Journal Article Annotations
2021, 2nd Quarter
Annotations by Jeylan Close, MD
April, 2021
The finding:
Authors conducted a systematic review and meta-analysis of pediatric case studies of serotonin toxicity. Inclusion criteria included meeting criteria for one of three adult-validated diagnostic criteria systems, Sternbach (SC), Radomski (RC), and Hunter (HC). 81% of described cases included all three typical symptom categories for serotonin toxicity: altered mental status, autonomic dysregulation, and neuromuscular hyperactivity. Neuromuscular hyperactivity was the most common, and present in 92% of cases. Differences by age were found including more activation symptoms in younger children, and seizures more frequently in adolescents and infants compared to children ages 4-12. In examining causal agents, it was found that 78% of cases involved an antidepressant, with a single agent was implicated in 60% of the cases. About 33% of cases involved talking medications as prescribed, with other exposures including accidental, misuse, or in-utero. In cases caused by an increase in prescribed dose of medication, onset was often delayed more than 24 hours. In contrast, cases of accidental or overdose exposure most commonly presented within 24 hours. The most common lab abnormalities included leucocytosis (22%) and elevated CK (36%). One death occurred in a patient with ornithine transcarbamyl transferase (OTC) deficiency and T-cell ALL. While not an aim of the study, they found discordance between the criteria models, including no agreement beyond chance between the SC and HC and suggesting the lack of a reliable model to diagnose serotonin toxicity in the pediatric population.
Strength and weaknesses:
While this study has the strength of being a systematic review and metanalysis, due to the rare nature of serotonin toxicity only 66 cases were included. Additionally, using case studies has risk of selection and publication bias favoring unusual or severe presentations. However, a benefit of using case studies is that a granular level of detail was obtainable for analysis from each case including types of hyperreflexia (e.g. myoclonus vs clonus) and specific lab abnormalities. A limitation to studying serotonin toxicity in children and adolescents includes disparities in diagnostic criteria models without a gold standard diagnostic tool.
Relevance:
This study is the first systematic review of serotonin toxicity in children and adolescents. While reviews have been performed for adults, it is vital to understand how psychotropic medications may uniquely effect patients across the age spectrum. As serotonergic agents are commonly used in paediatrics, it is imperative to be able to recognize toxicity in that population. Additionally, it is important to consider how adult diagnostic tools may not translate meaningfully to use in children and adolescents.
Type of study (EBM guide):
Systematic review or meta-analysis
The finding:
The authors designed a tool entitled, “What Matters to Me,” as a way of eliciting goals and preferences of care in a developmentally appropriate way for pediatric patients. The tool asks patients to write 3-5 things that they considered to be most important during their admission. Young children were assisted by a Certified Child Life Specialist. The authors administered the tool to 21 patients receiving stem-cell transplants and analysed the qualitative results via directed content analysis. They found that three main themes emerged including expressing identity, communication preferences, and care preferences. Communication preferences ranged from preferring limited involvement to preferring direct and open communication. Care preferences often involved preferences around line access or environment of care.
Strength and weaknesses:
Limitations include the small number of patients receiving a stem-cell transplant at a single site. While the study included a range of ages and even gender distribution, there were not data on other demographic information such as race or socioeconomic factors. Strengths include a systematic way of coding qualitative data including assessing inter-reviewer agreement prior to the analysis.
Relevance:
Patient-centered care in pediatrics often involves families but less often incorporates specific preferences of the patients themselves, especially those of younger ages. The American Academy of Pediatrics has identified both the importance as well as the underuse of engaging patients in bi-directional discussions about their care. In addition to improving quality of life for the individual patient, there is evidence that communication of care preferences can also improve outcomes. This study provides a simple tool to facilitate improved care discussions for pediatric patients.
Type of study (EBM guide):
Case series or report