Assessing and further developing age-appropriate information for young people about reporting suspected adverse drug reactions

AIMS

The Medicines and Healthcare products Regulatory Agency Yellow Card scheme (YCS) is the UK's system that collects spontaneous reports about suspected adverse drug reactions (ADRs). Reporting of suspected ADRs by young people (age <19 years) in the UK is extremely uncommon, driving efforts to improve awareness and reporting.

METHODS

Quality improvement project, using an anonymous online survey about updated information for young people, distributed through school pupils (age 13-18 years) across the UK through the Alder Hey Research Ambassador programme.

RESULTS

Research Ambassadors were recruited in 21 schools and colleges, generating 2933 responses (15 November 2022-08 April 2023); 6.3% of respondents had heard of the YCS, and 0.8% had previously reported a Yellow Card. There were 307 suspected drug-event combinations reported, 36 of which required attendance at hospital. The updated YCS reporting guide was understood by 92.8% of young people, and 90.8% reported knowing more about ADRs after reading the guide. The percentage of young people 'Not comfortable' reporting a suspected ADR decreased from 13.3% (before reading) to 4.1% after reading (P < .000001), and 84.5% of young people reported willingness to report a side effect in the future. The most common comments regarding further improvement of the information were content, or length of the text could be altered in some way (n = 543, 26.1%) and graphic design could be improved (n = 357, 17.2%).

CONCLUSIONS

The age-appropriate information provided met many of their needs, increasing willingness to report. Integration into existing education curricula in the UK would facilitate knowledge transfer and improve reporting.

Impact of indoor environment on children's pulmonary health

INTRODUCTION

A child's living environment has a significant impact on their respiratory health, with exposure to poor indoor air quality (IAQ) contributing to potentially lifelong respiratory morbidity. These effects occur throughout childhood, from the antenatal period through to adolescence. Children are particularly susceptible to the effects of environmental insults, and children living in socioeconomic deprivation globally are more likely to breathe air both indoors and outdoors, which poses an acute and long-term risk to their health. Adult respiratory health is, at least in part, determined by exposures and respiratory system development in childhood, starting in utero.

AREAS COVERED

This narrative review will discuss, from a global perspective, what contributes to poor IAQ in the child's home and school environment and the impact that indoor air pollution exposure has on respiratory health throughout the different stages of childhood.

EXPERT OPINION

All children have the right to a living and educational environment without the threat of pollution affecting their health. Action is needed at multiple levels to address this pressing issue to improve lifelong respiratory health. Such action should incorporate a child's rights-based approach, empowering children, and their families, to have access to clean air to breathe in their living environment.

20 years on - the measurement of blood pressure and detection of hypertension in children and adolescents: a national descriptive survey

In 1997 a survey identified a general lack of standardisation of blood pressure (BP) measurement and little consensus on the criteria for diagnosing hypertension amongst paediatricians. We have conducted a new online survey in 2021, to compare clinical practice between the two time periods. A national quality improvement survey was approved by the GAPRUKI committee and then circulated to consultant-grade general paediatricians. 125 analysable replies from 34 different sites were received and compared with the 1997 data. 106 (84.8%) reported clinic nurse involvement in BP measurement, more than twice than reported previously (40.6%). Most paediatricians (53.6%) now rely on oscillometric devices, whereas the mercury sphygmomanometer was favoured previously (82.7%). If assessing BP manually (n = 89), most (79.8%) now use Korotkoff phase V as the auscultatory endpoint for diastolic BP (phase IV was previously used (52.1%)). Diagnostic criteria of hypertension, the criteria (≥95th centile for gender, age and height) were constant, and 100% of paediatricians diagnosed it using systolic BP, but only 43 (34.4%) used diastolic BP, a decrease from 79.4% previously. Ambulatory BP Monitoring was six times more available than in 1997 (81.6% vs 13.6%). Similar to previous findings, only 12 (9.6%) paediatricians would manage hypertensive patients themselves, however 82 (72.6%) would keep general paediatric input. There have been important changes in the assessment of BP in children, including increased nurse involvement and greater use of technology. However, fewer paediatricians are responding to high diastolic pressures than twenty years ago.

Laser-cutting: A novel alternative approach for point-of-care manufacturing of bespoke tablets

A novel subtractive manufacturing method to produce bespoke tablets with immediate and extended drug release is presented. This is the first report on applying fusion laser cutting to produce bespoke furosemide solid dosage forms based on pharmaceutical-grade polymeric carriers. Cylindric tablets of different sizes were produced by controlling the two-dimensional design of circles of the corresponding diameter. Immediate and extended drug release patterns were achieved by modifying the composition of the polymeric matrix. Thermal analysis and XRD indicated that furosemide was present in an amorphous form. The laser-cut tablets demonstrated no significant drug degradation (<2%) nor the formation of impurities were identified. Multi-linear regression was used to quantify the influences of laser-cutting process parameters (laser energy levels, scan speeds, and the number of laser applications) on the depth of the laser cut. The utility of this approach was exemplified by manufacturing tablets of accurate doses of furosemide. Unlike additive or formative manufacturing, the reported approach of subtractive manufacturing avoids the modification of the structure, e.g., the physical form of the drug or matrix density of the tablet during the production process. Hence, fusion laser cutting is less likely to modify critical quality attributes such as release patterns or drug contents. In a point-of-care manufacturing scenario, laser cutting offers a significant advantage of simplifying quality control and a real-time release of laser-cut products such as solid dosage forms and implants.

Participant perceptions and experiences of a novel community-based respiratory longitudinal sampling method in Liverpool, UK: A mixed methods feasibility study

Longitudinal, community-based sampling is important for understanding prevalence and transmission of respiratory pathogens. Using a minimally invasive sampling method, the FAMILY Micro study monitored the oral, nasal and hand microbiota of families for 6 months. Here, we explore participant experiences and opinions. A mixed methods approach was utilised. A quantitative questionnaire was completed after every sampling timepoint to report levels of discomfort and pain, as well as time taken to collect samples. Participants were also invited to discuss their experiences in a qualitative structured exit interview. We received questionnaires from 36 families. Most adults and children >5y experienced no pain (94% and 70%) and little discomfort (73% and 47% no discomfort) regardless of sample type, whereas children ≤5y experienced variable levels of pain and discomfort (48% no pain but 14% hurts even more, whole lot or worst; 38% no discomfort but 33% moderate, severe, or extreme discomfort). The time taken for saliva and hand sampling decreased over the study. We conducted interviews with 24 families. Families found the sampling method straightforward, and adults and children >5y preferred nasal sampling using a synthetic absorptive matrix over nasopharyngeal swabs. It remained challenging for families to fit sampling into their busy schedules. Adequate fridge/freezer space and regular sample pick-ups were found to be important factors for feasibility. Messaging apps proved extremely effective for engaging with participants. Our findings provide key information to inform the design of future studies, specifically that self-sampling at home using minimally invasive procedures is feasible in a family context.

Assessing the use of minimally invasive self-sampling at home for long-term monitoring of the microbiota within UK families

Monitoring the presence of commensal and pathogenic respiratory microorganisms is of critical global importance. However, community-based surveillance is difficult because nasopharyngeal swabs are uncomfortable and painful for a wide age range of participants. We designed a methodology for minimally invasive self-sampling at home and assessed its use for longitudinal monitoring of the oral, nasal and hand microbiota of adults and children within families. Healthy families with two adults and up to three children, living in and near Liverpool, United Kingdom, self-collected saliva, nasal lining fluid using synthetic absorptive matrices and hand swabs at home every two weeks for six months. Questionnaires were used to collect demographic and epidemiological data and assess feasibility and acceptability. Participants were invited to take part in an exit interview. Thirty-three families completed the study. Sampling using our approach was acceptable to 25/33 (76%) families, as sampling was fast (76%), easy (76%) and painless (60%). Saliva and hand sampling was acceptable to all participants of any age, whereas nasal sampling was accepted mostly by adults and children older than 5 years. Multi-niche self-sampling at home can be used by adults and children for longitudinal surveillance of respiratory microorganisms, providing key data for design of future studies.

Emergency diagnosis made easy: matrix removal and analyte enrichment from raw saliva using paper-arrow mass spectrometry

Paracetamol overdose is a leading cause of acute liver failure that can prove fatal. Establishing paracetamol concentration accurately and quickly is critical. Current detection methods are invasive, time-consuming and/or expensive. Non-invasive, rapid and cost-effective techniques are urgently required. To address this challenge, a novel approach, called Paper-Arrow Mass Spectrometry (PA-MS) has been developed. This technique combines sample collection, extraction, enrichment, separation and ionisation onto a single paper strip, and the entire analysis process, from sample to result, can be carried out in less than 10 min requiring only 2 μL of raw human saliva. PA-MS achieved a LOQ of 185 ng mL-1, mean recovery of 107 ± 7%, mean accuracy of 11 ± 8% and precision ≤5% using four concentrations, and had excellent linearity (r2 = 0.9988) in the range of 0.2-200 μg mL-1 covering the treatment concentration range, surpassing the best-in-class methods currently available for paracetamol analysis. Furthermore, from a panel of human saliva samples, inter-individual variability was found to be <10% using this approach. This technique represents a promising tool for rapid and accurate emergency diagnosis.

The readability of parent information leaflets in paediatric studies

BACKGROUND

Poor literacy can impact achieving optimal health outcomes. The aim of this project was to assess the readability of parent information leaflets (PILs).

METHODS

A single-centre study using paediatric PILs. Five readability tests were applied (Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), Flesch Kincaid Grade Level (FKGL), Coleman-Liau Index (CLI) and Automated Readability Index (ARI)). Results were compared to standards and by subtype.

RESULTS

A total of 109 PILs were obtained; mean (±SD) number of characters was 14,365 (±12,055), total words 3066 (±2541), number of sentences 153 (±112), lexical density 49 (±3), number of characters per word 4.7 (±0.1), number of syllables per word 1.6 (±0.1) and number of words per sentence 19.1 (±2.5). The Flesch reading ease score was 51.1 (±5.6), equating to reading age 16-17 years. The mean PIL readability scores were GFI (12.18), SMOG (11.94), FKGL (10.89), CLI (10.08) and ARI (10.1). There were 0 (0%) PILs classed as easy (score <6), 21 (19%) mid-range (6-10) and 88 (81%) were difficult (>10). They were significantly above the recommended reading age (p < 0.0001) and commercial studies were least accessible (p < 0.01).

CONCLUSION

Existing PILs are above the national reading level. Researchers should use readability tools to ensure that they are accessible.

IMPACT

Poor literacy is a barrier to accessing research and achieving good health outcomes. Current parent information leaflets are pitched far higher than the national reading age. This study provides data to demonstrate the reading age of a large portfolio of research studies. This work raises awareness of literacy as a barrier to research participation and provides tips on how to improve the readability of patient information leaflets to guide investigators.

The impact of poor housing and indoor air quality on respiratory health in children

It is becoming increasingly apparent that poor housing quality affects indoor air quality, significantly impacting on respiratory health in children and young people. Exposure to damp and/or mould in the home, cold homes and the presence of pests and pollutants all have a significant detrimental impact on child respiratory health. There is a complex relationship between features of poor-quality housing, such as being in a state of disrepair, poor ventilation, overcrowding and being cold, that favour an environment resulting in poor indoor air quality. Children living in rented (private or public) housing are more likely to come from lower-income backgrounds and are most at risk of living in substandard housing posing a serious threat to respiratory health. Children have the right to safe and adequate housing, and research has shown that either rehousing or making modifications to poor-quality housing to improve indoor air quality results in improved respiratory health. Urgent action is needed to address this threat to health. All stakeholders should understand the relationship between poor-quality housing and respiratory health in children and act, working with families, to redress this modifiable risk factor.

Educational aims

The reader should understand how housing quality and indoor air quality affect respiratory health in children.The reader should understand which children are at most risk of living in poor-quality housing.The reader should understand what policy recommendations have been made and what actions need to be undertaken to improve housing quality and respiratory health in children and young people.

For children admitted to hospital, what interventions improve medication safety on ward rounds? A systematic review

OBJECTIVE

Every year, medication errors harm children in hospitals. Ward rounds are a unique opportunity to bring information together and plan management. There is a need to understand what strategies can improve medication safety on ward rounds. We systematically reviewed published interventions to improve prescribing and safety of medicines on ward rounds.

DESIGN

Systematic review of randomised controlled trials and observational studies.

SETTING

Studies examining inpatient ward rounds.

PATIENTS

Children and young people aged between 0 and 18 years old.

INTERVENTIONS

Any intervention or combination of interventions implemented that alters how paediatric ward rounds review inpatient medications.

MAIN OUTCOME MEASURE

Primary outcome was improvement in medication safety on paediatric ward rounds. This included reduction in prescribing error rates, healthcare professionals' opinions on prescribing and improvement in documentation on ward rounds.

RESULTS

Three studies were eligible for review. One examined the use of an acrostic, one the use of a checklist, and the other a use of a specific prescribing ward round involving a clinical pharmacist and doctor. None of the papers considered weight-based errors or demonstrated reductions in clinical harm. Reductions in prescribing errors were noted by the different interventions.

CONCLUSIONS

There are limited data on interventions to improve medication safety in paediatric ward rounds, with all published data being small scale, either quality improvement or audits, and locally derived/delivered. Good-quality interventional or robust quality improvement studies are required to improve medication safety on ward rounds.

PROSPERO REGISTRATION NUMBER

CRD42022340201.

Hypertension in Turner syndrome: a review of proposed mechanisms, management and new directions

Acquired cardiovascular diseases account for much of the increased risk of premature death in patients with Turner syndrome (TS). Hypertension is a major modifiable cardiovascular risk factor. It has a high prevalence in TS developing at an early age and thus leading to prolonged exposure to high blood pressure. The aetiology for hypertension in TS is largely unknown. It is likely multifactorial, and recent hypotheses include altered sympathetic tone, vasculopathy and endocrine factors. In this review article we aim to provide a comprehensive review of data on mechanisms of hypertension in TS and their implication for diagnostics and optimal choice of antihypertensive treatments. Ultimately this knowledge should help prevent hypertension-related complications, and improve quality of life and life expectancy for patients with TS.

Assessing Paracetamol Overdose in Children: Acceptability and Potential Market for a Non-Invasive Testing Device

Background

Assessment of paracetamol overdose in children and teenagers in the emergency department (ED) requires blood, taken 4 hours post ingestion. A commercial partner developed transdermal paracetamol measuring technology. This work aims to understand the acceptability of such a device, and potential market size.

Methods

A questionnaire study was undertaken with children and parents attending Alder Hey Children's Hospital, and healthcare professionals (HCP) involved in their care. A retrospective audit of paracetamol ingestion presenting to a paediatric ED was undertaken.

Results

One hundred forty-three questionnaires were distributed, and 139 returned (response rate 97.2%), comprising 55 children, 52 parents and 32 HCP (recruited between August-October 2019). Overall device acceptability, assessed by favourability of appearance and willingness to wear was high, at 60.0% and 81.5% respectively. Concerns raised included bulky size and weight, and concern regarding the duration younger children would tolerate wearing the device. All groups, including children, ranked accuracy of results as the most important device feature and device comfort the least important. Parents prioritised avoidance of blood tests more than children. One hundred twenty-seven children presented to ED with paracetamol ingestion (September 2017-August 2018), with 57 (44.9%) categorised as accidental overdose. Overall, 106 (83.4%) required paracetamol concentration measuring, and 25 (19.7%) of these required treatment with N-acetylcysteine. Extrapolating nationally, over 7000 children will present with accidental overdose per annum in the UK.

Conclusion

Acceptability of a non-invasive paracetamol sensor was high in all groups, provided accuracy could be assured.

Genome-wide analyses of platinum-induced ototoxicity in childhood cancer patients: Results of GO-CAT and United Kingdom MAGIC consortia

Hearing loss (ototoxicity) is a major adverse effect of cisplatin and carboplatin chemotherapy. The aim of this study is to identify novel genetic variants that play a role in platinum-induced ototoxicity. Therefore, a genome-wide association study was performed in the Genetics of Childhood Cancer Treatment (GO-CAT) cohort (n = 261) and the United Kingdom Molecular Genetics of Adverse Drug Reactions in Children Study (United Kingdom MAGIC) cohort (n = 248). Results of both cohorts were combined in a meta-analysis. In primary analysis, patients with SIOP Boston Ototoxicity Scale grade ≥1 were considered cases, and patients with grade 0 were controls. Variants with a p-value <10^-5 were replicated in previously published data by the PanCareLIFE cohort (n = 390). No genome-wide significant associations were found, but variants in TSPAN5, RBBP4P5, AC010090.1 and RNU6-38P were suggestively associated with platinum-induced ototoxicity. The lowest p-value was found for rs7671702 in TSPAN5 (odds ratio 2.0 (95% confidence interval 1.5-2.7), p-value 5.0 × 10^-7). None of the associations were significant in the replication cohort, although the effect directions were consistent among all cohorts. Validation and functional understanding of these genetic variants could lead to more insights in the development of platinum-induced ototoxicity.

Ibuprofen efficacy, tolerability and safety in obese children: a systematic review

OBJECTIVE

Childhood obesity can affect drug disposition and efficacy of ibuprofen. The primary objective was to assess efficacy of ibuprofen in obese children.

DESIGN

A systematic review was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Studies were identified from 12 databases. Two independent reviewers evaluated studies against the inclusion criteria and assessed for methodological quality.

SETTING

Any clinical setting.

PATIENTS

Patients under 18 years who were overweight/obese.

INTERVENTIONS

Patients taking ibuprofen for any indication, dose or regimen.

MAIN OUTCOME MEASURES

The efficacy and tolerability of ibuprofen treatment in obese children and presence of any adverse drug reactions.

RESULTS

Searches identified 1305 studies. Four studies met inclusion criteria: three retrospective cohort studies (n=583, median age: 6 years, range: 1-18 years; n=200, median age: 11 years, range: 3-18 years; n=358 median age: 3.1 years, range: 1.2-8.5 years, respectively) and one case study. Each study differed in their method of dosing ibuprofen (weight-based, age-based and adjusted body weight dosing). Various doses were used: 5 mg/kg every 6 hours, 400 mg three times a day, 120 mg/dose and a dose calculated using adjusted body weight. One study reported efficacy (obese n=189, non-obese, n=394), where adequate pain control was achieved using 5 mg/kg. The other three studies did not determine if efficacy differed between obese and non-obese children.One study described adverse effects. An increased risk of bleeding with ibuprofen was noted but did not differentiate between obese and non-obese children.

CONCLUSION

There are little published data to guide clinicians prescribing ibuprofen in obese children.

PROSPERO REGISTRATION NUMBER

CRD42021213500.

Platelet-derived growth factor D expression in adrenal cells is modulated by corticosteroids: putative role in adrenal suppression

BACKGROUND

Adrenal suppression is a clinically concerning side effect of inhaled corticosteroid (ICS) treatment in patients with asthma. Increased susceptibility to ICS-induced adrenal suppression has previously been identified in those with the rs591118 polymorphism in platelet-derived growth factor D (PDGFD). The mechanism underpinning this relationship is not known.

METHODS

H295R cells were genotyped for rs591118 using a validated Taqman PCR allelic discrimination assay. H295R cell viability was determined after treatment with beclometasone and fluticasone (range 0-330 μM). Cortisol was measured in cell culture medium using competitive enzyme immunoassay.

RESULTS

PDGFD protein expression in H295R cells was confirmed using Western blotting. When ACTH and forskolin were added to H295R cells, a reduction in PDGFD expression was seen, which was then restored by incubation with prochloraz, a known inhibitor of steroidogenesis. A dose-dependent, decrease in PDGFD expression was observed with beclometasone (over a 24 h incubation period) but not with beclometasone incubations beyond 24 h nor with fluticasone (at 24 or 48 h).

CONCLUSIONS

H295R cells express PDGFD protein, which can be modulated by incubation with steroidogenesis agonists and antagonists and additionally with exogenous beclometasone.

IMPACT

PDGFD is expressed in the human adrenal cell line, H295R, and expression can be modulated by beclometasone as well as agonists/antagonists of steroidogenesis. This builds on previous research that identified a SNP in PDGFD (rs591118) as an independent risk factor for adrenal suppression in adults and children with obstructive airway disease treated with inhaled corticosteroids. First in vitro experiments to support a link between the PDGF and cortisol production pathways, supporting the hypothesis that PDGFD variants can affect an individual's sensitivity to corticosteroid-induced adrenal suppression.

Factors Associated With Diabetic Ketoacidosis at Onset of Type 1 Diabetes Among Pediatric Patients: A Systematic Review

IMPORTANCE

Presenting with diabetic ketoacidosis (DKA) at onset of type 1 diabetes (T1D) remains a risk. Following a 2011 systematic review, considerable additional articles have been published, and the review required updating.

OBJECTIVE

To evaluate factors associated with DKA at the onset of T1D among pediatric patients.

EVIDENCE REVIEW

In this systematic review, PubMed, Embase, Scopus, CINAHL, Web of Science, and article reference lists were searched using the population, intervention, comparison, outcome search strategy for primary research studies on DKA and T1D onset among individuals younger than 18 years that were published from January 2011 to November 2021. These studies were combined with a 2011 systematic review on the same topic. Data were pooled using a random-effects model.

FINDINGS

A total of 2565 articles were identified; 149 were included, along with 46 from the previous review (total 195 articles). Thirty-eight factors were identified and examined for their association with DKA at T1D onset. Factors associated with increased risk of DKA were younger age at T1D onset (<2 years vs ≥2 years; odds ratio [OR], 3.51; 95% CI, 2.85-4.32; P < .001), belonging to an ethnic minority population (OR, 0.40; 95% CI, 0.21-0.74; P = .004), and family history of T1D (OR, 0.46; 95% CI, 0.37-0.57; P < .001), consistent with the 2011 systematic review. Some factors that were not associated with DKA in the 2011 systematic review were associated with DKA in the present review (eg, delayed diagnosis: OR, 2.27; 95% CI, 1.72-3.01; P < .001). Additional factors associated with risk of DKA among patients with new-onset T1D included participation in screening programs (OR, 0.35; 95% CI, 0.21-0.59; P < .001) and presentation during the COVID-19 pandemic (OR, 2.32; 95% CI, 1.76-3.06; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, age younger than 2 years at T1D onset, belonging to an ethnic minority population, delayed diagnosis or misdiagnosis, and presenting during the COVID-19 pandemic were associated with increased risk of DKA. Factors associated with decreased risk of DKA included greater knowledge of key signs or symptoms of DKA, such as a family history of T1D or participation in screening programs. Future work should focus on identifying and implementing strategies related to these factors to reduce risk of DKA among new patients with T1D.

Improving the experience of obtaining repeat complex paediatric prescriptions in the UK

In the UK, medicines for chronic conditions in children and young people (CYP) are typically initiated within secondary or tertiary care, with responsibility for ongoing supply often then passed to the child's general practitioner (GP) and community pharmacist. The patient should then be reviewed in regular specialist clinics, with two-way communication for any changes in medications or clinical status undertaken between primary and secondary/tertiary care. This arrangement allows long-term medications to be obtained close to home.Although this is what parents expect, the reality is often messy, with families regularly needing to source some medicines from the GPs and others via hospitals or homecare services. In addition, these arrangements are not uniform, they vary across different areas of the UK and depend on individual GP or hospital prescriber acceptance. When neither primary, secondary or tertiary care accepts it is their responsibility to prescribe, or patients are under multiple specialists, families often feel left to navigate this complex and variable supply system themselves. Obtaining a prescription is only the start of the process for families as dispensing from a community pharmacy can also be challenging.In this article, we set out the barriers and potential solutions to this complex issue. We use the term specialist prescribers to include not only paediatricians but all other specialists looking after CYP including child and adolescent psychiatrists, ophthalmologists, dermatologists, surgeons, etc, as well as non-medical prescribers.

Information for children and young people about reporting suspected adverse drug reactions

BACKGROUND

When children and young people (CYP) report their own suspected adverse drug reactions (ADRs), different patterns of drugs and symptoms are noted. A new guide to reporting suspected ADRs using the Medicines and Healthcare Products Regulatory Agency (MHRA) Yellow Card scheme was developed by CYP, paediatric clinical pharmacology, Yellow Card Centres and the MHRA.

METHODS

An anonymous quality improvement project to assess the guide for CYP was undertaken (September 2020-February 2021).

RESULTS

The survey was completed by 234 CYP age 13-18 years. Within respondents, 68/226 (30.1%) were using medicines, 209/225 (92.9%) had used medicines previously, and 211/225 (93.8%) had heard of side effects. 79/225 (35.1%) believed they had experienced a side effect, with some requiring hospitalisation. Only 8/221 (3.6%) respondents were aware of the MHRA Yellow Card scheme.Overall, 182/196 (92.9%) of CYP both understood the guide and felt more knowledgeable about how to report suspected side effects. CYP comfortable to report their own suspected ADR increased from 179/222 (80.6%) before reading guide, to 189/196 (96.4%) after reading the new CYP guide. In addition, 156/196 (79.6%) believed they would report a side effect from a medicine used in future. Over 360 free-text comments were also received, providing comments about what was good about the new guide and areas for improvement that could be made.

CONCLUSION

The new guide for CYP to inform them about how to report a suspected ADR to the MHRA was well received and increased the knowledge, and confidence to report, in those who responded.

Multi-ancestry genome-wide association study of asthma exacerbations

BACKGROUND

Asthma exacerbations are a serious public health concern due to high healthcare resource utilization, work/school productivity loss, impact on quality of life, and risk of mortality. The genetic basis of asthma exacerbations has been studied in several populations, but no prior study has performed a multi-ancestry meta-analysis of genome-wide association studies (meta-GWAS) for this trait. We aimed to identify common genetic loci associated with asthma exacerbations across diverse populations and to assess their functional role in regulating DNA methylation and gene expression.

METHODS

A meta-GWAS of asthma exacerbations in 4989 Europeans, 2181 Hispanics/Latinos, 1250 Singaporean Chinese, and 972 African Americans analyzed 9.6 million genetic variants. Suggestively associated variants (p ≤ 5 × 10^-5 ) were assessed for replication in 36,477 European and 1078 non-European asthma patients. Functional effects on DNA methylation were assessed in 595 Hispanic/Latino and African American asthma patients and in publicly available databases. The effect on gene expression was evaluated in silico.

RESULTS

One hundred and twenty-six independent variants were suggestively associated with asthma exacerbations in the discovery phase. Two variants independently replicated: rs12091010 located at vascular cell adhesion molecule-1/exostosin like glycosyltransferase-2 (VCAM1/EXTL2) (discovery: odds ratio (OR_{T allele} ) = 0.82, p = 9.05 × 10^-6 and replication: OR_{T allele}  = 0.89, p = 5.35 × 10^-3 ) and rs943126 from pantothenate kinase 1 (PANK1) (discovery: OR_{C allele}  = 0.85, p = 3.10 × 10^-5 and replication: OR_{C allele}  = 0.89, p = 1.30 × 10^-2 ). Both variants regulate gene expression of genes where they locate and DNA methylation levels of nearby genes in whole blood.

CONCLUSIONS

This multi-ancestry study revealed novel suggestive regulatory loci for asthma exacerbations located in genomic regions participating in inflammation and host defense.

Pharmacogenomics and asthma treatment: acceptability to children, families and healthcare professionals

BACKGROUND

Evidence supporting personalised treatment for asthma based on an individual's genetics is mounting. The views of children and young people (CYP), parents and healthcare professionals (HCPs) about this evolution of clinical care are not known.

METHODS

A pilot prospective questionnaire-based study was undertaken of CYP with asthma, their parents and HCPs at a secondary/tertiary children's hospital in the UK.

RESULTS

Fifty-nine questionnaires were distributed and 50 returned (response rate 84.7%), comprising 26 CYP (10 were 5-11 years, 11 were 12-15 years and 5 were 16-18 years old), 13 parents and 11 HCPs. For all types of data, personal information was ranked as the 'most important' (n=19, 47.5%) and 'most private' (n=16, 40%), but with considerable variation across groups. Within health data, allergies were rated as 'most important' (n=12, 30.8%), and mental health records the 'most private' (n=21, 53.8%), again with variation across groups. A 'personalised genetic asthma plan' was acceptable to the majority overall (n=40, 80.0%). With regard to sharing CYP's genetic data, 23 (46%) of participants were happy for unconditional sharing between HCPs, and 23 (46%) agreed to sharing solely in relation to the CYP's asthma management. Forty-two (84.0%) of participants felt CYP should be informed about genetic data being shared, and the majority felt this should commence by 12 years of age.

CONCLUSION

The use of genetic information to guide management of asthma in CYP is largely acceptable to CYP, parents/guardians and HCPs. However, there are key differences between the opinions of CYP, parents and HCPs.

Deprescribing montelukast in children with asthma: a systematic review

BACKGROUND

National and international asthma guidelines recommend adjusting asthma treatment based on levels of control, yet no guidance is given regarding the stepping-down of montelukast in children and young people (CYP).

OBJECTIVE

To systematically review evidence regarding deprescribing montelukast in CYP with established asthma.

DESIGN

Systematic review.

DATA SOURCES

Embase, Medline, PubMed and CINAHL were searched up to October 2020.

STUDY SELECTION

Eligible studies contained patients aged 0-18 years with a diagnosis of asthma, who had been administering montelukast before it was withdrawn. All reasons for withdrawal were included.

RESULTS

The search identified 197 papers. After deduplication, five papers were included (three randomised control studies and two cohort studies). Four studies observed the impact of montelukast withdrawal for 2 weeks, and one study for 8 weeks. The impact of withdrawal was measured in the studies using a combination of lung tests (eg, forced expiratory volume in 1 s (FEV1), fractional exhaled nitric oxide (FeNO)), asthma scoring methods and exercise challenges. Of the 17 domains in the Core Outcome Set for Clinical Trials in Childhood Asthma, eight outcomes were measured in at least one of the five studies, with all five studies measuring the outcome of 'Lung Function'. No significant differences were found between the montelukast and placebo groups following montelukast withdrawal. Significant differences between the comparator points within the test group were found in nine outcomes across four studies; FEV1/forced vital capacity, FEV1, forced expiratory flows (25%-75%), asthma score (study specific), maximum % fall in FEV1 and time to recovery (post exercise) significantly decreased whereas FEV1/bronchodilator response, FeNO and eNO significantly increased.

CONCLUSION

Only limited, contradictory and short-term effects of deprescribing montelukast in CYP with established asthma are presented in literature. Definitive studies determining clinical stability, and impact of deprescribing montelukast in CYP are imperative to improve the safety of asthma treatment in CYP.

PROSPERO REGISTRATION NUMBER

CRD42020213971.

How paediatric drug development and use could benefit from OMICs: a c4c expert group white paper

The safety and efficacy of pharmacotherapy in children, particularly preterms, neonates, and infants, is limited by a paucity of good quality data from prospective clinical drug trials. A specific challenge is the establishment of valid biomarkers. OMICs technologies may support these efforts, by complementary information about targeted and non-targeted molecules through systematic characterization and quantitation of biological samples. OMICs technologies comprise at least genomics, epigenomics, transcriptomics, proteomics, metabolomics, and microbiomics in addition to the patient's phenotype. OMICs technologies are in part hypothesis-generating allowing an in depth understanding of disease pathophysiology and pharmacological mechanisms. Application of OMICs technologies in paediatrics faces major challenges before routine adoption. First, developmental processes need to be considered, including a sub-division into specific age groups as developmental changes clearly impact OMICs data. Second, compared to the adult population, the number of patients is limited as well as type and amount of necessary biomaterial, especially in neonates and preterms. Thus, advanced trial designs and biostatistical methods, non-invasive biomarkers, innovative biobanking concepts including data and samples from healthy children, as well as analytical approaches (e.g. liquid biopsies) should be addressed to overcome these obstacles. The ultimate goal is to link OMICs technologies with innovative analysis tools, like artificial intelligence at an early stage. The use of OMICs data based on a feasible approach will contribute to identify complex phenotypes and subpopulations of patients to improve development of medicines for children with potential economic advantages.

Pharmacogenomic testing in paediatrics: clinical implementation strategies

Pharmacogenomics (PGx) relates to the study of genetic factors determining variability in drug response. Implementing PGx testing in paediatric patients can enhance drug safety, helping to improve drug efficacy or reduce the risk of toxicity. Despite its clinical relevance, the implementation of PGx testing in paediatric practice to date has been variable and limited.

As with most paediatric pharmacological studies, there are well‐recognised barriers to obtaining high‐quality PGx evidence, particularly when patient numbers may be small, and off‐label or unlicensed prescribing remains widespread. Furthermore, trials enrolling small numbers of children can rarely, in isolation, provide sufficient PGx evidence to change clinical practice, so extrapolation from larger PGx studies in adult patients, where scientifically sound, is essential.

This review paper discusses the relevance of PGx to paediatrics and considers implementation strategies from a child health perspective. Examples are provided from Canada, the Netherlands and the UK, with consideration of the different healthcare systems and their distinct approaches to implementation, followed by future recommendations based on these cumulative experiences.

Improving the evidence base demonstrating the clinical utility and cost‐effectiveness of paediatric PGx testing will be critical to drive implementation forwards. International, interdisciplinary collaborations will enhance paediatric data collation, interpretation and evidence curation, while also supporting dedicated paediatric PGx educational initiatives. PGx consortia and paediatric clinical research networks will continue to play a central role in the streamlined development of effective PGx implementation strategies to help optimise paediatric pharmacotherapy.

Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial

IMPORTANCE

The optimal dose and duration of oral amoxicillin for children with community-acquired pneumonia (CAP) are unclear.

OBJECTIVE

To determine whether lower-dose amoxicillin is noninferior to higher dose and whether 3-day treatment is noninferior to 7 days.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, randomized, 2 × 2 factorial noninferiority trial enrolling 824 children, aged 6 months and older, with clinically diagnosed CAP, treated with amoxicillin on discharge from emergency departments and inpatient wards of 28 hospitals in the UK and 1 in Ireland between February 2017 and April 2019, with last trial visit on May 21, 2019.

INTERVENTIONS

Children were randomized 1:1 to receive oral amoxicillin at a lower dose (35-50 mg/kg/d; n = 410) or higher dose (70-90 mg/kg/d; n = 404), for a shorter duration (3 days; n = 413) or a longer duration (7 days; n = 401).

MAIN OUTCOMES AND MEASURES

The primary outcome was clinically indicated antibiotic re-treatment for respiratory infection within 28 days after randomization. The noninferiority margin was 8%. Secondary outcomes included severity/duration of 9 parent-reported CAP symptoms, 3 antibiotic-related adverse events, and phenotypic resistance in colonizing Streptococcus pneumoniae isolates.

RESULTS

Of 824 participants randomized into 1 of the 4 groups, 814 received at least 1 dose of trial medication (median [IQR] age, 2.5 years [1.6-2.7]; 421 [52%] males and 393 [48%] females), and the primary outcome was available for 789 (97%). For lower vs higher dose, the primary outcome occurred in 12.6% with lower dose vs 12.4% with higher dose (difference, 0.2% [1-sided 95% CI -∞ to 4.0%]), and in 12.5% with 3-day treatment vs 12.5% with 7-day treatment (difference, 0.1% [1-sided 95% CI -∞ to 3.9]). Both groups demonstrated noninferiority with no significant interaction between dose and duration (P = .63). Of the 14 prespecified secondary end points, the only significant differences were 3-day vs 7-day treatment for cough duration (median 12 days vs 10 days; hazard ratio [HR], 1.2 [95% CI, 1.0 to 1.4]; P = .04) and sleep disturbed by cough (median, 4 days vs 4 days; HR, 1.2 [95% CI, 1.0 to 1.4]; P = .03). Among the subgroup of children with severe CAP, the primary end point occurred in 17.3% of lower-dose recipients vs 13.5% of higher-dose recipients (difference, 3.8% [1-sided 95% CI, -∞ to10%]; P value for interaction = .18) and in 16.0% with 3-day treatment vs 14.8% with 7-day treatment (difference, 1.2% [1-sided 95% CI, -∞ to 7.4%]; P value for interaction = .73).

CONCLUSIONS AND RELEVANCE

Among children with CAP discharged from an emergency department or hospital ward (within 48 hours), lower-dose outpatient oral amoxicillin was noninferior to higher dose, and 3-day duration was noninferior to 7 days, with regard to need for antibiotic re-treatment. However, disease severity, treatment setting, prior antibiotics received, and acceptability of the noninferiority margin require consideration when interpreting the findings.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN76888927.

ADRB2 haplotypes and asthma exacerbations in children and young adults: An individual participant data meta-analysis

BACKGROUND

The polymorphism Arg16 in β2 -adrenergic receptor (ADRB2) gene has been associated with an increased risk of exacerbations in asthmatic children treated with long-acting β2 -agonists (LABA). However, it remains unclear whether this increased risk is mainly attributed to this single variant or the combined effect of the haplotypes of polymorphisms at codons 16 and 27.

OBJECTIVE

We assessed whether the haplotype analysis could explain the association between the polymorphisms at codons 16 (Arg16Gly) and 27 (Gln27Glu) in ADRB2 and risk of asthma exacerbations in patients treated with inhaled corticosteroids (ICS) plus LABA.

METHODS

The study was undertaken using data from 10 independent studies (n = 5903) participating in the multi-ethnic Pharmacogenomics in Childhood Asthma (PiCA) consortium. Asthma exacerbations were defined as asthma-related use of oral corticosteroids or hospitalizations/emergency department visits in the past 6 or 12 months prior to the study visit/enrolment. The association between the haplotypes and the risk of asthma exacerbations was performed per study using haplo.stats package adjusted for age and sex. Results were meta-analysed using the inverse variance weighting method assuming random-effects.

RESULTS

In subjects treated with ICS and LABA (n = 832, age: 3-21 years), Arg16/Gln27 versus Gly16/Glu27 (OR: 1.40, 95% CI: 1.05-1.87, I2  = 0.0%) and Arg16/Gln27 versus Gly16/Gln27 (OR: 1.43, 95% CI: 1.05-1.94, I2  = 0.0%), but not Gly16/Gln27 versus Gly16/Glu27 (OR: 0.99, 95% CI: 0.71-1.39, I2  = 0.0%), were significantly associated with an increased risk of asthma exacerbations. The sensitivity analyses indicated no significant association between the ADRB2 haplotypes and asthma exacerbations in the other treatment categories, namely as-required short-acting β2 -agonists (n = 973), ICS monotherapy (n = 2623), ICS plus leukotriene receptor antagonists (LTRA; n = 338), or ICS plus LABA plus LTRA (n = 686).

CONCLUSION AND CLINICAL RELEVANCE

The ADRB2 Arg16 haplotype, presumably mainly driven by the Arg16, increased the risk of asthma exacerbations in patients treated with ICS plus LABA. This finding could be beneficial in ADRB2 genotype-guided treatment which might improve clinical outcomes in asthmatic patients.

Identification of ROBO2 as a Potential Locus Associated with Inhaled Corticosteroid Response in Childhood Asthma

Inhaled corticosteroids (ICS) are the most common asthma controller medication. An important contribution of genetic factors in ICS response has been evidenced. Here, we aimed to identify novel genetic markers involved in ICS response in asthma. A genome-wide association study (GWAS) of the change in lung function after 6 weeks of ICS treatment was performed in 166 asthma patients from the SLOVENIA study. Patients with an improvement in lung function ≥8% were considered as ICS responders. Suggestively associated variants (p-value ≤ 5 × 10⁻⁶) were evaluated in an independent study (n = 175). Validation of the association with asthma exacerbations despite ICS use was attempted in European (n = 2681) and admixed (n = 1347) populations. Variants previously associated with ICS response were also assessed for replication. As a result, the SNP rs1166980 from the ROBO2 gene was suggestively associated with the change in lung function (OR for G allele: 7.01, 95% CI: 3.29–14.93, p = 4.61 × 10⁻⁷), although this was not validated in CAMP. ROBO2 showed gene-level evidence of replication with asthma exacerbations despite ICS use in Europeans (minimum p-value = 1.44 × 10⁻⁵), but not in admixed individuals. The association of PDE10A-T with ICS response described by a previous study was validated. This study suggests that ROBO2 could be a potential novel locus for ICS response in Europeans.

Implementing a specialist paediatric clinical pharmacology service in a UK children's hospital

Aims

Royal College of Paediatrics and Child Health subspecialist training in Paediatric Clinical Pharmacology and Therapeutics has been delivered in the UK for 20 years, but no specialist clinical services have been set up previously.

Methods

Prospective audit and service evaluation of paediatric clinical pharmacology service pilot phase and dedicated service at a UK children's hospital.

Results

Pilot scheme (May–October 2019), then weekly service (established June 2020). Service covers the High Dependency Unit, and inpatients with polypharmacy. The pilot demonstrated high levels of acceptance, with 89% of suggested medication changes agreed by lead clinical team, and success, with 97.5% of suggested changes continued until discharge/pilot completion. Economic analysis estimated direct annualised cost savings on medications of up to £10 000. After 20 ward rounds of the established service, 270 potential medication changes were identified, 213 were carried out (78.9%). The most common were deprescribing (n = 143), prescribing (n = 47) and dose adjustment (n = 8). Seventy‐five different medications were deprescribed, most commonly chloral hydrate (n = 12), Lactulose, ibuprofen, Bio‐Kult and sodium alginate (all n = 4). The percentage of inpatients prescribed ≥10 medications decreased from 38.5 to 32.1%, while the subset prescribed ≥20 medications decreased from 11.0 to 5.67%. The mean number of medicines prescribed decreased from 9.0 to 8.0, while the median was unchanged at 7. Annual Yellow Card reports of suspected adverse drug reactions more than doubled (n = 66).

Conclusion

A UK model for subspecialist paediatric clinical pharmacology service delivery has demonstrated a positive clinical impact and could be replicated at other UK secondary/tertiary children's hospitals.

Update and harmonisation of guidance for the management of diabetic ketoacidosis in children and young people in the UK

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus. Careful and timely intervention is required to optimise glycaemic control and reduce the risk of mortality and devastating complications. Of these, cerebral oedema is the leading cause of death, with a mortality rate of approximately 25%. This article highlights the recent updates to UK fluid therapy guidelines for DKA and provides clinical context for the benefit of paediatricians and junior doctors in light of this new guidance.

Genome-wide association study of asthma exacerbations despite inhaled corticosteroid use

RATIONALE

Substantial variability in response to asthma treatment with inhaled corticosteroids (ICS) has been described among individuals and populations, suggesting the contribution of genetic factors. Nonetheless, only a few genes have been identified to date. We aimed to identify genetic variants associated with asthma exacerbations despite ICS use in European children and young adults and to validate the findings in non-Europeans. Moreover, we explored whether a gene-set enrichment analysis could suggest potential novel asthma therapies.

METHODS

A genome-wide association study (GWAS) of asthma exacerbations was tested in 2681 children of European descent treated with ICS from eight studies. Suggestive association signals were followed up for replication in 538 European asthma patients. Further evaluation was performed in 1773 non-Europeans. Variants revealed by published GWAS were assessed for replication. Additionally, gene-set enrichment analysis focused on drugs was performed.

RESULTS

10 independent variants were associated with asthma exacerbations despite ICS treatment in the discovery phase (p≤5×10-6). Of those, one variant at the CACNA2D3-WNT5A locus was nominally replicated in Europeans (rs67026078; p=0.010), but this was not validated in non-European populations. Five other genes associated with ICS response in previous studies were replicated. Additionally, an enrichment of associations in genes regulated by trichostatin A treatment was found.

CONCLUSIONS

The intergenic region of CACNA2D3 and WNT5A was revealed as a novel locus for asthma exacerbations despite ICS treatment in European populations. Genes associated were related to trichostatin A, suggesting that this drug could regulate the molecular mechanisms involved in treatment response.

Adverse drug reactions of leukotriene receptor antagonists in children with asthma: a systematic review

BACKGROUND

Asthma is the most common chronic condition of childhood. Leukotriene receptor antagonists (LTRAs) are included in international guidelines for children and young people (CYP), but there have been highly publicised concerns about potential adverse effects. The aim was to identify and understand the reported frequency of adverse drug reactions (ADRs) attributed to LTRAs in CYP with asthma.

METHODS

Embase, MEDLINE, PubMed and CINAHL were searched up to October 2020. Reference lists of eligible papers were manually screened. Eligible studies identified adverse events attributed to an LTRA in individuals aged between 0 and 18 years diagnosed with asthma. Four different tools were used to assess risk of bias or quality of data to accommodate the papers assessed.

RESULTS

The search identified 427 papers after deduplication; 15 were included (7 case reports, 7 case-controlled or cohort studies and 1 randomised control trial (RCT)). 7012 patients were recorded, of which 6853 received an LTRA. 13 papers examined the ADRs attributed to montelukast, one to pranlukast and one to unspecified LTRAs. After language standardisation, 48 ADRs were found, 20 of which were psychiatric disorders. Across all studies, the most commonly reported ADRs were 'anxiety', 'sleep disorders' and 'mood disorders'. The frequency of ADRs could be calculated in seven of the eight studies. Applying standardised frequency terms to the prospective studies and RCT, there were 14 'common' and 'uncommon' ADRs. 'Common' ADRs included 'agitation/hyperactivity/irritability/nervousness', 'aggression' and 'headache'. The case reports showed a similar pattern, describing 46 different ADRs experienced by a total of eight patients.

CONCLUSIONS

LTRAs have a wide range of suspected ADRs in CYP, predominantly gastrointestinal and neuropsychiatric disorders. Careful monitoring of CYP with asthma is required, both to assess and manage ADRs and to step treatment down when clinically stable.

PROSPERO REGISTRATION NUMBER

CRD42020209627.

Pediatric asthma and COVID-19: The known, the unknown, and the controversial

The novel coronavirus disease-2019 (COVID-19), caused by the pathogen severe acute respiratory syndrome-CoV-2, is causing a global pandemic, with over 26.9 million cases and 880,000 deaths as of September 6, 2020. While there has been speculation and observational research about the impact of COVID-19 on asthma, much remains unknown. The goal of this article is to provide a scoping review on pediatric asthma and COVID-19 and summarize what we do and do not know from the first wave of the pandemic.

COVID-19 in children: what did we learn from the first wave?

A pandemic caused by the novel coronavirus, severe acute respiratory syndrome - coronavirus 2 (SARS-CoV-2), has caused high rates of mortality, predominantly in adults. Children are significantly less affected by SARS-CoV-2 with far lower rates of recorded infections in children compared to adults, milder symptoms in the majority of children and very low mortality rates. A suspected late manifestation of the disease, paediatric inflammatory multisystem syndrome - temporally associated with SARS-CoV-2 (PIMS-TS), has been seen in small numbers of children and has a more severe disease course than acute SARS-CoV-2. The pandemic has meant that children around the world have been kept off school, isolated from their extended family and friends and asked to stay inside. The UK has been declared as being in an economic recession and unemployment rates are increasing. These indirect effects of SARS-CoV-2 are likely to have a significant impact on many children for years to come. Consolidating the knowledge that has accumulated during the first wave of this pandemic is essential for recognising the clinical signs, symptoms and effective treatment strategies for children; identifying children who may be at increased risk of severe SARS-CoV-2 infection; planning the safe delivery of healthcare and non-health related services that are important for childrens' wellbeing; and engaging in, and developing, research to address the things that are not yet known. This article summarises the evidence that has emerged from the early phase of the pandemic and offers an overview for those looking after children or planning services.

Pediatric acute asthma scoring systems: a systematic review and survey of UK practice

BACKGROUND

Acute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known.

METHODS

A systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5-18 years of age with extractable severity parameters.

RESULTS

Sixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2-8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty-nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well-validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them.

CONCLUSION

Standardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.

Pharmacogenomic associations of adverse drug reactions in asthma: systematic review and research prioritisation

A systematic review of pharmacogenomic studies capturing adverse drug reactions (ADRs) related to asthma medications was undertaken, and a survey of Pharmacogenomics in Childhood Asthma (PiCA) consortia members was conducted. Studies were eligible if genetic polymorphisms were compared with suspected ADR(s) in a patient with asthma, as either a primary or secondary outcome. Five studies met the inclusion criteria. The ADRs and polymorphisms identified were change in lung function tests (rs1042713), adrenal suppression (rs591118), and decreased bone mineral density (rs6461639) and accretion (rs9896933, rs2074439). Two of these polymorphisms were replicated within the paper, but none had external replication. Priorities from PiCA consortia members (representing 15 institution in eight countries) for future studies were tachycardia (SABA/LABA), adrenal suppression/crisis and growth suppression (corticosteroids), sleep/behaviour disturbances (leukotriene receptor antagonists), and nausea and vomiting (theophylline). Future pharmacogenomic studies in asthma should collect relevant ADR data as well as markers of efficacy.

Prospective identification and causality evaluation of suspected adverse drug reactions in neonates

Neonates experience adverse drug reactions (ADRs), but under-reporting of suspected ADRs to national spontaneous reporting schemes in this population is particularly high. A prospective observational study collected suspected neonatal ADRs at a tertiary neonatal unit. Cases were analysed for causality by six assessors using three existing methods. Sixty-three suspected ADR cases were identified in 35/193 neonates (18.1%). The proportion of suspected ADRs where the drug was prescribed "off-label" was 30/68 (44.1%). When 34 cases were assessed for causality using three methods, global kappa scores of less than 0.3 for each tool suggested only "fair" inter-rater reliability. Neonatal ADRs can be captured and occur from a variety of drugs affecting many organ systems. The current tools for assessing causality need to be adapted before they can reliably assess neonatal ADRs.

Evaluating health information technologies: A systematic review of framework recommendations

OBJECTIVE

Evaluating Health Information Technologies (HITs) can be challenging, but studies are necessary so that the most beneficial interventions can be identified. Our objective was to systematically review the available recommendations for improving the methods used in HIT evaluations.

METHODS

HIT evaluation frameworks were identified from database (MEDLINE, EMBASE, CINAHL) and grey literature searches. Outcome measures included framework recommendations and characteristics. Recommendations were coded and organised using thematic analysis methods. A scoring instrument was used to measure framework quality.

RESULTS

The search identified 23 frameworks and 272 recommendations. These were organised into five evaluation domains and 42 themes. The themes included recommendations for improving the evaluation of technical aspects of HITs (e.g. describing aspects of HIT functionality) and suggestions for improving the evaluation of complex factors that may influence the overall effects of HITs (e.g. careful reporting of whether the HIT became integrated into existing working patterns). The frameworks were not generally developed in association with healthcare professionals, or with input from patients. The frameworks tended not to have been developed using systematic methods designed to reduce the risk of bias.

DISCUSSION

HIT evaluations are important but they are challenging to conduct and appraise. This review was conducted using systematic methods enabling the organisation of framework recommendations into key themes. These findings may help investigators to successfully plan, conduct and appraise HIT evaluations. The quality appraisal demonstrated that HIT evaluation research may be improved by using more systematic methods and the involvement of participants from a range of differing backgrounds.

Pharmacovigilance Reports Received from Children and Young People, and Development of Information to Aid Future Reporting from this Age Group

OBJECTIVES

This study aimed to determine the contribution of children and young people (CYP) to the Medicines and Healthcare Products Regulatory Agency (MHRA) Yellow Card Scheme (YCS), and to develop age appropriate information with CYP through focus groups to help aid future reporting by this cohort.

METHODS

Reports for suspected adverse drug reactions (ADRs) in patients < 19 years of age received by the MHRA YCS from 1 January 2008 to 29 November 2018 were collated and analysed. Consultation activities with CYP from regional, national and international groups were undertaken from November 2017 to July 2018 to develop CYP-appropriate information from current available literature about reporting ADRs to the YCS.

RESULTS

CYP contributed 2.3% of YCS reports for patients < 19 years (948 self-reports from a total of 41,630 YCS reports). Patients from 10 years of age contributed YCS reports, and the number of CYP reports represented in the total YCS reports rose by 3% in October 2018 compared with the previous year. Self-reported YCS from the CYP contain different suspected medications and reactions compared with YCS reported on behalf of patients aged < 19 years. The most reported medicines by self-reported YCS from CYP were adolescent vaccinations (such as the human papilloma virus [HPV] vaccine, n = 69), oral contraceptives, acne medication, anti-infectives, and antidepressants. The most commonly reported suspected ADRs submitted by CYP to the YCS were headache (n = 107), nausea and fatigue. CYP-generated reports included alternative suspected ADRs compared with adult reports about ADRs in CYP; these included depression, anxiety and suicidal ideation. The second part of the study used focus groups involving CYP from various backgrounds to develop two information leaflets regarding reporting suspected ADRs in the YCS; this was highlighted in phase I by CYP who identified divergent information needs dependent on age. Phase II-VI updated and improved the relevant information required for both age groups in a succinct and satisfactory manner. Overall, more than 300 CYP contributed to the development of the information.

CONCLUSIONS

CYP's contribution to the YCS is limited, but increasing, and demonstrates distinct patterns of suspected medications and reactions. Age-appropriate information for CYP to aid reporting of suspected ADRs has been developed.

Assessing the impact of breathing retraining on asthma symptoms and dysfunctional breathing in children

OBJECTIVE

To assess the impact of breathing retraining on asthma symptoms and dysfunctional breathing (DB) in children. Breathing retraining can improve DB but there is a lack of evidence in pediatrics.

METHODS

Participants attended outpatient physiotherapy appointments and received individually tailored interventions, particularly Buteyko breathing techniques. The primary outcome was the change in the Asthma Control Test (ACT) score or change in childhood ACT (CACT) score from first to final appointment. The ACT and CACT are validated in children more than or equal to 12 years and children aged 4 to 11, respectively. The secondary outcome measure was the change in Nijmegen Questionnaire (NQ) score from first to the final appointment (score range, 0-64) with a score of more than or equal to 23 indicating DB symptoms.

RESULTS

One hundred and sixty-nine children with asthma attended and completed a mean of six physiotherapy sessions, over a mean of 15 weeks. Patients were aged 2 to 18, mean 10 years. Fifty-five patients were more than or equal to 12 years old and 114 were less than or equal to 11 years. One hundred and seven patients were receiving BTS/SIGN asthma guideline step 1 to 3 therapy and 62 were on step 4 to 5 therapy. The mean ACT score improved by 4.4 (P < 0.0001), the mean CACT score improved by 4.9 (P < 0.0001), and the mean NQ score change improved by -9.3 points (P < 0.0001).

CONCLUSION

In addition to standard medical therapy, individually tailored physiotherapy interventions improved asthma control and DB in children on all levels of asthma treatment. A randomized controlled study is required to determine whether these improvements are due to the intervention.