(230) Real-world Considerations for Pediatric Brexanolone Infusion by an Inpatient Consultation-Liaison (CL) service

Abstract:

Background:   
Postpartum depression confers increased risk for poor bonding, reduced initiation of breastfeeding, limited prenatal care, problematic substance use, and poor nutritional status (Van Niel, 2020). Brexanolone is a Food and Drug Administration (FDA)-approved 60-hour infusion for postpartum depression in patients 15 years and older (Riesenberg, 2022). Studies on its use in pediatric populations regarding safety and tolerability remain limited, and therefore lack real-world application. At our institution, brexanolone is administered by consultation-liaison (CL) psychiatrists in the obstetrical hospital. We present a case of an adolescent who received the infusion, highlighting the medication’s potential use as a treatment option for teenagers, barriers to use, and our real-time experiences troubleshooting logistical challenges and enacting policies around it.  
  


Case:   
Ms. A is a 17-year-old G1P1 female with a history of anxiety, depression, and posttraumatic stress disorder (PTSD) from a rural area who presented to our hospital for brexanolone infusion for postpartum depression at 1month postpartum after reemergence of depressive symptoms in her third trimester, which was exacerbated in the postpartum period. Per hospital policies, she had a support person present, her boyfriend, as she opted to have her infant with her. She tolerated the initiation of the infusion without side effects; however, on the second night she requested to discontinue treatment as she was overwhelmed by her infant crying in the room, being far away from home, and felt the hospital exacerbated her PTSD from a history of institutionalization as a youth. Attempts to troubleshoot her concerns included encouraging Ms. A’s mother to present to the hospital for support, staff encouragement around infant care, and education on mindfulness techniques and distraction methods. The infusion was stopped the following morning without tapering to monitor for signs of respiratory depression. She tolerated the immediate discontinuation with a total infusion time of 43.5 hours.   
  


Discussion:   
This case highlights important aspects and considerations of brexanolone infusion for patients under the age of 18. Based on our experience with Ms. A, we recommend additional hospital policies and resources to support pediatric birthing parents including  in-house parental support in the hospital, development of mindfulness-based interventions, and comprehensive screening for trauma history with proactive development of a plan to support comorbid trauma-related disorders. Despite these logistical complications, the medication was overall well-tolerated with minimal side effects even after immediate discontinuation suggesting that brexanolone use in adolescents can be a safe consideration for CL psychiatrists.  
  


Conclusion:   
This case report serves to add to existing literature of safety and tolerability of pediatric brexanolone infusion while exploring real-world considerations.  
  


References:  
1. Van Niel MS, Payne JL. Perinatal depression: A review. Cleve Clin J Med. 2020 May;87(5):273-277. doi: 10.3949/ccjm.87a.19054. PMID: 32357982. 

2. Riesenberg R, Bankole K, Garafola S, Qin M, Hoffmann E, Brown C, et al. Brexanolone in adolescent patients with postpartum depression: Results from the phase 3, open-label Chickadee Study. American Journal of Obstetrics and Gynecology. 2022 Jan;226(1). doi:10.1016/j.ajog.2021.11.149

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: This case report is of a patient who is of an underrepresented minority (African American) in ethnicity as well as currently living in a rural community. Both are demographics that are usually absent in clinical studies, which is a major weakness and limitation of clinical studies. This case report will serve to provide more clinical data including both demographics.