The safety and efficacy of methylnaltrexone in pediatric oncology patients: A single center experience.

INTRODUCTION: Peripherally acting µ-opioid receptor antagonists (PAMORAs) are used in the treatment of opioid induced constipation without impacting the actions of opioid analgesics. Subcutaneous methylnaltrexone was one of the first PAMORAs approved in April 2008 for the treatment of opioid induced constipation in adult patients. The safety and effectiveness of methylnaltrexone has not been established in pediatric patients. In this study, the use of subcutaneous methylnaltrexone in pediatric patients is analyzed and reviewed. The primary outcome is occurrence of a bowel movement within 24 h after methylnaltrexone (MNTX) administration and the number of bowel movements following treatment with methylnaltrexone. Secondary outcomes include safety in this patient cohort. METHODS: This is a retrospective study of 79 pediatric patients with opioid induced constipation. Patients were administered methylnaltrexone during their inpatient stay. Data on bowel activity after methylnaltrexone was obtained from the hospital information system. RESULTS: Out of the 79 patients who received methylnaltrexone, there were seven patients from whom data could not be analyzed. Of the 72 patients whose data was available, 38% (N = 27) were documented as having a bowel movement, 62% (N = 45) did not have a bowel movement. Reported adverse events were minimal with nausea (N = 3), vomiting (N = 1), and flatulence (N = 6). CONCLUSION: Methylnaltrexone appears safe in the pediatric population and produces bowel movements in more than a third of pediatric patients. It is a feasible and safe option for opioid induced constipation in pediatric patients.

Sleep in Hospitalized Children With Cancer: A Cross-Sectional Study.

OBJECTIVES: Many children with cancer have repeated and prolonged hospitalizations, and in-hospital sleep disruption may negatively affect outcomes. Our objective for this study was to characterize sleep quality and quantity in hospitalized children with cancer by using parental surveys and actigraphy, to evaluate the association between subjective and objective sleep measures, and to describe hospital-associated risk factors related to poor sleep. METHODS: Cross-sectional study of children aged 0 to 18 years old admitted to a pediatric oncology ward. Parents completed a baseline sleep questionnaire describing their child's sleep at home before hospitalization, followed by daily questionnaires describing their child's sleep for up to 3 nights while in the hospital. A subgroup of children aged 5 to 18 years wore actigraphs during the same time period. Demographic and clinical data were extracted from the electronic medical record. The primary outcome was inadequate sleep, defined by the total sleep duration adjusted for age. RESULTS: Among 56 participants over 135 hospital nights, 66% (n = 37) reported inadequate sleep. Actigraphy was completed on 39 nights (29%), with a median total sleep time of 477 (interquartile range 407-557) minutes. There was a strong correlation between subjective questionnaire measures and actigraphic measures (r = 0.76). No patient-specific demographic factors were related to inadequate sleep. A multivariable model indicated the following hospital-related factors were associated with inadequate sleep: noise (adjusted odds ratio [aOR] 3.0; confidence interval [CI] 1.2-7.7), alarms (aOR 3.1; CI 1.2-8.3), child's worries (aOR 2.8; CI 1.1-7.2), and receipt of benzodiazepines (aOR 2.9; CI 1.2-7.5). CONCLUSIONS: A majority of children experienced inadequate sleep during hospitalization. Subjective report of sleep duration correlated well with objective measures of sleep by actigraphy. Several potentially modifiable factors were independently associated with poor sleep. Further interventional studies are required to test approaches to optimize sleep in hospitalized children with cancer.

Select practice behaviors of clinicians on the use of opioids for adolescents with subacute and chronic nonmalignant pain.

OBJECTIVES: To characterize the opioid prescribing and monitoring practices of providers for chronic nonmalignant pain (CNP) and subacute postoperative pain (SAPOP) in adolescents. DESIGN: Web-based cross-sectional self-report survey. SETTING: Free-standing pediatric tertiary academic center. PARTICIPANTS: A total of 183 physicians and nurse practitioners were eligible. Of 115 (62.8 percent) participants who responded, 108 (93.9 percent) completed the survey. MAIN OUTCOME MEASURES: Self-reported frequency of opioid prescription for SAPOP and CNP conditions and frequency of associated monitoring practices. RESULTS: For 10 of the 13 pain conditions included, some participants endorsed "monthly or more opioid prescriptions" while others endorsed "opioids do not represent appropriate management." Opioid prescribing is present for almost all pain conditions but is substantially more common for nonacute vaso-occlusive-related sickle cell disease, scoliosis correction, and video-assisted pectus excavatum-related pains. When compared with the reference group, CNP with no identifiable pathology, the odds ratio (OR) of an opioid being prescribed for CNP states with identifiable pathology was not significantly higher. The OR for SAPOP was significantly higher (p < 0.0001). None of the opioid prescribers reported collecting urine toxicology before or during opioid therapy. CONCLUSIONS: This survey identifies a diversity of self-reported clinician opioid prescribing practices for adolescents with CNP and SAPOP. Urine collection for drug toxicology screening is not utilized by opioid prescribers. Surveys of similar clinician practice behaviors at other institutions are warranted to replicate this finding and to establish common clinicalpractice for usage and monitoring of opioids in conditions where guidelines do not yet exist.