An Outpatient Methadone Weaning Program by a Neonatal Intensive Care Unit for Neonatal Abstinence Syndrome.

Through retrospective chart review, this study described characteristics and length of stay for a cohort of newborns discharged on methadone following an inpatient weaning for neonatal abstinence syndrome (NAS). Data were assessed for all term infants born between January 1, 2010, and December 31, 2014, admitted to the hospital with a co-diagnosis of NAS at discharge, for gestational age, length of stay, days on treatment protocol before discharge, time to once-daily interval methadone dosing, and hospital charges, as well as for categorical characteristics. The 53 patients were predominantly male (58%), white (71%), and covered by Medicaid insurance (72%). Mean gestational age was 39.5 ± 1.1 weeks; length of hospital stay was 11.8 ± 5 days. Common co-diagnoses were newborn feeding problems (26%) and neonatal hypoglycemia (23%). In conclusion, use of the study site's methadone weaning protocol, which can be easily replicated, resulted in a relatively short length of stay and low readmission rates for these patients.

Fatal Cardiac Arrest in 2 Children: Possible Role of Ondansetron.

INTRODUCTION: Ondansetron is commonly used to treat vomiting in gastroenteritis, but has a United States Food and Drug Administration black box warning for risk of Q wave to T wave time interval (QT) prolongation. We report 2 pediatric cases of fatal refractory cardiac arrest after administration of ondansetron. CASES: A 10-year-old previously healthy boy presented to the emergency room with gastroenteritis symptoms. After intravenous fluids, morphine, antibiotics, and 2 doses of ondansetron, the patient became unresponsive with agonal respirations and a wide complex tachycardia consistent with ventricular tachycardia. In a second case, an 86-day-old infant with previously unidentified congenital cardiomyopathy presented to our emergency department with gastroenteritis symptoms. The patient received ondansetron and subsequently experienced repeated bouts of supraventricular tachycardia which progressed to ventricular fibrillation. Resuscitation efforts failed in each case, and both patients expired. DISCUSSION: Ondansetron can cause dose-dependent QT prolongation effects, which are more clinically relevant when other proarrhythmic elements are present. There is very limited published experience on use of ondansetron in children younger than 2 years. Our 2 cases join 2 previous case reports of death after ondansetron administration for gastroenteritis. The pharmacology of ondansetron's cardiac effects and drug-induced QT prolongation is discussed. CONCLUSIONS: Patients may have hidden risk factors that, together with ondansetron, could result in a proarrhythmic state that could lead to adverse effects, such as arrhythmias. Administration of ondansetron should be individualized and used cautiously in patients with risk factors for arrhythmia.

Evaluation of vancomycin dosing and corresponding drug concentrations in pediatric patients.

OBJECTIVE: To describe the relationships between dosing strategy, age, and vancomycin trough concentrations in pediatric patients. METHODS: This is a retrospective review of hospitalized pediatric patients between 2 months and 17 years of age treated with intravenous vancomycin from 2008 to 2011. The primary outcome was the number of patients achieving a target trough concentration of 10 to 20 µg/mL in each age group and dosing group. The secondary outcomes were the number of patients in each group to achieve a trough concentration of 15 to 20 µg/mL and the incidence of vancomycin-induced nephrotoxicity. RESULTS: A total of 102 patients were included in the analysis. Forty-six of 159 evaluated troughs (28.9%) were within the target range of 10 to 20 µg/mL. Dose was found to have a statistically significant effect on the ability to achieve a trough within the target range (P = .01). Of the 159 trough concentrations evaluated, only 11 (6.9%) were within the range of 15 to 20 µg/mL. Nephrotoxicity occurred in 7 patients and was not associated with supratherapeutic trough concentration or dose. CONCLUSIONS: The number of trough concentrations within the target range of 10 to 20 µg/mL was low, and younger patients often needed doses >60 mg/kg per day to achieve a trough concentration in this range. The dose of vancomycin was found to have a statistically significant effect on the ability to achieve a trough concentration within the target range.

A randomized, controlled trial to evaluate topical anesthetic for 15 minutes before venipuncture in pediatrics.

OBJECTIVES: The aim of the study was to assess the differences in reported pain from venipuncture comparing liposomal 4% lidocaine with placebo cream in a pediatric population. Other factors assessed were patient anxiety, difficulty of venipuncture, and history of venipuncture. METHODS: A prospective, randomized, double-blind, placebo control study design was used in which subjects were assigned to receive either liposomal 4% lidocaine or placebo cream. The study population consisted of pediatric patients aged 5 to 18 years old who presented to 1 site of a multisite, academic, community emergency department. Once subjects had consented and randomized, the liposomal 4% lidocaine or placebo cream was applied for 15 minutes under occlusion. A 6-point validated FACES pain scale was used to evaluate each patient's level of pain during venipuncture. Patient anxiety was evaluated using a 100-mm visual analogue scale before, during, and after the venipuncture. Heart rate was captured as an indirect measurement of pain. RESULTS: There were no significant differences between the study and placebo groups (P > .05) in mean levels of patient ratings of anxiety, patient heart rate, or the patient's mean rating of pain before, during, or after the venipuncture procedure. There was an association between increased anxiety with an increase in venipuncture pain and an inverse association between age and pain. CONCLUSION: Topical liposomal 4% lidocaine cream in this case did not prove to be effective with a 15-minute dwell time under occlusion because there were no differences in pain between study groups.