Notice - Adoption of ICH Guidance: Clinical Investigation of Medicinal Products in the Pediatric Population E11
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December 17, 2003
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Adoption of ICH Guidance: Clinical Investigation of Medicinal Products in the Pediatric Population E11.
Health Canada is pleased to announce the adoption of the ICH guidance Clinical Investigation of Medicinal Products in the Pediatric Population E11.
This guidance has been developed by the appropriate ICH Expert Working Group and has been subject to consultation by the regulatory parties, in accordance with the ICH Process. The ICH Steering Committee has endorsed the final draft and recommended its adoption by the regulatory bodies of the European Union, Japan and USA.
In adopting this ICH guidance, Health Canada endorses the principles and practices described therein. This document should be read in conjunction with this accompanying notice and with the relevant sections of other applicable Health Canada guidances.
It is recognizes that the scope and subject matter of current Health Canada guidances may not be entirely consistent with those of the ICH guidances that are being introduced as part of our commitment to international harmonization and the ICH Process. In such circumstances, Health Canada adopted ICH guidances take precedence.
Health Canada is committed to eliminating such discrepancies through the implementation of a phasedin work plan that will examine the impact associated with the adoption of ICH guidances. This will result in the amendment or, depending on the extent of revisions required, withdrawal of some Health Canada guidances.
This and other Guidance documents are available on the Therapeutic Products Directorate / Biologics and Genetic Therapies Directorate / Marketed Health Products Directorate Website (s) (http://www.hc-sc.gc.ca/hpfb-dgpsa/tpd-dpt/). The availability of printed copies of guidance documents may be confirmed by consulting the Guidelines and Publications Order Forms (available on the TPD/BGTD/MHPD Website) or by contacting the Publications CoordinatorFootnote 2.
Should you have any questions regarding the content of the guidance, please contact:
Submission Management Division
Centre for Policy and Regulatory Affairs
Biologics and Genetic Therapies Directorate
Fax: (613) 957-0364
Senior Medical Advisor Bureau
Therapeutic Products Directorate
Fax: (613) 954-4474
Guidance For Industry
Clinical Investigation of Medicinal Products in the Pediatric
ICH Topic E11
Draft Date 2003/12/17
Effective Date 2003/12/17
Health Products and Food Branch Guidance Document
Catalogue No. H42-2/67-23-2003 E
This guidance has been developed by the appropriate ICH Expert Working Group and has been subject to consultation by the regulatory parties, in accordance with the ICH Process. The ICH Steering Committee has endorsed the final draft and recommended its adoption by the regulatory bodies of the European Union, Japan and USA.
In adopting this ICH guidance, Health Canada endorses the principles and practices described therein. This document should be read in conjunction with the accompanying notice and the relevant sections of other applicable guidances.
Guidance documents are meant to provide assistance to industry and health care professionals on how to comply with the policies and governing statutes and regulations. They also serve to provide review and compliance guidance to staff, thereby ensuring that mandates are implemented in a fair, consistent and effective manner.
Guidance documents are administrative instruments not having force of law and, as such, allow for flexibility in approach. Alternate approaches to the principles and practices described in this document may be acceptable provided they are supported by adequate scientific justification. Alternate approaches should be discussed in advance with the relevant program area to avoid the possible finding that applicable statutory or regulatory requirements have not been met.
As a corollary to the above, it is equally important to note that Health Canada reserves the right to request information or material, or define conditions not specifically described in this guidance, in order to allow the Department to adequately assess the safety, efficacy or quality of a therapeutic product. Health Canada is committed to ensuring that such requests are justifiable and that decisions are clearly documented.
Table Of Contents
- 1. Introduction
- 2. Guidance
- 2.1 Issues When Initiating a Pediatric Medicinal Product Development Program
- 2.2 Pediatric Formulations
- 2.3 Timing of Studies
- 2.3.1 Medicinal Products for Diseases Predominantly or Exclusively Affecting Pediatric Patients
- 2.3.2 Medicinal Products Intended to Treat Serious or Life-Threatening Diseases, Occurring in Both Adults and Pediatric Patients, for Which There Are Currently No or Limited Therapeutic Options
- 2.3.3 Medicinal Products Intended to Treat Other Diseases and Conditions
- 2.4 Types of Studies
- 2.5 Age Classification of Pediatric Patients
- 2.6 Ethical Issues in Pediatric Studies
1.1 Objectives of the Guidance
The number of medicinal products currently labeled for pediatric use is limited. It is the goal of this guidance to encourage and facilitate timely pediatric medicinal product development internationally. The guidance provides an outline of critical issues in pediatric drug development and approaches to the safe, efficient, and ethical study of medicinal products in the pediatric population.
Other ICH documents with relevant information impacting on pediatric studies include:
- E2: Clinical Safety Data Management
- E3: Structure and Content of Clinical Study Reports
- E4: Dose-Response Information to Support Drug Registration
- E5: Ethnic Factors in the Acceptability of Foreign Clinical Data
- E6: Good Clinical Practice: Consolidated Guideline
- E8: General Considerations for Clinical Trials
- E9: Statistical Principles for Clinical Trials
- E10: Choice of Control Group in Clinical Trials
- M3: Nonclinical Safety Studies for the Conduct of Human Clinical Trials for Pharmaceuticals
- Q1: Stability Testing
- Q2: Validation of Analytical Procedures
- Q3: Impurity Testing
1.3 Scope of the Guidance
Specific clinical study issues addressed include: (1) considerations when initiating a pediatric program for a medicinal product; (2) timing of initiation of pediatric studies during medicinal product development; (3) types of studies (pharmacokinetic, pharmacokinetic/pharmacodynamic (PK/PD), efficacy, safety); (4) age categories; and (5) ethics of pediatric clinical investigation. This guidance is not intended to be comprehensive; other ICH guidances, as well as documents from regional regulatory authorities and pediatric societies, provide additional detail.
1.4 General Principles
Pediatric patients should be given medicines that have been appropriately evaluated for their use. Safe and effective pharmacotherapy in pediatric patients requires the timely development of information on the proper use of medicinal products in pediatric patients of various ages and, often, the development of pediatric formulations of those products. Advances in formulation chemistry and in pediatric study design will help facilitate the development of medicinal products for pediatric use. Drug development programs should usually include the pediatric patient population when a product is being developed for a disease or condition in adults and it is anticipated the product will be used in the pediatric population. Obtaining knowledge of the effects of medicinal products in pediatric patients is an important goal. However, this should be done without compromising the well-being of pediatric patients participating in clinical studies. This responsibility is shared by companies, regulatory authorities, health professionals, and society as a whole.
2.1 Issues When Initiating a Pediatric Medicinal Product Development Program
Data on the appropriate use of medicinal products in the pediatric population should be generated unless the use of a specific medicinal product in pediatric patients is clearly inappropriate. The timing of initiation of clinical studies in relation to studies conducted in adults, which may be influenced by regional public health and medical needs, is discussed in section 2.3. Justification for the timing and the approach to the clinical program needs to be clearly addressed with regulatory authorities at an early stage and then periodically during the medicinal product development process. The pediatric development program should not delay completion of adult studies and availability of a medicinal product for adults.
The decision to proceed with a pediatric development program for a medicinal product, and the nature of that program, involve consideration of many factors, including:
- The prevalence of the condition to be treated in the pediatric population
- The seriousness of the condition to be treated
- The availability and suitability of alternative treatments for the condition in the pediatric population, including the efficacy and the adverse event profile (including any unique pediatric safety issues) of those treatments
- Whether the medicinal product is novel or one of a class of compounds with known properties
- Whether there are unique pediatric indications for the medicinal product
- The need for the development of pediatric-specific endpoints
- The age ranges of pediatric patients likely to be treated with the medicinal product
- Unique pediatric (developmental) safety concerns with the medicinal product, including any nonclinical safety issues
- Potential need for pediatric formulation development
Of these factors, the most important is the presence of a serious or life-threatening disease for which the medicinal product represents a potentially important advance in therapy. This situation suggests relatively urgent and early initiation of pediatric studies.
Information from nonclinical safety studies to support a pediatric clinical program is discussed in ICH M3, section 11. It should be noted that the most relevant safety data for pediatric studies ordinarily come from adult human exposure. Repeated dose toxicity studies, reproduction toxicity studies and genotoxicity tests would generally be available. The need for juvenile animal studies should be considered on a case-by-case basis and be based on developmental toxicology concerns.
2.2 Pediatric Formulations
There is a need for pediatric formulations that permit accurate dosing and enhance patient compliance. For oral administration, different types of formulations, flavors and colors may be more acceptable in one region than another. Several formulations, such as liquids, suspensions, and chewable tablets, may be needed or desirable for pediatric patients of different ages. Different drug concentrations in these various formulations may also be needed. Consideration should also be given to the development of alternative delivery systems.
For injectable formulations, appropriate drug concentrations should be developed to allow accurate and safe administration of the dose. For medicinal products supplied as single-use vials, consideration should be given to dose-appropriate single-dose packaging.
The toxicity of some excipients may vary across pediatric age groups and between pediatric and adult populations, e.g., benzyl alcohol is toxic in the preterm newborn. Depending on the active substance and excipients, appropriate use of the medicinal product in the newborn may require a new formulation or appropriate information about dilution of an existing formulation. International harmonization on the acceptability of formulation excipients and of validation procedures would help ensure that appropriate formulations are available for the pediatric population everywhere.
2.3 Timing of Studies
During clinical development, the timing of pediatric studies will depend on the medicinal product, the type of disease being treated, safety considerations, and the efficacy and safety of alternative treatments. Since development of pediatric formulations can be difficult and time consuming, it is important to consider the development of these formulations early in medicinal product development.
2.3.1 Medicinal Products for Diseases Predominantly or Exclusively Affecting Pediatric Patients
In this case, the entire development program will be conducted in the pediatric population except for initial safety and tolerability data, which will usually be obtained in adults. Some products may reasonably be studied only in the pediatric population even in the initial phases, e.g., when studies in adults would yield little useful information or expose them to inappropriate risk. Examples include surfactant for respiratory distress syndrome in preterm infants and therapies targeted at metabolic or genetic diseases unique to the pediatric population.
2.3.2. Medicinal Products Intended to Treat Serious or Life-Threatening Diseases, Occurring in Both Adults and Pediatric Patients, for Which There Are Currently No or Limited Therapeutic Options
The presence of a serious or life-threatening disease for which the product represents a potentially important advance in therapy suggests the need for relatively urgent and early initiation of pediatric studies. In this case, medicinal product development should begin early in the pediatric population, following assessment of initial safety data and reasonable evidence of potential benefit. Pediatric study results should be part of the marketing application database. In circumstances where this has not been possible, lack of data should be justified in detail.
2.3.3 Medicinal Products Intended to Treat Other Diseases and Conditions
In this case, although the medicinal product will be used in pediatric patients, there is less urgency than in the previous cases and studies would usually begin at later phases of clinical development or, if a safety concern exists, even after substantial postmarketing experience in adults. Companies should have a clear plan for pediatric studies and reasons for their timing. Testing of these medicinal products in the pediatric population would usually not begin until Phase 2 or 3. In most cases, only limited pediatric data would be available at the time of submission of the application, but more would be expected after marketing. The development of many new chemical entities is discontinued during or following Phase 1 and 2 studies in adults for lack of efficacy or an unacceptable side effect profile. Therefore, very early initiation of testing in pediatric patients might needlessly expose these patients to a compound that will be of no benefit. Even for a nonserious disease, if the medicinal product represents a major therapeutic advance for the pediatric population, studies should begin early in development, and the submission of pediatric data would be expected in the application. Lack of data should be justified in detail. Thus, it is important to carefully weigh benefit/risk and therapeutic need in deciding when to start pediatric studies.
2.4 Types of Studies
The principles outlined in ICH E4, E5, E6, and E10 apply to pediatric studies. Several pediatric-specific issues are worth noting. When a medicinal product is studied in pediatric patients in one region, the intrinsic (e.g., pharmacogenetic) and extrinsic (e.g., diet) factorsFootnote 3 that could impact on the extrapolation of data to other regions should be considered.
When a medicinal product is to be used in the pediatric population for the same indication(s) as those studied and approved in adults, the disease process is similar in adults and pediatric patients, and the outcome of therapy is likely to be comparable, extrapolation from adult efficacy data may be appropriate. In such cases, pharmacokinetic studies in all the age ranges of pediatric patients likely to receive the medicinal product, together with safety studies, may provide adequate information for use by allowing selection of pediatric doses that will produce blood levels similar to those observed in adults. If this approach is taken, adult pharmacokinetic data should be available to plan the pediatric studies.
When a medicinal product is to be used in younger pediatric patients for the same indication(s) as those studied in older pediatric patients, the disease process is similar, and the outcome of therapy is likely to be comparable, extrapolation of efficacy from older to younger pediatric patients may be possible. In such cases, pharmacokinetic studies in the relevant age groups of pediatric patients likely to receive the medicinal product, together with safety studies, may be sufficient to provide adequate information for pediatric use.
An approach based on pharmacokinetics is likely to be insufficient for medicinal products where blood levels are known or expected not to correspond with efficacy or where there is concern that the concentration-response relationship may differ between the adult and pediatric populations. In such cases, studies of the clinical or the pharmacological effect of the medicinal product would usually be expected.
Where the comparability of the disease course or outcome of therapy in pediatric patients is expected to be similar to adults, but the appropriate blood levels are not clear, it may be possible to use measurements of a pharmacodynamic effect related to clinical effectiveness to confirm the expectations of effectiveness and to define the dose and concentration needed to attain that pharmacodynamic effect. Such studies could provide increased confidence that achieving a given exposure to the medicinal product in pediatric patients would result in the desired therapeutic outcomes. Thus, a PK/PD approach combined with safety and other relevant studies could avoid the need for clinical efficacy studies.
In other situations where a pharmacokinetic approach is not applicable, such as for topically active products, extrapolation of efficacy from one patient population to another may be based on studies that include pharmacodynamic endpoints and/or appropriate alternative assessments. Local tolerability studies may be needed. It may be important to determine blood levels and systemic effects to assess safety.
When novel indications are being sought for the medicinal product in pediatric patients, or when the disease course and outcome of therapy are likely to be different in adults and pediatric patients, clinical efficacy studies in the pediatric population would be needed.
Pharmacokinetic studies generally should be performed to support formulation development and determine pharmacokinetic parameters in different age groups to support dosing recommendations. Relative bioavailability comparisons of pediatric formulations with the adult oral formulation typically should be done in adults. Definitive pharmacokinetic studies for dose selection across the age ranges of pediatric patients in whom the medicinal product is likely to be used should be conducted in the pediatric population.
Pharmacokinetic studies in the pediatric population are generally conducted in patients with the disease. This may lead to higher intersubject variability than studies in normal volunteers, but the data better reflect clinical use.
For medicinal products that exhibit linear pharmacokinetics in adults, single-dose pharmacokinetic studies in the pediatric population may provide sufficient information for dosage selection. This can be corroborated, if indicated, by sparse sampling in multidose clinical studies. Any nonlinearity in absorption, distribution, and elimination in adults and any difference in duration of effect between single and repeated dosing in adults would suggest the need for steady state studies in the pediatric population. All these approaches are facilitated by knowledge of adult pharmacokinetic parameters. Knowing the pathways of clearance (renal and metabolic) of the medicinal product and understanding the age-related changes of those processes will often be helpful in planning pediatric studies.
Dosing recommendations for most medicinal products used in the pediatric population are usually based on milligram (mg)/kilogram (kg) body weight up to a maximum adult dose. While dosing based on mg/square meter body surface area might be preferred, clinical experience indicates that errors in measuring height or length (particularly in smaller children and infants) and calculation errors of body surface area from weight and height are common. For some medications (e.g., medications with a narrow therapeutic index, such as those used in oncology), surface-area-guided dosing may be necessary, but extra care should be taken to ensure proper dose calculation.
Practical considerations to facilitate pharmacokinetic studies
The volume of blood withdrawn should be minimized in pediatric studies. Blood volumes should be justified in protocols. Institutional Review Boards/Independent Ethics Committees (IRB's/IEC's) review and may define the maximum amount of blood (usually on a milliliters (mL)/kg or percentage of total blood volume basis) that may be taken for investigational purposes. Several approaches can be used to minimize the amount of blood drawn and/or the number of venipunctures.
- Use of sensitive assays for parent drugs and metabolites to decrease the volume of blood required per sample
- Use of laboratories experienced in handling small volumes of blood for pharmacokinetic analyses and for laboratory safety studies (blood counts, clinical chemistry)
- Collection of routine, clinical blood samples wherever possible at the same time as samples are obtained for pharmacokinetic analysis
- The use of indwelling catheters, etc., to minimize distress as discussed in section 2.6.5.
- Use of population pharmacokinetics and sparse sampling based on optimal sampling theory to minimize the number of samples obtained from each patient. Techniques include:
- Sparse sampling approaches where each patient contributes as few as 2 to 4 observations at predetermined times to an overall "population area-under-the-curve"
- Population pharmacokinetic analysis using the most useful sampling time points derived from modeling of adult data
The principles in study design, statistical considerations and choice of control groups detailed in ICH E6, E9, and E10 generally apply to pediatric efficacy studies. There are, however, certain features unique to pediatric studies. The potential for extrapolation of efficacy from studies in adults to pediatric patients or from older to younger pediatric patients is discussed in section 2.4. Where efficacy studies are needed, it may be necessary to develop, validate, and employ different endpoints for specific age and developmental subgroups. Measurement of subjective symptoms such as pain requires different assessment instruments for patients of different ages. In pediatric patients with chronic diseases, the response to a medicinal product may vary among patients not only because of the duration of the disease and its chronic effects but also because of the developmental stage of the patient. Many diseases in the preterm and term newborn infant are unique or have unique manifestations precluding extrapolation of efficacy from older pediatric patients and call for novel methods of outcome assessment.
ICH guidances on E2 topics and ICH E6, which describe adverse event reporting, apply to pediatric studies. Age-appropriate, normal laboratory values and clinical measurements should be used in adverse event reporting. Unintended exposures to medicinal products (accidental ingestions, etc.) may provide the opportunity to obtain safety and pharmacokinetic information and to maximize understanding of dose-related side effects.
Medicinal products may affect physical and cognitive growth and development, and the adverse event profile may differ in pediatric patients. Because developing systems may respond differently from matured adult organs, some adverse events and drug interactions that occur in pediatric patients may not be identified in adult studies. In addition, the dynamic processes of growth and development may not manifest an adverse event acutely, but at a later stage of growth and maturation. Long-term studies or surveillance data, either while patients are on chronic therapy or during the posttherapy period, may be needed to determine possible effects on skeletal, behavioral, cognitive, sexual, and immune maturation and development.
2.4.4 Postmarketing Information
Normally the pediatric database is limited at the time of approval. Therefore, postmarketing surveillance is particularly important. In some cases, long-term followup studies may be important to determine effects of certain medications on growth and development of pediatric patients. Postmarketing surveillance and/or long-term followup studies may provide safety and/or efficacy information for subgroups within the pediatric population or additional information for the entire pediatric population.
2.5 Age Classification of Pediatric Patients
Any classification of the pediatric population into age categories is to some extent arbitrary, but a classification such as the one below provides a basis for thinking about study design in pediatric patients. Decisions on how to stratify studies and data by age need to take into consideration developmental biology and pharmacology. Thus, a flexible approach is necessary to ensure that studies reflect current knowledge of pediatric pharmacology. The identification of which ages to study should be medicinal product-specific and justified.
If the clearance pathways of a medicinal product are well established and the ontogeny of the pathways understood, age categories for pharmacokinetic evaluation might be chosen based on any "break point" where clearance is likely to change significantly. Sometimes, it may be more appropriate to collect data over broad age ranges and examine the effect of age as a continuous covariant. For efficacy, different endpoints may be established for pediatric patients of different ages, and the age groups might not correspond to the categories presented below. Dividing the pediatric population into many age groups might needlessly increase the number of patients required. In longer term studies, pediatric patients may move from one age category to another; the study design and statistical plans should prospectively take into account changing numbers of patients within a given age category.
The following is one possible categorization. There is, however, considerable overlap in developmental (e.g., physical, cognitive, and psychosocial) issues across the age categories. Ages are defined in completed days, months, or years.
- Preterm newborn infants
- Term newborn infants (0 to 27 days)
- Infants and toddlers (28 days to 23 months)
- Children (2 to 11 years)
- Adolescents (12 to 16-18 years (dependent on region))
2.5.1 Preterm Newborn Infants
The study of medicinal products in preterm newborn infants presents special challenges because of the unique pathophysiology and responses to therapy in this population. The complexity of and ethical considerations involved in studying preterm newborn infants suggest the need for careful protocol development with expert input from neonatologists and neonatal pharmacologists. Only rarely will it be possible to extrapolate efficacy from studies in adults or even in older pediatric patients to the preterm newborn infant.
The category of preterm newborn infants is not a homogeneous group of patients. A 25-week gestation, 500-gram (g) newborn is very different from a 30-week gestation newborn weighing 1,500 g. A distinction should also be made for low-birth-weight babies as to whether they are immature or growth retarded. Important features that should be considered for these patients include: (1) gestational age at birth and age after birth (adjusted age); (2) immaturity of renal and hepatic clearance mechanisms; (3) protein binding and displacement issues (particularly bilirubin); (4) penetration of medicinal products into the central nervous system (CNS); (5) unique neonatal disease states (e.g., respiratory distress syndrome of the newborn, patent ductus arteriosus, primary pulmonary hypertension); (6) unique susceptibilities of the preterm newborn (e.g., necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity); (7) rapid and variable maturation of all physiologic and pharmacologic processes leading to different dosing regimens with chronic exposure; and (8) transdermal absorption of medicinal products and other chemicals. Study design issues that should be considered include: (1) weight and age (gestational and postnatal) stratification; (2) small blood volumes (a 500-g infant has 40 mL of blood); (3) small numbers of patients at a given center and differences in care among centers; and (4) difficulties in assessing outcomes.
2.5.2 Term newborn infants (0 to 27 days)
While term newborn infants are developmentally more mature than preterm newborn infants, many of the physiologic and pharmacologic principles discussed above also apply to term infants. Volumes of distribution of medicinal products may be different from those in older pediatric patients because of different body water and fat content and high body-surface-area-to-weight ratio. The blood-brain barrier is still not fully mature and medicinal products and endogenous substances (e.g., bilirubin) may gain access to the CNS with resultant toxicity. Oral absorption of medicinal products may be less predictable than in older pediatric patients. Hepatic and renal clearance mechanisms are immature and rapidly changing; doses may need to be adjusted over the first weeks of life. Many examples of increased susceptibility to toxic effects of medicinal products result from limited clearance in these patients (e.g., chloramphenicol grey baby syndrome). On the other hand, term newborn infants may be less susceptible to some types of adverse effects (e.g., aminoglycoside nephrotoxicity) than are patients in older age groups.
2.5.3 Infants and toddlers (28 days to 23 months)
This is a period of rapid CNS maturation, immune system development and total body growth. Oral absorption becomes more reliable. Hepatic and renal clearance pathways continue to mature rapidly. By 1 to 2 years of age, clearance of many drugs on a mg/kg basis may exceed adult values. The developmental pattern of maturation is dependent on specific pathways of clearance. There is often considerable interindividual variability in maturation.
2.5.4 Children (2 to 11 years)
Most pathways of drug clearance (hepatic and renal) are mature, with clearance often exceeding adult values. Changes in clearance of a drug may be dependent on maturation of specific metabolic pathways.
Specific strategies should be addressed in protocols to ascertain any effects of the medicinal product on growth and development. Children achieve several important milestones of psychomotor development that could be adversely affected by CNS-active drugs. Entry into school and increased cognitive and motor skills may affect a child's ability to participate in some types of efficacy studies. Factors useful in measuring the effects of a medicinal product on children include skeletal growth, weight gain, school attendance, and school performance. Recruitment of patients should ensure adequate representation across the age range in this category, as it is important to ensure a sufficient number of younger patients for evaluation. Stratification by age within this category is often unnecessary, but it may be appropriate to stratify patients based on pharmacokinetic and/or efficacy endpoint considerations.
The onset of puberty is highly variable and occurs earlier in girls, in whom normal onset of puberty may occur as early as 9 years of age. Puberty can affect the apparent activity of enzymes that metabolize drugs, and dose requirements for some medicinal products on a mg/kg basis may decrease dramatically (e.g., theophylline). In some cases, it may be appropriate to specifically assess the effect of puberty on a medicinal product by studying pre- and postpubertal pediatric patients. In other cases, it may be appropriate to record Tanner stages of pubertal development or obtain biological markers of puberty and examine data for any potential influence of pubertal changes.
2.5.5 Adolescents (12 to 16-18 years (dependent on region))
This is a period of sexual maturation; medicinal products may interfere with the actions of sex hormones and impede development. In certain studies, pregnancy testing and review of sexual activity and contraceptive use may be appropriate.
This is also a period of rapid growth and continued neurocognitive development. Medicinal products and illnesses that delay or accelerate the onset of puberty can have a profound effect on the pubertal growth spurt and, by changing the pattern of growth, may affect final height. Evolving cognitive and emotional changes could potentially influence the outcome of clinical studies.
Many diseases are also influenced by the hormonal changes around puberty (e.g., increases in insulin resistance in diabetes mellitus, recurrence of seizures around menarche, changes in the frequency and severity of migraine attacks and asthma exacerbations). Hormonal changes may thus influence the results of clinical studies.
Within this age group, adolescents are assuming responsibility for their own health and medication. Noncompliance is a special problem, particularly when medicinal products (for example, steroids) affect appearance. In clinical studies compliance checks are important. Recreational use of unprescribed drugs, alcohol and tobacco should be specifically considered.
The upper age limit varies among regions. It may be possible to include older adolescents in adult studies, although issues of compliance may present problems. Given some of the unique challenges of adolescence, it may be appropriate to consider studying adolescent patients (whether they are to be included in adult or separate protocols) in centers knowledgeable and skilled in the care of this special population.
2.6 Ethical Issues in Pediatric Studies
The pediatric population represents a vulnerable subgroup. Therefore, special measures are needed to protect the rights of pediatric study participants and to shield them from undue risk. The purpose of this section is to provide a framework to ensure that pediatric studies are conducted ethically.
To be of benefit to those participating in a clinical study, as well as to the rest of the pediatric population, a clinical study must be properly designed to ensure the quality and interpretability of the data obtained. In addition, participants in clinical studies are expected to benefit from the clinical study except under the special circumstances discussed in ICH E6, section 4.8.14.
2.6.1 Institutional Review Board/Independent Ethics Committee (IRB/IEC)
The roles and responsibilities of IRB's/IEC's as detailed in ICH E6 are critical to the protection of study participants. When protocols involving the pediatric population are reviewed, there should be IRB/IEC members or experts consulted by the IRB/IEC who are knowledgeable in pediatric ethical, clinical, and psychosocial issues.
Recruitment of study participants should occur in a manner free from inappropriate inducements either to the parent(s)/legal guardian or the study participant. Reimbursement and subsistence costs may be covered in the context of a pediatric clinical study. Any compensation should be reviewed by the IRB/IEC.
When studies are conducted in the pediatric population, an attempt should be made to include individuals representing the demographics of the region and the disease being studied, unless there is a valid reason for restricting enrollment.
2.6.3 Consent and Assent
As a rule, a pediatric subject is legally unable to provide informed consent. Therefore pediatric study participants are dependent on their parent(s)/legal guardian to assume responsibility for their participation in clinical studies. Fully informed consent should be obtained from the legal guardian in accordance with regional laws or regulations. All participants should be informed to the fullest extent possible about the study in language and terms they are able to understand. Where appropriate, participants should assent to enroll in a study (age of assent to be determined by IRB's/IEC's or be consistent with local legal requirements). Participants of appropriate intellectual maturity should personally sign and date either a separately designed, written assent form or the written informed consent. In all cases, participants should be made aware of their rights to decline to participate or to withdraw from the study at any time. Attention should be paid to signs of undue distress in patients who are unable to clearly articulate their distress. Although a participant's wish to withdraw from a study must be respected, there may be circumstances in therapeutic studies for serious or life-threatening diseases in which, in the opinion of the investigator and parent(s)/legal guardian, the welfare of a pediatric patient would be jeopardized by his or her failing to participate in the study. In this situation, continued parental (legal guardian) consent should be sufficient to allow participation in the study. Emancipated or mature minors (defined by local laws) may be capable of giving autonomous consent.
Information that can be obtained in a less vulnerable, consenting population should not be obtained in a more vulnerable population or one in which the patients are unable to provide individual consent. Studies in handicapped or institutionalized pediatric populations should be limited to diseases or conditions found principally or exclusively in these populations, or situations in which the disease or condition in these pediatric patients would be expected to alter the disposition or pharmacodynamic effects of a medicinal product.
2.6.4 Minimizing Risk
However important a study may be to prove or disprove the value of a treatment, participants may suffer injury as a result of inclusion in the study, even if the whole community benefits. Every effort should be made to anticipate and reduce known hazards. Investigators should be fully aware before the start of a clinical study of all relevant preclinical and clinical toxicity of the medicinal product. To minimize risk in pediatric clinical studies, those conducting the study should be properly trained and experienced in studying the pediatric population, including the evaluation and management of potential pediatric adverse events.
In designing studies, every attempt should be made to minimize the number of participants and of procedures, consistent with good study design. Mechanisms should be in place to ensure that a study can be rapidly terminated should an unexpected hazard be noted.
2.6.5 Minimizing Distress
Repeated invasive procedures may be painful or frightening. Discomfort can be minimized if studies are designed and conducted by investigators experienced in the treatment of pediatric patients.
Protocols and investigations should be designed specifically for the pediatric population (not simply re-worked from adult protocols) and approved by an IRB/IEC as described in section 2.6.1.
Practical considerations to ensure that participants' experiences in clinical studies are positive and to minimize discomfort and distress include the following:
- Personnel knowledgeable and skilled in dealing with the pediatric population and its age-appropriate needs, including skill in performing pediatric procedures
- A physical setting with furniture, play equipment, activities, and food appropriate for age
- The conduct of studies in a familiar environment such as the hospital or clinic where participants normally receive their care
- Approaches to minimize discomfort of procedures, such as:
- Topical anesthesia to place IV catheters
- Indwelling catheters rather than repeated venipunctures for blood sampling
- Collection of some protocol-specified blood samples when routine clinical samples are obtained
IRB's/IEC's should consider how many venipunctures are acceptable in an attempt to obtain blood samples for a protocol and ensure a clear understanding of procedures if an indwelling catheter fails to function over time. The participant's right to refuse further investigational procedures must be respected except as noted in section 2.6.3.
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