Stomach Pains
What is the dose and frequency of famotidine therapy for a neonatal patient with GERD?
0.5 mg/kg (up to 1 mg/kg) by mouth once daily.
What baseline lab assays should be ordered for unfractionated heparin (UFH)?
PT/INR, aPTT, CBC w/ platelets.
True or False: Breastfeeding is recommended by professional organizations for mothers taking cannabis.
False.
What is the first line agent given during an acute neonatal seizure (name drug and dose)?
Lorazepam 0.1 mg/kg IV x1 or buccal midazolam 0.25-0.5 mg/kg/dose (max: 10 mg; must use 5 mg/mL concentration).
Additional info: May repeat in 5 min x1 if still seizing.
True or False: The majority of errors and potential ADEs (adverse drug events) (~70-80%) occur in the prescribing phase. True or False?
True.
Name two associated adverse effects with metoclopramide (Reglan)?
Irritability, dystonic reactions, drowsiness, emesis, and apnea.
What is the mainstay of therapy for patients with anemia of prematurity (AOP)?
RBC transfusions and limit volumes of blood drawn for lab testing.
Additional info: Erythropoiesis stimulating agents (ESAs) have now become more standard of therapy for anemia of prematurity (eg Darbepoetin, a long acting ESA) Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529960/
True or False. Breastfeeding is recommended by AAP and ACOG for opioid-dependent women.
True.
Additional info: Advise against abruptly stopping if on methadone and some concerns about illicit drug use.
What is the second line agent after benzodiazepines given during an acute neonatal seizure (name drug and dose)?
Phenobarbital 20 mg/kg IV x1.
Additional info: May repeat 10 mg/kg/dose IV PRN up to 50 mg/kg/dose.
Medication errors and adverse drug events (ADEs) must be reported on a national and institutional level.
True.
Additional info: The FDA Adverse Event Reporting System (FAERS) is a database that contains information and medication error reports submitted to the FDA. Use the MedWatch site and consider institutional reporting.
What neonatal condition is histamine-2 receptor antagonists (H2RAs) used to treat and what specific adverse effect may occur between 2-6 weeks of therapy?
GERD and Tachyphylaxis.
Additional info: Tachyphylaxis is the rapidly diminishing response to successive doses of a drug, rendering it less effective.
What is the name for the emergency reversal antidote for heparin?
Protamine.
What is the dose of morphine for treatment of severe neonatal abstinence syndrome (NAS) and at what FNAS score (Finnegan Neonatal Abstinence Score)?
Morphine 0.05 - 0.2 mg/kg/dose every 3-4 hours for FNAS score of > 8 x 3 or > 12 x 2.
What are zero-order kinetics and what anti-seizure medication follows zero-order kinetics at therapeutic concentrations?
Phenytoin follows Michaelis-Menten (saturable) or zero-order PK. This occurs when the number of drug molecules overwhelms or saturates the enzyme’s ability to metabolize the drug. When this occurs, steady-state drug serum concentrations increase in a disproportionate manner after a dosage increase.
Name at least 2 reasons for increased risk of adverse drug events (ADEs) in the neonatal population.
Different and changing pharmacokinetic parameters.
Lack of pediatric formulations, dosage forms, and guidelines.
Calculation errors.
Inconsistent measurement of preparations.
Problems with drug delivery systems.
Name two types of medication classes that may be associated with necrotizing enterocolitis (NEC).
NSAIDs, caffeine, antibiotics, vasopressors.
What is the half-life elimination rate of unfractionated heparin (UFH) in premature neonates?
~30 minutes.
Name two second-line agents used for severe NAS.
Phenobarbital, clonidine, buprenorphine.
Which benzodiazepine has the shortest half-life?
Midazolam (Versed).
Additional info: Midazolam’s half life is ~2.5 hours compared to diazepam’s half-life is ~30-60 hours. Diazepam has the longest half-life of the benzodiazepine.
What are some methods to prevent prescribing errors (name at least 2 methods)?
Avoid verbal orders – only for emergency situations (always read back).
Include patient weight in each order.
Review all drug orders for accuracy.
Avoid abbreviations.
Do not use u for unit – spell out ‘unit’.
Do not use cc; use mL.
Follow up and evaluate periodically the need for continued drug therapy.
Which vasopressor increases gastrointestinal mucosal blood flow?
Dobutamine.
Additional info: Dobutamine stimulates myocardial beta1-adrenergic receptors and some alpha-1 receptor agonism, resulting in increased contractility and heart rate as well as increased SVR, and stimulates both beta2 and alpha1-receptors in the vasculature. Rates range from 2-20 mcg/kg/min. Rates of 10-20 mcg/kg/min have more alpha-1 receptor agonism resulting in an increased SVR.
Name two contraindications and/or cautions for using unfractionated heparin (UFH).
Allergy to heparin or hypersensitivity to pork products, history of heparin induced thrombocytopenia (HIT), active bleeding, use caution with IM injections & arterial punctures, use caution w/ medications that affect platelet function (i.e. NSAIDs, aspirin, clopidogrel, etc), use caution in patients with platelets <60 x 109/L.
By how much percentage should morphine be weaned daily for a NAS patient?
10-20% of the peak dose per day.
Additional info: may need to go slower near final taper; look for rebound of symptoms several days after major wean or discontinuation.
What factor needs to be taken into account when conducting therapeutic drug monitoring for unbound concentrations of phenytoin or “total phenytoin level”?
Decreased protein binding due to hypoalbuminemia (< 3 g/dL) or total bilirubin concentrations that are > 2 mg/dL.
What are some methods to prevention calculation errors (name at least 2 methods)?
Require calculated dose and dose per weight (i.e. mg/kg) on each order.
Use pre-calculated dose sheets.
Standardize dosing and concentrations.
Encourage rounding to whole numbers when. possible.
Appropriately use decimal points.
Require independent double check of dosing calculations.