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KIDs List Lowdown | Pediatric Pharmacist Review · Pharmacy Podcast Network

• 0:07
  Speaker 1: Thanks for listening to the Pharmacy Podcast Network.
• 0:19
  Speaker 2: Hey, Adverse drug reactions are ADRs are a serious issue
• 0:29
  Speaker 2: in healthcare today.
• 0:30
  Speaker 3: The pharmacist is the last line of defense to help
• 0:33
  Speaker 3: prevent ADRs. A rising role of the pharmacist is the
• 0:37
  Speaker 3: specialist who focuses on our children. Pediatric pharmacy ensures safe
• 0:41
  Speaker 3: and effective drug use and optimal medication therapy outcomes and
• 0:45
  Speaker 3: children up to eighteen years of age. Currently, there are
• 0:48
  Speaker 3: more than one four and fifty board certified pediatric pharmacy
• 0:52
  Speaker 3: specialists known as BPS. If you're interested in this expanding
• 0:57
  Speaker 3: field of pharmacy, this podcast is for you. All Right, everyone,
• 1:01
  Speaker 3: let's give it up for our host.
• 1:04
  Speaker 4: Welcome to the Pediatric Pharmacist Review. I am Justin Cole,
• 1:08
  Speaker 4: and I am here with my co host Mary Vong. Mary,
• 1:11
  Speaker 4: how you been even great?
• 1:13
  Speaker 5: Super busy, but it's all great kinds of busy because
• 1:15
  Speaker 5: we're out here helping kids. How are you, Justin?
• 1:18
  Speaker 6: I am doing well.
• 1:19
  Speaker 4: And one of the things, of course we have in
• 1:21
  Speaker 4: common and many of you podcast listeners do, is.
• 1:23
  Speaker 6: Exactly what you said.
• 1:24
  Speaker 4: We are here for the kids, and I'm excited about
• 1:27
  Speaker 4: this next podcast episode that is also all about the
• 1:30
  Speaker 4: kids in particular drug safety as we care for them. Well,
• 1:34
  Speaker 4: so if listeners you go back in the archives of
• 1:37
  Speaker 4: the Pediatric Pharmacist Review, you're going to find another podcast
• 1:41
  Speaker 4: about something called The Kids List. And so today we've
• 1:45
  Speaker 4: brought two of the authors back on the podcast with us,
• 1:48
  Speaker 4: both Rachel Myers and Dave Hoff, and they are here
• 1:51
  Speaker 4: to talk about the new updates to the next version
• 1:54
  Speaker 4: of the Kids List. So I'm excited to have them back.
• 1:57
  Speaker 4: Dave and Rachel, thanks for joining us today. Thanks for
• 2:00
  Speaker 4: having us.
• 2:01
  Speaker 1: We're excited about it.
• 2:03
  Speaker 6: Great. Well, let's do this again.
• 2:05
  Speaker 4: You could go back a few podcasts to listen to
• 2:08
  Speaker 4: Dave and Rachel talk about themselves, but we're going to
• 2:10
  Speaker 4: give them an opportunity again.
• 2:12
  Speaker 6: So how about this.
• 2:13
  Speaker 4: Dave, could you start us off and tell us a
• 2:15
  Speaker 4: bit about your background and how you ended up having
• 2:18
  Speaker 4: the vision for and working on the original Kids List?
• 2:21
  Speaker 7: Sure, right now, justin. I'm a pharmacy consultant. I've been
• 2:26
  Speaker 7: doing that for about a year. Prior to that, I
• 2:29
  Speaker 7: worked at Children's Minnesota. I was pharmacy director there for
• 2:32
  Speaker 7: about a year and a half, Director of clinical Pharmacy
• 2:35
  Speaker 7: for a year and a half and then it was
• 2:38
  Speaker 7: some twenty three years. I was a clinical leader clinical
• 2:41
  Speaker 7: coordinator type individual, and I did most of my work
• 2:46
  Speaker 7: in critical care, but my work did span the whole
• 2:49
  Speaker 7: pharmacy spectrum. So going back, we can look back all
• 2:54
  Speaker 7: the way to the early nineteen nineties. The Beers criteria
• 2:58
  Speaker 7: was generated by doctor Beer's for the elderly population, so
• 3:04
  Speaker 7: medications that are potentially inappropriate for use in the elderly.
• 3:08
  Speaker 7: And when I came out of pharmacy school and I
• 3:11
  Speaker 7: began working, the first thing I did was I tried
• 3:15
  Speaker 7: to think of some medications that you shouldn't use in
• 3:17
  Speaker 7: kids because they're just dangerous. I remembered in school there
• 3:21
  Speaker 7: were probably five or six that I was taught we
• 3:25
  Speaker 7: shouldn't use in wine. And I thought, for sure there
• 3:28
  Speaker 7: was a there's a publication somewhere that had this list.
• 3:33
  Speaker 8: It was definitive.
• 3:35
  Speaker 7: But I found that no list existed at the time.
• 3:39
  Speaker 7: And this is pre internet days, so I thought, well,
• 3:41
  Speaker 7: maybe it's out there. I just didn't know, Okay, dating myself,
• 3:45
  Speaker 7: Rachel's shuckling, but you know, I just kind of assembled
• 3:50
  Speaker 7: medications in my head from other pharmacists and docs, and
• 3:56
  Speaker 7: I thought those were the medications, and so that really
• 3:59
  Speaker 7: kind of form the basis for where I'm coming from
• 4:02
  Speaker 7: for wanting a list for pediatrics.
• 4:04
  Speaker 8: It is because there was.
• 4:06
  Speaker 7: No list for kids, and we really needed one for
• 4:09
  Speaker 7: the kids so that we can improve medication safety.
• 4:15
  Speaker 4: Well that's great, and I have to say we have
• 4:17
  Speaker 4: a way better name and acronym for the pediatric list
• 4:21
  Speaker 4: than the Beers criteria do. Right, named after of course
• 4:24
  Speaker 4: a physician, but the kid's list just fits so well,
• 4:28
  Speaker 4: so memorable, So it's amazing.
• 4:30
  Speaker 6: Anyway, let's turn to Rachel.
• 4:31
  Speaker 4: Rachel, tell us a bit about yourself and how you
• 4:34
  Speaker 4: got to working on the kids list.
• 4:38
  Speaker 1: Sure, so, I'm Rachel Myers.
• 4:40
  Speaker 9: I'm a clinical professor at Rutgers University's Ernest Mario School Pharmacy,
• 4:45
  Speaker 9: and I'm a pediatric pharmacist. My practice site is at
• 4:49
  Speaker 9: Cooperman Barnabas Medical Center in upstate New Jersey. And I
• 4:54
  Speaker 9: guess I think I was in the right place at
• 4:56
  Speaker 9: the right time when Dave started talking about making this list.
• 5:00
  Speaker 9: I think the timing was I was the chair of
• 5:03
  Speaker 9: the Advocacy committee at PPA and so heard about these
• 5:07
  Speaker 9: discussions and asked if I could be part of it,
• 5:09
  Speaker 9: and was just excited to jump in on that project.
• 5:13
  Speaker 9: It was a big project, but I think it's been
• 5:16
  Speaker 9: very valuable and really exciting to be.
• 5:18
  Speaker 1: A part of.
• 5:21
  Speaker 5: Super exciting. So it's so great to have you both here.
• 5:24
  Speaker 5: So we talked a little bit about the history of
• 5:26
  Speaker 5: the Beer's List. What does the Kids List stand for?
• 5:29
  Speaker 5: Because I know that kids, it's cute, we love kids,
• 5:32
  Speaker 5: but I know it has a fun name behind it, you.
• 5:35
  Speaker 7: Know, Rachel, it's the key and appropriate Drugs in Kids,
• 5:41
  Speaker 7: lest in children lesson.
• 5:43
  Speaker 8: That's pretty much what it stands.
• 5:44
  Speaker 9: For, right, Yeah, it took us a long time to
• 5:47
  Speaker 9: come up with that. Kelly Mattson from the University of
• 5:50
  Speaker 9: Rhode Island was actually the one who came up with it.
• 5:53
  Speaker 9: It took a lot, I don't know what was it,
• 5:54
  Speaker 9: six months or so. We kept going back and forth
• 5:56
  Speaker 9: with different names, but she's the one that came up with,
• 6:00
  Speaker 9: uh yeah, keep potentially inappropriate drugs and pediatrics, which you know, yeah,
• 6:05
  Speaker 9: got us our acronym of kids.
• 6:07
  Speaker 8: I think it was the hardest thing we did as
• 6:09
  Speaker 8: a group.
• 6:10
  Speaker 5: Yeah, compiling the literature not not hard, but naming things.
• 6:14
  Speaker 5: But we definitely feel the same with perfecting peeds anytime
• 6:17
  Speaker 5: we renamed platforms or anytime like for the logo. It
• 6:21
  Speaker 5: was super hard trying to redo it. So funny thing
• 6:24
  Speaker 5: with perfecting peds. Some people don't know that ped s's
• 6:27
  Speaker 5: peeds like pediatric, and they think it's peeds like pedicure.
• 6:30
  Speaker 5: So a lot of people would ask us if we
• 6:32
  Speaker 5: did FEE. So Jenna made it an urgent matter about
• 6:35
  Speaker 5: a year ago to rebrand and to change the logo,
• 6:38
  Speaker 5: so people knew for a fact that we didn't do feed.
• 6:41
  Speaker 5: So sorry for that squirrel.
• 6:44
  Speaker 6: But when you were going.
• 6:45
  Speaker 5: Through this, I know that the hardest part was naming it,
• 6:47
  Speaker 5: But how do you did you actually go through and define,
• 6:49
  Speaker 5: like what was your criteria for defining these potentially inappropriate medications?
• 6:55
  Speaker 4: Sure?
• 6:56
  Speaker 9: Dave, do you want to start with how we did
• 6:57
  Speaker 9: it originally? And I could talk about how we did
• 6:59
  Speaker 9: the second edition?
• 7:01
  Speaker 7: Sure, I think maybe we'll just kind of get to
• 7:04
  Speaker 7: methods if you want to start there. You know, with
• 7:08
  Speaker 7: the first kids list, we assembled a group of individuals
• 7:12
  Speaker 7: with different pharmacy clinical backgrounds really, and these were individuals
• 7:16
  Speaker 7: that were recommended by the board at PPA, and and
• 7:19
  Speaker 7: we got a group together and then we said, hey,
• 7:21
  Speaker 7: we need a couple more in these areas, and we
• 7:23
  Speaker 7: did that and that's kind of how we got the
• 7:25
  Speaker 7: first group. And then with the second edition, we've added
• 7:29
  Speaker 7: some additional sub specialties impeds to our group, so we
• 7:34
  Speaker 7: have emergency department and psych and some other and safety
• 7:39
  Speaker 7: added to our group.
• 7:41
  Speaker 8: But really what we did is we have.
• 7:44
  Speaker 7: We've taken a methodological approach to identifying the medications that
• 7:51
  Speaker 7: might be highest risk of kids. So what we're talking
• 7:55
  Speaker 7: about is adverse drug reactions in children that are more
• 7:59
  Speaker 7: common in children then in adults. Okay, these are this
• 8:03
  Speaker 7: isn't just a list of adverse drug reactions that happen
• 8:06
  Speaker 7: in kids, but these are specifically ones that happened more
• 8:10
  Speaker 7: commonly in adults. And so we did a literature search,
• 8:14
  Speaker 7: We did a PubMed search, and we searched for several
• 8:18
  Speaker 7: specific criteria looking for an adverse drug reaction a d
• 8:22
  Speaker 7: R and so on. So we looked at that, We
• 8:26
  Speaker 7: looked at UH an up to date lexi so back
• 8:31
  Speaker 7: you know, the Pediatric lexi comp database. They allowed us
• 8:35
  Speaker 7: access to the database and we queried their database UH
• 8:40
  Speaker 7: Walter Walter's Cluer's database for certain triggers like caution and
• 8:45
  Speaker 7: avoid and you know those kinds of things in the
• 8:49
  Speaker 7: Lexi database. We also went to the fd A Alerts,
• 8:54
  Speaker 7: So the f d A has a place on the
• 8:58
  Speaker 7: website that caught against you certain alerts and warnings. We
• 9:03
  Speaker 7: picked out the ones that were specific for pediatrics. We
• 9:06
  Speaker 7: added those to the baseline list. And then finally we
• 9:10
  Speaker 7: all had a list of medications in our own heads.
• 9:14
  Speaker 7: Not surprisingly, everybody's list was different, very different in some cases,
• 9:20
  Speaker 7: but we all had our list. And so I think,
• 9:22
  Speaker 7: I don't know, I might have had I don't know,
• 9:25
  Speaker 7: thirty or something, and then Rachel probably had thirty.
• 9:28
  Speaker 1: And the years was the longest day, seventy one.
• 9:32
  Speaker 7: I don't know what it was, but yeah, So from
• 9:36
  Speaker 7: these different places we had, we had a strict methodological
• 9:42
  Speaker 7: approach to identifying what might constitute one of these medications
• 9:47
  Speaker 7: that would be higher risk, and then we pulled the articles.
• 9:52
  Speaker 7: We had two individuals review each article using was it
• 9:58
  Speaker 7: the Prisma techn and so we identified articles that might
• 10:04
  Speaker 7: be might indicate that a kid would have a higher
• 10:06
  Speaker 7: risk of ADR than an adult, and only one that
• 10:11
  Speaker 7: reviewer needed to agree on that, and once we got
• 10:17
  Speaker 7: agreement on that, we pulled the article. We read the
• 10:19
  Speaker 7: whole article and then only one of the reviewers needed
• 10:22
  Speaker 7: to agree on that to submit it to the full group,
• 10:25
  Speaker 7: and then the fund began. We sat down as a
• 10:29
  Speaker 7: group and we hashed it out. We kind of talked
• 10:32
  Speaker 7: about the medications and the relative merits of what we're
• 10:36
  Speaker 7: seeing in the study versus what we see in practice,
• 10:39
  Speaker 7: and then that's how we came up with the list.
• 10:47
  Speaker 9: And then I guess I'll talk about how we came
• 10:49
  Speaker 9: up with the second list, which is hopefully we'll be
• 10:51
  Speaker 9: published in the coming months. Basically, we obviously had a
• 10:55
  Speaker 9: good starting place because we had our published list, and
• 10:58
  Speaker 9: fortunately we had written and down the date that.
• 11:02
  Speaker 1: We did our our literature search the first.
• 11:05
  Speaker 9: Time, so we knew what date to go back to
• 11:07
  Speaker 9: when we did our literature search the second time. So
• 11:11
  Speaker 9: we did again second literature literature search. We looked at
• 11:14
  Speaker 9: LEXI again, we looked at the FDA database again. And
• 11:18
  Speaker 9: then I think, in my opinion, what kind of made
• 11:21
  Speaker 9: the biggest change the second go round was just feedback
• 11:24
  Speaker 9: from pharmacists, you know, from PPA members. You know, I
• 11:28
  Speaker 9: would get emails from friends, did you guys consider this?
• 11:31
  Speaker 1: You know, what about this? So we have an issue
• 11:32
  Speaker 1: with this? So those kinds of things.
• 11:38
  Speaker 9: That really helped us sort of fine tune some of
• 11:41
  Speaker 9: the drugs that were already on there, and then again
• 11:45
  Speaker 9: got our group together again. We added a few more
• 11:47
  Speaker 9: people so that we could have some more specialists, especially
• 11:50
  Speaker 9: I think it was really good to add somebody in
• 11:52
  Speaker 9: the psychiatry community because there was so much debate with
• 11:56
  Speaker 9: those medications, So adding some more specialists helped us.
• 12:00
  Speaker 7: Well, yeah, I'll say we did have a one month.
• 12:05
  Speaker 8: Period where the PPA membership we had public input.
• 12:09
  Speaker 7: This was kind of just before COVID hit, honestly, and
• 12:16
  Speaker 7: then our publication came out in early twenty twenty, and
• 12:21
  Speaker 7: I think with the second iteration we've had much more response. Right, So,
• 12:27
  Speaker 7: the first edition's been out there, it was kind of
• 12:30
  Speaker 7: launched under COVID, but the second edition is coming out now.
• 12:34
  Speaker 7: And now we'll say, we just submitted the Galilees today,
• 12:37
  Speaker 7: Rachel to the journal. So this one morning, the final
• 12:42
  Speaker 7: Gallalley proof was submitted.
• 12:45
  Speaker 4: Well, first, congratulations on the publication of that. I know
• 12:49
  Speaker 4: this is a labor of love that PPA has gotten behind,
• 12:54
  Speaker 4: and also you and many of your other colleagues have
• 12:57
  Speaker 4: along the process, and we're very grateful for it. As
• 13:00
  Speaker 4: fellow pediatric pharmacists. So let's dive into some of the
• 13:04
  Speaker 4: nitty gritty of the second edition, can we sure?
• 13:07
  Speaker 6: Okay, let's do it. Okay, So what do.
• 13:11
  Speaker 4: You think are some of the most significant additions or
• 13:14
  Speaker 4: maybe removals in the second edition. I had the privilege
• 13:17
  Speaker 4: of sitting in on your roundtable at the PPA meeting
• 13:20
  Speaker 4: out in Portland, Oregon and was super enlightened by it.
• 13:22
  Speaker 4: So I'd love to maybe rehash some of those to
• 13:25
  Speaker 4: our listeners. So Dave, they actually, let's do this. Rachel,
• 13:29
  Speaker 4: can you go first and maybe give us a couple
• 13:31
  Speaker 4: examples and then Dave can do the same.
• 13:34
  Speaker 9: Sure, So we'll talk about my favorite. Dave knows what
• 13:37
  Speaker 9: my favorite is. Montal lucast Monte Lucas is so difficult.
• 13:42
  Speaker 9: We went back and forth so much with it. Of course,
• 13:46
  Speaker 9: the big question with Monto Lucas is about the neuropsychiatric reactions,
• 13:51
  Speaker 9: specifically spleep sleep disturbances is what we landed on. And
• 13:56
  Speaker 9: the issue is this really sort of came out and
• 14:00
  Speaker 9: the last few years. It was one of the newer
• 14:01
  Speaker 9: things that we considered, and there's an FDA warning. But
• 14:06
  Speaker 9: the issue in terms of whether to include it on
• 14:08
  Speaker 9: the kids list or not, is if it's different than adults,
• 14:11
  Speaker 9: because remember, that's what makes the drugs and the kids
• 14:14
  Speaker 9: list unique, is that these are ADRs that specifically happen
• 14:18
  Speaker 9: more often in kids than adults, because we know these
• 14:21
  Speaker 9: reactions occur in both kids and adults. So we were
• 14:25
  Speaker 9: trying to peace out, well, is there any particular reaction
• 14:31
  Speaker 9: that was more common in kids, because again we have
• 14:34
  Speaker 9: adults that have these issues. So and the literature was
• 14:38
  Speaker 9: kind of back and forth, but at the end of
• 14:40
  Speaker 9: the day we kind of landed on the sleep disorder's
• 14:44
  Speaker 9: part does seem to have some clear evidence, at least
• 14:46
  Speaker 9: from what's out there now, that that is more common
• 14:49
  Speaker 9: in kids than adults.
• 14:52
  Speaker 1: And also, we.
• 14:52
  Speaker 9: Always kind of think about its efficacy because if this
• 14:56
  Speaker 9: is a drug where it's the only drug that you
• 14:57
  Speaker 9: can use for that disease state, then maybe the benefits,
• 15:01
  Speaker 9: you know, outweigh the risk. But in this case it's
• 15:05
  Speaker 9: not true, because of course, we have much better drugs
• 15:07
  Speaker 9: that we can use for asthma and other options for
• 15:10
  Speaker 9: allergies as well. So that's why that one was that
• 15:13
  Speaker 9: was a tough one that we went back and forth
• 15:15
  Speaker 9: on a lot.
• 15:18
  Speaker 1: The other one.
• 15:18
  Speaker 9: That's sort of my favorite is you know, ethanol, and
• 15:22
  Speaker 9: there's nothing really different about ethanol there, except that we
• 15:27
  Speaker 9: have some more data about ethanol's use. I actually had
• 15:30
  Speaker 9: one of my pharmacy students look at and calculate the
• 15:34
  Speaker 9: blood alcohol levels that kids would get by taking some
• 15:37
  Speaker 9: of the common medications. So we just did you know,
• 15:40
  Speaker 9: simple math based on usual doses for different weight ranges
• 15:45
  Speaker 9: and just showing you know, the blood alcohol levels that
• 15:48
  Speaker 9: would result. So we just had a little more data
• 15:51
  Speaker 9: in there. And that's an example too of where we're
• 15:53
  Speaker 9: hoping that things that are in the Kids list will
• 15:55
  Speaker 9: sort of inspire these kinds of projects so that we
• 15:58
  Speaker 9: can know more about what we're giving to kids.
• 16:02
  Speaker 1: By what your favorites were.
• 16:04
  Speaker 7: Oh, I thought you would start with that, but I
• 16:07
  Speaker 7: started with the other one, the loucast. Yeah, I've got
• 16:10
  Speaker 7: a couple of So tetracyclines are growing, you'll notice that
• 16:15
  Speaker 7: in this edition. So in the first we just had
• 16:18
  Speaker 7: a tetracycling and the mechl cycling I think. And so
• 16:21
  Speaker 7: now we're adding it as a class and we're able
• 16:24
  Speaker 7: to do that because some additional actually, you know, some
• 16:28
  Speaker 7: additional publications were came out from the time we published
• 16:34
  Speaker 7: the first time and the second time, so that allowed
• 16:38
  Speaker 7: us to open up the class and take another critical.
• 16:40
  Speaker 8: Look at it.
• 16:41
  Speaker 7: And so you'll find every tetracyclinge UH in the you know,
• 16:45
  Speaker 7: in the tetracycling classes in the list, with the exception
• 16:50
  Speaker 7: of doxy cycling. So you'll notice that one difference. And
• 16:54
  Speaker 7: really the tetracycling class we we we looked at the
• 16:58
  Speaker 7: level of evidence and you'll see that in the list,
• 17:01
  Speaker 7: the level of evidence on tooth discoloration mainly UH and
• 17:06
  Speaker 7: some have very you know.
• 17:08
  Speaker 8: Fairly robust data, like tetracycling itself.
• 17:11
  Speaker 7: Some have more limited data, and then some couple are
• 17:14
  Speaker 7: just package insert data. But we think, you know, we
• 17:17
  Speaker 7: think it's a class effect in that case. But with
• 17:20
  Speaker 7: doxy cycling, the medication has been out there for a
• 17:24
  Speaker 7: while and we just haven't seen a lot of tooth
• 17:26
  Speaker 7: discoloration with doxy and so right now we feel comfortable
• 17:31
  Speaker 7: leaving it off the list and allowing its use for
• 17:35
  Speaker 7: any time where it's a first line drug where where
• 17:40
  Speaker 7: other medications aren't more you know, superior, So doxy cycling
• 17:45
  Speaker 7: for up to twenty one days wherever it's recommended is okay,
• 17:52
  Speaker 7: let's see what another big change we had, we're the antipsychotics.
• 17:58
  Speaker 8: With the first edition, we had a lot of debate
• 18:00
  Speaker 8: around whether or.
• 18:02
  Speaker 7: Not we were going to fully break out the second
• 18:06
  Speaker 7: generation as psychotics and the metabolic effects. I remember there
• 18:11
  Speaker 7: was there was a lot of conversation around that. This
• 18:14
  Speaker 7: time we definitely broke it out the whole second generation
• 18:19
  Speaker 7: classes in the kids list. The first generations there as
• 18:22
  Speaker 7: well with the cute dys tonic reactions that we all
• 18:26
  Speaker 7: know about, but the second class is in there. We
• 18:28
  Speaker 7: have I think we have more robust data and Rachel,
• 18:31
  Speaker 7: you know, correct me if I'm wrong, but I think
• 18:33
  Speaker 7: we have more robust data around the metabolic effects a
• 18:35
  Speaker 7: lanzepine leading the charge there, and then we were able
• 18:39
  Speaker 7: to show which ones have greater risk metabolic risk and
• 18:44
  Speaker 7: which have lesser. So you'll see that big change in
• 18:48
  Speaker 7: there as well as a class.
• 18:53
  Speaker 9: The other thing that we tried to clarify was how
• 18:56
  Speaker 9: we defined age. So age is define so many different
• 19:01
  Speaker 9: ways in different places.
• 19:02
  Speaker 6: You know.
• 19:03
  Speaker 9: I think example, an infant we usually say is twelve
• 19:06
  Speaker 9: months and under, but the FDA says it's two years
• 19:08
  Speaker 9: and under. So you know, that kind of left us
• 19:12
  Speaker 9: scratching our heads a lot. So we decided to sort
• 19:14
  Speaker 9: of just I don't know, like not define it and
• 19:17
  Speaker 9: basically just say the age for each particular drug, so
• 19:20
  Speaker 9: that it was more clear and we stopped trying to
• 19:23
  Speaker 9: define it and lump kids into different groups.
• 19:28
  Speaker 6: I think.
• 19:30
  Speaker 5: There'll go ahead, go ahead, just on the topic of age.
• 19:33
  Speaker 5: I think one thing that's really interesting after COVID is
• 19:36
  Speaker 5: how we have so many larger children and we have
• 19:41
  Speaker 5: smaller adults. So like factoring in like age and weight,
• 19:45
  Speaker 5: I feel like is really important. So I guess, like
• 19:47
  Speaker 5: for the Kids List, did you look at age only
• 19:50
  Speaker 5: or were there weight cut offs as well? Like what
• 19:52
  Speaker 5: a weight of forty five kilos disqualify a kid from
• 19:56
  Speaker 5: the Kids List?
• 20:00
  Speaker 8: No, weight did not do it.
• 20:03
  Speaker 7: Where weight comes into play is in some of the recommendations.
• 20:08
  Speaker 7: We have a dose limits, so milligram per kilo, but
• 20:13
  Speaker 7: weight itself wasn't a cut off we did. I didn't
• 20:17
  Speaker 7: see anything in the literature showing that weight had an
• 20:21
  Speaker 7: independent effect on whether an eight R was greater or lesser.
• 20:28
  Speaker 8: I don't know.
• 20:28
  Speaker 7: If if if that's what your question is, it was
• 20:32
  Speaker 7: it was mainly based on age looking at it development,
• 20:36
  Speaker 7: I will add you know, there were there were a
• 20:38
  Speaker 7: number of other changes that we had in the list
• 20:41
  Speaker 7: we support. We've summarized them in the supplemental material. You
• 20:45
  Speaker 7: can read it and find all the little details about
• 20:49
  Speaker 7: what we did.
• 20:49
  Speaker 8: But we were removed.
• 20:51
  Speaker 7: I think it looks like five medications because they are
• 20:54
  Speaker 7: no longer manufactured in the United States.
• 20:58
  Speaker 8: And that's one thing that.
• 20:59
  Speaker 7: You need to keep into consideration is this is this
• 21:02
  Speaker 7: is a list of medications for drugs that are labeled
• 21:06
  Speaker 7: for use in the United States only, and other countries
• 21:09
  Speaker 7: may have them, but they won't be on our list
• 21:12
  Speaker 7: if they're not produced and labeled for use in the
• 21:16
  Speaker 7: United States. So we lost hexachlorophine and dinevereer lending and
• 21:22
  Speaker 7: paragoric I know, all fast movers, but they were all
• 21:26
  Speaker 7: removed because they're no longer available in the US, but
• 21:28
  Speaker 7: they may still be available in other countries.
• 21:33
  Speaker 4: I think that's a super helpful tidbit, because again I
• 21:36
  Speaker 4: think the Kids list has gotten international attention because it's
• 21:40
  Speaker 4: really the only list that's similar to the Beers criteria
• 21:44
  Speaker 4: that gives us some more guidance that we can point
• 21:47
  Speaker 4: back to as clinicians. So that's a really important thing,
• 21:51
  Speaker 4: and it kind of leads to this next question. How
• 21:54
  Speaker 4: do you envision pediatric pharmacists and other providers using the
• 21:57
  Speaker 4: Kids List in their daily practice? And here let me
• 22:01
  Speaker 4: give you some context. These are potentially inappropriate medications. Correct,
• 22:06
  Speaker 4: These are not never used, and so there requires clinical
• 22:10
  Speaker 4: judgment to determine well for this patient the benefits outweigh
• 22:15
  Speaker 4: the risks. And so what are some of those practical
• 22:18
  Speaker 4: ways in which you would suggest pharmacists use the Kids
• 22:22
  Speaker 4: List in their daily practice.
• 22:25
  Speaker 9: I think number one is to just be aware of it,
• 22:28
  Speaker 9: know that it exists as a resource, and that it
• 22:31
  Speaker 9: has good references, you know. I think that's one thing
• 22:33
  Speaker 9: we're very proud of, is the references that we've used,
• 22:36
  Speaker 9: and we've sort of told everybody this is where we
• 22:39
  Speaker 9: made like, this is the information that we use to
• 22:41
  Speaker 9: make our decision. And so if you need to use
• 22:43
  Speaker 9: it and you want to look at that to make
• 22:45
  Speaker 9: your own clinical decision, then you know, go ahead. And
• 22:49
  Speaker 9: then I think the next big thing is working it
• 22:51
  Speaker 9: into EMRs right as warnings. So but like you said,
• 22:54
  Speaker 9: this is not a list that do not use. This
• 22:57
  Speaker 9: is we're telling you about the risks and you need
• 23:01
  Speaker 9: to take your clinical situation into account.
• 23:04
  Speaker 7: It's very important the list should be punitive. It should
• 23:09
  Speaker 7: be for like quality assurance and general advice. Nothing in
• 23:15
  Speaker 7: here is a concrete yes or no. So everything in
• 23:20
  Speaker 7: clinical practice must be judged with the benefits and the
• 23:24
  Speaker 7: risks in mind. And a lot of the medications on
• 23:26
  Speaker 7: this list, if you look at them, they may be
• 23:30
  Speaker 7: perfectly fine for a five year old, but not fine
• 23:33
  Speaker 7: for you know, a very low birthwright infant. Okay, So
• 23:38
  Speaker 7: just because it's on the list doesn't mean that it's
• 23:40
  Speaker 7: inappropriate for all age groups or patients in the pediatric spectrum.
• 23:45
  Speaker 9: And the other thing to consider is even if it's
• 23:47
  Speaker 9: not on the list, that doesn't mean it is okay,
• 23:50
  Speaker 9: you know what I'm saying. It just means we didn't
• 23:52
  Speaker 9: have the information. Dave, you're gonna last laugh.
• 23:57
  Speaker 1: Last week I had a two year old who had.
• 23:59
  Speaker 9: Been for cyclamine, and I'm like, what, so looking at
• 24:04
  Speaker 9: the kids list, it's only do not use for we
• 24:07
  Speaker 9: have six months, is what we put.
• 24:09
  Speaker 1: But like, that's one where I was not comfortable with
• 24:12
  Speaker 1: this two year old. There was no reason for him
• 24:14
  Speaker 1: to be getting it.
• 24:15
  Speaker 9: I think it might have been I don't know, some
• 24:18
  Speaker 9: resident like a family Medicine resident or something like that
• 24:21
  Speaker 9: who was used to prescribing for adults. So that's an
• 24:23
  Speaker 9: example where that wasn't really on the kids list, but
• 24:26
  Speaker 9: not appropriate.
• 24:28
  Speaker 7: And I'll add I think we looked at the quality
• 24:31
  Speaker 7: of evidence certainly from high to very low, and we
• 24:34
  Speaker 7: included a very low level of evidence in peedes because
• 24:37
  Speaker 7: because there is very low qualities of evidence, unlike the
• 24:43
  Speaker 7: Beers criteria, which they have a little bit better evidence
• 24:47
  Speaker 7: than the older adults, in kids, we have such limited
• 24:50
  Speaker 7: data that we allowed a very low level of evidence
• 24:53
  Speaker 7: like just a package insert for example.
• 24:56
  Speaker 8: So you have to take that into consideration.
• 24:59
  Speaker 7: It's very very possible that, you know, evolving evidence will
• 25:04
  Speaker 7: change our recommendations on.
• 25:06
  Speaker 8: The list, and the list is it's not static.
• 25:09
  Speaker 7: It is something that does change over time, and it
• 25:12
  Speaker 7: is a bit evolving.
• 25:15
  Speaker 5: On the topic of things evolving, I'm just kind of
• 25:17
  Speaker 5: in this mindset of like you then it should be
• 25:20
  Speaker 5: integrated into EHRs. Is there anything out there or is
• 25:24
  Speaker 5: there anything in the works, like any sort of API
• 25:26
  Speaker 5: to get it into EHRs.
• 25:29
  Speaker 9: I'm not aware of anything, but I know that some
• 25:32
  Speaker 9: drug databases like lexicomp have picked it up and included it.
• 25:37
  Speaker 9: So I think that's going to be an evolving thing,
• 25:39
  Speaker 9: and I think it can also be done, you know,
• 25:41
  Speaker 9: on a hospital level. I also to another thing that
• 25:45
  Speaker 9: pharmacists can do to include it in their practice is
• 25:48
  Speaker 9: just sort of look at their formulary, right and look
• 25:51
  Speaker 9: and see what they've got. Like for example, at my hospital,
• 25:53
  Speaker 9: for our liquid benadryl, we were carrying the one that
• 25:55
  Speaker 9: had alcohol, so we got rid of it and we
• 25:58
  Speaker 9: subbed it out for the alcohol free one, you know,
• 26:00
  Speaker 9: just a simple example, or like tile and all with coding.
• 26:04
  Speaker 9: I think I tried to get rid of it ten
• 26:06
  Speaker 9: years ago, but there were still some adults who were
• 26:08
  Speaker 9: using it. But we tried again in the last year
• 26:11
  Speaker 9: or so and the adults had stopped using it too,
• 26:13
  Speaker 9: so we were finally able to just get it off formulary.
• 26:17
  Speaker 9: So that's just something just looking individually at at your formulary.
• 26:22
  Speaker 5: I feel like there's a lot of men safety projects
• 26:25
  Speaker 5: that can be like I guess for residents listening, this
• 26:28
  Speaker 5: is a great idea, like use this for your residency
• 26:31
  Speaker 5: project this year. This is a great like QI and
• 26:33
  Speaker 5: it's brand new literature. Hits all out there, So when
• 26:37
  Speaker 5: and where will the second edition of the Kids List
• 26:39
  Speaker 5: be published.
• 26:42
  Speaker 8: It'll be published very soon.
• 26:43
  Speaker 7: So as I mentioned earlier, it was just we just
• 26:47
  Speaker 7: submitted the galleys, the final galley proof this morning, so
• 26:52
  Speaker 7: June twenty third, it is in to the publisher, and
• 26:56
  Speaker 7: just as soon as those changes get made to the
• 27:00
  Speaker 7: original document, it's going to be up on the JPPT
• 27:02
  Speaker 7: website as an early publication, even before the next edition
• 27:08
  Speaker 7: comes out, So before the fourth edition of JPPT or
• 27:12
  Speaker 7: the edition, this will be up on the website. So
• 27:15
  Speaker 7: I'd be looking for it fairly soon. I would say,
• 27:18
  Speaker 7: I don't know, crossing my fingers next couple of weeks.
• 27:21
  Speaker 6: Oh that's great.
• 27:22
  Speaker 4: So this has been infinitely helpful for me, not only
• 27:25
  Speaker 4: in clinical practice, but I'm an educator just like Rachel.
• 27:28
  Speaker 4: I'm in the classroom with kids, helping them to be
• 27:30
  Speaker 4: ready to take care of pediatrics. I just called my
• 27:34
  Speaker 4: students kids. They're adults, okay. But one of the things
• 27:39
  Speaker 4: that I've done which has been a blast is when
• 27:41
  Speaker 4: I'm teaching all of our students in their year about pediatrics,
• 27:45
  Speaker 4: we actually do a kids a scavenger hunt, but it's
• 27:48
  Speaker 4: in the clinical context of a mini case where some
• 27:51
  Speaker 4: of them they may find information, but they then have
• 27:55
  Speaker 4: to go and decide, well, but is this the only
• 27:57
  Speaker 4: drug that might work for this patient for X y reason?
• 28:01
  Speaker 4: And it has been a blast, So Rachel, I would
• 28:04
  Speaker 4: love to know. Are there any unique educational things that
• 28:08
  Speaker 4: you've done with the Kids List at your own practice?
• 28:11
  Speaker 9: No, but I love that, and I might try incorporating that.
• 28:16
  Speaker 1: For me.
• 28:17
  Speaker 9: Like at at Rutgers, we've just tried to incorporate it
• 28:20
  Speaker 9: into our you know, Piet's classes, our therapeutics, just so
• 28:25
  Speaker 9: that again, students are aware of its existence. At my hospital. Again,
• 28:29
  Speaker 9: I've been trying to do the things I said before.
• 28:31
  Speaker 9: Going through our formulary, I gave a grand rounds. You
• 28:35
  Speaker 9: wouldn't believe how many older physicians were so upset that
• 28:39
  Speaker 9: aspirin didn't get a bigger warning, because you know, that
• 28:43
  Speaker 9: one was always that was very controversial the first time
• 28:45
  Speaker 9: it came around. But yeah, but no, I love the
• 28:48
  Speaker 9: idea of the scavenger hunt. That's a great one.
• 28:50
  Speaker 7: Along with that, Rachel, I would say, you run into
• 28:54
  Speaker 7: very unexpected interesting thelements when you're trying to roll out
• 28:58
  Speaker 7: the kids List and incorporate it into your EHR. Like
• 29:02
  Speaker 7: I ran into a little problem with sodium phosphate solution,
• 29:05
  Speaker 7: like you know, hyperphosphatemia and renal dysfunction in kids lessen too,
• 29:11
  Speaker 7: I think it is. Yeah, And I ran into a
• 29:14
  Speaker 7: couple of er docs that were just they had to
• 29:17
  Speaker 7: have it, you know, and it's interesting. You don't expect
• 29:21
  Speaker 7: you're going to run into a problem and then then
• 29:24
  Speaker 7: you run into something and have a nice conversation about that.
• 29:28
  Speaker 4: Yep.
• 29:30
  Speaker 5: Just on the same note of the scavengerhead. I think
• 29:32
  Speaker 5: one of the most fun educational activities I did for
• 29:34
  Speaker 5: my residence way back when was doing an escape room.
• 29:39
  Speaker 5: So it was just in a conference room and I
• 29:41
  Speaker 5: ended up hiding lots of things, so they had to
• 29:44
  Speaker 5: answer all the drug questions. I remembered one of the
• 29:47
  Speaker 5: questions was like which medication causes your CO two to drop?
• 29:52
  Speaker 5: And then they had to find the total MAX bottle,
• 29:54
  Speaker 5: So I hit a total Max bottle like somewhere in
• 29:56
  Speaker 5: the room. So of having the kids list medications hidden
• 29:59
  Speaker 5: somewhere in a common and room would be fun for
• 30:01
  Speaker 5: them to identify.
• 30:03
  Speaker 1: I love it.
• 30:04
  Speaker 4: Yeah, for educators out there, lots of creative things, but
• 30:07
  Speaker 4: again it's more about awareness and exposure, right.
• 30:10
  Speaker 6: This is a tool just like, we have so.
• 30:12
  Speaker 4: Many other clinical tools in our armamentarium to take care
• 30:15
  Speaker 4: of kids, but it's a significant one where we just
• 30:18
  Speaker 4: have this catalog of questions for different drugs that remind
• 30:23
  Speaker 4: us to think critically, and I think the Kids List
• 30:25
  Speaker 4: does that fantastically. I want to transition now again, the
• 30:30
  Speaker 4: second edition is an amazing thing. But if I know you,
• 30:35
  Speaker 4: Rachel and Dave, you're probably thinking forward even more, right,
• 30:38
  Speaker 4: So what are your hopes and dreams for the future
• 30:42
  Speaker 4: of the Kids List? And maybe I can ask a
• 30:44
  Speaker 4: specific example and you can answer broadly, But for example,
• 30:48
  Speaker 4: has pharmacogenomic data been discussed as being added to some
• 30:53
  Speaker 4: of the descriptions of the drugs where that's pertinent data
• 30:57
  Speaker 4: on whether you should should not use a drug, modify
• 30:59
  Speaker 4: a dose, et cetera. Or is that beyond the scope
• 31:02
  Speaker 4: of what you see for the Kids List?
• 31:04
  Speaker 1: Well, I think we incorporated it into coding, right.
• 31:07
  Speaker 9: Basically it all yeah, yeah, because we know places like
• 31:12
  Speaker 9: Saint Jude, you know, do that the kind of screening routinely.
• 31:15
  Speaker 9: So if they have that tool and that information, then
• 31:19
  Speaker 9: we don't want to block them or from using it.
• 31:22
  Speaker 1: So I think that's appropriate. But to answer your earlier
• 31:25
  Speaker 1: question in terms of hopes and dreams. My hopes and dreams.
• 31:28
  Speaker 9: Are to make sure this is available to all pharmacists,
• 31:32
  Speaker 9: especially in the community setting. We want to make sure
• 31:35
  Speaker 9: our community colleagues know about this and use.
• 31:38
  Speaker 1: It as a resource.
• 31:40
  Speaker 9: Just for an example, you know, here in New Jersey,
• 31:42
  Speaker 9: line disease is, you know, a pretty big problem, and
• 31:46
  Speaker 9: I know my infectious disease physicians, says she routinely gets
• 31:50
  Speaker 9: doxycycling calls from retail pharmacistsing it's inappropriate for kids because
• 31:55
  Speaker 9: that's what you were taught in school. So you know,
• 31:57
  Speaker 9: I get that, and that's probably what they're warning, you know,
• 32:00
  Speaker 9: system in their whatever HR system they use at that
• 32:04
  Speaker 9: particular store is. So we want to you know, roll
• 32:08
  Speaker 9: this out so that community pharmacists who take care of
• 32:12
  Speaker 9: a lot of kids, probably more than I do in
• 32:14
  Speaker 9: a single day, that they are aware of this resource.
• 32:19
  Speaker 7: And we need additional research. Just comparing the last the
• 32:24
  Speaker 7: first edition of the Kids List with the second edition,
• 32:26
  Speaker 7: you'll see numerous, numerous changes, and that just calls out
• 32:30
  Speaker 7: the need for more research, more publication. If you come
• 32:33
  Speaker 7: across a case, publish it. If you do a case,
• 32:37
  Speaker 7: a case series, or a cohort in your hospital, publish it.
• 32:41
  Speaker 7: We need that published. We don't go on feeling, we
• 32:45
  Speaker 7: go on the evidence based. So we do need more
• 32:48
  Speaker 7: publication with this. And so what we decided originally with
• 32:53
  Speaker 7: the first publication was that we would kind of look
• 32:55
  Speaker 7: at publishing it about every five years. And I don't
• 32:59
  Speaker 7: know how that's going to be, how that's going to
• 33:02
  Speaker 7: be borne out here. It's it's going to be five
• 33:05
  Speaker 7: years with this one. I think at the PPA board there,
• 33:09
  Speaker 7: I just looked at their h their their strategy, and
• 33:13
  Speaker 7: they were looking at updating the kids list every three
• 33:15
  Speaker 7: years in the in the in the strategy, So I
• 33:20
  Speaker 7: don't know, you know, that would be more of a
• 33:21
  Speaker 7: continuous thing because it takes so long to do the
• 33:24
  Speaker 7: date of mind and getting the people together and hashing
• 33:27
  Speaker 7: it out. We we've also talked about having a just
• 33:31
  Speaker 7: sort of a place on the website at p PA
• 33:34
  Speaker 7: where people can submit comments and it won't go to me.
• 33:38
  Speaker 7: I'm the corresponding author, so people can email me at home,
• 33:42
  Speaker 7: or they can email Rachel, or we can have a
• 33:44
  Speaker 7: nice place on the p PA website where people can
• 33:47
  Speaker 7: go and possibly in the future the document could be
• 33:51
  Speaker 7: more living Uh, it could. It could exist more on
• 33:53
  Speaker 7: the on the website, So that's something that we could
• 33:56
  Speaker 7: consider as well.
• 33:59
  Speaker 5: And like a little drop box like I found this
• 34:03
  Speaker 5: and that'll help people that even more. I'm thinking, like
• 34:06
  Speaker 5: I'm in this technology bubble right now where I'm thinking
• 34:10
  Speaker 5: of having that integrate with like the drug interaction checker
• 34:13
  Speaker 5: for like LEXI or clinical pharmacology where when you punch
• 34:16
  Speaker 5: in the drug interactions, and especially for the retail setting,
• 34:19
  Speaker 5: like if they were to put that into the system,
• 34:22
  Speaker 5: it would flag and be like, hey, this is on
• 34:24
  Speaker 5: the kids list.
• 34:29
  Speaker 4: So Dave and Rachel, how can we as pediatric pharmacists
• 34:33
  Speaker 4: be a part of getting the word out? I know
• 34:35
  Speaker 4: that was a big discussion at the PPA meeting. And
• 34:38
  Speaker 4: this is a is a pharmacist driven document, which I
• 34:42
  Speaker 4: think is super super cool. It's applicable to all pediatric
• 34:45
  Speaker 4: pharmacy practice, but it's pharmacists driven. I'm likeke the Beers criteria,
• 34:48
  Speaker 4: which does involve farm dees in it, and so I
• 34:51
  Speaker 4: don't want to mischaracterize that, but this is pharmacy driven,
• 34:54
  Speaker 4: and so we should be proud of it, not only
• 34:56
  Speaker 4: because of that, but because of the kind of value
• 35:00
  Speaker 4: brings as another tool in our ommitarium. So just to
• 35:04
  Speaker 4: go back and relate the question, how can we get
• 35:07
  Speaker 4: the word out about the Kids List?
• 35:10
  Speaker 9: I think educators teach it right, just like you're saying, justin,
• 35:14
  Speaker 9: I think that is where you start right, teaching the
• 35:17
  Speaker 9: new ones. And then we're doing our best with our
• 35:20
  Speaker 9: Dog and Pony Show to take it around. We're hoping,
• 35:24
  Speaker 9: you know, to partner with some other organizations so we
• 35:26
  Speaker 9: can present more on it.
• 35:28
  Speaker 7: Yeah, it'd be nice to get a little bit more
• 35:31
  Speaker 7: of our community colleagues, right, and our ambulatory colleagues find
• 35:36
  Speaker 7: ways to reach them through associations or societies. But yeah,
• 35:41
  Speaker 7: teach it, use it, bring it to practice, bring it
• 35:45
  Speaker 7: to P and T and incorporate that will get a
• 35:49
  Speaker 7: lot of buzz.
• 35:49
  Speaker 8: It'll get a lot of people talking.
• 35:51
  Speaker 7: So educating on it, researching on it, using it, referencing it.
• 35:57
  Speaker 8: I think we'll get the word out. Will take some time, but.
• 36:04
  Speaker 4: Well, we appreciate both of you coming on to the
• 36:07
  Speaker 4: podcast to give us a little bit of a taste
• 36:10
  Speaker 4: of the updates that are coming.
• 36:12
  Speaker 6: Are there any last things about the Kids List?
• 36:14
  Speaker 4: Do you want to make sure that our listeners are
• 36:16
  Speaker 4: left with any words of wisdom or last pieces that
• 36:19
  Speaker 4: you think are important with this update.
• 36:22
  Speaker 9: Just I think for me, I'm so grateful to all
• 36:24
  Speaker 9: the pharmacists who read our early editions, both the first
• 36:27
  Speaker 9: edition and the second edition, look through the table and
• 36:30
  Speaker 9: gave us comments. It's a better document for it, and
• 36:34
  Speaker 9: we just are really appreciative of that without question.
• 36:37
  Speaker 7: And I would add the additional subspecialists on our on
• 36:42
  Speaker 7: our team have been invaluable. They have insight, they walk
• 36:47
  Speaker 7: in places that I don't normally walk, and so they've
• 36:49
  Speaker 7: brought a lot of value to the final product. So
• 36:53
  Speaker 7: it's a lot better. But you know, it's something that's
• 36:56
  Speaker 7: just going to keep changing as we get more information.
• 36:59
  Speaker 8: So there were a.
• 37:00
  Speaker 7: Lot of changes between the first and second Sorry about that,
• 37:04
  Speaker 7: but as the data changes, we have to move with it.
• 37:10
  Speaker 4: Well, if we're practicing evidence based medicine, we've got to
• 37:13
  Speaker 4: do that right. We've got to be willing to pivot
• 37:15
  Speaker 4: and sometimes even call things that work standard of care
• 37:19
  Speaker 4: no longer the standard of care when we need to.
• 37:22
  Speaker 4: So that's part of having that clinical humility, if you will,
• 37:26
  Speaker 4: right of understanding that sometimes we didn't have the data
• 37:30
  Speaker 4: we wished we did, and when it changes, we follow it,
• 37:32
  Speaker 4: so we appreciate you guys helping us do that again.
• 37:35
  Speaker 4: Thank you so much, Rachel and Dave for joining us
• 37:37
  Speaker 4: on the podcast. Mary.
• 37:39
  Speaker 6: Always great to talk.
• 37:40
  Speaker 4: With you, and we look forward to seeing you on
• 37:43
  Speaker 4: thet on this next podcast episode of The Pediatric Pharmacy Review.
• 37:49
  Speaker 5: Thanks, thank you, every good tea.
• 37:52
  Speaker 8: Thanks so much.
• 37:53
  Speaker 6: Yeah, thanks guys, We appreciate you so greatly. Students.
• 37:56
  Speaker 4: Hopefully this is a great learning experience. If you haven't
• 37:59
  Speaker 4: heard of the kids list, my apologies. Give me your faculty,
• 38:02
  Speaker 4: your peed's faculty members name, and I'll email them and.
• 38:05
  Speaker 6: Suggest that they look at it for you.
• 38:07
  Speaker 4: So well.
• 38:08
  Speaker 1: Joshua, I know, is one of ours.
• 38:10
  Speaker 6: So oh great. Okay, so he's covering. Good job. Sounds good. Well,
• 38:15
  Speaker 6: thanks again, guys.
• 38:16
  Speaker 1: All right, thank you guys, thank you, thanks for having
• 38:19
  Speaker 1: us a great week.
• 38:20
  Speaker 3: That's all for today's episode. Thanks for listening, and remember
• 38:24
  Speaker 3: to subscribe on Apple Podcast and leave us a review.