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Paediatric prescribing guidelines and tips

The well-organised practice should be aware of the many pitfalls of paediatric prescribing and should be familiar with all the resources available to help, says Dr Louise Wilson

The well-organised practice should be aware of the many pitfalls of paediatric prescribing and should be familiar with all the resources available to help, says Dr Louise Wilson

Set against the number of prescriptions GPs write each week ­ on average, between 250 and 350 items ­ medication errors occur infrequently.

However, such mistakes account for a quarter of settled claims against GP members of the Medical Defence Union, costing £12.5million over a five-year period. In addition, errors such as failing to monitor side-effects and drug interactions have the potential to cause real harm to patients, particularly if the patient is a young child.

In one hospital case reported in 2004, a baby suffered a cardiac arrest and died after being given 10 times the recommended amount of digoxin owing to a mistake with a decimal point. He was given 220µg when he should have received just 22. In fact, prescribing medication for children can present a number of problems for GPs because children are not 'mini-adults' in terms of dosages and drug handling ­ dosages must be tailored to each child, calculated by weight and age.

As we revealed in a column in Pulse last year, MDU figures show that 20 per cent of 399 cases alleging medication errors over a recent seven-year period involved children under 15. Common reasons for allegations of paediatric medication error made against GP members included adverse drug reactions, which accounted for 20 per cent of the notified cases, and the patient receiving the wrong dose or wrong drug, which accounted for 12 per cent.

Other reasons included delay in prescribing, the wrong preparation of drug being given, and parental consent not being obtained. The drugs involved included vaccines, antibiotics and analgesics.

Off-licence prescribing

Most drugs for everyday children's ailments are licensed for paediatric use but drugs developed for adults are not always tested for children. The use of medicines that have been licensed for adults but not children (off-licence) is often necessary in paediatric practice and this presents a further challenge to doctors.

In such cases, the GMC advises doctors to 'be satisfied that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its efficacy. The manufacturer's information may be of limited help, in which case the necessary information must be sought from other sources.

'When noting the medicines prescribed in the medical record, doctors are reminded that 'where you are not following common practice, your reasons for prescribing the medicine' should also be included.

When obtaining consent for the use of off-licence medicine, the GMC tells doctors: 'It is good practice to give as much information as patients, or those authorising treatment on their behalf, require or which they may see as significant.' It may also be appropriate to show parents documentation that shows that the use of the medication is backed by a responsible body of medical opinion if this is available.

The GMC stresses: 'You must explain the reasons for prescribing a medicine that is unlicensed or being used outside the scope of its licence where there is little research or other evidence of current practice to support its use, or where the use of the medicine is innovative.'

A new resource for doctors

In the past, GPs may have needed to go to a number of sources to help calculate the correct dose for a particular child, or find out formulations, known interactions and whether the treatment is licensed ­ not always easy during a consultation. This changed in September 2005, when the BNF, the reference manual for medicines, launched the first information resource for doctors, pharmacists, nurses and other health care professionals on medication for children up to the age of 18.

The British National Formulary for Children (BNFC) is a joint publication of the BMA, the Royal Pharmaceutical Society of Great Britain, the Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group. It gives a wide range of guidance and information on paediatric prescribing, from choosing the best available drug to specific doses and formulations. The information has been validated against emerging evidence, best practice guidelines, and advice from a network of clinical experts.

The BNFC includes information about off-licence paediatric uses of medication, drawing information from manufacturers, local paediatric formularies, clinical literature and publications by recognised authorities. In certain cases GPs may therefore find it useful to refer to the BNFC when obtaining consent for treatment that is not licensed for children.

The BNFC gives general advice on the use of medicines for managing childhood conditions, information on prescribing controlled drugs and the management of palliative care. It also gives advice on how to report adverse drug reactions and outlines the general principles of the use of medicines in hepatic impairment, renal impairment, pregnancy and breastfeeding.

Tips for paediatric prescribing

Although the BNFC is a useful resource, there are other issues to consider when prescribing drugs for children.

You should always:

  • Check the patient's past clinical history, records and concurrent medication before prescribing any new drug, and check for known allergies or hypersensitivities.
  • If prescribing drugs you are unfamiliar with, check contraindications and side-effects. Discuss known side-effects with parents and ensure that valid consent is sought before administration.
  • Take special precautions when prescribing medicines with similar names. · Give information to patients, relatives and other carers about what to do if the condition worsens.
  • Seek consent before giving any vaccine and ensure that this is noted in the patient record.
  • Ensure all vaccines are recorded accurately, including the date, time, vaccine and batch number, as well as site and mode of injection.
  • Review or reassess the diagnosis if symptoms fail to progress as expected or if test results do not correlate with the clinical findings.
  • Review all medication on regular repeats, paying particular attention to topical steroid preparations and children with conditions such as epilepsy.

Louise Wilson is a medicolegal adviser with the MDU

Case history

How the BNFC might assist GPs when prescribing for children

A mother brought her nine-month-old son to the GP. The child was suffering from diarrhoea and high temperature. The mother had been giving paracetamol at home. While in the waiting room the mother approached the receptionist. Her son was becoming irritable and she was worried that his fever was getting worse. On examination the GP agreed the child was pyrexial and, after checking that the patient's mother was not aware of any previous adverse reaction, he decided to prescribe and administer a dose of ibuprofen.

The child's mother had given her consent after the GP had explained the need for this treatment and warned her of possible side-effects. The GP was able to refer to a copy of the BNFC, where the appropriate ibuprofen dosage was displayed by age and weight. He administered the dose orally and asked the practice nurse to keep the child under observation to monitor his temperature before he returned home.

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