Unanswered Questions in Pediatric Clinical Trials: Literature Review
https://doi.org/10.15690/10.15690/pf.v19i1.2375
Abstract
This literature review provides information on the deficit of clinically proven data on the drugs use in pediatric practice. Issues on why children are widely administrated with drugs that are normally intended for use in adults without any prior qualitative estimation of their safety and efficacy in appropriate clinical studies involving children have been analyzed. The authors considered the issues of carrying out clinical trials with the participation of children as study subjects: ethical, regulatory, and psychological aspects of this complex task. There are decisions for every of the listed aspect. The authors of analyzed sources and the authors of this article believe that these decisions may help to address all the challenges and evade the incorrect assessment and interpretation of initial data by children’s parents and adoptive parents (legal representatives). Issues of doctors’ alertness were considered separately. Information and excerpts from regulatory acts were given, as well as information from publications on awareness raising and in support of doctors-researches. This literature review has been carried out to solve problems of information gap in the field of drugs safety and efficacy in pediatric practice. The disclosure of discussion points for clinical trials with children will ultimately help to improve the quality of healthcare provided to children in the future and take advantage of recent technologies used in patients’ cohorts of other age groups.
About the Authors
Leyla S. Namazova-BaranovaRussian Federation
MD, PhD, Professor, Academician of the RAS; eLibrary SPIN: 1312-2147
Moscow, Belgorod
Disclosure of interest:
Not declared
Nilab Sadeqi
Russian Federation
MD
10/1 Fotievoy Str., 119333 Moscow, +7 (499) 400-47-33
Moscow
Disclosure of interest:
Not declared
Alexander A. Baranov
Russian Federation
MD, PhD, Professor; eLibrary SPIN: 3570-1806; eLibrary SPIN: 3570-1806
Moscow
Disclosure of interest:
Not declared
References
1. Joseph PD, Craig JC, Caldwell PH. Clinical trials in children. Br J Clin Pharmacol. 2015;79(3):357–369. doi: https://doi.org/10.1111/bcp.12305
2. Pharmacokinetics and Pharmacodynamics in Children versus Adults. In: Rational Therapeutics for Infants and Children: Workshop Summary. Institute of Medicine (US) Roundtable on Research and Development of Drugs, Biologics, and Medical Devices; Yaffe S, ed. Washington (DC): National Academies Press (US); 2000. Available online: https://www.ncbi.nlm.nih.gov/books/NBK225507. Accessed on November 25, 2021.
3. van den Anker J, Reed MD, Allegaert K, Kearns GL. Developmental Changes in Pharmacokinetics and Pharmacodynamics. J Clin Pharmacol. 2018;58(Suppl 10):S10–S25. doi: https://doi.org/10.1002/jcph.1284
4. Germovsek E, Barker CIS, Sharland M, et al. Pharmacokinetic-Pharmacodynamic Modeling in Pediatric Drug Development, and the Importance of Standardized Scaling of Clearance. Clin Pharmacokinet. 2019;58(1):39–52. doi: https://doi.org/10.1007/s40262-018-0659-0
5. Schrier L, Hadjipanayis A, Stiris T, et al. Off-label use of medicines in neonates, infants, children, and adolescents: a joint policy statement by the European Academy of Paediatrics and the European society for Developmental Perinatal and Pediatric Pharmacology. Eur J Pediatr. 2020;179(5):839–847. doi: https://doi.org/10.1007/s00431-019-03556-9
6. Nir-Neuman H, Abu-Kishk I, Toledano M, et al. Unlicensed and Off-Label Medication Use in Pediatric and Neonatal Intensive Care Units: No Change Over a Decade. Adv Ther. 2018;35(7):1122–1132. doi: https://doi.org/10.1007/s12325-018-0732-y
7. Ballentine C. Sulfanilamide Disaster. FDA Consumer magazine. June 1981. Available online: https://www.fda.gov/files/about%20fda/published/The-Sulfanilamide-Disaster.pdf. Accessed on November 25, 2021.
8. Curran WJ. The thalidomide tragedy in Germany: the end of a historic medicolegal trial. N Engl J Med. 1971;284(9):481–482. doi: https://doi.org/10.1056/NEJM197103042840906
9. Ackerman TF. The ethics of drug research in children. Paediatr Drugs. 2001;3(1):29–41. doi: https://doi.org/10.2165/00128072-200103010-00003
10. Institute of Medicines of the National Academies: Committee on Clinical Research Involving Children. The Ethical Conduct of Clinical Research Involving Children. Washington, DC: The National Academies Press; 2004.
11. Burns LE, Hodgman JE, Cass AB. Fatal Circulatory Collapse in Premature Infants Receiving Chloramphenicol. N Engl J Med. 1959;261:1318–1321. doi: https://doi.org/10.1056/NEJM195912242612604
12. Vanchieri C, Butler AS, Knutsen A. Addressing the Barriers to Pediatric Drug Development: Workshop Summary. Washington, DC: The National Academies Press; 2008.
13. Shirkey HC. Therapeutic orphans — everybody’s business. Ann Pharmacother. 2006;40(6):1174. doi: https://doi.org/10.1345/aph.140023
14. Shirkey HC. Therapeutic orphans 1970. J Infect Dis. 1970; 121(3):348–350. doi: https://doi.org/10.1093/infdis/121.3.348
15. Burckart GJ, Kim C. The Revolution in Pediatric Drug Development and Drug Use: Therapeutic Orphans No More. J Pediatr Pharmacol Ther. 2020;25(7):565–573. doi: https://doi.org/10.5863/1551-6776-25.7.565
16. Christensen ML, Helms RA, Chesney RW. Is pediatric labeling really necessary? Pediatrics. 1999;104(Suppl 3):593–597.
17. European Medicinec Agency. Human regulatory. Paediatric Regulation. Available online: https://www.ema.europa.eu/en/human-regulatory/overview/paediatric-medicines/paediatricregulation. Accessed on November 25, 2021.
18. Regulation (EC) No. 1901/2006 of the European Parliament and of the Council of 12 December 2006 on medicinal products for paediatric use and amending Regulation (EEC) No. 1768/92, Directive No. 2001/20/EC, Directive No. 2001/83/EC and Regulation (EC) No. 726/2004. Available online: https://wipolex.wipo.int/ru/legislation/details/5940. Accessed on November 25, 2021.
19. Bren L. The Road to the Biotech Revolution — Highlights of 100 Years of Biologics Regulation. FDA Consumer magazine. Centennial Edition (Jan.-Feb. 2006). Available online: https://www.fda.gov/files/about%20fda/published/The-Road-to-the-Biotech-Revolution-Highlights-of-100-Years-of-Biologics-Regulation.pdf. Accessed on December 12, 2021.
20. Zavidova SS, Namazova-Baranova LS, Topolyanskaya SV. Clinical trials of drugs in pediatrics: problems and achievements. Pediatricheskaya farmakologiya — Pediatric pharmacology. 2010;7(1):6–14. (In Russ.)
21. Peltzman S. An Evaluation of Consumer Protection Legislation: The 1962 Drug Amendments. The Journal of Political Economy. 1973;81(5):1051. doi: https://doi.org/10.1086/260107
22. Code of Federal Regulation: A point in time eCFR system. Available online: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46?toc=1. Accessed on December 12, 2021.
23. Labson MS. Pediatric Priorities: Legislative and Regulatory Initiatives to Expand Research on the Use of Medicines in Pediatric Patients. J Health Care Law Policy. 2002;6(1):34–72.
24. Frakking NJ, van der Lee JH, Klassen TP, Offringa M. Survey of current guidance for child health clinical trials. The StaR Child Health Project: Standards for Research with Children. Available online: https://www.who.int/childmedicines/publications/GUIDANCECHILDHEALTH.pdf?ua=1. Accessed on December 12, 2021.
25. Food and Drug Regulations, CRC c 870, C.08.004.1(4).
26. Watts G. WHO launches campaign to make drugs safer for children. BMJ. 2007;335(7632):1227. doi: https://doi.org/10.1136/bmj.39423.581042.DB
27. Department of Health and Human Services Food and Drug Administration. Best Pharmaceuticals for Children Act and Pediatric Research Equity Act. July 2016 Status Report to Congress. Available online: https://www.fda.gov/media/99184/download. Assessed on December 20, 2021.
28. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2019;67(4):674–694. doi: https://doi.org/10.1111/jgs.15767
29. Meyers RS, Thackray J, Matson KL, et al. Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List. J Pediatr Pharmacol Ther. 2020;25(3):175–191. doi: https://doi.org/10.5863/1551-6776-25.3.175
30. Butler E, Ludwig K, Pacenta HL, et al. Recent progress in the treatment of cancer in children. CA Cancer J Clin. 2021;71(4):315–332. doi: https://doi.org/10.3322/caac.21665
31. Ivanovska V, Rademaker CM, van Dijk L, et al. Pediatric drug formulations: a review of challenges and progress. Pediatrics. 2014; 134(2):361–372. doi: https://doi.org/10.1542/peds.2013-3225.
32. AMA. Pediatric Decision Making. Available online: https://www.ama-assn.org/delivering-care/ethics/pediatric-decision-making. Assessed on December 14, 2021.
33. Neyro V, Elie V, Thiele N, Jacqz-Aigrain E. Clinical trials in neonates: How to optimise informed consent and decision making? A European Delphi survey of parent representatives and clinicians. PLoS ONE. 2018;13(6):e0198097. doi: https://doi.org/10.1371/journal.pone.0198097
34. Pace RA, Ciruzzi S, Ferreres AR. The Pediatric Patient as a Self-Individual and Decision-Maker. In: Surgical Ethics. Ferreres A, ed. Cham: Springer; 2019. pp. 231–238. doi: https://doi.org/10.1007/978-3-030-05964-4_21
35. Ethical considerations for clinical trials on medicinal products conducted with minors Recommendations of the expert group on clinical trials for the implementation of Regulation (EU) No 536/2014 on clinical trials on medicinal products for human use Revision 1 18 September 2017. Available online: https://ec.europa.eu/health/sites/default/files/files/eudralex/vol-10/2017_09_18_ethical_consid_ct_with_minors.pdf. Accessed on December 13, 2021.
36. Regulation (EU) No 536/2014 of the European Parliament and of the Council of 16 April 2014 on clinical trials on medicinal products for human use, and repealing Directive 2001/20/EC. Available online: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:02014R0536-20140527&from=EN. Accessed on December 12, 2021.
37. Neznanov NG, Nikitin EN, Miroshenkov PV. Biomeditsinskie issledovaniya v pediatrii. Kachestvennaya klinicheskaya praktika = Good Clinical Practice. 2002;(2):40–48. (In Russ).
38. Family Code of the Russian Federation dated December 29, 1995 N 223-FZ. (In Russ).
39. Topolyanskaya SV. Ethical aspects of clinical investigations in children. Pediatricheskaya farmakologiya — Pediatric pharmacology. 2010;(3):6–11. (In Russ).
40. Gu S, Wang F, Patel Nitesh P, et al. A Model for Basic Emotions Using Observations of Behavior in Drosophila. Fron Psychol. 2019;10:781. doi: https://doi.org/10.3389/fpsyg.2019.00781
41. Izard CE. The Psychology of Emotions, Springer Science & Business Media. Springer US; 1991. 452 p.
42. Shilling V, Young B. How do parents experience being asked to enter a child in a randomised controlled trial? BMC Med Ethics. 2009;10:1. doi: https://doi.org/10.1186/1472-6939-10-1
43. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–2194. doi: https://doi.org/10.1001/jama.2013.281053
44. All Union State Standard Р 52379-2005 “Natsional’nyi standart Rossiiskoi Federatsii Nadlezhashchaya klinicheskaya praktika. Good Clinical Practice (GCP)”. Date of validity April 01, 2006. (In Russ). Доступно по: https://docs.cntd.ru/document/1200041147. Ссылка активна на 25.11.2021.
45. Woolfall K, Shilling V, Hickey H, et al, Parents’ agendas in paediatric clinical trial recruitment are different from researchers’ and often remain unvoiced: a qualitative study. PLoS One. 2013;8(7):e67352. doi: https://doi.org/10.1371/journal.pone.0067352
46. European Union. Ethical considerations for clinical trials on medicinal products conducted with the pediatric population. Eur J Health Law. 2008l;15(2):223–250. doi: https://doi.org/10.1163/157180908x333228
47. de Wildt SN, Ito S, Koren G. Challenges for drug studies in children: CYP3A phenotyping as example. Drug Discov Today. 2009;14(1–2):6–15. doi: https://doi.org/10.1016/j.drudis.2008.07.007
48. Shakhnovich V, Hornik CP, Kearns GL, et al. How to Conduct Clinical Trials in Children: A Tutorial. Clin Transl Sci. 2019;12(3):218–230. doi: https://doi.org/10.1111/cts.12615
49. Turner MA. Clinical trials of medicines in neonates: the influence of ethical and practical issues on design and conduct. Br J Clin Pharmacol. 2015;79(3):370–378. doi: https://doi.org/10.1111/bcp.12467
50. General Clinical Pharmacology Considerations for Neonatal Studies 2 for Drugs and Biological Products Guidance for Industry, draft version. Available online: https://www.fda.gov/media/129532/download. Assessed on December 14, 2021.
51. Greenberg RG, Corneli A, Bradley J, et al. Perceived barriers to pediatrician and family practitioner participation in pediatric clinical trials: Findings from the Clinical Trials Transformation Initiative. Contemp Clin Trials Commun. 2017;9:7–12. doi: https://doi.org/10.1016/j.conctc.2017.11.006
52. PPA. The mission of the Pediatric Pharmacy Association. Available online: https://www.ppag.org/?pg=Mission. Accessed on November 25, 2021.
53. Stultz JS, Knoderer CA, Manasco KB, et al. Identification of Factors Associated With the Desire to Participate in a Pediatric Pharmacy Practice-Based Research Network. J Pediatr Pharmacol Ther. 2018;23(6):479–485. doi: https://doi.org/10.5863/1551-6776-23.6.479
54. Pica N, Bourgeois F. Discontinuation and nonpublication of randomized clinical trials conducted in children. Pediatrics. 2016;138(3):e20160223. doi: https://doi.org/10.1542/peds.2016-0223
55. Glasser SP, Howard G. Clinical trial design issues: at least 10 things you should look for in clinical trials. J Clin Pharmacol. 2006;46(10):1106– 1115. doi: https://doi.org/10.1177/0091270006290336
Review
For citations:
Namazova-Baranova L.S., Sadeqi N., Baranov A.A. Unanswered Questions in Pediatric Clinical Trials: Literature Review. Pediatric pharmacology. 2022;19(1):61-71. (In Russ.) https://doi.org/10.15690/10.15690/pf.v19i1.2375