The Pediatric Trials Network (PTN) recently published research in Antimicrobial Agents and Chemotherapy that tested the safety of intravenous rifampin for both premature and term infants. Rifampin is used to treat many different infections, including those caused by methicillin-resistant staphylococcus bacteria and tuberculosis. The newly published study shares findings from a study led by PTN investigator Dr. P. Brian Smith of the Duke Department of Pediatrics.
The study, which enrolled 27 infants total, analyzed plasma pharmacokinetic samples and safety data to determine the appropriate dosing of rifampin for infants. No adverse effects related to rifampin were seen, and drug clearance increased as weight and maturation increased.
Results showed that, for infants less than 14 days old, 8 milligrams of rifampin per kilogram of weight resulted in comparable exposure to adults receiving rifampin as a therapy against staphylococci infections and tuberculosis. In infants 14 days old or older, 15 milligrams per kilogram of weight showed similar results.
Representatives from the International Children’s Advisory Network (iCAN), a worldwide consortium of children’s advisory groups that provide a voice for children and families in medicine and research, shared their insights at a recent PTN symposium held Sunday, April 28, at the annual Pediatric Academic Societies (PAS) Meeting in Baltimore, Md.
Reece Ohmer, a high school senior who is preparing to go to college in the fall, has lived with type 1 diabetes since she was 8 years old. She discussed the experience of “turning a negative into a positive” by using her voice to advocate for better research for young people.
She joined iCAN when she was 12, after an especially taxing doctor’s appointment. She had received upsetting lab results, but no one had engaged her in the conversation.
“The doctor was talking to my mom and my mom was talking to my doctor, and I pretended I wasn’t listening,” she said. “But I was.”
After the appointment, she tearfully shared her frustrations with her mother, who responded by asking her what she would do to make that experience better for another child. Reece eventually joined the hospital’s teen advisory council, which in 2014 became one of seven hospitals participating in iCAN.
Through the consortium, she has worked to advocate for better funding for pediatric research, ensure access for more children, provide input on assent and consent forms to make them more understandable, and verify that available research is actually the research children need.
“We’ve helped increase understanding within the medical community that in patient-centered care, even the youngest voice matters,” Reece said.
iCAN representatives acknowledged that there is an element of distrust when researchers approach patients and families. Patients are often unsure where the researchers are coming from and whether they have their best interest at heart.
“They don’t know me and my life,” said Sophia Klaudt, an iCAN member and high school junior living with cystic fibrosis. “It’s hard to build that relationship with researchers when I’m just a case study to them.”
The iCAN representatives suggested that researchers may not be the best people to make the initial contact about research opportunities. “Have existing families who have already been through this experience help bridge that gap for you,” said Amy Ohmer, Reece’s mother and director of iCAN. “These patient ambassadors can share that empathy because they understand what it’s like to be in their shoes.”
When researchers need to approach patients directly, iCAN representatives suggested that a nurse or someone in a trusted position introduce them as a new member of the team who is coming from a genuine place of care and concern.
The iCAN representatives acknowledged the challenges of getting adolescents, who enjoy more freedom and are less bound by their parents’ demands, to adhere to their medications.
To better incentivize patients, Reece encouraged clinicians to get to know them and where they are in their care journey. Treating a 7-year-old is completely different than treating a 17-year-old, she said, and each group has its own motives.
“When I was seven, candy would have motivated me, or a chart on my refrigerator,” she said. “Now things that would incentivize me would be being able to do things on my own independently of my family, which is something I had to work for.”
Sophia stressed the importance of compromise, and trusting adolescents to make responsible decisions. “Ultimately, I know it’s my health,” she said.
Amy Ohmer added that, as a parent, it is critical to stop scolding and start empathizing.
“We don’t say enough to our young people that what they’re doing is tough,” she said. “We need to remind them of what’s happening that’s positive in their life.”
Communicating with patients
Asked how researchers can better communicate with young patients, Sophia recommended that they tailor communications to the patient’s age and maturity level, and that they ensure the patient is informed throughout the process.
“I’ve been in studies where I felt informed at the beginning, but I wasn’t informed throughout,” she said. “[Patients] need to understand what’s going on throughout the whole process and be informed of the results.”
iCAN representatives reminded researchers to keep the patient first in mind when developing materials. They recommended putting the most important information front and center, providing clear timelines so patients get a better sense of the level of commitment involved, and thanking participants and informing them of the impact they have had. Finally, they encouraged the use of newer technologies to communicate with young people, meeting them where they are.
“We are the future, and we are going to be the biggest return on your clinical research investment,” Reece concluded.
The Pediatric Trials Network (PTN) will be presenting its research at the Pediatric Academic Societies (PAS) Meeting May 5-8 at the Metro Toronto Convention Centre in Toronto, Canada.
The annual PAS Meeting brings together thousands of researchers, academics, and clinical care providers united by a common mission: to improve the health and well-being of children worldwide. It is supported by the American Pediatric Society, the Society for Pediatric Research, the Academic Pediatric Association, and the American Academy of Pediatrics.
During the annual meeting, PTN investigators will share information on a variety of studies involving antibiotic safety, treatment of hospital-associated and ventilator-acquired bacterial pneumonia, infant weight estimation, personal protective equipment, and the development of a data repository to aid in pediatric research. See a detailed schedule of PTN-related presentations below or view the online program guide on the PAS website.
Saturday, May 5
1:15 p.m. – Validation and Human Factors Evaluation of a New Device for Infant Weight Estimation – Dr. Susan Abdel-Rahman, Children’s Mercy Kansas City (Poster)
1:15 p.m. – The Use of PPE during Pediatric Resuscitation: Which Tasks are Most Affected? The Results of a Survey during a Simulation Trial – Dr. Aaron Donoghue, Children’s Hospital of Philadelphia (Poster)
Sunday, May 6
11 a.m. – The Impact of Personal Protective Equipment on Performing Critical Procedures for Pediatric Patients in the Pre-Hospital Setting – Dr. Maybelle Kou, Inova Fairfax Hospital (Platform)
3:45 p.m. – Population Pharmacokinetics of Milrinone in Infants and Children – Dr. Christoph Hornik, Duke University (Platform)
4:45 p.m. – Development of an Electronic Health Record Derived Multicenter Inpatient Pediatric Data Repository – Dr. Christoph Hornik, Duke University (Platform)
5:45 p.m. – Hospital Associated and Ventilator Acquired Bacterial Pneumonias in Infants and Children – Dr. Jessica Ericson, Penn State Milton S. Hershey Medical Center (Poster)
5:45 p.m. – Population Pharmacokinetics and Safety of Sildenafil in Premature Infants – Dr. Daniel Gonzalez, UNC Eshelman School of Pharmacy (Poster)
Monday, May 7
2 p.m. – Antibiotic Safety and Efficacy in Infants with Complicated Intra-Abdominal Infections (cIAIs) – Dr. Michael Smith, Duke University (Platform)
5:45 p.m. – Dosing-Safety Relationship for Acyclovir in the Treatment of Neonatal Herpes Simplex Virus Disease – Dr. Jessica Ericson, Penn State Milton S. Hershey Medical Center (Poster)
5:45 p.m. – Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance – Dr. Aaron Donoghue, Children’s Hospital of Philadelphia (Poster)
5:45 p.m. – Weight Gain and Metabolic Syndrome in Children Exposed to Second-Generation Antipsychotic Medications – Dr. Angela Czaja, Children’s Hospital Colorado (Platform)
Tuesday, May 8
7:30 a.m. – Correlating Pulmonary Hypertension by Echocardiogram with Mortality in Premature Infants – Dr. Rachel Torok, Duke University (Platform)
The Pediatric Trials Network (PTN) welcomed its first two Australian sites in February. Sydney Children’s Hospitals Network and the Royal Children’s Hospital in Melbourne are now participating in PTN’s Pharmacokinetics of Understudied Drugs in Infants and Children (POPS) study.
The sites are currently involved in the Paediatric Trials Network Australia (PTNA), a counterpart of PTN that brings together pediatric researchers from across Australia who are committed to improving child health through the facilitation of pediatric clinical trials.
“These sites bring considerable experience in pediatric research and will make a significant contribution to PTN’s work,” said Dr. Danny Benjamin, principal investigator for the PTN. “In addition, their involvement will expand PTN’s global footprint, allowing us to gather data from a more diverse and widespread group of children and infants that can better inform our research.”
The POPS study is designed to assess the pharmacokinetics of a variety of commonly used drugs in children and infants that have limited safety and dosing information in the pediatric population. More than 70 drugs used to treat nearly 50 diseases and conditions have been studied so far.
The Pediatric Trials Network (PTN) is undertaking a groundbreaking study to assess the safety of commonly used off-patent medications when they are given to breastfeeding mothers. The study will track how different drugs are passed through breastmilk to determine dosing levels that are safe for both mom and baby.
Although the U.S. Food and Drug Administration (FDA) has implemented a guidance document on conducting lactation studies, off-patent drugs are not included in that rule. The PTN seeks to fill this knowledge gap.
“Although the benefits of breastfeeding are well-documented, we still don’t know enough about the effects of many prescription and over-the-counter off-patent drugs when they are passed to infants through their mother’s breastmilk,” said Dr. Kevin Watt, an assistant professor of pediatrics at Duke University who is leading the study. “As a rule, we discourage unnecessary drug use during lactation, but it’s quite common for new mothers to have symptoms or medical conditions that must be treated with drugs.”
“Many breastfeeding moms struggle with the decision to take medications because of the fear that these drugs will harm their children,” Watt said. “In the end, it often comes down to either stopping breastfeeding or discontinuing needed medications. We want to take the guesswork out of this decision and allow moms to breastfeed without worry.”
The study is expected to begin in April of 2018 and will enroll approximately 50 lactating women, along with their breastfed infants, for each drug studied. Initially 10 off-patent drugs will be studied, including medications used to treat bacterial infections, depression and anxiety, high blood pressure, diabetes, and chronic pain. Mothers will be enrolled in the study only if they are already taking one of the study drugs as part of their routine care.
Mothers who participate in the study will provide samples of breastmilk, their blood, their infants’ blood, or a combination to help researchers measure drug levels and determine the safest dose. Mothers and infants are expected to remain in the study until the infants reach 180 days of age.
The study, supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), will also explore the effects of maternal obesity on drug exposure and long-term outcomes of breastfed infants exposed to drugs in breastmilk.
See the NIH LactMed database for more information on the levels of various substances in breastmilk and infant blood, and possible adverse effects.
When treating gastroesophageal reflux disease (GERD) in obese kids, the common practice of dosing stomach acid blockers based on children’s weight could actually cause more harm than good, said Dr. Valentina Shakhnovich, investigator for the Pediatric Trials Network (PTN) and Associate Program Director for the Gastroenterology Fellowship Research Program at Children’s Mercy Hospitals in Kansas City, Missouri. Shakhnovich shared her research on The Children’s Mercy’s Transformational Pediatrics podcast.
GERD, commonly called acid reflux, is a long-term condition in which stomach acid comes back up into the esophagus, causing heartburn, indigestion, and tissue damage. Because the occurrence of GERD is associated with excess weight gain, pediatricians are seeing more cases, as the number of overweight and obese children increases.
Pantoprazole belongs to a class of drugs known as proton-pump inhibitors (PPIs), which have long been used to treat GERD and other conditions related to excess stomach acid. Pediatricians typically dose pantoprazole based on a child’s weight. However, this common practice can actually put bigger kids at risk for unwanted long-term side effects, associated with higher doses of PPIs, such as low bone density and vitamin deficiencies.
“A lot of us have the knee-jerk reaction that if we see a 10-year-old who’s twice the size of an average 10-year-old, maybe we should double the dose,” Dr. Shakhnovich said. “What our research has shown is that’s actually not the best thing to do for obese kids, and it appears that they actually require a lower dose of proton-pump inhibitors than their non-obese counterparts.”
Dr. Shakhnovich suggested including a statement on the pantoprazole label, warning pediatricians not to give more of the drug to overweight and obese children. “Until clear dosing guidelines come from the FDA, think twice before dose escalating just because a child is obese,” she said.
She commended PTN for its awareness of the problem and for leading the way in finding the safest and most effective dose of commonly used medications for overweight and obese children.
“One in 6 children is obese. One in 3 is overweight,” Dr. Shakhnovich said. “It’s essential to start including obese patients in clinical trials so we’re not trying to guess at the correct dose and we’re not trying to play catch-up.”
Early this summer, Lucas,* a one-month-old infant born 9 weeks prematurely, was receiving routine respiratory support in the neonatal intensive care unit at the University of North Carolina Children’s Hospital when he suddenly developed a dangerous neck abscess. Upon testing, the infection was found to be caused by methicillin-resistant Staphylococcus aureus (MRSA) bacteria. Staphylococcus infections in general can be life-threatening in the NICU, but because MRSA is resistant to many commonly used antibiotic therapies, Lucas’ treatment options were limited from the outset.
Neonatologist Jackie Patterson, who was caring for Lucas in the NICU, immediately turned to the medical literature to determine the best course of treatment. During her search, she found an article published in the May 2016 issue of Antimicrobial Agents and Chemotherapy that was directly relevant to Lucas’ case. The article reported results from a trial sponsored by the Pediatric Trials Network (PTN) that explored dosing for antibiotics including clindamycin in infants being treated for staph infections.
Clindamycin was originally approved by the FDA in 1997 and is used to treat bacterial infections when other antibiotics, including penicillin and methicillin, are ineffective. The PTN “Anti-Staph Trio” study, a multicenter trial that evaluated 3 different antibiotic therapies for staph infections, was designed to identify drug dosages appropriate for use in term and pre-term infants—information that was not available in existing product labeling.
By combining their findings with pharmacokinetic and safety data from two other studies, the authors were able to describe a dosing regimen for clindamycin in premature infants based on postmenstrual age and total body weight that would allow physicians to effectively treat the infection while avoiding unwanted side effects.
Dr. Patterson knew, based on lab results, that Lucas’ particular strain of MRSA was sensitive to clindamycin. Thanks to the data published in the PTN study, she was able to choose a dosing strategy that would be most effective for Lucas.
“After only a couple of days, we saw a dramatic improvement with no adverse effects,” she said. Lucas recovered completely by the end of the week-long treatment, and was discharged healthy later in the summer.
Although Lucas’s parents had initial concerns about the treatment, they were reassured when Dr. Patterson referenced the study.
“We were confident about our treatment because of the literature,” she said. “This made the family confident in us.”
However, Dr. Patterson noted that this is not always the case, pointing out that information to guide dosing for infants and premature neonates is often sorely lacking.
“In pediatrics, we’re often extrapolating from adult data,” Dr. Patterson said. “In part because families are reluctant to enroll their children in clinical trials, it’s hard to find data specifically related to infants and children.”
Bridging this gap is a key goal for the PTN, an alliance of more than 100 clinical research sites cooperating in the design and conduct of pediatric clinical trials. Sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the PTN works to improve healthcare for the youngest patients by providing much-needed information on optimal dosing of commonly used drugs.
“The work that PTN is doing is critical,” Dr. Patterson said. “Especially when working with life-threatening conditions in the newborn population, the more science behind our medical practices, the more confident we can be that we will deliver the best outcomes for our patients and their families.”
*Name has been changed to protect confidentiality.
Check out the July 2017 issue of the PTN Post, the newsletter for the Pediatrics Trials Network — this issue highlights new research and new recommendations for pediatric research. We hope you enjoy it, and as always, we welcome your comments and feedback.