Drug Therapy and Hazardous Substances Committee

Question 1

What are factors associated with fatalities from over-the-counter cough and cold medications in children? (7)

Answer 1

1. Age < 2 yo2. Use in daycare setting (lots of kids, easy to misdose)3. Use of the medication for sedation4. Combining 2 or more medications with same ingredient5. Failure to use a measuring device6. Product misidentification7. Use of products intended for adults

Question 2

What is the recommendation from Health Canada on the use of over the counter cough and cold medications?

Answer 2

Do NOT use any cough or cold formulations in children < 6 yo-for children > 6 yo, need to use with caution***There is no evidence that these medications cause improvement of symptoms

Question 3

What is the evidence for use of the following in treatment of children with cough and cold symptoms due to a viral illness? (Recommended, meh, or not recommended)-fluids-humidified air-NSAIDs-antihistamines-echinacea-zinc-honey-vitamin c

Answer 3

1. Fluid intake: RECOMMENDED (softens secretions and maintains hydration)2. Humidified air: Meh. No evidence proving that it works 3. NSAIDs (ie. ibuprofen): Meh. (decreases discomfort or pain but does not reduce duration of cold)3. Antihistamines: NOT RECOMMENDED (too sedating with no positive effect)4. Echinacea: NOT RECOMMENDED (no evidence in Cochrane review showing that it actually works in children as treatment or prophylaxis)5. Zinc: NOT RECOMMENDED (no evidence that it works) 6. Pasteurized honey: RECOMMENDED (very safe, decreases mucous, antioxidant properties, increases cytokine release which may result in antimicrobial effects, shown to effectively decrease cough frequency/severity and child/parent sleep quality; give 2.5 ml of honey before sleep to improve cough and sleep quality) 7. Vitamin C: NOT RECOMMENDED FOR TREATMENT (cochrane review of more than 30 comparisons and 11,000 participants, no significant improvement of symptoms was noticed with the use of Vitamin C) BUT may be useful for PREVENTION OF COLD/COUGH (consistent benefit shown in multiple studies but no clear recommendation can be made with dosing or how to use regularly)

Question 4

Fill in the blanks: failure of neural tube closure at the cranial end results in ______ whereas failure of closure at the caudal end results in ______.

Answer 4

Cranial end: anencephaly-Caudal end: spina bifida

Question 5

What is the most prevalent congenital malformation associated with mortality in the immediate perinatal period? -2nd most common?

Answer 5

Most common: cardiac malformations-2nd most common: neural tube defects

Question 6

What two drugs taken during pregnancy can increase risk of neural tube defects?

Answer 6

1. Valproic acid2. Carbamazepine

Question 7

What are the 2 most common neural tube defects diagnosed at birth?

Answer 7

1. Anencephaly: not compatible with long term survival2. Spina bifida: can be surgically corrected but may not improve motor function

Question 8

Which 3 ethnic groups are at higher risk for neural tube defects compared to the general population?

Answer 8

1. Welsh2. Irish3. Sikh

Question 9

What is the recurrence rate for women who have had a pregnancy which resulted in an infant with a neural tube defect?

Answer 9

2%

Question 10

What are 2 prenatal screening tests to detect neural tube defects?-detection rate?

Answer 10

1. Maternal AFP2. Obstetrical ultrasound-together detects 85-90% of affected pregnancies if performed between 15-20 weeks of gestation

Question 11

If a woman has had a previous child with neural tube defect, what can you offer during her current pregnancy to try to determine whether the fetus has a neural tube defect?-detection rate?-risk of fetal loss?

Answer 11

Can offer amniocentesis for measurement of amniotic fluid alpha fetoprotein-detects in >95% of cases-assocaited with 0.5-1% risk of fetal loss

Question 12

What is the recommended dose of folic acid for women of child-bearing age in order to reduce the risk of neural tube defects?-what about dose in women with previous child with neural tube defect?-what is the reduction in risk?

Answer 12

In women of child-bearing age: 0.4-0.8 mg folic acid per day-in women with previous affected child: 0.8-4 mg (optimal dose is yet to be found)-reduction in risk: 60-70%

Question 13

What are the neurological complications of pernicious anemia?

Answer 13

Pernicious anemia = vitamin B12 deficiency1. Peripheral neuropathy2. Posterolateral spinal cord degeneration

Question 14

What is the concern with fortifying foods with folic acid so that all women of child-bearing age will receive enough?-is there merit to this concern?

Answer 14

Concern is that for people with pernicious anemia (ie. vit B12 deficiency), the addition of folate can mask their megaloblastic anemia and thus delay diagnosis of pernicious anemia-HOWEVER this does not occur at the doses of folate recommended for primary prevention of neural tube defects and there have been no case reports of pernicious anemia masked by folic acid in these doses

Question 15

Which food could be chosen for fortification with folic acid to provide an average daily intake for women of child bearing age of betwen 0.5-1 mg per day?

Answer 15

Flour!

Question 16

For which issues (2) are homeopathy in pediatrics most commonly used?

Answer 16

1. ENT issues2. Resp issues

Question 17

In which subgroup of the peds population is rates of natural health products use the highest?

Answer 17

1. Children with chronic medical conditions (arthritis, cancer, cystic fibrosis, relapses of cancer)2. Homeless youth (suffer from chronic physical and mental health issues and tend to be disillusioned by mainstream institutions)

Question 18

What are the main differences between children and adults that may lead to increased risk of overdose or underdose with medications? (4)

Answer 18

1. Volume of distribution of products are different: children have higher BSA to weight ratio and different body water/fat composition2. Babies < 1 mo do not yet have an intact blood brain barrier thus allowing active products to gain access to CNS with resultant toxicity3. Oral absorption of products less predictable in younger patients due to decreased hepatic and renal clearance4. Rapid weight changes with growth necessitates frequent dosage adjustments

Question 19

What are 3 factors that increase the likelihood of drug-herb interactions?

Answer 19

All these factors increase the risk of drug interaction between natural health product and prescribed medication1. Patients with serious, chronic or recurrent illness are the most likely to use CAM and these patients are the most likely to be on prescription meds2. Most patients using CAM use it to complement their health care and not repalce it3. Substantial proportion of Canadians use more than one natural health product simultaneously

Question 20

Why are natural health products-drug interactions difficult to characterize?

Answer 20

1. Poor system with no mandatory reporting of adverse events with natural health products2. Herb may have been substituted or adulterated OR the identify and the quality of the product is variable between manufacturers or even between bottles

Question 21

What are the obstacles to CAM research?

Answer 21

1. Limited clinical data2. Lack of standardized products3. Complex interventions that are highly dependent on the individual4. Concerns about the applicability of traditional research methodology