Allison B. Blackmer

Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review.

Neurodevelopmental disorders (NDDs) are defined as a group of disorders caused by changes in early brain development, resulting in behavioral and cognitive alterations in sensory and motor systems, speech, and language. NDDs affect approximately 1–2% of the general population. Up to 80% of children with NDDs are reported to have disrupted sleep; subsequent deleterious effects on daytime behaviors, cognition, growth, and overall development of the child are commonly reported. Examples of NDDs discussed in this review include autism spectrum disorder, cerebral palsy, Rett syndrome, Angelman syndrome, Williams syndrome, and Smith‐Magenis syndrome. The etiology of sleep disorders in children with NDDs is largely heterogeneous and disease specific. The diagnosis and management of sleep disorders in this population are complex, and little high‐quality data exist to guide a consistent approach to therapy. Managing sleep disorders in children with NDDs is critical both for the child and for the family but is often frustrating due to the refractory nature of the problem. Sleep hygiene must be implemented as first‐line therapy; if sleep hygiene alone fails, it should be combined with pharmacologic management. The available evidence for the use of common pharmacologic interventions, such as iron supplementation and melatonin, as well as less common interventions, such as melatonin receptor agonists, clonidine, gabapentin, hypnotics, trazodone, and atypical antipsychotics is reviewed. Further, parents and caregivers should be provided with appropriate education on the nature of the sleep disorders and the expectation for modest pharmacologic benefit, at best. Additional data from well‐designed trials in children with NDDs are desperately needed to gain a better understanding of sleep pharmacotherapy including efficacy and safety implications. Until then, clinicians must rely on the limited available data, as well as clinical expertise, when managing sleep disorders in the population of children with NDDs.

Three-in-One Parenteral Nutrition in Neonates and Pediatric Patients Risks and Benefits

Parenteral nutrition (PN) is a life-sustaining therapy designed to deliver essential nutrients to patients unable to meet nutrition needs via the enteral route. PN may be delivered via a 2-in-1 system (one solution containing amino acids, dextrose, electrolytes, vitamins, minerals, and fluids and one solution containing intravenous fat emulsions [IVFEs]) or via a 3-in-1 system (all nutrients mixed in one container). Although the use of 3-in-1 PN solutions is not necessarily therapeutically advantageous, certain benefits may exist such as the potential to reduce the risk of contamination due to decreased manipulations; ease of administration, particularly in the home care setting; possible cost savings; and reduced IVFE wastage. However, the incorporation of IVFE in 3-in-1 solutions also presents unique risks for the neonatal and pediatric population such as decreased stability, increased lipid globule size, decreased sterility and the potential for increased microbial growth/infectious complications, the need to use a larger filter size, precipitation and compatibility risks, and an increased chance of catheter occlusion. This review outlines the unique issues and challenges to be considered when formulating neonatal and pediatric 3-in-1 PN admixtures. While 3-in-1 PN solutions may be advantageous for certain pediatric populations, specifically those dependent on home PN, the risks do not outweigh the benefits in neonatal patients, and use should be avoided in this population.

Clinical pharmacy academic career transitions: Viewpoints from the fieldPart 1: Understanding feedback, evaluation, and advancement

The six authors of this commentary series, who have recently transitioned into or within an academic career, discuss challenging aspects of an academic career change. This is a three-part commentary series that explores select challenges: 1) feedback, evaluation and advancement; 2) understanding and balancing of distribution of effort; 3) learning how and when to say yes. Faculty, or those interested in pursuing a career in pharmacy academia, can refer to this commentary series as a reference. Schools of pharmacy may utilize this as a tool for new faculty members during orientation in order to ensure smooth integration into the academic environment.

Clinical pharmacy academic career transitions: Viewpoints from the field part 3: Learning when and how to say yes

The six authors of this commentary series, who have recently transitioned into or within an academic career, discuss challenging aspects of an academic career change. This is Part 3 of a three-part commentary series that focuses on when and how to say yes to the multitude of opportunities available to pharmacy practice faculty. Part 1 discusses feedback, evaluation, and advancement. Part 2 explains distribution of effort (DOE) and how to marry the different components of teaching, research, and service. While the entire series is intended to be read in continuity, faculty, or those interested in pursuing a career in pharmacy academia, can refer to Part 3 as a reference on how to screen opportunities within academia to maximize professional and personal growth and minimize career burnout. Schools of pharmacy may utilize this as a tool for new faculty members during orientation to help ensure faculty success.

Clinical pharmacy academic career transitions: Viewpoints from the field Part 2: Understanding and balancing the distribution of effort

INTRODUCTION The six authors of this commentary series, who have recently transitioned into or within an academic career, discuss challenging aspects of an academic career change. The authors represent faculty members teaching within a large, state-funded, research-intensive School of Pharmacy located within a large academic health center. The authors have various backgrounds and represent individuals making transitions at various points in their careers (from residency into academia, from a non-academic environment into academia, and from one academic environment to another). COMMENTARY This is Part 2 of a three-part commentary series that focuses on understanding and balancing the distribution of effort. Parts 1 and 3 of this commentary series explore feedback, evaluation and advancement; and learning when and how to say yes, respectively. While the entire series is intended to be read in continuity, faculty, or those interested in pursuing a career in pharmacy academia, can refer to Part 2 as a reference to aid in understanding and balancing the different components and the distribution of effort associated with a position in academic pharmacy, specifically. IMPLICATIONS Schools of Pharmacy may utilize this as a tool for new faculty members during orientation in order to help ensure faculty success.

Steps Toward Evidence‐Based Management of Sleep Problems in Children with Neurodevelopmental Disorders

Blackmer and Feinstein, in an article published online in Pharmacotherapy, comprehensively reviewed pharmacotherapy for sleep disorders in children with neurodevelopmental disorders (NDDs). Sleep problems (particularly insomnia) are extremely common in individuals with NDDs, with deleterious effects on daily functioning for affected individuals and their families. As clinician-scientists in the field of NDDs, we are encouraged by attention to this significant health problem. However, we feel compelled to comment on one aspect of the article. The abstract states, “Sleep hygiene must be implemented as first-line therapy; if sleep hygiene alone [emphasis ours] fails, it should be combined with pharmacologic management.” This statement and references within the body of the article suggest that the authors may have conflated sleep hygiene recommendations and systematic behavioral interventions. Such confusion may be related to how interventions for children’s sleep are delivered. Adult insomnia can be treated effectively using cognitive behavioral therapy (CBT), which involves patients directly in changing their own sleep patterns. Pediatric sleep hygiene interventions often consist of parent psychoeducation—that is, information to promote empowerment and behavior change. In contrast, pediatric behavioral sleep interventions are characterized by systematic evidence-based procedures implemented by parents to alter their children’s sleep-related behavior. Examples of effective procedures to address insomnia in children, including those with NDDs, are graduated extinction and faded bedtime. We agree that remediating sleep hygiene is the first step in addressing sleep problems. Further, we concur that high-quality data on treatment of sleep disorders in youth with NDDs are sparse and research is needed. However, clinical best practice for effective management of pediatric insomnia is to encourage implementation of good sleep hygiene practices, followed (if needed) by specific behavioral intervention, adding pharmacologic management when both have been ineffective. Lack of appropriately trained clinicians is a major barrier to pursuing this therapeutic sequence.