!

The use of complementary and alternative medicine (CAM) in Canada is increasing. This may be due to a variety of factors, including limitations of current therapy and patient perceptions of safety. The increasing use of CAM is exposing large numbers of patients to various forms of CAM Commentary - patients who might be very different from the populations who have traditionally used the type of CAM in question, including children and pregnant women. It is critically important that therapies involving CAM be evaluated for safety, efficacy and cost-effectiveness in order to determine where they might fit in the healthcare system. One potential approach is the creation of a Canadian Institute of Therapeutics, with a broad mandate to evaluate conventional, complementary, alternative and novel therapies. Such an Institute, in partnership with investigators and conventional and CAM practitioners, might provide a focus and impetus for studies to define where CAM and other therapies are best configured in the Canadian healthcare system.

A multicentre prospective controlled study to determine the safety of trazodone and nefazodone use during pregnancy

OBJECTIVES

Trazodone and nefazodone are phenylpiperazine antidepressants. Currently, there are no adequate, well-controlled studies on the fetal safety of these drugs. Our primary objective was to determine whether the use of trazodone or nefazodone during pregnancy is associated with an increased risk for major malformations. Secondary outcomes of interest included rates of spontaneous and therapeutic abortions, rates of premature labour, and birth weight.

METHODS

Pregnant women from 5 centres who had been exposed to these drugs (n = 147) were enrolled in the study during their first trimester. We compared the women with 2 groups of women who took either other antidepressant drugs (n = 147) or nonteratogenic drugs (n = 147). All the women were followed up after delivery to ascertain pregnancy outcome and the health of the baby.

RESULTS

We have completed 147 follow-ups. There were 121 (82.4%) live births, 20 (13.6%) spontaneous abortions, and 6 (4%) therapeutic abortions. Of the live births, there were 2 (1.6%) major malformations. In all cases, drug exposure occurred during the first trimester, with 52 (35%) of the women using these drugs throughout pregnancy. The mean gestational age at birth was 38 weeks (SD 4.2), and the mean birth weight was 3306.34 g (SD 655). We found no statistically significant differences among the 3 groups in any of the endpoints of interest that we examined. Of the sample, 58 women were exposed to trazodone, and 89 were exposed to nefazodone.

CONCLUSION

Our results suggest that these drugs do not increase the rates of major malformations above the baseline rate of 1% to 3%.

Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers

OBJECTIVE

To evaluate the palatability of 4 common flavoring vehicles (water, chocolate milk [CM], orange juice [OJ], and cola) combined with activated charcoal (AC) in pediatric volunteers.

DESIGN

A single-blind taste test of 4 different vehicles (water, OJ, a cola drink, and CM) was conducted in healthy volunteer children. Each child tasted 1.25 mL of Charcodote (0.2g/mL) mixed with 1.25 mL of each vehicle.

SETTING

Palatability testing was conducted at the office of 1 of the authors.

PARTICIPANTS

Thirty children (16 male, 14 female), aged 6.5 +/- 1.4 years (range 5-9 years).

OUTCOME MEASURES

After each test dose, each child rated its taste on a modified 10 cm visual analog scale incorporating a facial-hedonic scale. Each child was also asked for his/her overall preference.

RESULTS

Taste scores (cm) were as follows: water 5.6 +/- 1.8, OJ 5.4 +/- 1.0, cola 7.6 +/- 0.7, and CM 5.6 +/- 0.8. There was a significant difference in the taste scores between the cola drink (P = 0.01) and the other 3 vehicles. The cola drink was also selected as the most preferred vehicle by 50% of the children as compared with 19.2% for CM and 15.4% for OJ. In contrast, water was selected as the least preferred vehicle by 36.4% of children versus 31.8% for CM and 27.3% for OJ. Only 4 children (15.4%) stated that water was their preferred vehicle, and only 1 child (4.5%) stated that cola drink was the least preferred drink.

CONCLUSIONS

Children rate the palatability higher and prefer charcoal given with a cola drink rather than with water. OJ and CM do not seem to improve the acceptability of charcoal.

Pregnancy outcome following gestational exposure to venlafaxine: a multicenter prospective controlled study

OBJECTIVE

Because there are no studies available on the safety of venlafaxine during pregnancy, the authors' goal in this study was to determine whether venlafaxine increases the risk for major malformations.

METHOD

Data on 150 women exposed to venlafaxine during pregnancy in seven pregnancy counseling centers were compared with data from studies of pregnant women who 1) received selective serotonin reuptake inhibitor antidepressants (SSRIs) (N=150) and 2) who received nonteratogenic drugs (N=150).

RESULTS

Among the 150 women who were exposed to venlafaxine during pregnancy, 125 had live births, 18 had spontaneous abortions, and seven had therapeutic abortions; two of the babies had major malformations. There were no significant differences between these women and the two comparison groups on any of the measures analyzed.

CONCLUSIONS

These results suggest that the use of venlafaxine during pregnancy does not increase the rates of major malformations above the baseline rate of 1%-3%.

Multiple antibiotic sensitivity syndrome in children

BACKGROUND

Multiple antibiotic sensitivity syndrome with adverse drug reactions to multiple classes of antibiotics has been described in adults but is not well characterized in children.

PATIENTS AND METHODS

Charts of children referred to the adverse drug reaction clinic at the Children's Hospital of Western Ontario, London, Ontario, with adverse drug reactions to multiple antibiotics were reviewed to determine the number of patients with adverse drug reactions to multiple classes of antibiotics and the clinical characteristics of the adverse events.

RESULTS

The records of 97 children who were selected as possible candidates for multiple antibiotic sensitivity were studied. These records constituted 11% of referrals to a highly specialized adverse drug reaction clinic, suggesting that in usual clinical practice, this entity, if it does indeed constitute a distinct clinical entity, is quite uncommon. Age at time of the first adverse drug reaction was 26.1+/-26.3 (mean +/- SD) months. Among the 97 children, adverse reactions to five classes of antibiotic were noted in 3.1%, to four in 10.3%, to three in 47. 4% and to two in 39.2%. Most children (85.6%) experienced an adverse reaction to a penicillin, while 71.1% reacted to a cephalosporin, 80. 4% to a sulphonamide and 35.1% to a macrolide. Clinical presentations of the adverse reactions included urticaria or pruritus, other rash, serum sickness-like reaction, angioedema or anaphylaxis, erythema multiforme or Stevens-Johnson syndrome.

CONCLUSIONS

There are children who have what appears to be immunologically mediated adverse drug reactions to antibiotics of multiple classes. These reactions, which most commonly manifest as urticaria or other rashes, follow drug use patterns. It remains to be defined whether this is a distinct clinical syndrome or a manifestation of a more fundamental problem in dealing with xenobiotics in the setting of infection. Further work on the immunological and/or biochemical determinants of the multiple antibiotic sensitivity syndrome (MASS) is needed to understand the pathophysiology and determinants of MASS and whether MASS constitutes a distinct clinical entity.