Abstracts

Arch Dis Child: first published as 10.1136/archdischild-2019-nppc.27 on 19 June 2019. Downloaded from http://adc.bmj.com/ on January 24, 2023 by guest. Protected by copyright.
scheme. 30 participants were aware that parents could report may benefit from a structured medication review for their
using the scheme. 10 participants had been aware of an child although further research is required to determine the
adverse drug reaction but decided not to report it. The most effectiveness of such an intervention. This study has identified
common reason for this was being too busy. The most com- parent practices that could be included in such a review.
mon suggestion on how to improve accessibility to the Yellow
Card Scheme was the implementation of a mobile phone REFERENCES
application. 1. National Institute for Health and Care Excellence. Medicines optimisation: the safe
and effective use of medicines to enable the best possible outcomes. London:
Conclusion Most participants were aware of the Yellow Card NICE. 2015.
scheme although undergraduates less so. Many had reported, 2. Santer M, Ring N, Yardley L, et al. Treatment non-adherence in paediatric long-
although some had chosen not to report because they were: term medical conditions: systematic review and synthesis of qualitative studies of
too busy; not being concerned enough; not knowing how to; caregivers’ views. BMC Pediatrics 2014;14:63.
3. Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective
having forgotten. An app already exists, but awareness of this medicines use by consumers: an overview of systematic reviews. Cochrane Data-
appears low, as it was the commonest suggestion to aid the base of Systematic Reviews 2014, Issue 4. Art. No.: CD007768.
low reporting.

P017 BLUE BABY BLUES – A CASE REPORT; IMPLICATIONS OF

P016 PARENT/CARER INTENDED NON- ADHERENCE TO MATERNAL SELECTIVE SEROTONIN REUPTAKE
THEIR CHILD’S MEDICATION REGIMEN INHIBITOR USE FOR SUDDEN INFANT DEATH
1 SYNDROME
Jeff Aston, 2Keith Wilson, 2David Terry. 1Birmingham Women’s and Children’s NHS
Foundation Trust; 2University, Aston Peter Mulholland, Alexander Simpson, Jonathan Coutts. Royal Hospital for Children

10.1136/archdischild-2019-nppc.26 10.1136/archdischild-2019-nppc.27

Aim To identify intended non-adherence reported by parents/ Background A baby girl, (38 +2 weeks, 3.026 kg) was admit-
carers of children/young people taking long-term medication. ted on day 3 from home following 2 cyanotic episodes. The
Methods A 10 question postal survey was sent to 180 parents pregnancy was uneventful, the mother was prescribed fluoxe-
of patients receiving medication via homecare at a tertiary tine 20mg daily during pregnancy.
paediatric hospital with a single repeat mailing. Demographic Investigations Respiratory studies revealed significant hypoxia
details collected were age, current prescribed medication and in air with episodes of hypoventilation and apnoea. Time
duration. Participants were asked about changes that they had spent below 94% saturation was 19%, 68 dips per hour
made to their child’s medication without consulting a health- >4%, pCO2 was raised at 7 kPa. She had a normal cranial
care professional. They were asked about delaying/not starting MRI. Genetic testing for PHOX2B polyalanine expansion
new medication, compliance with medication instructions, mutation was normal excluding Congenital Central Hypoventi-
with-holding medication, altering the dose of medication, alter- lation Syndrome (CCHS).
ing medication taking to fit in with daily life and strategies to Outcome Incremental increase in the prescription of low flow
aid administering medication. The data were analysed using oxygen normalised her saturation study. She was discharged
SPSS version 23 and NVivo version 11. home on day 14 with an oxygen prescription for 0.5lpm and
Results The response rate was 32/180 (17.8%). The mean age an apnoea monitor. Parents and family members were taught
of respondents was 8.4 years (range 0.83 to 17 years). One basic life support. Clinic follow up at 5 months shows baby is
hundred and fifty-eight medications were prescribed with a thriving, developing normally and the oxygen flow rate has
mean of 5 medications per patient (range 1 to 15). In total, been reduced to 0.3lpm following repeat saturation studies.
16/32 (50%) respondents had made changes to their child’s Discussion Hypoventilation is not a recognised complication of
medication. The most common change (9/32, 28.1%) was maternal fluoxetine usage. A population based health registry
adjusting the medication regimen to fit around daily life fol- study found exposure to SSRI in utero increased the rate of
lowed by delaying initiating a new medication (7/32, 20.6%). neonatal deaths,1 although a causal relationship could not be
No respondents indicated that they had not started a new established. Two separate randomised controlled trials have
prescribed medication. Six (17.6%) respondents indicated that looked at the relationship between maternal SSRI use and
they had not followed the medication instructions. Four neonatal death.2 3 Neither demonstrated a statistically signifi-
(11.8%) respondents advised that they had withheld their cant correlation, although both showed odds ratios approach-
child’s medication. Four (11.8%) respondents communicated ing statistical significance (95% confidence intervals 0.82–1.99
that they had given a higher than prescribed dose and four and 0.97–3.94 respectively). Mouse models demonstrate the
(11.8%) a lower dose. Three (8.8%) respondents adjusted respiratory response to acidosis is abolished by drugs targeting
how they gave their child’s medication to aid administration. the serotonergic system.4 This system is not the primary regu-
Conclusion Half of respondents made changes to their child’s lator of respiration,4 and there may be a multi-factorial aetiol-
medication without consultation with a healthcare professional. ogy to any link between SSRI exposure in utero and the
Commonly changes were made to fit around daily life. The development of hypoventilation. This hypothesis somewhat
decision to prescribe medication should be undertaken in part- correlates with the ‘triple-risk model’ for Sudden Unexpected
nership with patients.1 Adherence to medication in long-term Death in Infancy (SUDI), which describes three important risk
paediatric conditions is particularly complex requiring parents factors; a critical development period, an exogenous stressor
to balance the daily needs of their child taking medication and an underlying vulnerability. It is possible that this underly-
with everyday life.2 Strategies to support medication adherence ing vulnerability could potentially be accounted for by down-
include self-management programmes, simplified dosing regi- regulation of the serotonergic respiratory response in associa-
mens and pharmacist led medication reviews.3 Parents/carers tion with maternal fluoxetine use. Fluoxetine is the preferred

14 of 32 Arch Dis Child 2019;104:e2

 Abstracts

Arch Dis Child: first published as 10.1136/archdischild-2019-nppc.27 on 19 June 2019. Downloaded from http://adc.bmj.com/ on January 24, 2023 by guest. Protected by copyright.
SSRI for use in pregnancy. Our case has shown significant placebo MD [95% CI]; 8.66 [5.17, 12.15]. The risk of
hypoventilation in an otherwise healthy infant exposed to adverse events per 100 patients who received ibuprofen from
maternal fluoxetine in utero with no primary cause identified. data from prospective studies was 8.9 for GI bleeding, 7.6–
This potential correlation should be considered when advising 7.8 for oliguria, 5.2 for rise in serum creatinine and 2.6 for
mothers on safe drug use and in the management of neonatal renal failure. Increase in serum creatinine after treatment was
hypoventilation. most commonly reported in retrospective cohort studies (460
cases out of 1786 adverse events). Nine cases of GI bleeding
REFERENCES led to discontinuation of ibuprofen treatment.
1. Colvin L, et al. Early morbidity and mortality following in utero exposure to selec-
Conclusion Our meta-analysis of the RCT data supported
tive serotonin reuptake inhibitors: a population-based study in Western Australia.
CNS Drugs. 2012;26:e1–14. results of previous systematic reviews.2 3 Combined results
2. Jimenez-Solem E, Andersen JT, Petersen M, Broedbaek K, Lander AR, Afzal SA, from RCTs and prospective cohort studies in our review show
Torp-Pedersen C, Poulsen HE. SSRI Use During Pregnancy and Risk of Stillbirth that oliguria is the most commonly reported adverse event
and Neonatal Mortality. American Journal of Psychiatry 2013;170:3. 299–304.
among the renal adverse events. However, the high number of
3. WuWen S, Yang Q, Garner P, Fraser W, Olatunbosun O, Nimrod C, Walker M.
Selective serotonin reuptake inhibitors and adverse pregnancy outcomes. American rising serum creatinine after treatment from retrospective stud-
Journal of Obstetrics and Gynaecology. 2006. 194: 4. 961–966. ies should also be considered when treating preterm neonates
4.. Voituron N, et al. Fluoxetine Treatment Abolishes the In Vitro Respiratory with ibuprofen for PDA. Paracetamol might be favoured as it
Response to Acidosis in Neonatal Mice PLoS One 2010;5(10):e13644. associated with less risk of GI bleeding when compared to
ibuprofen.

REFERENCES
P018 RENAL ADVERSE EVENTS AND GASTROINTESTINAL 1. Loke Y.K, Price D., Herxheimer A., et.al. Systematic reviews of adverse effects:
BLEEDING WITH IBUPROFEN USE IN PRETERM framework for a structured approach. BMC Med Res Methodol 2007 July 5;7:32.
NEONATES WITH PATENT DUCTUS ARTERIOSUS (PDA) 2. Ohlsson A., Walia R., Shah SS. Ibuprofen for the treatment of patent ductus arte-
riosus in preterm or low birth weight (or both) infants. Cochrane Database of Sys-
1
Asma Al-Turkait, 1Janine Abramson, 1Imti Choonara, 2Lisa Szatkowski, 1Shalini Ojha. tematic Reviews, 2015, Issue 2. Art. No.: CD003481. doi: 10.1002/14651858.
1
Child Health, Division of Graduate Entry Medicine, School of Medicine, University of CD003481.pub6
Nottingham; 2Division of Epidemiology and Public Health, School of Medicine, Nottingham 3. Ohlsson A., Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in
City Hospital preterm and/or low birth weight infants. Cochrane Database of Systematic
Reviews, 2011, Issue 7. Art. No.: CD004213. doi:10.1002/14651858.CD004213.
pub3Save
10.1136/archdischild-2019-nppc.28

Aim To identify all the reported adverse events associated

with ibuprofen use in preterm neonates for PDA closure and P019 TREATING CONJOINED TWINS
quantify the risk per 100 patients.
Lucy Wheeler. Cardiff and Vale UHB
Methods We followed the Cochrane standards for conducting
systematic reviews of adverse events.1 Eight electronic data- 10.1136/archdischild-2019-nppc.29
bases [Embase, Medline, BNI, PubMed, Cochrane library, IPA,
CINAHL, clinical trials.gov] were searched to identify relevant Situation D and M are conjoined twins born without an ante-
studies using a predetermined search strategy. Published con- natal diagnosis and assessed as not suitable for separation. At
ference abstracts, grey literature, and reference lists of the the time of admission they were 21 months old with a com-
retrieved articles were also searched. All studies providing bined weight of 17.1 Kg. D presented unwell with a raised
information on adverse events of ibuprofen in preterm neo- heart rate and respiratory rate. A working diagnosis of sepsis
nates with PDA were included. Following quality assessment (possibly urinary tract infection) was made. Advice was
of the retrieved studies, meta-analysis was performed to pool sought from pharmacy on the doses of ceftriaxone and para-
the results from the RCTs using Rev man 5.3 software. cetamol. Peripheral intravenous (IV) access was only available
Results of the observational studies are descriptively reported in twin M.
and analysed. Protocol registered in PROSPERO Background The twins are joined side by side from the upper
(CRD42018067600). chest to the pelvis. They have separate heads, three arms and
Results The complete adverse events systematic review includes 2 legs. They have 2 hearts with a fused aorta, a shared liver,
84 studies (38 RCTs, 10 case reports, 4 case series, 31 cohort 2 gallbladders, 2 stomachs, 3 kidneys and a single bladder. D
studies and 1 case-control study). The majority of adverse has a complex congenital heart condition and a poor progno-
events were captured in retrospective cohort studies. Gastroin- sis. On admission, D was receiving propranolol, but M was
testinal (GI) bleeding: Pooled results from RCTs that com- not. The dose was based on the combined weight of the twins
pared ibuprofen to placebo showed significant difference RR divided by 2. Conjoined twins are a rare phenomenon, occur-
[95% CI]: 1.99[1.13, 3.50] favouring placebo. Similarly, com- ring 1 in 50,000 to 100,000 births.1 Around 60% of these
pared to paracetamol, ibuprofen was also associated with an are stillborn or die shortly after birth. There are many differ-
increased risk of GI bleeding RR [95% CI]: 7.00[1.91, 25.61]. ent types of join with differences in shared organs and limbs.
There was no significant difference in GI bleeding when com- Consequently each twin pair is almost unique and considera-
paring ibuprofen to indomethacin RR [95% CI]; 0.98[0.48, tion must be given as to how medication is dosed according
2.00]. Renal adverse events: Data from RCTs showed that ibu- to pharmacokinetic principles.
profen had a significantly low risk of oliguria compared to Outcome Opinion of the multidisciplinary team was that the
indomethacin RR [95% CI]: 0.38[0.25, 0.56]. However, no twins have relatively separate circulations, although some
difference in risk of oliguria was found when comparing ibu- cross-circulation would be expected. On admission, saturations
profen to paracetamol RR [95% CI]: 2.16[0.91, 5.11]. Serum in the right arm (twin D) were 75%. On the left side (twin
creatinine levels after ibuprofen treatment compared to pla- M) this was 95%. Ceftriaxone is a highly protein bound,
cebo was reported by 4 RCTs with favourable results to hydrophilic antibiotic,2 The degree of cross circulation (how

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