Grading the level of evidence of neonatal pharmacotherapy: midazolam and phenobarbital as examples

Advocating for drug development in newborn infants

Neonatal care needs more robust guidance on pharmacotherapy, (formulation, dosage regimen, safety and efficacy information). This requires structured advocacy. We therefore discuss advocacy related to improving information about medicines including current practices, clinical trials, the current setting, and trial preparedness. This steps can improve neonatal drug development by generating evidence, particularly if a programmatic approach (identify dosing, eligibility criteria, and outcomes) to evidence generation is followed. Trial design should be guided by the intended use of the medicine and the benefits/risks that the study participant is exposed to. Regulatory trials (explanatory, controlled environment, internal validity, endpoints reflect clinically important outcomes, strong causal evidence) are sometimes necessary. However, some research questions are best addressed with informative trials. In either case, trial design can be supported by real world data and evidence, extrapolation from other subpopulations, or physiologically-based pharmacokinetic modeling. Data management, safety reporting, and management of drugs should be specified and proportionate. Trial design and conduct also necessitate awareness of Good Clinical Practice specific to neonates. Relevant aspects include protocol and trial design, research skills and interactions with Ethics Committees or Institutional Research Boards, capacities and competences needed within the research team, and aspects related to consent and recruitment.