Implementation of a Guideline to Decrease Use of Acid-Suppressing Medications in the NICU

Angelidou, Asimenia; Bell, Katherine; Gupta, Munish; Leeman, Kristen T.; Hansen, Anne

doi:10.1542/peds.2017-1715

Cited by 15 publications

(7 citation statements)

References 32 publications

(23 reference statements)

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“…During the same period, recent alerts pointed to the association of PPIs with bone fractures, community-acquired pneumonia and bacterial diarrhoea [57] . Furthermore, the PPI efficiency for reflux symptoms is not demonstrated amongst infants [58] . This prompted the re-affirmation of clinical guidelines for the judicious and limited use of PPIs in paediatric patients [ 59 , 60 ].…”

Section: Discussionmentioning

confidence: 92%

Paediatric outpatient prescriptions in France between 2010 and 2019: A nationwide population-based study

Taine

Offredo

Dray‐Spira³

et al. 2021

The Lancet Regional Health - Europe

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Background Paediatric outpatient prescription (POP) monitoring is pivotal to identify inadequate prescriptions and optimize drug use. We aimed at describing recent trends in POPs in France. Methods All reimbursed dispensations of outpatient prescribed drugs (excluding vaccines) were prospectively collected for the paediatric population (<18 years old) in the French national health database in 2010–2011 and 2018–2019 (mean 117,356,938/year). POP prevalence (proportion of children receiving ≥1 drug prescriptions/year) was calculated by age groups and compared by prevalence rate ratios (PRRs). Given the large sample size, 95% confidence intervals of POP prevalences and PRRs did not differ from estimates. Findings Among the 14,510,023 children resident in France in 2018–2019, mean POP prevalence was 857‰ children. Most prescribed therapeutic classes were analgesics (643‰), antibiotics (405‰), nasal corticosteroids (328‰), nonsteroidal anti-inflammatory drugs (NSAIDs) (244‰), antihistamines (246‰) and systemic corticosteroids (210‰). POPs decreased with age from 976‰ for infants to 782‰ for adolescents. Children <6 years old were notably more exposed to inhaled corticosteroids (PRR=3.06), non-penicillin beta-lactam antibacterial agents (PRR=3.05) and systemic corticosteroids (PRR=2.11) than older ones. The POP prevalence was slightly higher (PRR=1.04) during 2018–2019 than 2010–2011, with marked increases for anti-emetics (PRR=1.84), vitamin D (PRR=1.49), proton pump inhibitors (PRR=1.42), systemic contraceptives (PRR=1.24) and nasal corticosteroids (PRR=1.21) and decreases for propulsive/prokinetic agents (PRR=0.09), NSAIDs (PRR=0.73) and systemic antibiotics (PRR=0.88). Interpretation POP remained highly prevalent in France throughout the 2010s, especially for children <6 years old, with only a few improvements for selected therapeutic classes. These findings should prompt clinical guidance campaigns and/or regulatory policies. Funding Internal funding

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Section: Discussionmentioning

confidence: 92%

Paediatric outpatient prescriptions in France between 2010 and 2019: A nationwide population-based study

Taine

Offredo

Dray‐Spira³

et al. 2021

The Lancet Regional Health - Europe

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“…Medicines utilization research informs us on trends, on between unit variability and on the impact of guideline implementation. This utilization research is not limited to exposure to antibiotics [ 4 , 9 , 10 , 11 , 12 , 13 , 14 , 20 ], but has been illustrated using data on drugs for gastroesophageal reflux, analgesics or anti-epileptic drugs [ 4 , 17 , 18 , 19 , 20 , 21 ]. We hereby illustrate how a shift in practices can result in another irrational practice with another compound (shift from prokinetics to anti-acid drugs to treat reflux associated-apnea).…”

Section: Discussion: Perspectives To Further Improve Rational Use mentioning

confidence: 99%

“…Extensive variability in the use of analgesics is observed. For both ATC groups, research on implementation strategies proved to be effective [ 21 , 26 ]. For AEDs, we use the data on the minor shifts in drug utilization patterns to illustrate the relevance to develop tools for more accurate diagnosis, and guidelines to reduce the duration of exposure [ 27 ].…”

Section: Discussion: Perspectives To Further Improve Rational Use mentioning

confidence: 99%

“…The stable prescription of erythromycin (27th and 24th most commonly prescribed drug in the consecutive cohorts) also illustrates the limitations of such analysis without simultaneous collection of data on indications (infection related or as prokinetic) [ 4 , 20 ]. A strategy how to implement a guideline (set at target, plan–do–study–act, feedback and education) to decrease the use of acid-suppressing medicines in a neonatal intensive care unit has recently been described [ 21 ].…”

Section: Neonatal Clinical Pharmacologymentioning

confidence: 99%

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Rational Use of Medicines in Neonates: Current Observations, Areas for Research and Perspectives

Allegaert

2018

Healthcare

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A focused reflection on rational medicines use in neonates is valuable and relevant, because indicators to assess rational medicines use are difficult to apply to neonates. Polypharmacy and exposure to antibiotics are common, while dosing regimens or clinical guidelines are only rarely supported by robust evidence in neonates. This is at least in part due to the extensive variability in pharmacokinetics and subsequent effects of medicines in neonates. Medicines utilization research informs us on trends, on between unit variability and on the impact of guideline implementation. We illustrate these aspects using data on drugs for gastroesophageal reflux, analgesics or anti-epileptic drugs. Areas for additional research are drug-related exposure during breastfeeding (exposure prediction) and how to assess safety (tools to assess seriousness, causality, and severity tailored to neonates) since both efficacy and safety determine rational drug use. To further improve rational medicines use, we need more data and tools to assess efficacy and safety in neonates. Moreover, we should facilitate access to such data, and explore strategies for effective implementation. This is because prescription practices are not only rational decisions, but also have psychosocial aspects that may guide clinicians to irrational practices, in part influenced by the psychosocial characteristics of this population.

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“…By educating care providers and staff regarding appropriate evidence-based use of these medications, their use was reduced, although there was no concomitant decrease in potentially associated adverse events such as infection, fractures, or NEC. However, the authors reported NEC and fractures to be such rare events in their unit that a conclusion relating to these adverse outcomes with H2RA/PPI use could not be drawn [54].…”

Section: Gerd Treatmentsmentioning

confidence: 97%

Gastro-Esophageal Reflux in the Newborn: Pathologic Event or Does Spit Happen?

Stepanovich¹,

Donn²

2021

OBM HG

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Infants admitted to Neonatal Intensive Care Units (NICUs) are among the most vulnerable patients in medicine and are at risk for a variety of morbidities, many of which require pharmacologic therapy. Gastroesophageal Reflux Disease (GERD) is a common diagnosis in the NICU patient population and may or may not represent a truly pathologic process. Regardless, pharmacologic therapy is provided to many infants, who are already exposed to an inordinate number of pharmacologic agents, of which most are off label and have an inadequate evidence base to establish either efficacy or safety. Furthermore, as infancy represents a time of dramatic growth and development, many conditions resolve over time, making treatment unnecessary and potentially dangerous. Infants with GERD, especially those born prematurely, exemplify the complexity of attempting pharmacologic therapy with unproven consistent benefit versus “watching and waiting.” The following will present physiology of GERD, gastrointestinal tract anatomy and development as well as options for pharmacologic and non-pharmacologic therapies.

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Implementation of a Guideline to Decrease Use of Acid-Suppressing Medications in the NICU

Abstract: Implementation of an evidence-based guideline in our unit led to a significant decrease in nonindicated use of acid-suppressing medications and reduced the burden of exposure to PPIs/H2RAs. This intervention could feasibly be implemented in other similar inpatient settings.

Cited by 15 publications

References 32 publications

Paediatric outpatient prescriptions in France between 2010 and 2019: A nationwide population-based study

Paediatric outpatient prescriptions in France between 2010 and 2019: A nationwide population-based study

Rational Use of Medicines in Neonates: Current Observations, Areas for Research and Perspectives

Gastro-Esophageal Reflux in the Newborn: Pathologic Event or Does Spit Happen?

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