title: Paediatric Polypharmacy and Deprescribing
Creators: name: Moss, James
Publisher: name: University of Liverpool Repository
Year: 2024

description: Introduction: Polypharmacy, the concurrent use of multiple medications, is not exclusive to adults; children and young people (CYP) also experience it. Those taking numerous medications often face challenges such as poor adherence, reduced quality of life, increased adverse drug reactions and a higher risk of drug-drug interactions. The number of children surviving with complex chronic conditions is increasing, yet most research and guidance in managing polypharmacy and deprescribing targets older adults. 
Methods: To address this gap, we performed a systematic review using search terms based upon three main themes: “Deprescribing”, “Paediatric”, and “Guideline”. Additionally, we surveyed healthcare professionals (HCPs) caring for children in the United Kingdom (UK) over one month and collected paediatric prescribing data from both primary and secondary/tertiary care, in a UK city, over one day. We also assessed the attitudes of CYP and their parents toward deprescribing through adaptation and subsequent validation of a paediatric version of the Revised Patients’ Attitudes Towards Deprescribing (rPATD) used in older adults. 
Results: Our systematic review did not identify any paediatric deprescribing guidelines. 
Among the 332 HCPs completing the survey, the most common thresholds for problematic polypharmacy were three (n=57, 17%), five (n=56, 17%) and four (n=52, 16%) medications. Most respondents (n=206, 62%) described concern about polypharmacy in CYP at least weekly. The primary barrier to deprescribing was patient/family anxiety (n=198, 61%). Medications prescribed by multiple specialists was also highlighted as contributing to polypharmacy. Overall, 87% (n=287) supported the development of deprescribing guidelines for CYP.
Of the 110,097 CYP registered in primary care (85 practices), in Liverpool, 17,271 (16%) were prescribed ≥2 medications, 715 (0·6%) ≥10, and 202 (0·2%) ≥15. Of the 85 practices, 81 had at least one CYP taking ≥10 medications. Within secondary/tertiary care, 126 (91%) were prescribed ≥2 medications, 47 (34%) ≥10, and 139 (14%) ≥15. The median number of medications was seven and the maximum was 31. Within secondary/tertiary care paracetamol was the most frequently prescribed. When ‘as and when required’ medications were removed, omeprazole was the most frequently prescribed. 
Factor analysis showed that the Child and Parent Attitudes Towards Deprescribing (CHATD) questionnaire aligned well with the underlying structure of the rPATD. Two -hundred and sixteen participant responses were analysed. Participants, especially parents, expressed their desire to be involved in medication management. Most parents (70%) and 55% of CYP were willing to have a medication deprescribed under the guidance of their doctor. 
Conclusion: Polypharmacy is prevalent amongst CYP, especially within hospital settings. Whilst HCPs identified patient and parent anxiety as a significant barrier to deprescribing, responses to the CHATD questionnaire suggested a willingness to discontinue medications under clinician guidance. Developing guidelines to assist HCPs in managing polypharmacy and facilitate deprescribing in CYP would be beneficial.