Say no to drugs: wait and watch strategy for medications used in the neonatal intensive care unit (NICU)
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Say no to drugs: wait and watch strategy for medications used in the neonatal intensive care unit (NICU) Hilary Tice1 · Shabih Manzar2 · Nitin Walyat2 · Kelsey Trimble3 Received: 13 September 2019 / Accepted: 1 November 2019 © Children’s Hospital, Zhejiang University School of Medicine 2019
From the presentation of gray baby syndrome with chloramphenicol use to gasping baby syndrome with exposure from benzyl alcohol in bacteriostatic flushes, historical clinical precedence has shown that babies cared for in the neonatal intensive care unit (NICU) are at higher risk of adverse effects from medication administration than other populations [1, 2]. Historical precedence led to a discussion amongst the multi-disciplinary team questioning whether medications are used excessively in the NICU. A recent review paper by Hsieh et al. [3] has elaborated on this question in detail, in which a downward trend in the use of certain medications was shown. The NICU is a very high-risk environment with a higher than normal potential for medication errors to occur. This increased potential for medication errors forms a basis for the importance of instituting safe medication practices in the NICU [4]. Therefore, a vigilant strategy is needed regarding the non-beneficial use of medications in this population. Unfortunately, most drugs are not studied and approved by the Food and Drug Administration (FDA) for use in the NICU leading to off-label use of most drugs [5, 6]. In addition to the off-label use of drugs, pharmacokinetic parameters are not readily available for extremely low birth weight premature infants for most drugs. This commentary will review some examples of drugs that are frequently used in neonatal medicine that should be viewed critically. The first example is the use of morphine * Shabih Manzar [email protected] 1
University of Louisiana at Monroe, 1501 Kings Highway, Shreveport Campus, 1725 Claiborne Avenue, Shreveport, LA 71103, USA
2
Division of Neonatology, Louisiana State University Health Sciences Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA
3
Department of Pharmacy, Ochsner – LSU Health Shreveport, 1541 Kings Highway, Shreveport, LA 71103, USA
and methadone in the treatment of infants with neonatal abstinence syndrome. A recent article published by Ryan et al. [7], clearly shows that non-pharmacological management of these infants far exceeds drug therapy in improving the outcome and affecting the length of stay in the NICU. Another example is the use of ranitidine for suspected gastroesophageal reflux disease. Several studies have shown that ranitidine not only increases the risk of necrotizing enterocolitis, but also makes the neonate susceptible to infections [8, 9]. Metoclopramide used for feeding intolerance is a third example of a drug, in which the safety index has been questioned in small premature infants [10]. In 2009, Clark et al. [11] showed an increase in mortality among neonatal infants exposed to cefotaxime. Since the publication of their finding,
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