By Dr. Rachel Meyers, Clinical Associate Professor in the Pharmacy Practice Department at the Ernest Mario School of Pharmacy, Rutgers University
Towards a Renaissance of Pediatric Pharmaceutical Development
Successful drug delivery to pediatric patients depends on overcoming basic differences between children and adults. Pharmacokinetic and pharmacodynamic differences can make drug development challenging for very young patients. One can think of pediatric medicines as one of the last uncharted frontiers in patient-centric drug development.
Oral dosage forms, the preferred administration route, may not always be palatable or available in doses appropriate for children. Thus pills and tablets are often manipulated in ways that are not ideal for delivering safe, effective, and consistent doses. Compounding pharmacies can help but their results are not always reproducible. Parents often resort to dividing doses, crushing and dissolving them in liquids, and administering drugs in quantities that have not been adequately tested.
Alternative delivery vehicles are similarly problematic. Rectal dosage forms provide consistent dosing but are not patient-friendly. Younger children in particular have problems with nebulization masks that do not fit their face properly or cause them distress. Achieving reliably metered therapeutic dosages is complicated when small gaps exist between the mask and the patient’s face.
Most issues in pediatric drug development arise from the fact that drugs are traditionally developed for adults and not children. However, many improvements in pediatric drug development have occurred during the last 15 years.
Several regulatory changes have resulted in the recent development of close to 600 drugs supported by new pediatric studies. Relevant laws include:
BCPA and PREA have a sound scientific basis. The occurrence of suicidal thoughts in children taking the antidepressant Paxil® was not uncovered until FDA ordered sponsor GlaxoSmithKline to conduct pediatric studies. The result was an FDA warning, in 2008, for prescribers to consider the risks of prescribing Paxil to patients younger than 18.
Before BCPA and PREA were enacted, as many as 80 percent of drugs prescribed to children were untested in that patient population. By 2008 between 50 and 60 percent of such medications had been studied at some level in children. Nevertheless, children have been described as the “orphans” of drug development.
A bioavailability classification system (BCS) is not yet available for classifying the suitability of biopharmaceuticals for pediatric administration. However, preliminary investigations suggest that such a system may be available within a few years.
Many shortcomings of pediatric-administered medicines arise from less-than-perfect dosage forms and delivery mechanisms. Improvements in these areas could be achieved with minimal regulatory risk.
Unpleasant taste is a perennial issue for many drugs administered to children. Clindamycin, an antibiotic for treating Gram positive and anaerobic infections, has a particularly bitter taste and unpleasant smell. Dosing is frequent and of long duration. Moreover the drug is available only as a dilute suspension requiring large administration volumes, which for young patients amplifies its negatives and complicates administration of therapeutic doses. Other antibiotics routinely administered to pediatric patients have similar issues.
Sabril® (vigabatrin; Lundbeck LLC), which is prescribed for infantile seizures, is a classic case of a drug that has not been ideally formulated for its intended patient population. Sabril is available as a 500 mg tablet or a 500 mg packet. The tablet is too large for very young children to swallow. Parents must suspend the packet contents in relatively large volumes of water, which introduces issues previously mentioned. It also requires caregivers to perform a multi-step process in order to mix and measure the prescribed dose.
Infant acetaminophen, available in several liquid formulations, comes with no directions for parents. While a dosing syringe is provided, there is no indicated dose for the age-group for which this product is intended.
Other important medications commonly prescribed for children also require liquid compounding. These include Lamotrigine, Topiramate, Tacrolimus, Metronidazole, Lansoprazole, Spironolactone, and many others. As always, compounding carries inherent risks in preparation and administration such as inadequate shaking and errors in calculations and measurements.
Measuring volumes of liquid pediatric medicines is critical for delivery of safe, effective doses. Available metering devices include cups, syringes, droppers, and vials, and the ubiquitous teaspoon. Only 12.8% of pediatric oral prescription liquid products come with measuring devices, and pharmacists only occasionally provide them. Even when available, the devices’ inherent inconsistencies can result in under- or over-dosing.
Improvement on the Way?
Thanks to regulatory and market incentives, more drug developers than ever are tapping into the potentially lucrative and medical need-fulfilling pediatric drug market.
The Michigan Pediatric Safety Collaboration was founded to address the lack of standardization for oral compounded liquid pediatric medicines. The state-wide, FDA-funded pilot program maintains a database of more than 100 recipes for pharmacies to refer to, ensuring consistency in compounded formulations in the state.
Drug developers are doing their part as well. The benzodiazepine Midazolam, for example, was approved as a rectal formulation in 1997 but presented the usual problems. The drug is administered to children who are experiencing seizures. An intranasal form of Midazolam, delivered through an atomization mister, was found to be as effective as the rectal dose and much easier to administer, however a commercially available product is still needed.
For drugs most suitable for administration by tablet or capsule, orally disintegrating tablets have shown benefit. Lansoprazole, prednisolone, and ondansetron are now available in this format, providing an attractive alternative dosage form for these pediatric-relevant products.
Even with dedicated development programs pediatric drugs present numerous obstacles. Pharmacokinetic and pharmacodynamic studies performed within ideal clinical settings may not reflect real-world results. Additionally, dosage form and delivery platforms require close consideration in children. Industry and regulators recognize these facts, and are working harder than ever to introduce safer, more effective pediatric medicines to address specific patient-centric issues.
 Lin H. et al. Respiratory Care. 2007; 52(8) 1021-26.
 Grant B. Are the kids alright? The Scientist, March 2012.
 Shawana R. Pediatric biopharmaceutical classification system: using age-appropriate initial gastric volume. AAPS J. 2016 May;18(3):728-36.
 How to give Sabril to your baby. Accessed at: http://sabril.net/infants/giving_sabril/
 Sobhani P et al. Ann Pharmacother. 2008;42:46-52.
 Johnson A, Meyers R. Evaluation of measuring devices packaged with prescription oral liquid medications. J Pediatr Pharmacol Ther. 2016 Jan-Feb; 21(1): 75–80.
 Holsti M et al. Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy. Arch Pediatr Adolesc Med. 2010 Aug;164(8):747-53.