In the late 1940s, Patricia Sanchez remembers sleeping on a cot in her oldest son’s bedroom most winter nights, listening for the vaporizer to run out of water so she could quickly refill it. The flu or even a bad cold invariably exacerbated his asthma, often causing him to wheeze and gasp for breath.
“We didn’t have any good medicines. It was a scary time,” she says. “I think we had to take him to the emergency department almost every winter.”
Today, with such medical advances as inhaled corticosteroids, many hospitalizations for asthma-related conditions can be avoided. Similarly, the use of ondansetron (Zofran) in children with gastroenteritis has decreased hospitalization rates. Many such medications originally developed for adults are helping to advance the treatment of childhood diseases, especially in oncology. But has the attraction of newer, stronger medications contributed to overuse for certain pediatric diseases?
A number of pediatric hospitalists think it has. Medication use in children has—for the most part—not received enough study. Therefore, hospitalists don’t always have enough evidence to guide their treatment decisions for young patients. Until the research catches up with the medications, hospitalists should be cautious.
HM physicians must stay abreast of the latest drug information and treatment guidelines. More importantly, they need to maintain clear lines of communication and outline reasonable expectations with their patients and their patients’ families.
Too Much, Too Soon?
Overuse of antibiotics and the growing threat of methicillin-resistant Staphylococcus aureus (MRSA) and other resistant strains frequently affect hospitalists in their practices, says Jack Percelay, MD, MPH, FAAP, FHM, a pediatric hospitalist with E.L.M.O. Pediatrics in New York City and a member of SHM’s board of directors. So does pressure from worried parents who want to employ whatever it takes to make their child better. “We want to be really careful about giving kids antibiotics,” he says, “and not use the biggest, newest guns in the hospital when they are not necessary.”
[Pediatric hospitalists] routinely use medications in children where the dosing is arbitrarily guessed at.
—Brian Alverson, MD, pediatric hospitalist, Hasbro Children’s Hospital, Providence, R.I.
Knowing how young and how much is safe and effective isn’t easy. Samir S. Shah, MD, MSCE, assistant professor of pediatrics and epidemiology at the University of Pennsylvania School of Medicine and attending physician in the divisions of infectious diseases and general pediatrics at The Children’s Hospital of Philadelphia, and his colleagues examined the use of adjuvant corticosteroids in children with bacterial meningitis. What they found was a worrisome upward trend of increased steroid administration, even though current evidence does not warrant the approach.1 When bacterial meningitis is caused by Haemophilus influenzae type B, adjuvant corticosteroids show a reduction in hearing loss in children, but studies conducted in the current era (when Streptococcus pneumoniae and Neisseria meningitidies are common causes of bacterial meningitis) do not show similar benefit.
In childhood cancer, oncology physicians and researchers have done an excellent job of refining treatment protocols, says Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and pediatric editor of The Hospitalist. Nearly 70% of all children with cancer in the U.S. are enrolled in clinical trials, which allows for expanded evidence on treatments and outcomes.
In other settings, it might be too early to tell whether children are being overmedicated, undermedicated, or appropriately medicated. The real question: What will the consequences of long-term medication be?
Direct-to-consumer advertising; expansion of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for attention deficit hyperactivity disorder (ADHD), bipolar disorder, and autism spectrum disorder; and the acceptance of “biological psychiatry” as the theoretical basis for the etiology of behavioral and emotional disorders all contribute to the increased use of psychotropics, says Julie M. Zito, PhD, professor of pharmacy and psychiatry in the Pharmaceutical Health Services Research Department at the University of Maryland at Baltimore. Using Medicaid administrative claims data for Texas youth in foster care in 2004, Dr. Zito and colleagues found that more than a third of these children (37.9%) had been prescribed a psychotropic medication.2 Of those receiving medications, 41.3% were receiving at least three different classes of drugs, most frequently antidepressants, ADHD drugs, and anti-psychotic agents.