Prescribing in Paediatrics How to do it well!

1. Prescribing in PaediatricsHow to do it well! Rowena MCArtney and Liz Webb Senior Information Pharmacists, Cardiff & Vale NHS Trust. David Tuthill, Consultant Paediatrician, Children's Hospital for Wales.

2. Mistakes happen but how do we learn and improve our performance?

3. ? • How risky are healthcare systems as a cause of mortality? e.g. compared to cancer, MIs etc • Top 5 • 6-10 • 11- 20 • 21-50 • 51-100

4. Background • There are eight steps to prescribing. • 624 million prescriptions in NHS….. error prone • Single largest group of errors by doctors • Second largest payout in children • Potential for significant harm

5. Paediatric errors • Intrathecal vincristine BMJ 2009

6. ? • How many paediatric admissions are complicated by a medication error?

7. Children are more at Risk-Why? • 5% of paediatric admissions are complicated by medication error • Subsequent resulting harm in 2 - 7% • Weight, pharmacokinetics, physiology and autonomy • All Wales guidance exists on prescribing practice to reduce potential errors • All Wales Standard Drug chart

8. GMC report Dec 2009 RM

9. Prescribing in paediatrics • Is prescribing for children any different than adults? • What do we need to consider in prescribing for children? • What are the common problems in prescribing for children?

10. Factors to consider in prescribing for children • Size factors • Age • Weight; excessively fat or thin? • Surface area • Dose : Choose correct dose for age, weight and disease • Dose interval : Fit into child's waking day if possible

11. Common sources of error in prescribing for children • Most products are designed for adults • Miscalculations • 10 fold and 100 fold overdoses • mg/Kg dose versus mg/Kg/day • Confusion between doses in mg and in ml • Confusion between units • milligrams/ micrograms/ nanograms)

12. Help is at hand - BNFc • National BNFc should be used • gives safe advisable doses taking into account: • age • prematurity • weight • surface area • Disease state • Use the latest version; App available

13. How to use BNFc: • Look at appropriate drug section • Any contraindications? • Any allergies? • What's the indication? • Check dose against weight • Frequency? • Prescribe clearly • use block capitals • sign and date • bleep number

14. Example • You admit a 10 year old weighing 30Kg with meningitis. Prescribe ceftriaxone. • BNFc 2012-13 - pg 274 • Select appropriate indication-infections due to gram –ve organisms. • Check weight-under 50kg • Give 80mg/Kg/day dose (for severe infection and meningitis): 30 x 80= 2400mg dose daily • Correct dose = 2.4g daily • Note - slow infusion due to the high dose.

15. Summary Of C&V NHS Trust Prescribing Standards - 1 • Minimum acceptable patient identity details • Name • Address • DOB • Unit number • Weight (accurate in kg) • Allergies no/ yes-what to? Reaction?

16. Summary Of C&V NHS Trust Prescribing Standards - 2 • Indelible black pen (Not fountain or felt-tip pen) • NO abbreviations • Approved names • Sign and date at time of writing • Bleep number • Sign and date any changes made • Crossing off drugs (through prescribing section AND through administration boxes)

17. Summary Of C&V NHS Trust Prescribing Standards - 3 • Label multiple charts e.g. 1 of 2 • Care with units mg / μgm / ng can be misread - write in full: micrograms and nanograms • Avoid decimal points! e.g..5mg should be written up as 500micrograms • Don’t use mls use the dose in mg • UNITS must be written out in full

18. What’s the error?

20. Use your common sense 940mg?? Weight 7.5 kg!

21. Things to avoid Missing bleep no Missing route Do not amend frequency like this Do not write dose in ml No strength and dose in ml

22. All Wales Chart- What’s missing? Details as per addressograph Important – do not forget to complete

23. That’s better ! Sign and date when changing dose or route Sign and date crossing off Cross off at front and end of the prescription Include strength but don’t prescribe in ml

25. Now to put it into practice! • Use Calculators or your mobile • Please write your name on the drug chart , year of graduation and any Paediatric postgraduate qualifications • Please ask if you are unclear regarding any question. They are not meant to trick you! • Answers will be given out once the sheets have been collected! (you will be given feedback later) • Thank you for taking part. Hope this has been helpful to you!

26. Question 1 • Tinkywinky is a 3 year old child who weighs 14kg • She has scalded skin syndrome and no IV access. • Prescribe prn paracetamol and regular oral morphine for her.

27. Question 2 • Milo is a 7 year old oncology patient who weighs 24kg. • He is immunocompromised and has been admitted with chickenpox. • Prescribe IV aciclovir for him for 7days. • BSA for child 24kg is 0.9m2

28. Question 3 • Sara is a 10 year old surgical patient who weighs 45kg. • She has complicated appendicitis with abscess formation. • Prescribe piperacillin/tazobactam for her for 7 days.

29. Question 4 • Bella is 20 days old and has been admitted febrile and irritable, probably septic; possibly meningitic. • She weighs 3kg. • Prescribe amoxicillin and cefotaxime for her for 7 days.

30. Answers and 2 last things!

31. Question 1 • Tinkywinky is a 3 year old child who weighs 14kg, She has scalded skin syndrome and no IV access. Prescribe prn paracetamol and regular oral morphine for her. • Paracetamol • pain; pyrexia with discomfort • BNFC – 1-6years 120-250mg every 4-6hours (Max QDS) – for this age choose mid range eg 180mg • New MHRA dose - 2-4 years 180mg (7.5ml) QDS • Common practice is 15mg/kg QDS = 210mg (in patient) • severe pain dose in BNFc is now stipulated only for post-op pain

32. New MHRA guidance on paracetamol dosing – Nov11 • Infant paracetamol suspension (120mg in 5mL):

33. Question 2 • Milo is a 7 year old oncology patient who weighs 24kg. He is immunocompromised and has been admitted with chickenpox. Prescribe IV aciclovir for him. • BSA for child 24kg is 0.9m2 • Aciclovir for chickenpox and herpes zoster - IV infusion • 3 month-12 years – 250mg/m2 TDS (doubled if immunocompromised) • i.e. 500mg/m2 = 450mg TDS

34. Question 3 • Sara is a surgical patient who weighs 45kg. She is 10 years old. She has ruptured appendix with abscess. Prescribe piperacillin/tazobactam for her. • Answer – complicated appendicitis – age 2-12 years • 112.5mg/kg every 8 hours (max 4.5g every 8 hours) for 5-14 days. • 112.5 x 45 = 5062mg (5.062g) • Correct dose is therefore 4.5g TDS

35. Question 4 • Bella is 20 days old and has been admitted with sepsis (signs of possible meningitis). Prescribe amoxicillin and cefotaxime for her. She weighs 3kg. • Amoxicillin for listerial meningitis, Group B strep, enterococcal endocarditis • neonate 7-21 days 50mg/kg every 8 hours (doubled if meningitis is likely) • correct answer is 300mg TDS • Cefotaxime dose is 25mg/kg every 8 hours for neonate 7-21 days, doubled in severe infection and meningitis 50mg/kg every 8 hours = 150mg TDS

36. C&V Child Health Sepsis guidelines *Dose of Amoxicillin may be increased if suspicion of Listeria meningitis is high.

38. Discharges • Plan 24 hours in advance if possible • Get T T H done asap • Ward pharmacist collects mid morning • Include all regular medicines on the discharge letter as a record for GP • If no meds to be dispensed write “pts own”