The Midland Hotel in Derby was the venue for the 5th annual conference of the Neonatal and Paediatric Pharmacists Group (NPPG) held from November 12 to 14 1999. One hundred and forty pharmacists from Great Britain, Ireland, Norway, New Zealand, Italy, France, Sweden and Oman gathered to participate in workshops, poster sessions and plenary sessions covering a wide range of topics in the field of neonatal and paediatric pharmacy.
New for this conference was a session aimed at new paediatric pharmacists, which took place before the beginning of the main conference. Subjects covered included life stages, developmental pharmacology, kinetics and drug related problems, medication errors, calculations, communicating with patients and reference sources. Thirty delegates from a variety of countries attended the session.
Opening the plenary session PROFESSOR MIKE CULLEN ( (Consultant Pharmacist, Derby), described how pharmacy had progressed over the past twenty years from being a task orientated profession to an emphasis on the patient. Paediatrics was a priority area in healthcare that was often overlooked, and as a result there were too few paediatric pharmacists for the potential roles. However pharmacists should not wait until resources are provided but should grab opportunities as they arise and sort out the resources later.. If pharmacists do not take an active role in patient care they may as well just continue with drug supply. There are lots of roles for paediatric pharmacists as any review of headlines in the Pharmaceutical Journal over the past 18 months makes clear. Among these are:
- Community service pharmacy – this is seen as a mainly adult service, but it also has paediatric needs.
- Health education
- Primary care groups
- Pharmaceutical scientists in paediatric and neonatal medicine development
It is up to pharmacists to become involved in all agenda which involve children.
A recent EEC ruling stated that hospital pharmacy is not a specialisation. A follow on to this is that paediatric pharmacy can be designated a specialism. What now needs to be developed is a training pathway similar to that found in medicine for paediatric specialists.
In the discussion that followed Dr Malcolm Partridge (Chairman, NPPG) noted that the group has picked up on many of theses topics and queried whether it would be better to adopt a European approach to the situation. Professor Cullen said that he felt that, as 40% of hospital pharmacists in Europe are based in the UK, it would be better to concentrate on the UK initially, concentrating on the links already established with the Royal College of paediatrics and Child Health, and then roll out into Europe.
Speaking about current controversies in paediatrics DR RICHARD MORTON (Consultant Paediatrician, Derbyshire Children’s Hospital)) detailed the use of botulinum, melatonin, midazolam, baclofen and methylphenidate in current paediatric practice. Many drugs used in paediatrics are used ‘off label’.
Botulinum toxin is only licensed for a few specific purposes, but has been shown to be effective in weakening spastic muscle in cerebral palsy with 67% of patients treated at Derby obtaining a good outcome. What is not known is whether the drug will maintain it’s efficacy in the long term and , if so, will it prevent muscle contraction. There is also the question of how the NHS will pay for the treatment. Intra-thecal baclofen is another unlicensed, expensive, treatment used in children. Although expensive, at approximately £17,000 per patient over 5 years, Dr Morton argued that the cost savings from such items as reduced orthopaedic surgery requirements, wheelchairs and other care requirements far outweighed this cost, with the benefit of a greatly improved quality of life for the patient.
Sleep disturbance is common in neurologically impaired children, especially if they also have visual impairment. This is a major problem for both the child and carers. The product is cheap but remains unlicensed. Patients need to be assessed and started with trial doses, increasing if necessary. If treatment is successful then the General Practitioner should be encouraged to continue the treatment.
Attention Deficit Hyperactivity Disorder (ADHD) is estimated to affect 5% of children in the USA. In the UK, where stricter diagnosis criteria are used, it is estimated that 1% of children are affected by the disorder. Methylphenidate is the drug treatment of choice but is an example of a product that, even though it is licensed for the treatment of ADHD in children, causes problems when treatment is continued in the community, with many GPs unwilling to continue its prescription. The requirement to take the medicine after meals means that schools often have to be involved in the patient’s treatment, and this an area where pharmacists have an important role to play. In the discussion that followed Mr. STEVE TOMLIN (Guy’s and St Thomas) said that the use of s/r methylphenidate, which is available in the USA, would solve the need for the medication to be given at school, but, because of controlled drug regulations, it is difficult to import. Mrs. MARGARET DOLAN (West Lothian Trust) said that this was an example of seamless care that was very variable throughout the UK. Dr Morton agreed, stating that it was now more difficult to have PCGs pay for treatment than it was under GP Fundholding. Often cost is not the issue, e.g. melatonin, but it is not acceptable to not put care of the patient first. He said that what was needed was a proper informed debate on the treatment.
Opening the second session CATHERINE HALL (Royal Victoria Infirmary) presented the case of drug treatment of a foetus in utero by administration of medication to the mother. A baby with SVT was treated in late pregnancy by administration of amiodarone to the mother. When the baby was born the mother stopped taking the amiodarone and wanted to breast feed. As amiodarone has a long half life there were concerns about the continued transfer of amiodarone into the breast milk. Most cases in the literature concerned breast feeding in mothers who continued to take amiodarone. The decision was made to allow the baby to breast feed with monitoring of thyroid function and amiodarone concentration in the breast milk. The case highlighted how drug treatment in utero could continue to have an effect after birth and cessation of treatment and was an example of how new challenges continue to arise for pharmacists involved in neonatal medicine.
Christine Nye (Jessop Hospital, Sheffield) presented a case of Bartter Syndrome. Features include hypokalaemia, hypocalcaemia, elevated plasma renin and aldosterone, normal BP, increased urinary Potassium and Chloride loss and an inability to concentrate. Treatment involved sodium and potassium supplements, potassium sparing diuretics and ACE inhibitors. Early diagnosis and treatment improves outcome. The case highlighted the need for close collaboration between hospital and community pharmacists when children are transferred into the community on unusual preparations.
Following the launch of Yellow Card reporting by community pharmacists PETER ARLETT (MCA CSM Pharmacovigilance section) presented on the use of medicines ‘off label’ in children and how the Yellow Card scheme can help to obtain safety data on drug use in children. The presence of a licensed product on the market does not preclude the use of an unlicensed medicine, if the clinician feels that the benefit outweighs the risk. However effective safety monitoring systems need to be in place and monitored continuously. A key part of this is the yellow card scheme which is an immediate report on current clinical use and will flag any problems quicker than any other database. Hospital pharmacists are now reporting more serious adverse drug reactions than hospital doctors. This is a role that paediatric pharmacists can develop for ‘off label’ medicine use.
Reporting on the recent launch of Medicines For Children, the national paediatric formulary produced jointly by the Royal College of Paediatrics and Child Health and NPPG, Mr. TONY NUNN (Director of Pharmacy, Alder Hey Children’s Hospital, Liverpool) said that the editorial board was looking towards electronic publication for future editions and that the formulary could only develop if feedback was received by users.
NPPG launched its web site one year ago. Mr. Peter Mulholland (Southern General Hospital, Glasgow) presented details of the site progress and future plans. The site currently consists of a variety of communication and information sources for group members, both within the site and on the wider Internet. Plans for the coming year include the creation of a member interest database to further progress the work already undertaken by special interest groups within NPPG, and the collation and publication of protocols used within paediatric pharmacy across the UK. The site will also become a repository for information on any paediatric pharmacy research work being undertaken by group members.
AMANDA CLARKSON (Academic Division of Child Health, Derbyshire Children’s Hospital) presented a report on a pilot scheme to establish a paediatric regional monitoring service for paediatric Adverse Drug Reactions (ADRs). It was set up in October 1998 to raise awareness and stimulate the reporting of ADRs, and involves 20 hospitals in the Trent region. A modification to the Yellow Card ensures that all reports go to the pilot scheme before onward transmission to the MCA. Preliminary results show a large increase in reporting, with the most common drugs being topical local anaesthetics, anticonvulsants, antibiotics, vaccines and inhaled steroids. The pilot is to run for 3 years.
Neonatal medicine is one of the most challenging areas facing pharmacists and was the subject of two research present presentations.
ROISIN LANNIGAN (Royal Hospital for Sick Children, Glasgow) presented a paper on the evaluation of current neonatal dosage guidelines for gentamicin. A variety of dosing schedules are used throughout the UK and using a prediction model none was found to be entirely satisfactory. Work is being undertaken validating an alternative dosage schedule.
LOUISE GALLARD (Guys and St Thomas) presented a paper on the safety and efficacy of ibuprofen in patent ductus arteriosus. A licensed product is available for this treatment (indomethacin) but is known to have a range of side effects including a decrease in cerebral blood flow, oxygen delivery and blood volume. Ibuprofen injection is available as a named patient import from Germany and a trial of its use was undertaken. Results showed that it appears to be as effective as indomethacin, with fewer side effects. However numbers were small and further data collection is required to substantiate the results.
SATURDAY 13TH NOVEMBER
Workshop Session A
1. ‘An ABC of neonatal intensive care’ – Dr John McIntyre, Senior Lecturer, Academic Division of Child Health, (University of Nottingham), Derbyshire Children’s Hospital
Aims and Objectives
· Understand the achievements and limitations of modern neonatal intensive care
· Appreciate some of the current approaches to caring for the sick newborn infant
· Explore the relevance of pharmacy input on NICU
1. In a lecture the trends in infant mortality and morbidity data were reviewed. The way NICU has contributed to improving the outlook for the sick newborn infant was highlighted. NICU was shown to be a cost-effective use of resources despite the perceived expense. Some of the recent advances in treatment and their impact were discussed
2. In 5 groups the following areas were explored with respect to the role of pharmacy input on NICU:
The use of surfactant and dexamethasone
The use of indomethacin and nitric oxide
The use of aminoglycosides and antibiotics
The use of anti-convulsants and sedatives
The use of cisapride and vitamins
3. After group discussion there was a feedback between groups and lively discussion about the different approaches respective units were adopting to the above issues and the session was drawn to a conclusion.
2. An introduction to neonatal cardiology – Andrea Gill, Principal Pharmacist, Alder Hey Children’s Hospital, Liverpool & Catherine Hall, Directorate Pharmacist of Women’s and Children’s Services, RVI, Newcastle
The approach of the workshop was to look at neonatal cardiology from two sides – a regional neonatal intensive care unit and a regional cardiology surgical unit.
The workshop started with a background to Neonatal Cardiology. This was followed by a brief brainstorming session to list some of the cardiac problems and the drugs which pharmacists would come across in the treatment of these patients.
The group was divided into smaller groups to look at two case studies:
i) A baby on a NICU with RDS developed low BP. Inotropes were required. The baby developed a Patent Ductus Arteriosus (PDA) which was treated with indomethacin. NEC was then suspected and the baby was also investigated for perforation of the gut. The group were asked about PDA and its treatment with indomethacin. What are the problems associated with giving indomethacin? There were several drug-related issues which needed to be considered with this patient. Alternative treatments for PDA were considered.
ii) A baby was transferred from a DGH to the regional cardiology unit for treatment of transposition of the great arteries (TGA). The baby was given a dinoprostone infusion prior to surgery. Following surgery he was treated with dobutamine and enoximone, sedation, netilmicin and teicoplanin. The patient was transferred to a cardiology ward and received oral frusemide and amiloride. The group were asked to consider problems associated with dinoprostone and enoximone. The use of sedation was also discussed. Information for the parents on discharge medication was requested.
There was a short feedback session on the two case studies. The group were given handouts with detailed answers to the case studies.
The group then prepared a Pharmaceutical Care checklist for cardiology patients which pharmacists would need to consider including fluid balance, pharmacokinetics, licensing, PILs, formulation issues, compatibilities and pain and sedation issues.
3. Paediatric Epilepsy – Kate O’Donnell, Senior Paediatric Pharmacist, Derbyshire Children’s Hospital, Derby
A networking session to allow pharmacists providing pharmaceutical care to epileptic patients to discuss current issues with their peers, and clinical problems they may have encountered. The workshop will include looking at new drug developments and what the future holds for this group of patients.
4. Self-medication/Use of PODs in children – Clive Newman, Senior Pharmacist, Janine Falconer and Ali Wright Queen’s Medical Centre, Nottingham
The workshop aimed to give participants a framework to tackle the main issues surrounding self administration of medicines in children. Although based on the workshop leaders experiences at the QMC hospital, Nottingham many issues would be common to any hospital initiating such a scheme. Costings (both capital and drugs) would need to be carefully considered especially as the potential for savings on drugs costs (as seen in adult medical wards) was not large.
Any such project must be multi-disciplinary. Do not attempt such a project without the support of nursing (and medical) colleagues. A robust code of practice is the key to success especially as accountability and roles must be well defined
Participants were then divided into 1 of 3 groups to consider
1 ) Storage and supply of medicines. This tackled issues of where & how to store drugs, the labelling requirements of medicines and effects on the pharmacy department.
2 ) Patient selection and assessment of POD’s. This tackled issues of child/family selection, who assesses the child’s’ medicines and how.
3) Documentation and patient monitoring. This tackled issues of obtaining consent (child and/or parental), information required by families, checks that need to be in place and potential problems from poor communication.
After feedback and discussion from each of the groups the workshop ended with a slide presentation summarising a typical child’s’ admission on a self- administering ward.
5. Metabolic diseases – the practical issues – Annette Adams, Community Liaison Pharmacist, Manchester Children’s Hospital
The workshop started with a short introduction on the general treatment approaches to metabolic diseases. Metabolic diseases occur when there is a disruption to the body’s normal function. This could be because of a missing enzyme, co-factor or defect in transport vehicle, membrane pump or structural element. Treatment is based on the following
· Decrease the load on the affected pathway
· Removing toxic substances
· Blocking the effect of excess substrates
· Replacing the deficient products
These aims can be achieved by dietary and/or drug management.
The workshop then went on to discuss the treatment of hyperammonaemia in the neonatal period, focusing on urea cycle defects. This can often start in a general hospital before transfer to a specialist unit. In urea cycle defects the body is unable to effectively remove ammonia. A build up of ammonia occurs which is very toxic to the body. The main aim of treatment is to remove this toxic substance. By
1. decreasing dietary protein
2. drugs – sodium benzoate, sodium phenylbutyrate, arginine
4. provision of adequate calories to prevent body protein breakdown
The drugs used are unusual and the practical aspects of dilution, administration and the sodium load from the drugs was discussed.
The second half of the workshop looked at a case study of a baby admitted with abnormal PKU results, which was later diagnosed as a disorder or tetrahydrobiopterin synthesis. The aim of the case study was not to look at the disorder in detail but to look at the issues affecting pharmacy, such as
1. how to obtain drugs for these unusual metabolic disorders
2. how to ensure that the drug obtained is suitable to give to a patient
3. formulation issues
Finally the group looked briefly at the options for this baby once discharged from the hospital, with regard to the supply of medication
6. Complementary therapies in children– Jo Barnes MRPharmS – Centre for Pharmacognosy & Phytotherapy, School of Pharmacy, University of London
Complementary medicine (also known as “alternative”, “holistic” and “integrative” medicine; terms are frequently used synonymously) comprises a vast array of treatments; the 4 most common therapies in the UK are acupuncture, manipulation, herbalism and homoeopathy. Herbalism and homoeopathy are the two therapies of most relevance to pharmacy, although there are others that involve the administration of remedies, such as essential oils used in aromatherapy and Bach flower remedies.
Increasing use of complementary medicine
The use of complementary remedies and therapies is increasing. In the UK, a report by the Mintel market research group on retail sales of complementary medicines (defined in its study as licensed herbal medicines, homoeopathic remedies and essential oils) estimated the market for 1996 to be worth £72 million, having increased by more than a third over the previous 5 years.1 Data from nationwide telephone surveys of US adults report a statistically significant increase in the use of alternative therapies during the 12 months preceding the surveys from 34% of the sample in 1990 to 42% in 1997 (p £ 0.001).2
Use of complementary therapies is not limited to adults—several studies have investigated the use of complementary medicine in children for various conditions.3 The prevalence of use varies widely and because of differences in, e.g. methodology, it is not possible to compare across studies. Nevertheless, it is apparent that complementary medicine is used in a considerable proportion of children, particularly those with chronic conditions.
One study, a questionnaire survey (521 questionnaires analysed; response rate = 61%) of parents of children attending outpatient clinics at 6 centres in Bath, reported that 21% of children had used one or more forms of complementary medicine.4 Of these children, 42% were aged between 0 and 4 years, 33% between 5 and 9 years, and 23% between 10 and 15 years. 66% of children had used one therapy, 28% had used two and 6% had used three or more. Homoeopathy (47% of children), aromatherapy (17%) and osteopathy (11%) were the therapies used most commonly; respiratory conditions, e.g. asthma, and dermatological conditions, egg eczema, were among those most commonly treated with complementary therapies. The authors concluded that there was a marked use of complementary medicine in children attending outpatient clinics and suggested that child health professionals should be aware of this and ask about complementary medicine use when taking a child’s medical history
In a study investigating parental attitudes towards complementary medicine use, an anonymous questionnaire was sent to all parents of children on a neonatal/paediatric intensive care unit (ICU) of a university hospital in Switzerland.5 289 questionnaires were returned (52% response rate). 18% of parents reported that they had administered complementary medicine to their child on the ICU; of these, 59% had discussed this with medical or nursing staff, whereas 41% had not. 61% had used one therapy, 31% used two and 6% used three or more. Homoeopathy (55% of respondents), flower remedies (27%), healing stones (16%) and acupressure (10%) were the therapies most commonly administered. Of the non-users, 21% had wanted to use complementary medicine in their child, and 10% of these had discussed with hospital staff.
The use of complementary medicine in children raises several safety issues. Some of these are similar to those that apply to the use of certain conventional drugs in children, such as a lack of data from controlled clinical trials and therefore a lack of data on dosages, efficacy, contraindications, warnings etc. Other issues are unique to complementary medicine. For example, many complementary remedies are unlicensed and their quality, efficacy and safety has not been assessed by the licensing authority. There are also some issues relating to complementary medicine practitioners, for example, some practitioners may advise stopping treatment with conventional drugs or may advise against immunisation.
In summary, complementary medicine is used in a marked proportion of children for a variety of conditions. Use is not always disclosed to healthcare professionals, and professionals may not ask parents/children about their use of complementary therapies. While some remedies/therapies may be helpful in specific conditions, there is a lack of clinical research of the effects of complementary medicine in children. Future research should focus on complementary therapies and remedies that are commonly used in children, on those with established efficacy in adults, and in areas where conventional medicine is insufficient.
1. Anon. Complementary medicines. London: Mintel International Group Ltd, 1997.
2. Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine use in the United States, 1990-1997. Results of a national follow-up survey. JAMA 1998;280:1569-1575
3. Ernst E. Prevalence of complementary/alternative medicine for children: a systematic review. Eur J Pediatr 1999;158:7-11
4. Simpson N, Pearce A, Finlay F et al. The use of complementary medicine in paediatric outpatient clinics. Ambulatory Child Health 1998;3:351-6
5. Moenkhoff M, Baenziger O, Fischer J et al. Parental attitude towards alternative medicine in the paediatric intensive care unit. Eur J Pediatr 1999;158:12-17
Kemper KJ, Cassileth B, Ferris T. Holistic pediatrics: a research agenda. Pediatrics 1999;103(4):902-9
SUNDAY 14TH NOVEMBER
Workshop Session B
1. Aminoglycoside dosing in neonates and children – the NPPG alternatives? – Nigel Gooding, Senior Pharmacist, Leicester Children’s Hospital, Leicester
The aims of this workshop discussion, were to consider what current practice is around the country with respect to gentamicin dosing in neonates, and once daily gentamicin dosing in infants and children, and to see if there was any way that the group to come to a way forward in producing one schedule for gentamicin dosing.
The workshop started with Nigel Gooding (Leicester Royal Infirmary) presenting results of a retrospective audit of neonatal gentamicin levels based on an historical regimen that was used (2.5mg/kg/dose given 24 hourly for neonates <28 weeks gestation, 18 hourly for neonates between 28 – 34 weeks gestation, 12 hourly for neonates >35 weeks gestation, and 8 hourly for term babies over 7 day). This showed that 77% of results showed an acceptable trough level, only 30% showed an acceptable peak level, and only 22% of neonates had an acceptable trough and peak level. Following on from this 64% of gentamicin doses needed one change before correct levels were achieved, 11% of neonates needed 2 changes made to their gentamicin dose, and 3% needed 3 changes to their dose before achieving correct levels.
After a literature search and discussion with paediatric pharmacists at other centres a new regime was chosen based on the gentamicin schedule in the ‘Medicine’s for Children’ formulary, with a slight adjustment. This new regimen was: –
<28 weeks gestation 4mg/kg every 36 hours
28-31 weeks gestation 4mg/kg every 24 hours
32 – 38 weeks gestation 4mg/kg every 18 hours
> 38 weeks gestation 3.5mg/kg every 24 hours
Originally the actual gentamicin schedule in the ‘Medicine’s for Children’ formulary was used but we achieved very high trough levels in the >38 week group, and therefore had to adjust the schedule.
Using this new regimen 80% of doses had an acceptable trough, 61% of doses had an acceptable peak, and 49% of doses had both an acceptable trough & peak level. In addition only 47% of doses needed one change, and 6% needed 2 changes to achieve correct levels.
Sharon Conroy (Derby Children’s Hospital) then presented similar work, with similar results based on gentamicin levels in neonates at Derby. Sharon’s new schedule was: –
Give all neonates a loading dose of 4mg/kg then if: –
< 28 weeks gestation 3mg/kg every 36 hours*
28 – 31 weeks gestation 3mg/kg every 24 hours
32 – 35 weeks gestation 3mg/kg every 18 hours
term > 36 weeks gestation 4mg/kg every 24 hours*
* take levels after 2nd dose instead of usual 3rd dose.
However results from using this schedule in certain gestational age groups were still not much improved. Sharon is now considering another schedule.
Neil Caldwell (Wirral Hospital NHS Trust) then presented results from using a completely different schedule for netilmicin in neonates. This schedule gives all neonates a loading dose of 7mg/kg. Netilmicin concentrations were then measured at 2 and 8 hours post dose. This allows elimination rate constant, elimination half-life, and volume of distribution to be calculated. From these calculations a dosing schedule can then be worked out to achieve a peak concentration of 8-12mg/L, and trough of <2mg/L.
This was a completely different concept to what everyone else in the group was doing, and although being impressed by the data shown, several members of the workshop was still unsure if such a schedule would work in their hospitals.
The final discussion regarded once daily gentamicin. Nigel Gooding presented information about the use of once daily dosing at Leicester. A dose of 7mg/kg once a day is given over 20-30 minutes and a level is taken between 6-12 hours post dose. However there is no specific paediatric nomogram for once daily gentamicin in children, and an adult nomogram was used to interpret data. This regimen was initially used in the febrile neutropenic population, but had then been extended to the rest of the Children’s Hospital. Nobody else in the workshop group was using a once daily regimen, but several issues were raised about the timings of the samples, and whether a peak level should be taken to check whether a dose had been received.
Other issues that were discussed in the workshop were when levels were being taken and what ranges everyone were using, again this varied from centre to centre.
Where do we go from here?
To conclude the session. Several members of the group said they also had problems with their current gentamicin schedules, and were keen to return to their hospitals to audit their practice. In terms of distributing this information, members of the group were keen to have a page on the NPPG website to discuss results of their audits, and current practice, so that information could be passed on to other interested pharmacists.
2. Paediatric Formulations- Tony Nunn (Alder Hey Children’s Hospital, Liverpool) and André Rieutord (Hopital Robert Debr, Paris)
The objective of this workshop was to share information on the problems encountered in formulating oral medicines for children and to examine ways of solving them.
Data was presented on independent surveys of practice in UK and France, methods of dealing with extemporaneous dispensing in the two countries were examined and preliminary results of a European survey of practice were discussed. It was obvious that extemporaneous dispensing is widespread even when ‘specials’ manufacture or import of internationally licensed medicines were practical alternatives. Stability data was available for only 50% of the formulations used. In the UK the majority of oral formulations were liquids whilst in France they were capsules.
The group identified the following as major problems :-
Quality assurance of ingredients
Duplication of effort
Interface problems – communication, patient convenience, medication error potential
Information on the use of injections orally
The group exchanged information on commonly prepared extemporaneous oral liquid products and reflected the findings of the national survey. The following were amongst those most commonly prepared :-
The workshop agreed that ways must be found to co-operate, to produce stability data, to use licensed imports or ‘specials’ where appropriate and to investigate the approach used in other countries. There was particular interest in using the vehicles Ora-Plus and Ora-Sweet (Paddock Laboratories, USA) with a range of active ingredients for which much stability information is made available by the manufacturer and published in American Journal of Health-System Pharmacists.
3. Pharmaceutical Care of the Neonatal/Paediatric Intensive Care Patient – Hussain Mulla, Directorate Pharmacist, Anaesthetics and Critical Care, Glenfield Hospital, Leicester
The session began with an overview on Neonatal Respiratory Distress Syndrome (RDS). The presentation covered pathophysiology, management and future strategies. Within management, the role of extra corporeal membrane oxygenation (ECMO), where conventional therapies have failed was discussed. The discussion on future strategies included liquid ventilation and superoxide dismutase.
The second phase of the session involved a RDS case study. The case concerned a preterm neonate with RDS, initially managed conventionally with surfactant, SIMV and then HFOJ with nitric oxide. Unfortunately, the child continued to deteriorate and was therefore referred to an ECMO centre. Once stabilised on ECMO, the child was then weaned off after 5 days. The audience were split into small groups to answer questions based around the case. Issues covered included differences between natural and synthetic surfactants, pulmonary vasodilators, sedatives, stress ulcer prophylaxis, dosing in continuous veno-venous haemofiltration, and the role of postnatal dexamethasone in RDS. One member from each group presented the answers generating lively discussion and debate.
Finally, the session was rounded off by a short slide presentation on ECMO at Glenfield Hospital NHS Trust. The slides covered the history of ECMO as well as principles and practice.
4. Neonatal TPN – Current Issues –
A popular workshop back by request! This was a networking session to allow pharmacists providing neonatal TPN services to discuss current issues with their peers. Both clinical and formulation issues were discussed and the practical implications of the latest research were explored.
5. Evaluating new treatments for children – Antonio Addis, Laboratory for Mother and Child Health, Milan
This workshop examined the management of the seemingly never ending introduction of new drugs onto the market. Which drugs should we choose for our patients? What are the issues to be taken into account? Drug selection, drug surveillance and pharmaco-economic considerations were discussed.
6. An Introduction to Paediatric Renal Disease – Desiree Kunac, Lecturer in Clinical Pharmacy, University of Otago & Clinical Pharmacist, Dunedin Hospital, New Zealand
This session provided an introduction to the pharmaceutical management of renal disease in children. The objectives of the workshop were to enable participants to
· Gain an understanding of common conditions that may cause renal impairment in children
· Identify and target those children with renal impairment
· Assess renal function in a child
· Make appropriate drug therapy recommendations
· Monitor continued therapy
A brief presentation covered the background to the subject including kidney development and function, methods of assessing renal function in children and revision of the common paediatric conditions such as acute and chronic renal failure, nephrotic syndrome and haemolytic uraemic syndrome.
Participants then broke up into smaller groups to discuss clinical case scenarios and in particular the role of the pharmacist. Within the working groups participants were able to compare their own practice with others. Differences arose in methods of estimating renal function, from eye-balling serial creatinine results to calculations using the serum creatinine. The majority agreed that the following formula was most useful:
Estimated creatinine clearance (ml/min/1.73m2) = 40 x height (cm) / Serum creatinine (micromol/L)
The need for a useful guide for adjusting drug doses for children with renal impairment was highlighted. Information on references in use were exchanged and it was noted that the new release of the ‘Medicines for Children’ book appeared to address this issue – participants looked forward to obtaining a copy.POSTER PRESENTERS
Antonio ADDIS1, Peter MULHOLLAND2, Hedvig NORDENG3, 1) Laboratory for Mother and Child Health, Milan 2) Southern General Hospital, Glasgow 3) Department of Pharmacotherapeutics, University of Oslo, Use of information sources about drugs in pregnancy and breastfeeding in a cross European group of pharmacists
Sara BARROW, Royal Hampshire County Hospital, Winchester, Development of a pharmacy Centralised Intravenous Additive Service to provide intravenous drug therapy for paediatric outpatients
Kathryn BETHUNE, Great Ormond Street Hospital for Children, London, Investigation of particulate contamination in paediatric parenteral nutrition in a clinical setting
Kathryn BETHUNE, Great Ormond Street Hospital for Children, London, Review of the use of parenteral nutrition in a specialist paediatric hospital 1996-98
Amanda COOPER, Poole Hospital, Poole, Development of a prescribing document for use by advanced neonatal nurse practitioners on NICU
Helen CUNLIFFE, St James’s University Hospital, Leeds, Retrospective review of once daily intravenous tobramycin in paediatric cystic fibrosis patients
Andy FOX, St. Mary’s Hospital, Portsmouth, An investigation of the teaching of paediatric pharmacy in the undergraduate syllabus in the UK
Mark HARRIES, University College Hospital, London, Neonatal and paediatric dose calculation by pharmacists – follow on from last year’s winning poster
Quality improvement – Service development – Pharmacist Transcription of Paediatric Surgical day case TTAs from Protocols
Author Penny Fletcher BSc, MSc, MRPharmS Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH
· Long waiting times for discharge medicines (TTAs) for day case elective surgical patients.
· Resulting in delays to discharge.
· TTAs would arrive in pharmacy over the lunch hour, marked urgent.
· No clinical check of prescriptions by the paediatric pharmacist.
· Most patients required analgesics and occasionally antibiotics.
Using the hospital computerised prescribing system it was possible to identify exactly when prescribing had taken place. TTAs were often written after the patient was ready to go home. After discussions of how to resolve this it was decided to pilot pharmacist transcription of TTAs from protocols.
Development of protocols
Protocols were written jointly by the surgeons, the Paediatric consultant in charge of the wards and the paediatric pharmacist. These consisted of a list of surgical operations and the drugs and doses that are needed on discharge. After discussion with nursing staff they were approved and signed by the relevant consultants.
The paediatric pharmacist receives the day case admissions list each week. On the morning of surgery the pharmacist completes a pharmaceutical care information sheet by discussion with the parent and child. This includes information on the procedure, age and weight, drug history, relevant medical history and allergies, drugs to be prescribed (and doses), and whether liquids or tablets are required.
The paediatric pharmacist transcribes the TTAs onto the computerised prescribing system and a doctor signs the printed discharge letter. This is then faxed or taken to the dispensary.
The medication is delivered to the ward on the existing porter’s rounds, saving nursing time.
Results of pilot study
10 TTAs written by doctors was compared with 10 TTAs transcribed by the pharmacist.
Mean duration of delay to discharge
Written by doctors 2 hours (20 mins – 3 hours)
Transcribed by Pharmacist 0 hours
i.e. All TTAs ready at time of discharge
Mean time TTAs arrived in Pharmacy
Written by doctors 1pm (12.30pm – 2pm)
Transcribed by Pharmacist 10.30am (10am – 11.30am)
i.e. TTAs dispensed while dispensary is fully staffed.
Other outcomes for medical and nursing staff, parents and pharmacist.
Uniformity of TTAs, as dictated by consultant, release of junior doctors’ time
Discharge medicines on ward before the child is ready to go home, i.e. no delays.
TTAs delivered by porters
Increased counselling of parents / patients
Extended role of pharmacist – increased job satisfaction
Louise GALLARD, Steve TOMLIN, Guy’s Hospital, London, Efficacy and safety of ibuprofen in patent ductus arteriosus
John KRISTIANSEN, Starship Children’s Hospital, Auckland, New Zealand, An audit of Ceftriaxone/Cefotaxime use in ‘seen not admitted’ patients at Starship Children’s Hospital
Steve TOMLIN, Guy’s Hospital, London, A survey of topical anaesthesia in paediatric practice
EAHP March 99 Paediatric Symposium abstracts
Chairman: Tony Nunn
PARENTERAL NUTRITION: PREVENTING ERRORS
B. Nouaille-Degorce, JB Rey, F Brion
Hôpital Robert Debre-AP-HP-Service Pharmacie et laboratoire de Toxico-Pharmacologie- Paris – France
Total parenteral solutions manufacturing requires to work in aseptic conditions with the right solutions at the right dose for the right patient. Hospital pharmacists are therefore in charge of this function. This includes :
1- compounding technique validation including software validation, sterility validation and personnel validation
2- prescription and final product testing including electrolytes and osmolality measurements, stability controls, sterility testing and labels and dispensing control
3- control of surrounding area, surfaces and supplies disinfection programs associated to environment testing and technicians hygiene.
All these steps are discussed and examples from experiences given.
This points out that standard operation procedures must be written, understood, followed and staff skills assessed to keep pharmaceutical assurance quality.
An example of the use of new technology to facilitate cross European pharmaceutical collaboration in the field of drugs in pregnancy and breast feeding
Peter Mulholland (Pharmacy Dept., Southern General Hospital, Glasgow, United Kingdom)
Background: The growth of new technology and the expansion of the Internet, opens up new avenues for pharmacists working in specialised areas to liase with like minded colleagues throughout the world. The proliferation of newsgroups on the Internet is an example of how this technology can be used in an unstructured and informal manner. Anyone can subscribe to a newsgroup and the content is totally unregulated. A more formal arrangement is offered by companies such as mailbase, a United Kingdom based higher education funded group. Newsgroups can be set up through mailbase – an example being child health – and work in a similar manner to the unregulated groups i.e. anyone can join a group and participate in information exchange. The main difference is that mailbase will remove any subscribers abusing the system. What I would like to detail is a third method which has come about as a result of discussions at the recent ESCP conference on Mother and Child Health held in Hungary.
Methods: A workshop on Drug Information in Pregnancy and Breast Feeding at the conference identified the need for more collaboration across Europe between pharmacists involved in this field. Delegates attending the workshop have proposed the formation of an informal group of pharmacists who are interested in this field and are willing to collaborate and share information. Examples of areas of interest would include:
· Information provision on rational and optimal drug use in pregnancy e.g. folic acid, anti-epileptics, antibiotics, for pregnant women and health care workers. Information for use of medicines during pregnancy is presented in different ways in different countries. A standardised format for similar future information campaigns, which could then be adapted to local needs, would be of use.
· Information provision on rational drug use in breast feeding. Again different advice is given to women depending on the country they live in and there is often unfounded concern about drug transfer into breast milk because of manufacturers labelling. In many cases breast feeding is stopped unnecessarily. The intention of this group is to undertake a large pan European study.
· Disease management during pregnancy e.g. nausea and vomiting
· Studying women’s attitudes towards medicines and medicine compliance during pregnancy in Europe – some unpublished studies have been undertaken showing that compliance during pregnancy is poor but the intention of the group is to undertake a larger pan European study
We believe non-compliance during pregnancy is partly due to fear of harming the unborn child. This anxiety can cause more harm than the drugs themselves. When these women choose to not take their medication it is because they believe they are protecting the child. In many cases (infections) they may be doing the opposite.
A database of interested pharmacists has been compiled, who can then circulate information or requests among the group. It also opens up the possibility of cross Europe collaboration on research projects. The database of pharmacists is maintained in Milan and all members are circulated with the details and Email addresses. This enables members to contact the group as a whole or just to contact individual members. The initial work of the group was to compare by a questionnaire about the kind of reference sources e.g. books, databases etc being used to give advice on this topic. This has been completed and the results circulated. The next step will be to run questions testing the group on their response to a controversial question e.g. the treatment of nausea during pregnancy or the treatment of depression during breastfeeding. Also to investigate the difference in information given to a woman before a drug is taken by a pregnant woman, to those who have already been exposed to the drug in pregnancy, to the information given to a woman who wants to know if she can take the drug whilst breast feeding
Conclusion: The world is shrinking and by embracing the opportunities afforded by new technology pharmacists working in specialised therapeutic areas can collaborate with colleagues. At present it can be difficult to obtain sufficient patients when carrying out studies to make the study statistically meaningful. The creation of this group should help to alleviate this problem by encompassing a larger patient base. This format of this group can act as an example for pharmacists in other specialised field to promote communication and research on a larger scale than that afforded by current paper based methods.
For further details, or if you are interested in joining the group please contact firstname.lastname@example.org
Paediatric Drug Information and Cochrane Collaboration
Antonio Addis, Piero Impicciatore, Maurizio Bonati, Regional Drug Information Centre (C.R.I.F), Laboratory for Mother and Child Health, Istituto di Ricerche Farmacologiche “Mario Negri” Milano, Italy
The availability of evidence based information is a limiting factor for rational drug prescribing. This is even more true in area, such as drug use in children, where ethical and methodological problems, make more difficult to produce new data. In this context, the reliability of the sources of information become crucial.
Understanding the different types of primary and secondary sources of information that are available is important to knowing their reliability. Examples on hierarchy of evidence and bias associated with different sources of information regarding drug use in children, will be illustrated.
Since in paediatric practice, drug prescribing often does not comply with an evidence based medicine approach, the need for systematic reviews to efficiently integrate valid information and provide a basis for rational decision making become more and more important.
Systematic reviews establish where the effects of healthcare are consistent and research results can be applied across populations, settings, and differences in treatment (e.g. dose); and where effects may vary significantly. The use of explicit, systematic methods in reviews limits bias and reduces random errors, thus providing more reliable results upon which to draw conclusions and make decisions. Meta-analysis, the use of statistical methods to summarise the results of independent studies, can provide more precise estimates of the effects of healthcare than those derived from the individual studies included in a review. In this context, Cochrane library may be an excellent resource for information of data, establishing effectiveness and efficacy drug treatment on children. The Cochrane library offers an updated collection of systematic reviews and other information put together by Cochrane Collaboration, the NHS centre for Reviews and Dissemination and others. The Cochrane Collaboration is an international organisation dedicated to the systematic collection of research information on the effects of health care interventions. The Cochrane Library may be seen just as a new and useful source of information, but it is also particularly helpful when used as a tool for evidence based approach to rationalising drug use in children.
Posters presented at the conference covered a wide range of paediatric topics including information for families, drug administration guides for medics and nurses, use of growth hormone, neonatal parenteral nutrition and drug use in pregnancy. MARK HARRIES and colleagues (University College London Hospitals) presented a poster on the competence of pharmacists in calculating neonatal and paediatric drug doses. Papers published in the past have concentrated on the competence of nurses and doctors in calculating doses and it is assumed that pharmacists are particularly good in this task and are often regarded as a ‘safety net’ by fellow health professionals. Thirty pharmacists completed a written test involving twelve drug calculations, no warning having been given to the participants. Only five pharmacists answered all the questions correctly and 5 failed with a score of less than 6 marks, calculations involving doses expressed as dose/kg/unit time caused the greatest difficulty. The authors concluded that pharmacists providing services to neonatal and paediatric should have their computational competency assessed before being allowed to practice in that area or check prescriptions.
Delegates participated in a busy series of workshops covering many aspects of neonatal and paediatric pharmaceutical care. A workshop on palliative care discussed the benefits of developing an initial care plan covering all potential symptoms a child may experience during palliative care and the advantages of supplying all the necessary drugs and doses in cases of situations arising outside normal hours. Examples of how the care plans are prepared were shown.
The use of fentanyl patches was discussed at length with particular emphasis on the problem high doses cause for children. Options to reduce the risk of adverse effects could include
Medication errors are particularly critical in paediatric practice and participants agreed that they happen and that it is critical to analyse why and what we can do to prevent them. They can be sub-divided into prescribing, dispensing and administration problems, e.g. calculation & transcription errors, dispensing, e.g. incorrect extemporaneous dispensing and administration problems e.g. given by the wrong route such as oral drugs given IV. Examples were given of a prospective new product risk assessment system together with reviews of dispensing and manufacturing processes, which now include a 3rd check for extemporaneous products, minimum dispensing times, checklists and checking tutorials.
List of Workshops
Paediatric and neonatal pharmacy continues to present new challenges to the pharmaceutical profession and participants internationally are faced with similar problems. Once again the NPPG annual conference has stimulated pharmacists involved in the field to continue in their efforts to raise the profile of this patient population