Full Transcript for Using the KIDs List to Improve Pediatric Medication Safety

Let's try to figure out and honestly really try to recreate what the BIERS criteria did for older adults for pediatric patients. 00:04:20.000 --> 00:04:25.279 So they it's really the Beers criteria I want to stress was a really big inspiration for us. 00:04:25.600 --> 00:04:26.639 That's what I was gonna ask. 00:04:26.639 --> 00:04:38.399 If you sort of followed the even the development process, the the process for developing the, you know, uh congregating the authors together, like was that sort of modeled on what was done with the Beers criteria? 00:04:38.720 --> 00:04:41.439 Yeah, so we definitely looked at how they did things. 00:04:41.439 --> 00:04:47.759 They used the grade criteria in terms of um ranking the level of evidence and everything, and we tried to mimic that. 00:04:47.759 --> 00:04:54.240 One thing that we would like to do in the future that I think Beers does a great job of right now is being multidisciplinary. 00:04:54.240 --> 00:04:56.319 And right now we are just pharmacists. 00:04:56.319 --> 00:05:02.160 So we would love to expand that um with future editions, but you know, you got to start somewhere. 00:05:02.160 --> 00:05:02.480 Yeah. 00:05:02.480 --> 00:05:09.759 Um, and so we started with as a group, a small group of authors, but we did try to make our authors um come from different areas. 00:05:09.759 --> 00:05:16.879 So we had someone that was a specialist in the uh NICU area, another who was a specialist in oncology, et cetera. 00:05:16.879 --> 00:05:19.040 So we were sort of getting that broad scope. 00:05:19.040 --> 00:05:28.160 And then when we moved to the 2025 author group, we expanded even more because we realized we had some more questions, especially about like psychiatric medications. 00:05:28.160 --> 00:05:31.439 So we brought somebody in for that, infectious disease. 00:05:31.439 --> 00:05:36.240 You know, we brought people up more, a bigger author group to kind of you know spread our reach. 00:05:36.560 --> 00:05:40.160 That's a okay, great philosophy and great uh background to be aware of. 00:05:40.160 --> 00:05:48.720 And just to clarify, too, the the first one, the first kids list was published in 2020, and then more recently the updated list was published in 2025. 00:05:48.720 --> 00:05:49.439 Is that right? 00:05:49.680 --> 00:05:50.240 That's correct. 00:05:50.240 --> 00:05:57.279 Yeah, we published the first kids list in April of 2020, which is probably the absolute worst time for a publication. 00:05:57.279 --> 00:05:59.120 Oh my gosh, thinking about that. 00:05:59.120 --> 00:05:59.439 Wow. 00:05:59.439 --> 00:06:02.000 Yes, the timing was terrible. 00:06:02.000 --> 00:06:04.480 Um, and we had this whole plan. 00:06:04.480 --> 00:06:14.000 We were gonna present it at our um annual meeting, the Pediatric Pharmacy Association annual meeting, and it was gonna be in April and it was gonna coincide so perfectly with our publication. 00:06:14.000 --> 00:06:18.000 And then of course that meeting had to be, you know, converted to online. 00:06:18.000 --> 00:06:22.879 And yeah, and people were just concerned with other things at that time, understandably. 00:06:22.879 --> 00:06:30.000 So I feel like it's it was a little slow to take off because of that, but um, you know, we're gaining ground now, we're making up for lost time. 00:06:30.319 --> 00:06:31.439 That is fascinating, actually. 00:06:31.439 --> 00:06:37.839 I do wonder how much that did impact the the sort of launch of this this list and awareness around it. 00:06:37.839 --> 00:06:52.879 So thinking about uh the the evidence, you sort of alluded to the fact that often the evidence may be lacking in pediatric patients, or uh you know, there's anecdotal sort of data that people are working off of. 00:06:52.879 --> 00:06:57.439 How did how did that affect the development of the kids list? 00:06:57.759 --> 00:07:01.600 Yeah, so we tried to be very open about a what evidence we were using. 00:07:01.600 --> 00:07:07.680 So that's one thing that one key difference with us and the Beers criteria is that we list all of our references. 00:07:07.680 --> 00:07:18.079 Our entire reference list is in the reference section, and we grade the evidence and and basically say if there's better evidence, would this change our opinion or not? 00:07:18.079 --> 00:07:20.879 Um so we try to leave it up also to the clinician. 00:07:20.879 --> 00:07:24.399 So the idea is that there's poor evidence here, and here's what we looked at. 00:07:24.399 --> 00:07:28.240 You may come to a different conclusion based on your specific situation. 00:07:28.240 --> 00:07:32.160 So again, all these drugs are quote unquote potentially inappropriate. 00:07:32.160 --> 00:07:39.839 And again, we borrowed that term right from the Beers criteria because we know that there are situations where they may be perfectly appropriate for your patient. 00:07:39.839 --> 00:07:50.160 But again, we wanted users to A, see what we thought, but also B, have that opportunity to look at that same literature and make their own conclusions based on their situation. 00:07:50.480 --> 00:07:51.360 Okay, that's great. 00:07:51.360 --> 00:07:56.800 I I love the transparency there and also, as you said, really individualizing to the clinician and the patient. 00:07:56.800 --> 00:08:02.480 In terms of application, so reviewing, and this is publicly available, freely available. 00:08:02.480 --> 00:08:03.439 Yes. 00:08:03.600 --> 00:08:13.519 If you just Google the kids list, um you may come up with some other things, but if you if you Google uh with Pediatric Pharmacy Association, if you include that term, um you should get right there. 00:08:13.519 --> 00:08:13.839 Yeah. 00:08:13.839 --> 00:08:15.199 But it is, yes, free. 00:08:15.199 --> 00:08:15.519 Yeah. 00:08:15.839 --> 00:08:16.079 Okay. 00:08:16.079 --> 00:08:16.720 Okay, great. 00:08:16.720 --> 00:08:26.879 So so if I had it in front of me and I was thinking about, you know, what considerations, how how

to think about applying this in my practice versus the beers criteria, would you sort of go about it with the same approach? 00:08:26.879 --> 00:08:35.519 I do want to get into specific drugs, but just thinking about that process of reviewing and applying it to practice high level, would you say it's a similar sort of thought process? 00:08:35.840 --> 00:08:36.720 Yeah, I I do. 00:08:36.720 --> 00:08:38.080 I think it's a good reference. 00:08:38.080 --> 00:08:44.960 Um, what we're really pushing for and advocating for is integration into electronic health record systems. 00:08:44.960 --> 00:08:52.639 And there it is integrated into at least two that I know of uh drug information references that are online, which is great. 00:08:52.639 --> 00:09:13.519 But get getting it into those electronic health records and into those warning systems, kind of like Beer's criteria generally is, to us is our next step because that's going to help that user, that prescriber, the pharmacist in sort of being aware that this is the kids list medication and we should, you know, at least consider our risks before moving forward. 00:09:13.519 --> 00:09:14.240 Absolutely. 00:09:14.240 --> 00:09:16.000 That that's what we're hoping for. 00:09:16.000 --> 00:09:20.960 But I also just want pharmacists to know about it and maybe for be familiar with what drugs are on there. 00:09:20.960 --> 00:09:24.399 So if a situation comes up, they know they have that to turn to. 00:09:24.720 --> 00:09:25.279 A reference. 00:09:25.279 --> 00:09:25.600 Yeah. 00:09:25.600 --> 00:09:26.000 Yeah. 00:09:26.000 --> 00:09:27.039 And I agree. 00:09:27.039 --> 00:09:36.480 We of course want things like that to be systematic and embedded in our workflow, but also just as you say, awareness and um just being familiar with some of these drugs. 00:09:36.480 --> 00:09:53.759 So without further ado, let's get into some of those drugs that are on the list and think about maybe how many are on there, what are some of the top drugs for pharmacists to know about, whether it's a change from the 2020 list that was originally published or just sort of have been on this list since first publication. 00:09:53.759 --> 00:09:58.080 Let's just dive into it and think about some of those highest impact opportunities. 00:09:58.480 --> 00:09:59.200 Sure, sure. 00:09:59.200 --> 00:10:05.200 So a lot of these, let me just say that um a lot of them are documenting what we were already doing, what we already kind of knew. 00:10:05.200 --> 00:10:08.720 So, like a classic example is very old antibiotic. 00:10:08.720 --> 00:10:11.759 We don't even use it in adults very much these days. 00:10:11.759 --> 00:10:22.879 But back in the, I want to say it was the 1970s, they had started using it in um in neonates in the NICU, and they were getting this, what they now term that gray baby syndrome. 00:10:22.879 --> 00:10:28.480 And it was actually really interesting, because that that was my drug that I got to pour into that literature. 00:10:28.480 --> 00:10:41.120 But it was really interesting to see those initial case reports where they were kind of figuring it out as they went along and figuring out that it was because of the metabolism of chlorophenicol and that this really was not an appropriate drug in kids. 00:10:41.120 --> 00:10:43.200 So again, we're we're documenting that. 00:10:43.200 --> 00:10:50.000 We're saying, hey, if you ever like get asked this question, here's the literature that shows you, you know, that why it is not good. 00:10:50.000 --> 00:10:57.840 So it's sort of nice instead of just you just learn, oh, you shouldn't use chlorophenicol, now here we have here's exactly where that came from, and we know about it. 00:10:57.840 --> 00:11:03.120 So another interesting one that's on there that I think we've we've kept in practice is aspirin. 00:11:03.120 --> 00:11:15.759 So aspirin is on the list, but what we found when we dove into the literature in in con in contrast to chloramphenicol is there was not a very clear link in terms of that risk of Rice syndrome. 00:11:15.759 --> 00:11:18.879 Um, and we couldn't find that link anywhere, right? 00:11:18.879 --> 00:11:25.440 And and so while it was documented that these kids were having these reactions, it was very not as clear that it was drug related. 00:11:25.440 --> 00:11:30.159 Now, it may have been, but again, the evidence was not as strong. 00:11:30.159 --> 00:11:32.720 So we kept it on the kids list. 00:11:32.720 --> 00:11:35.360 Nobody's ever gonna do that study now, right? 00:11:35.360 --> 00:11:40.639 No IRB is gonna approve a study to test the safety of aspirin in children. 00:11:40.639 --> 00:11:41.840 It's not gonna happen. 00:11:41.840 --> 00:11:46.320 But we wanted to be honest like, hey, this this evidence is not that great. 00:11:46.320 --> 00:11:53.840 And of course, we know that we use it in kids sometimes for certain disease states like Kawasaki disease and other uh and other disease states. 00:11:53.840 --> 00:12:05.039 So again, that's an example of where there's this sort of this dogma that's passed down and it was you know so ingrained that this drug is very dangerous unless you're using it for a very specific indication. 00:12:05.039 --> 00:12:08.240 And we were like, oh, maybe, maybe it's not as bad. 00:12:08.240 --> 00:12:09.679 We we don't know for sure. 00:12:09.679 --> 00:12:15.120 You know, it's sort of gotten this black eye from the Rye syndrome stuff, but we're we're not 100% sure. 00:12:15.120 --> 00:12:17.440 And again, I'm not saying use aspirin in everybody. 00:12:17.440 --> 00:12:18.639 Right, right, of course, of course. 00:12:18.639 --> 00:12:23.039 I'm it's on the list, it still is on the list, but it still is on the list of supporting evidence, right? 00:12:23.039 --> 00:12:23.440 Right. 00:12:23.440 --> 00:12:24.399 Yeah interesting. 00:12:24.399 --> 00:12:30.799 So just a couple of examples there of things that are on the list and stayed on the list, yeah,

because of uh because of the evidence. 00:12:30.799 --> 00:12:35.519 And again, we're just trying to be very clear and transparent about what is out there and in the literature. 00:12:35.759 --> 00:12:36.480 That's excellent. 00:12:36.480 --> 00:12:36.960 Yeah. 00:12:36.960 --> 00:12:43.840 So what were some of the biggest changes from 2020 to 25 and uh which would be be aware of? 00:12:44.240 --> 00:12:44.559 Yeah. 00:12:44.559 --> 00:12:57.120 Um, so I think interestingly enough, like a good example would be Daptamycin was on the first list because there uh in the package insert it said there was risk in young uh like neonatal dogs. 00:12:57.120 --> 00:13:07.360 And what we saw in the five years between the two publications is that there's more and more evidence and documentation of safe use in infants. 00:13:07.360 --> 00:13:14.240 And so we value that as higher, you know, better evidence than this dog data. 00:13:14.240 --> 00:13:19.200 And so we decided, you know what, there's clinical evidence, people are showing they're using it safely. 00:13:19.200 --> 00:13:21.039 So we actually removed it from the list. 00:13:21.039 --> 00:13:23.600 Okay, and that's exactly what we want to happen, right? 00:13:23.600 --> 00:13:27.200 We want, we would love evidence to change our opinion. 00:13:27.200 --> 00:13:28.559 Uh, more evidence is always good. 00:13:28.559 --> 00:13:39.519 And that and that's one of our main goals with the kids list is to say, he, hey, here are some that we think are not good in kids and have a safety risk, but we need more information. 00:13:39.519 --> 00:13:45.360 And maybe that will, you know, cause people to to to do these studies and to document these things. 00:13:45.360 --> 00:13:56.720 So the other one would be the um antipsychotics, and that's why we brought on um a pharmacist who really specializes in that area, especially those first generation uh antipsychotics. 00:13:56.720 --> 00:14:11.519 And again, because remember that a key part of the kids list is that these drugs are A, they have their higher risk of adverse drug reactions in kids than adults, and also there has to be a safe alternative or a safer alternative. 00:14:11.519 --> 00:14:20.320 And so if it was a known risky drug, but and you know you're gonna cause ADRs, but we don't have any alternative, then it's not gonna be on the list because what are you gonna do? 00:14:20.559 --> 00:14:20.799 Okay. 00:14:20.960 --> 00:14:25.440 Um, but we know that we have second generation antipsychotics now that are safer. 00:14:25.440 --> 00:14:36.720 And so we really wanted to sort of highlight that and make sure you know people are aware that these first generation antipsychotics, when you're using them, you know, you had another option. 00:14:36.720 --> 00:14:42.080 And so we want to we want to highlight um their risks based on newer medications. 00:14:42.799 --> 00:14:50.559 So that's an interesting example because I know there has been quite a lot of attention even

recently around antipsychotic use in in children and appropriate use. 00:14:50.559 --> 00:15:04.879 And so it with that example, for those of us who haven't looked at the kids list and know how it's formatted and set up, so are first generation antipsychotics on there and second generation are not, or is it sort of a discussion globally around antipsychotics? 00:15:04.879 --> 00:15:11.120 And and I guess a follow-on question to that is does it provide alternatives or is that up to the discretion of the clinician? 00:15:11.519 --> 00:15:14.480 Yeah, so we don't specifically lay out alternatives. 00:15:14.480 --> 00:15:20.799 Um, and in this example, the second generations are also on the list because they have their own um you know risks. 00:15:20.799 --> 00:15:24.159 Um, a key, a good example would be a olanzepine, right? 00:15:24.159 --> 00:15:31.519 Great drug, but we know that you know it has its own risks as well, like for metabolic syndrome and that kind of thing, um, and weight gain. 00:15:31.519 --> 00:15:37.039 And so, you know, again, every drug has and every situation has to be weighed on its own. 00:15:37.039 --> 00:15:42.399 But we hope that this will help clinicians again weigh those risks and choose appropriately. 00:15:42.639 --> 00:15:43.039 Mm-hmm. 00:15:43.039 --> 00:15:54.080 Now, um you were mentioning the dog studies before, and actually that one piqued my interest because it made me wonder if fluoroquinolones are on there, because I think that was also data with dogs and and the joint issues. 00:15:54.080 --> 00:15:55.279 Are they on that list? 00:15:55.519 --> 00:15:55.759 Yeah. 00:15:55.759 --> 00:15:59.600 So very I love to talk about the quinolones too, because they are not on the list. 00:15:59.600 --> 00:16:02.960 So um great quinolones have never been on the list. 00:16:02.960 --> 00:16:11.120 And of course, you know, when we were starting this project, one of the first things we did is as authors, we made our own lists and then we kind of merged those. 00:16:11.120 --> 00:16:11.440 Okay. 00:16:11.440 --> 00:16:15.759 So it was like all the ones we had learned about, you know, growing up or what have you. 00:16:15.759 --> 00:16:18.399 Um and quinalones, of course, we had to discuss. 00:16:18.399 --> 00:16:25.759 But when we dived into the literature, we could not find evidence that the risk in children was higher than that in adults. 00:16:25.759 --> 00:16:28.480 So we know there's all kinds of risks to quinolones. 00:16:28.480 --> 00:16:33.200 You know, there's been um blood sugar issues, right? 00:16:33.200 --> 00:16:37.440 The cartilage issues, but those are documented in adults as well, you know. 00:16:37.440 --> 00:16:37.759 Okay. 00:16:37.759 --> 00:16:48.000 And so again, this idea that we should avoid them in kids more than we should avoid them in adults is not really real, at least based on what's in the literature. 00:16:48.000 --> 00:16:51.600 Yeah, now we're not saying go ahead, use equinoline in every kid. 00:16:51.600 --> 00:16:59.039 Yeah, because obviously they are uh, you know, very broad spectrum antibiotics and they should really only be used for a very specific population. 00:16:59.039 --> 00:17:04.480 And there are, you know, risks for their attendance, but it's just not riskier than in adults. 00:17:04.480 --> 00:17:12.480 So again, we're not saying just because it's not on the list doesn't mean safe to use, it just means not more risky than in adults. 00:17:12.480 --> 00:17:13.599 So interesting. 00:17:13.599 --> 00:17:15.119 That's a really good clarification. 00:17:15.680 --> 00:17:16.319 Yeah, yeah. 00:17:16.319 --> 00:17:18.160 Definitely a good point to clarify. 00:17:18.160 --> 00:17:31.759 Some of the other ones that I saw highlighted in uh the 2025 update were things like Montalucas, which I think is uh uh historically thought of as generally, you know, fairly safe in pediatrics. 00:17:31.759 --> 00:17:38.079 And so I would be interested to hear a little bit more about that, and then also the the codeine tram et al uh recommendation and also the tetracyclines too. 00:17:38.079 --> 00:17:40.480 Those three were sort of the ones that caught my eye and some of the revisions. 00:17:40.480 --> 00:17:42.240 So I'd love to hear you talk about those a little bit. 00:17:42.559 --> 00:17:43.119 Yeah, sure. 00:17:43.119 --> 00:17:52.079 So Montalucas was tough because A, some of the risks, which are mostly psychiatric in nature, they're definitely in adults as well. 00:17:52.079 --> 00:17:59.359 And so we really had to sort of piece through is there any one of these in particular that seems to happen more in kids? 00:17:59.359 --> 00:18:04.000 And it's it was sleep disturbances that sort of popped out. 00:18:04.000 --> 00:18:07.920 Um but all the other psychiatric reactions can happen too in kids. 00:18:07.920 --> 00:18:13.119 But again, it's risky in adults, but it seemed to be that sleep disturbances were more common in kids. 00:18:13.119 --> 00:18:16.960 But again, this is a drug that we see used in kids. 00:18:16.960 --> 00:18:22.720 And I don't think again, you just have to think about it and use judgment before you use it. 00:18:22.720 --> 00:18:30.720 And I think that a very good point with monoleucast is making sure that counsel the parents and make them aware that this is a possibility. 00:18:30.720 --> 00:18:34.559 Now, in most kids, it's probably not gonna happen and it's gonna be fine. 00:18:34.559 --> 00:18:43.119 But a lot of times if a child is having sleep disturbances, the parents aren't necessarily gonna associate that with their child's allergy medicine, right? 00:18:43.119 --> 00:18:45.279 That doesn't a logical connection. 00:18:45.279 --> 00:18:58.240 So just sort of good counseling and being aware, and also, you know, and I think pulmonologists already know this, we don't use it first line for asthma because it doesn't have as good of evidence in asthma as our inhaled corticosteroids. 00:18:58.240 --> 00:19:06.559

Um, but also like if we if it gets added on to just be aware of the risks and again making sure that we're telling parents and also adults too, right? 00:19:06.559 --> 00:19:09.759 Adults who use Montoleucast, again, there are risks there as well. 00:19:09.759 --> 00:19:16.960 There was a really interesting article in the New York Times a couple of years ago about this issue, specifically Montoleucast in children. 00:19:16.960 --> 00:19:23.920 And they the parents they interviewed, it was really compelling because they spoke about how they wish their doctor had told them. 00:19:23.920 --> 00:19:29.279 They wish their pharmacists had told them because they had no idea that this was coming from this medication. 00:19:29.279 --> 00:19:34.720 So again, I think just being transparent with patients um and caregivers is really important. 00:19:34.720 --> 00:19:39.279 The other one I love talking about that you mentioned is the tetracyclines. 00:19:39.279 --> 00:19:40.000 Yes, uh. 00:19:40.000 --> 00:19:43.759 Yeah, we know uh the tetracyclines have risks. 00:19:43.759 --> 00:19:49.200 In 2025, we added some of the newer tetracyclines that have come on the market in the last few years. 00:19:49.200 --> 00:19:53.279 But the big one I like to talk about in terms of not being there is doxycycline. 00:19:53.279 --> 00:19:55.039 So I live in New Jersey. 00:19:55.039 --> 00:19:59.119 We have Lyme disease here, and I know we do in lots of parts of the country. 00:19:59.119 --> 00:20:07.920 And um, I have had many complaints from my physicians that I work with that they write prescriptions for doxycycline, which is first line for Lyme. 00:20:07.920 --> 00:20:15.359 And and the pharmacist refuses to uh fill it because they say it's not safe in children because it's a tetracycline. 00:20:15.359 --> 00:20:29.440 And we know now that doxycycline specifically, and especially because it's just a short course, doesn't show the same risks to you know, the teeth enamel, et cetera, that tetracycline itself does. 00:20:29.440 --> 00:20:35.359 And so I want to point out that while tetracyclines are on there, they are not all on there. 00:20:35.359 --> 00:20:40.720 And doxycycline is specifically left out because we know it doesn't have um those risks. 00:20:40.720 --> 00:20:46.079 And so we just need to be careful as pharmacists to not sort of overapply things that we've learned. 00:20:46.079 --> 00:20:57.599 And and again, the literature today, despite what may be in the package insert, right, is that these are safe and they are like the first line in guidelines, and it's perfectly fine for for kids to take these meds. 00:20:57.680 --> 00:21:00.319 So for toxicline specifically, for toxicline. 00:21:00.319 --> 00:21:10.240 In the context, and especially in the context of Lyme, as that great example of where it is a first line and um without that safety concern balance, that it it's okay. 00:21:10.240 --> 00:21:20.400 I mean, like the so it so say that specific example, like you said, um the pharmacist declines to fill because of that concern. 00:21:20.400 --> 00:21:27.680 If a pharmacist gets that prescription for a child, do they have to have that communication with the prescriber at all? 00:21:27.680 --> 00:21:37.200 Like what is the what is sort of based on the fact that it's not on the list, what would be your process for handling that prescription if you saw it in practice? 00:21:37.680 --> 00:21:38.799 I mean, I would just fill it. 00:21:38.799 --> 00:21:40.559 Yeah, because I know it's safe. 00:21:40.559 --> 00:21:41.359 Yeah, it's safe. 00:21:41.359 --> 00:21:41.599 Yeah. 00:21:41.599 --> 00:21:42.720 Yeah, okay, okay. 00:21:42.720 --> 00:21:52.720 And yeah, I don't we're in the inpatient side, we don't you usually see Lyme disease as much, but um in the outpatient side, yeah, these are this is one of those drugs that again, historical dogma. 00:21:52.720 --> 00:21:58.400 You know, I learned as a pediatric pharmacist we we don't use tetracyclines in kids, you know, under eight. 00:21:58.400 --> 00:22:12.640 Um, but now I know, you know, it's not the all the class and there and there have been studies and the CDC even says you know perfectly safe in young kids when you're treating old kids so yeah that's a really great call out and I I think that's probably something that most people don't necessarily know about who are listening. 00:22:12.720 --> 00:22:13.599 So great call out there. 00:22:13.599 --> 00:22:13.920 Thank you. 00:22:13.920 --> 00:22:22.799 Yeah okay and then the coding of trimital I'm curious about that one too because I know that was a I suspect added because of some of the FDA alerts around that. 00:22:23.119 --> 00:22:24.160 Yes, absolutely. 00:22:24.160 --> 00:22:27.599 The risks of your ultra rapid metabolizers, right? 00:22:27.599 --> 00:22:43.279 So this came out from FDA, I want to say like almost 10 years ago at this point, where basically codeine is converted to morphine and if you have an ultra rapid metabolizer then basically you're converting it to morphine very quickly and kids can have respiratory depression. 00:22:43.279 --> 00:23:10.799 And so when I started practice we used uh especially acetaminophen with codeine all the time especially in our tonsilectomy adenoidectomy patients um that was the standard of care and those patients also remember if you're tinkering in their airway so they're at higher risk for respiratory depression too and that specific use is now absolutely um not okay I think and I hope that this is an example of a drug that's on the list that we've already sort of stopped using. 00:23:10.799 --> 00:23:16.160 But we have to be aware of it because again sometimes physicians may not have heard of that yet. 00:23:16.160 --> 00:23:22.960 Right especially if they have a practice where they mostly see adults and maybe they have to a kid once in a while they may have forgotten that piece. 00:23:22.960 --> 00:23:25.200 So we just have to be careful with that

use. 00:23:25.200 --> 00:23:30.480 And also you know codeine's not that great of a pain medication anyway. 00:23:30.480 --> 00:23:38.559 And then the acetaminophen with codeine liquid has a very low concentration of acetaminophen so you're getting not much acetaminophen either. 00:23:38.559 --> 00:23:40.559 So I think it was a good practice shift. 00:23:40.720 --> 00:23:40.960 Okay. 00:23:41.200 --> 00:23:52.160 Nowadays at least the ANTs that I work with they do just acetaminophen and ibuprofen post op and it seems to work really well and they just schedule it so they you know kids get ahead of the pain. 00:23:52.160 --> 00:23:53.680 But yeah we stopped using it. 00:23:53.680 --> 00:23:58.480 But it's something too that what you could do if you worked in a hospital is remove it from formulary. 00:23:58.480 --> 00:24:05.440 Or you know if the adults still need it which is questionable make sure it's only stocked in those areas. 00:24:05.440 --> 00:24:42.400 So okay yep yeah practical and tram and all is similar it's because of the FDA results our um reports um and warnings and again they have uh the FDA we we always look at their FDA um med watch warnings because they have that med watch program so they're getting these reports so we consider those reports very valuable and look at those very closely yeah yep so excipients are also on the list and thinking about liquids and like alcohol content is one that comes to mind as something that might be a concern but maybe you could speak a little bit about the excipient consideration and and what we might be not thinking about off the top of our head. 00:24:42.400 --> 00:24:46.720 Yeah sure I think alcohol or ethanol uh is the big one. 00:24:46.720 --> 00:24:51.119 Sorry ethanol yeah yeah um I think I think that's really the biggest one. 00:24:51.119 --> 00:24:59.680 The other ones are mostly in IV medications and and generally we know like with benzyl alcohol to avoid it in um in neonates. 00:24:59.680 --> 00:25:02.079 Ethanol is my passion project. 00:25:02.079 --> 00:25:12.319 Um that one um because it's basically to give a little background is it's been used in medications for a very long time for preservative reasons, right? 00:25:12.319 --> 00:25:20.640 It helps you know prevent bacterial growth and also sometimes it's used to help certain meds which are not that soluble it increases their solubility. 00:25:20.640 --> 00:25:28.319 So it's always been seen as this really great excipient but what we're starting to pay attention to more now is that maybe we're relying on it too much. 00:25:28.319 --> 00:25:37.599 And so a good example would be with dexamethasone elixir which is 5% alcohol which you might say oh it's 5% it's not that much. 00:25:37.599 --> 00:25:45.359 But the dexamethasone elixir that's commonly used is one milligram per ml and which is pretty dilute. 00:25:45.359 --> 00:26:16.640 And the doses that we often need when we give it to patients in respiratory distress like an asthma, oftentimes these kids are needing more generally at least 50 mls of liquid per dose okay and so and then you say oh five percent of 50 mls is now quite a lot right and so we did a project actually one of my students and I, we actually looked at ethanol content of medications and what blood alcohol level it should be producing, right? 00:26:16.640 --> 00:26:24.000 Because if you know the dose and you know the percentage of alcohol you can calculate um because we know the volume of distribution of ethanol. 00:26:24.000 --> 00:26:26.880 So you can calculate what blood alcohol content they're getting. 00:26:26.880 --> 00:26:40.240 And for some of these kids and we published that data for some of these kids we're you know we're getting blood alcohol levels of you know 0.5 0.1 even up to 0.3 for some of them where 0.8 at 0.8 you can't drive. 00:26:40.240 --> 00:26:51.279 Penobarbital oral liquid the elixir that routinely at sort of normalish doses is getting kids to a blood alcohol content of 0.3 and again at 0.8 you can't drive anymore. 00:26:51.279 --> 00:26:53.359 So at 0.3 you are feeling it. 00:26:53.359 --> 00:26:59.839 So yeah we're trying to just raise awareness of this because the FDA actually doesn't have guidance on it. 00:26:59.839 --> 00:27:17.359 It has guidance for over the counter medications but just in terms of percent and so percent to me isn't really a good a good guidance because then it depends on the concentration right if you're if it's a low percent but you're giving a lot then that's you know that's a different story. 00:27:17.359 --> 00:27:22.240 So anyway I'm hoping that we can draw more attention to ethanol and get away from its use. 00:27:22.240 --> 00:27:32.240 In the hospital by the way the way we work around that dexamethasome problem is that we use the IV formulation and we give it orally because the IV formulation doesn't have any alcohol. 00:27:32.240 --> 00:27:38.799 Interesting and it's also a lot more concentrated okay and it's 10 meg per ml instead of one meg per ml. 00:27:38.799 --> 00:27:41.359 So now we have a much smaller volume. 00:27:41.359 --> 00:27:48.640 Yeah it doesn't taste that great but when it's a one time dose and you're you know giving a very small volume then kids don't seem to mind. 00:27:48.640 --> 00:27:55.039 But on the other hand, you know I'm always reminding my hospital pediatricians you can't prescribe that outpatient. 00:27:55.039 --> 00:28:03.839 If you want the patient to go home but to get another dose tomorrow most community pharmacies can't access that IV preparation because it's for hospitals. 00:28:03.839 --> 00:28:09.519 And so you you generally either have to switch them to dexamethasone tablets or switch them to prednis alone. 00:28:09.519 --> 00:28:17.759 So it's sort of a conundrum we get into but yeah excipients are really important in kids and we have to pay attention to the dose that they're getting and be aware. 00:28:17.759 --> 00:28:30.640 Absolutely interesting it's

something that I wanted to mention that pharmacists can also look out for because there's some medications like diphenhydramine that come with alcohol and but they also have alcohol free formulations. 00:28:30.640 --> 00:28:45.759 So that's one thing my hospital did um when I was writing the kid kids list and we were kind of reviewing things is we we noticed we we had the alcohol preparation and so it was just an easy switch right our purchaser just stopped purchasing that and she buys only the our alcohol free now. 00:28:45.759 --> 00:28:53.119 So okay that's sort of an example of an easy easy check that you can do um yeah and make a recommendation for alcohol free. 00:28:53.519 --> 00:28:59.119 Right and and again yeah yeah and again just to be sort of having that on your radar and thinking about that. 00:28:59.119 --> 00:29:01.599 So those are some fantastic examples. 00:29:01.599 --> 00:29:05.759 I do want to talk about how how to how to manage this in practice too. 00:29:05.759 --> 00:29:27.519 So what you know those are just examples and if we talk about any one of those and have a a patient that's prescribed one of these meds that might be on the list and is something that sort of raises that red flag what are your strategies that you recommend for communicating with the prescriber if needed a sort of weighing that patient consideration factor. 00:29:27.519 --> 00:29:32.079 How do how do you individualize care while balancing the fact that it might be on the list? 00:29:32.319 --> 00:29:33.119 Yeah, sure. 00:29:33.119 --> 00:29:40.000 So obviously it depends where you're working right in the community setting you might not have as much information on the patient and the situation. 00:29:40.000 --> 00:29:59.599 But if it's a kids list medication and you feel like there's a decent alternative I in my opinion it's worth a phone call, you know, asking the prescriber where they're coming from are they aware of this risk and you know that this is another alternative and just sort of getting the story because there may be a very good story sure behind it. 00:29:59.599 --> 00:30:08.559 And and we you just don't know but I think it's good to advocate for the patient and medication safety and to just always kind of get that that backstory. 00:30:08.720 --> 00:30:09.440 So yeah. 00:30:09.440 --> 00:30:23.680 Absolutely yeah getting the information and then if they they say this is what we discussed, this is why I'm prescribing it any sort of special documentation or other you know we think about um risk always in terms of practice and minimizing risk. 00:30:23.680 --> 00:30:29.279 So what what should you then do in terms of any documentation andor communication with the patient or caregiver? 00:30:29.839 --> 00:30:48.799 Yeah I mean I guess for internal records I would document the conversation with the prescriber and then for the family you know just talk to them about the risks and what to watch for because again I think parents and caregivers can

be the best advocates for their kids and they're the ones that are with the children you know all the time a lot more than the physician sees them. 00:30:48.799 --> 00:30:53.039 And so we want them to be aware I'm a great example again is that Montalucast, right? 00:30:53.039 --> 00:30:56.480 We want parents to be aware of the possible side effects. 00:30:56.480 --> 00:31:06.240 But again it's that doesn't mean they're gonna have it and and I most kids will not have it um but we want them to know because again it's they need to be an advocate for their child. 00:31:06.559 --> 00:31:30.720 Yeah absolutely yeah and counseling is such a critical part of pharmacists role and so just awareness around that too yeah in terms of finding alternatives if there are uh if the if a medication is on the list since that's not included in the kids list do you have any best practices or general tips around thinking about alternatives other than just sort of what we think about and you know it based on our experience but any any thoughts there? 00:31:31.119 --> 00:31:44.640 I guess I would just turn to practice guidelines because I think that a lot of guidelines have incorporated um you know the recommendations you know from from the not that they're taking kids list recommendations into effect but they they know about the risk of that drug. 00:31:44.640 --> 00:32:03.279 So a good example would be the um we have uh uh guidelines for inpatient treatment of neonates with a fever and for the first three white weeks of life they do not have ceftriaxone as a as an antibiotic to use again because they're aware of the risk and so they tell you what to use instead. 00:32:03.279 --> 00:32:07.279 So that would be just an example sort of already integrated into that guideline. 00:32:07.279 --> 00:32:14.640 So I would just you know again practice guidelines alternative to coding is acetaminophen and ibuprofen by themselves. 00:32:14.960 --> 00:32:23.680 Right, right right and uh I guess you know all of that comes down to say that clinical judgment is still the foundation of what we need to be thinking about. 00:32:23.680 --> 00:32:42.720 This is a this kids list is an awareness um uh it's a benefit in in terms of being aware of what's on there what might be risky in children but we need to consider the patient that discussion with the collaborator and collaboration with the prescriber and using our clinical judgment as pharmacists too right yeah I couldn't put it better myself. 00:32:42.960 --> 00:33:52.079 Okay okay okay I have three quick questions uh I'll do them rapid fire one is are supplements on the list no so especially herbal supplements we didn't look at them we were looking for FDA approved um drugs also vaccines same thing okay yeah and then the other piece is also drugs that are not approved in the US were not included so we really did focus on the US yeah okay okay makes sense um I was curious thinking earlier about the beers criteria and how that's been adopted

and used to develop quality measures uh and to support appropriate use do you see anything like that coming with the kids list as well is that something that's been in in discussion absolutely um we have seen already several um projects that have been done especially in the hospital setting looking at how they've integrated the kids list and also you know are are these medications being used um and how are they being used um but a lot of sort of formulary review kind of things um and those projects have come out I would love to see more just knowledge and use of it in the community setting and see if it can help things there. 00:33:52.079 --> 00:34:15.440 Again my my goal is to A provide the references but also to make pharmacists more comfortable for example like we talked about doxycycline you know it's not on the kids list we know it's it's it's okay to use in kids and so sort of to have that in writing and we discussed it in the first edition of um of the kids list because again we knew there was going to be that question. 00:34:15.599 --> 00:34:38.000 We also have a extensive discussion on uh quinolones not being on the list there as well okay yeah yeah yeah yeah interesting so even though not on the list there's still discussion and background uh within the document to so to clarify some of those maybe misconceptions yep yep now again that was our goal because that's so much of this again was was dogma and we were trying to look at the literature and say what's actually there. 00:34:38.000 --> 00:34:48.159 Yep okay great um and then in terms of updates going forward do you have a planned cadence of every five years or is there sort of a thought process there? 00:34:48.559 --> 00:34:51.199 Yeah uh that is our planned cadence is every five years. 00:34:51.199 --> 00:34:58.719 I'm I'm very proud of us for hitting that mark the first time because it can be a it's a lot of work to kind of pull it together. 00:34:58.719 --> 00:35:20.320 And then you know one of the key pieces um that we're proud of in terms of our methods was that once we were all done, we send it out to our membership, the Pediatric Pharmacist Association because those are our boots on the ground, you know, and we wanted to get their thoughts and um is there anything we missed, you know, and and then their input was really really important to us. 00:35:20.320 --> 00:35:26.159 So it's it's a long process to get it all written and then again to go through the reviews of all those experts. 00:35:26.320 --> 00:35:40.000 So absolutely yeah yeah but reassuring to know that it's sort of regular rigorously developed and vetted and is a a source of truth to some extent you know that people can rely on and use in their practice. 00:35:40.000 --> 00:35:41.039 So that's fantastic. 00:35:41.360 --> 00:35:57.440 Are there any other sort of things we might have missed or surprising examples you want to call out before we wrap up no I did want to say you know when you use it as a reference um we're very clear in our methods about when we did our literature search until you know it's a certain date. 00:35:57.440 --> 00:36:07.599 Yes got it so even though we published in August 2025 or I don't remember off the top of my head what it is it was only back maybe a a year and a half the last year and a half weren't in there. 00:36:07.599 --> 00:36:07.920 Right. 00:36:07.920 --> 00:36:17.199 And so sometimes we'll see something oh we have to add this nope that wasn't in our you know in our methods we will look at that new article for our next iteration. 00:36:17.199 --> 00:36:26.719 So if you see something that's published and you and you it it's going to change your mind it may change your mind and it may not be in the kids list because it just didn't make it in time for publication. 00:36:26.880 --> 00:36:34.159 So yeah that's a good to look in the literature yeah yeah yep and stay apprised of of what's happening in practice and alerts and that sort of thing. 00:36:34.159 --> 00:36:39.519 So yeah absolutely excellent well um so I think in I I I learned a lot. 00:36:39.519 --> 00:37:04.480 So thank you Rachel for for sharing uh those highlights and uh key considerations I think uh this is an awareness consideration a lot uh just being aware of of the fact that this list exists what to be looking for uh being familiar with what drugs were on the list how it was developed and some of those considerations about weighing that risk benefit based on your patient and and continuing to use your clinical judgment in in those discussions as well. 00:37:04.480 --> 00:37:07.599 So I it is our game changers podcast. 00:37:07.599 --> 00:37:13.679 So we always wrap up with the game changer and what you what's this sort of the key point that you want our our listeners to walk away with today. 00:37:14.559 --> 00:37:36.719 I think it would just be as you just said know the kids lists exists know that all of our references are there and it's for you to use we really um want it to be a really good tool for you know physicians but pharmacists definitely um nurses just those in healthcare to sort of see the documentation behind um adverse drug reactions in kids and that it's a work in progress. 00:37:36.960 --> 00:37:46.000 So absolutely yep and have those conversations with your colleagues and with patients and caregivers as you said awareness on all fronts I think is what we're going for here. 00:37:46.000 --> 00:37:46.480 This is great. 00:37:47.039 --> 00:38:01.599 Yep and I think pharmacists are such great advocates for patients um and I know both in the community hospital setting you know kids rely on us right to to look out for them and to provide good counseling and and uh make sure you know they get the best use of their medicines. 00:38:02.320 --> 00:38:06.239 Absolutely I think we can all um I agree with that. 00:38:06.239 --> 00:38:12.320 Thank you so much Rachel for your time really appreciate you sharing your expertise here and um this was fascinating. 00:38:12.320 --> 00:38:14.159 So really really appreciate your insights here. 00:38:14.159 --> 00:38:14.559 Thank you. 00:38:15.039 --> 00:38:23.440 Thanks for having me and that's it for this week be sure to log in to Healthmart University to claim your CE credit for this episode. 00:38:23.440 --> 00:38:25.840 As always have a great week and keep learning. 00:38:25.840 --> 00:38:27.199 We'll talk to you next week