High-Yield Topic: Adverse Drug Reactions (ADR) in Children | Pediatrics for NEET PG, FMGE & INI CET

[00:00:00]What is ADR? ADR is adverse drug reaction. Adverse drug reaction. It is a noxious nothing but a harmful. It is a noxious and unended response to a drug occurring at normal doses. Very important. It is a harmful and I have no intention but it came. So a noxious and uned response to a drug occurring at normal doses. Okay. Say stay again with me forever. You should remember what is the definition of ADR? Adverse drug reaction. It is a noxious and unintended response of a drug occurring at normal doses. The okay very importantly normal dose. You're giving normal paracetamol but that that paracetamol is causing some problem. Okay. Paracettool was given for fever but it is causing something else adverse drug reactions.

[00:00:44]Okay. Number one. How many of us have seen a rash after antibiotic and ignored it initially? Very important point. How many of us have seen a rash after giving antibiotic we thought it's a fever with rash case. The problem was it's not a fever with rash case. It is a fever case given then given antibiotic and then the b then the baby develop rash because of the antibiotic not because of the fever.

[00:01:06]So how many of us have seen a rash after antibiotic and ignored it completely.

[00:01:11]Now very importantly why it is important for us to understand that why are children more vulnerable to adverse drug reactions? Why it is the pediatric tropic that adverse drug reactions can happen in children? Because number one very importantly the children basically has a immature organ function. Their liver is very immature. Okay very immature is there. For example paracetamol paracetamol crosses through the liver. Okay. In babies and if the baby's liver is immature the par if you give a double dose of paracetamol that can be little hippattoxic for the baby that can cause a raised in SGOT SGPT you know enzymes basically liver enzymes because liver cannot detoxify them so fast. Why? because the baby has a immature organ function or a immature liver. So liver enzymes are immature and higher risk of toxicity. Why? Again what do you call I'm having cold. So why babies are more prone for adverse drug reactions? Because those children's pediatric patient have a reduced renal clearance because lower kidney function in infants and higher risk of accumulation or toxicity. So I'll repeat again very importantly why are children are more vulnerable for ADRs? Number one liver immature liver. Number two kidney immature kidney. Number three, immature weight. Weight basically weight based dozing challenges are there. Small dozing errors can lead to serious consequence. See, if you're giving a dopamine to an adult, we put we always say to sister, put 1 m a dopamine and one what do you call 500 ml of NS and give dopamine. But in children, it is not like that. It is 10 microgram per kg per minute. This microgram per kg per minute has to be converted into milligram and milligram has to be converted into ml and that is how you give. So that is why weight based dosing challenges that can you know this is the one of the cause for by children are more vulnerable to adverse drug reactions off label drug use very importantly many drugs not improve approved for children and higher risk of unexpected adverse drug reactions very importantly if you're going for a fever medicine so paristramol can also decrease fever even numisolide ibuprofen methal all these also can cause decrease in fever but mephanimic acid or mefile is given for something else ibuprofen is given for something else and plain paracetamol is given for something else that's why you know don't go to pharmacy and just buy the drug like that you need ask your local doctor and he's going to help you now very importantly one more thing for exam purposes polyarm pharmacy in NICO or ICU polyarm pharmacy means if you have a case of multiple antibiotic to one baby basically if I have a case of acute encphilitis syndrome then I will give antiviral antimmalarial and antibiotic for antiviral I will give asyclo for antimalarial I give particate and for antibiotic I'll give monosph or septra zone. So acute encphilitis syndrome a yes you always do like a cocktail therapy you cover the antiviral antimmalarial and antibiotic. So in that case it's multiple drugs you're giving and again the baby's liver is very immature and that is why the baby can land up into adverse drug reactions and last but not the least communication and reporting challenges basically because children may not express symptoms clearly you know that I'm having a rash or a itching like that delayed recognition and under reporting so that is why these childrens are these these are the causes why children are very vulnerable to adverse drug reaction let's revise again what is the definition of adverse drug reactions noxious or unintended response to a drug occurring at normal doses. Okay. And what do you call why are children more vulnerable? Because number one immature liver, number two, immature kidney.

[00:04:33]Number two is remember immature weight, weight based challenges are there.

[00:04:37]Number four, immature drug like the drug is immature. You don't know which drug to give actually. And last but not the least, we have polyfarm pharmacy in ICU.

[00:04:44]And last we have is communication problem with the baby. Now why very beautiful what are the common drugs causing adverse drug reactions in pediatric population? Common Se used to say common things are common and rare things are rare. Antibiotics starting with antibiotics common and the started antibiotics from starting and cause a rash then it can go for liver problem hepattoxicity nephrotoxicity or anaphylaxis. So yes antibiotic can causes rash, diarrhea or liver or kidney problem. Number two anti-epileptic now very very important like carbomin can cause steven Johnson syndrome you know that's an MCQ. So that also important for exam purpose you know that rashes can cause severe problem Steven Johnson syndrome and he hypattoxicity bone marrow suppression terattogenicity so if I give a proper heading what all drugs can cause adverse drug reaction number one antibiotics number two anti-epileptics number three anides number four are vaccines number five corticosteroids and number six is chemotherapy drugs so niids we all know that niids the painkillers and all that they can cause gastritis and GI plate gastritis and GI blade. And last but not the least, vaccines very importantly starting from fever to pain to rash and very important for exam purpose. Which vaccine causes incessant cry? Which vaccine causes incessant cry? Incesscent cry means inconsolable cry or too much of cry. The answer is DPT MCQ. DPT vaccine causes maximum cry. That's an exam question please remember. And corticosteroids also these drugs can cause immune suppression, hypoglycemia, hypertension and growth suppression. So steroids causing imunosuppression or growth suppression is very commonly we have seen in exams and chemotherapy drugs causing no nausea vomiting myopppression hippat toxicity and extravision injury. So with the take-home message for this slide is what are the drugs which can cause ADR antibiotics can cause ADR anti-epile start from bin anti-epileptic can cause ADR starts from NCIS vaccines can cause ADR corticosteroids and chemotherapy drugs okay corticosteroids last two are C and C for corticosteroids C for chemotherapy drugs remember that now what are the types of ADR very important question come in pharma also and here also very straightforward question very nice also there are six types Types of adverse adverse drug reaction type A B CDE E. Now what is A? Type A adverse drug reaction. Type A adverse drug reaction means A for A and A for augmented. What is the meaning of augmented? Very importantly augmented means exaggerated normal effect.

[00:07:15]Exaggerated normal effect. Okay. So for example for example if I give too much of insulin if I give insulin to a child.

[00:07:23]So I know the exaggerated normal effect of insulin it can cause hypoglycemia in the child. So insulin too much insulin can cause hypoglycemia. Even a normal insulin also you are giving you need to monitor for hypoglycemia in the baby.

[00:07:36]And say for example paracetamol if you're giving to a baby you need to see for the liver enzymes because paracetamol can cause liver toxicity causing raise in the sgot and sgpt. Okay serum glutinate you know what to call this sgotp enzymes. Okay so important for the exam purpose. So we have six types of adverse drug reaction. Type A is augmented. Augmented means exaggerated normal effects. So let's focus on type A. Type A what do you call adverse drug reaction? Number one very importantly they are predictable. I know if I give too much of paracetamol that will cause liver toxicity. They are dose related. Very very important they are dose related. They are preventable. If you stop the drug and everything is fine and they are reversible. So type A is straightforward important pointer that number one it is for the it is because of excess I have given the drug the drug which is normally working but double dose I have given so it is dose related predictable reaction due to exaggerated drug effect and it is predictable known drug effect like if I give up too much of paracetamol that will cause liver toxicity it is dose related that's right it is the commonest common adverse drug reactions it is preventable and it is reversible here straightforward exam question for example Example if you give excess insulin what will happen? The patient can have hypoglycemia. If you give anti-coagulants too much what will happen? Bleeding the baby will have antihistaminics can cause sedation.

[00:08:58]Anti-hypertensis can cause hypotension.

[00:09:00]Amino glycosytes cause nephrotoxicity.

[00:09:02]Star mark PYQ previous year questions.

[00:09:05]NIS causes gastritis MCQ and paracetamol MCQ causes liver toxicity hippatto toxicity. So these straightforward are MCQs are there that ni cause gastritis.

[00:09:16]Paracetamol can cause liver toxicity and neinologlycosytes can cause what you called nephrotoxicity. Straightforward okay now case based question I have a fivemonth old baby who came with complaints of vomiting irritability and poor feeding. vomiting, irritability, poor feeding. On examination, medication history, paracetamol was given. The mother had given 10 ml of paracetamol every four to 6. And on examination, the baby has a mild jaundice and hippatomically. And as I said, hippatomically, the patient has sgotp enzymes are raised. Okay. So very importantly, what do you think the problem over here is? The problem over here is a 5-month old baby giving paracetamol 10 ml that is like a double dose and every four to six hourly that's too much for him. And that is why that will cross the liver like too much of paracetamol will not be able to cross cross the liver and the baby will land up into very importantly paracetamol hippatto toxicity. So the answer for this question is the baby is suffering from paracetamol hippat toxicity and the straightforward what is the antidote knack and acetylcysteine. We all know that immediate paracet immediate stop the drug and knack and esty is the drug of choice like antidote basically for PCM poisoning. Paracetto poisoning is an exam question. Okay, straightforward you should know. Now what is type B adverse drug reaction? Type B means bizarre.

[00:10:33]Bizarre means unpredictable immune reaction. Unpredictable like unpredictable. Not every kid will have this problem but some kid can have this reaction to that drug. For example, very importantly carbomazipin causing Steven Johnson syndrome. Not every carbomipin tablet will cause Steven Johnson syndrome but some can cause. So it is unpredictable. It is not very commonly seen. Unpredictable. Remember that. So what is the special point of type B adverse drug reaction? Number one, it is bizarre. Number two, unpredictable immune reaction is unpredictable. It is unpredictable occur in few people. It is not it is not dose related. I'm giving normal carosen only but it is causing by mistake this problem. Okay. So it improves after stopping the drug and reexposure may cause reoccurrence. Okay.

[00:11:18]Because and what unpredictable reaction carbon zippin can cause skin rash or any problem basically the the drug can cause for example carbon zipin causes Steven Johnson syndrome that is an exam question remember that so the key learning point in type B is it is not dose related it is rare but it can come and early recognition and timely management it will be really helpful for you okay so stop the drug symptomatic treatment monitor the monitor and support and report the adverse drug reaction in the phicov vigilance program of India PVPI phic vigilance program of India there's something known as VB flow which is a online platform where basically you report the adverse drug reactions so these are the important point you should know regarding type B adverse drug now what happens in type A type A I was giving paracetamol but A for augmented or exaggerated drug like over you know what do you call use of the drug so I gave double paracetamol and that was causing hippartoxicity in type two I'm giving normal tablet carbonosipin but I know there's unpredictable reaction immune reaction that carbonosipin can cause Steven Johnson syndrome for example a 2-year-old child fever since 5 days followed by rash all over the body since 2 days fever since 5 days rash in 2 days in tablet carosipin was started 7 days back for the seizure and now the patient has rashes all over the body facial edema and CBC shows eocinophilia but the liver is normal so what is the problem the problem very importantly this is a type B adverse drug reaction it is a drug induced was macular rash because of karma zipin now very important okay so why type B because it is unpredictable and it is not dose related I did not give a double dose of caroxipin I give normal dose only but it was a unpredictable immune reaction it occurs in small portion of patients not linked to non-farmacological action improves after stopping the drug and reexposure may cause reoccurrence so what is the key learning in type B the key learning is the type B reactions are unpredictable and they are not dose related can occur with first time use also early recognize and then you timely stop the drug. So this is very important for type B. So let's revise again how many types of adverse drug reaction are there? There are six types. Type A what do you mean by type A? A for augmented means means exaggerated like basically the drug is giving an overdose. Okay. So type A that one word I want you guys to remember is this one that exaggerated drug effect. There is an exaggerated drug effect. Augmented itself means exaggerated drug effect. Type B for type B. B for bizarre. Bizarre very important. Bizarre means unpredictable immune reaction. Now the next is type C.

[00:13:56]What is type C advert drugs reaction?

[00:13:58]That is due to long continuous use.

[00:14:01]Straightforward chronic use. You're going to have this problem. For example, if I give steroids for long time, they cause growth retardation. Short sture like that. So continuously giving steroids can cause short stretch. It is a chronic drug reaction. It is not a exaggerated drug reaction. It is not a bizarre unpredictable reaction. I know this will cause but by chronic use it will cause a adverse drug reaction. So remember that. Okay. So type C. Yes.

[00:14:24]Exactly. This part is done. Hm. Yes. Now type C very importantly I have in this case scenario a three-year-old boy diagnosed with nephroic syndrome one year ago. One year ago he is on predisolon. Since then from last one year the patient is on predisolon. Now came to OPD with very importantly not poor hygiene, round face, increased appetite, frequent infections and easy bruising. So what do you think? So very importantly yes we all know that that this child has been using corticosteroids for long time. So now if I'm using corticosteroids from long time and the baby is getting this all these short stature and fat baby and all that.

[00:15:01]So what do you think this this adverse drug reaction is known as? Very importantly this is known as type C chronic adverse drug reaction because of chronic use of predicolon the baby is having a round face belly and a short stature. So type C is chronic drug adverse drug reaction. Now what is type D? Type D is delayed adverse drug reaction. Delayed means I gave a drug then I I gave a drug then I stopped it.

[00:15:24]After 3 months the baby got some problem. I gave something for 5 days then I stopped it the baby was fine. But after 3 months or after five months the baby got the problem that is known as delayed adverse drug reaction. There is a adverse drug reaction but not like suddenly there's a delayed adverse drug reaction. Remember that appears after a long delay. For example kampenicol can cause alastic anemia but not within one day it will cause like I'll give corenol after some time it will cause alastic anemia. Now type is very importantly delay in onset. It is not dose related.

[00:15:56]You gave a drug, you stopped, the baby was fine. After 2 months, after 3 months, the baby got the adverse drug reaction. That is a delayed adverse drug reaction. Remember that type D delayed reaction appears after after a significant time lag following the use of the drug. They are not related to the dose. Very straightforward question. For example, theomide will cause faucia like a limb defects. Very important exam question. If the mother has taken theidomide during pregnancy, the baby can land up into focalia. So, mother took theomide. After none 9 months a baby born with foam or limb defect it's a delayed ad adverse drug reaction like corticosteroids very importantly cause bone loss or fracture pluram fenicol alastic anemia is numbness or tingling okay or peripheral neuropathy these all are all are all our exam question is causing peripheral neuropathy corticosteroids causing bone density bone loss and theomide causing foamia if the mother has taken theomide during pregnancy the baby can land up into fomia all these are delayed adverse drug reaction. For example, a 2-year-old boy received a medication for a severe skin infection. The drug was stopped for 10 days. The drug was given for 10 days and stopped. After 3 months, the child was diagnosed with alastic anemia. So, one drug was given and stopped and after 3 months, the child came with alastic anemia and said this. Which type of adverse drug reaction is this? This is type D, delayed adverse drug reaction. Straightforward question. Last but not the least, we have type E adverse drug reaction. E means end of use. End of use means very simple, very easy. I gave medication for 10 to 10 days and 11th day the baby got the reaction. Straightforward question.

[00:17:32]I gave a seizure medication for 10 days.

[00:17:34]Once I stopped the seizure medication, the baby started showing a withdrawal symptoms or he got the seizure again like that. So once you stop the drug and the baby get the reaction that's way for example, very nice question. Type E means end of use. Okay, so think end.

[00:17:48]Okay, so it appears after the drug is stopped. For example, a six-year-old child was receiving predicolon for nephroic syndrome. Okay, he was receiving prennicolon for nephroic syndrome. He was given steroid for 3 months and then he stopped suddenly.

[00:18:02]Suddenly he stopped. After a few days, the baby developed weakness, vomiting and hypotension and investigation shows adrenal insufficiency. So which type of ADR is this? It is type E adverse drug reaction. Type E is end of use. You stop the predicolon, the baby got a problem.

[00:18:18]Straightforward. Okay. The reaction occurs after the drug is stopped. That is the highlighter over here. Now, last but not the least, we have type F, adverse drug reaction. Very easy. Type F is failure therapy. Failure means I gave an antibiotic.

[00:18:32]I gave for fever. 7 days antibiotic I gave but the baby is still having fever and I got the blood culture done and the baby's resistant to that antibiotic. So, this is known as failure therapy. This failure therapy. This is known as the drug is not responding. For example, antibiotic resistance naturally. So antibiotic I give and there is no response. That is failure to therapy.

[00:18:52]Failure therapy that you should know.

[00:18:54]For example, 8-year-old boy, he was diagnosed with typhoid fever. He was giving cyphix for 7 days. He took the medication regularly but after 5 days he still have high fever and not improving and the culture shows resistance to cphixim. This is a classical case of type F drug fails to produce the expected effect known as type F adverse drug reaction. Okay.

[00:19:16]very important for example 5-year-old child diagnosed with pulmonary TB you started on antitubercular therapy after two months of regular treatment he still have fever cuff and poor weight gain you got the sputum gene expert done and there was a persistence of microacterium tuberculosis that means no drug that mean the drug is not you know getting useful the drug is failing to produce the expected effect this is known as type fadr that is failure of therapy not due to adverse effect of the body it is due to the lack of the therapeutic effect. The lack of the therapeutic effect. Remember that. So that's it.

[00:19:50]That finishes this topic. Thank you so much. Remember now easy memory trick.

[00:19:54]There are six types of ADR. Type A. In type A the action is increased because it is dose related. I give too much of paracetamol. It causes liver toxicity. B for bizarre body reaction. Bizarre means unpredictable. Carmonazipin in some cases unpredictable. It can cause Steven Johnson syndrome but not not every baby.

[00:20:11]So unpredictable immune reaction. Type C is chronic continuous use. Predicone for one year. It will cause you know height low or short stature or growth suppression. Okay. Delayed damage.

[00:20:23]Delayed damage means I gave what called some drug and after 3 months it causes alastic anemia. So it's a delayed reaction. End of use. I gave a drug for 10 days. 11th day the baby got the problem. That is end of use and you after stopping you see the problem and F for failure of therapy means no effect.

[00:20:40]I gave a drug and there is no response.

[00:20:42]That means it's a failure therapy. So these are the beautiful points regarding the various types of ADR. So what is the take-h home message? Think about adverse drug reactions. You you need to sense in the baby. Recognize them early. Act promptly. Use drugs wisely of course and know types and mechanism. Which type of ADR it is? Type A, B, C, D, E. Okay, I gave the I gave the drug for cuff and cold. After 3 months, the baby got the problem. So it's a delayed reaction from the drug. You remember that very easy.

[00:21:08]So you assess the risk factors put the put the patient first first is your patient monitor very closely report the ADR for PVPI PVPI is far vigilance program of the India that you should know and most ADRs are reversible remember that so please take care and thank you and uh the revision for this is if the mother has taken felidomide the baby can land up into focalia paracetamol can cause nephrotoxicity or hypatxicity hippotoxicity and what's the drug of choice For paracetmal poisoning it is an acetyl system. Okay. If you give too much of insulin or normal insulin giving to the patient it can cause hypoglycemia or hypoglycemia.

[00:21:47]Hypoglycemia. So these are the beautiful revision question you must know for the adverse drug reactions. Life is beautiful and before leaving what is the quote? The quote is you are the best.

[00:21:57]The quote is be very confident in what you're studying. The quote is whatever you're reading no read in a way that you're reading this for the first and last time. Okay. It is a very important five marks question. EDR adverse drug reaction straight forward they'll ask you adverse drug reactions or they'll give you a case scenario and they will ask you which type of adverse drug reaction is this or they can ask you a question if the mother has taken theomide the baby can have phomia or they can show you the picture of where the baby is having defect in the limbs okay so please take care and thank