A prospective, observational audit of fluid administration in March and April 2012. Data was collected on fluid currently being administered only. Resuscitation fluids and replacement fluid for drain/stoma losses were excluded. Those patients who had complex fluid requirements (diabetic ketoacidosis, metabolic, congenital hyperinsulinaemia and patients with known pathological electrolyte disturbances) were also excluded as they were managed according to different fluid guidelines.

59 patients received intravenous fluid in the study period. Mean age 3.75 years (range 1 month–17 years) 65% of patients were fluid restricted to 70% of normal maintenance, while the remaining 35% received up to 110% of normal maintenance.

92% of patients were administered Plasmalyte148–5% glucose, or plain Plasmalyte148. Four patients received 0.45% sodium chloride with 5% glucose, and one patient received 0.9% sodium chloride. 17 patients on Plasmalyte148 (30%) had potassium chloride added to their fluids to the maximum 20 mmol/l allowed. The mean trigger potassium level for intervention was 3.3 mmol/l (range 2.5–4.4). Mean post addition potassium values were 3.7 mmol/l (range 2.4–4.4) eight patients were on drug therapy that predisposed them to hypokalaemia.

During the study period, there were 18 parenteral potassium infusions in eight patients. 45% were potassium acid phosphate for hypophosphataemia, and 55% were to correct hypokalaemia. For hypokalaemia the mean trigger level for intervention was 2.8 mmol/l (range 1.9–3.4).

Concentrated potassium is added to 31% of administered bags of Plasmalyte. There is evidence of habitual prescribing of fluid with potassium. 5/17 patients with potassium in Plasmalyte had potassium levels >3.5 mmol/l prior to addition. Excluding these five cases, the incidence of addition is 22%. This is in a population pre-disposed to electrolyte derangements.

This presents a challenge in rolling out balanced crystalloids into general paediatric practice as the use of concentrated potassium outside of critical care areas is usually restricted.

The number of parenteral potassium corrections is surprisingly low. Further study should be undertaken to evaluate the impact of balanced solutions on potassium-homeostasis.

A data collection form was used to determine if patients visiting AED between 15 and 28 November 2010 were prescribed an appropriate regimen of antibiotics. The Trust antibiotic guidelines were used as the audit standard. Prescriptions were included for analysis if an antibiotic was prescribed. Patient details recorded included: initials, age, clerking in time, antibiotic prescribed, route of administration, duration of therapy, clinical indication, and allergy status. Prescriptions were excluded if the name of antibiotic was missing from patient records, or if the indication being treated was not in the Trust guidelines. Patients not receiving an antibiotic were also excluded.

2092 patients visited AED between 15 and 28 November 2010 of which 287 were given a prescription for an antibiotic. eight prescriptions did not have the name of the antibiotic recorded, and 20 were for clinical indications not listed in Trust guidance so were excluded from the study. Therefore, 259 prescriptions were eligible for analysis purposes of which 27 (approx 10%) were deemed non-compliant with Trust policy.

The majority of non-compliance occurred out-of-hours when the pre-printed prescription was not in use: 7/146 antibiotic prescriptions between 9:00 h and 17:00 h were non-compliant compared to 20/132 out-of-hours.

The recently introduced antibiotic specific prescription proforma helped prescribers in AED achieve 90% compliance with the Trust antimicrobial guidelines. The majority of prescriptions that were not compliant with guidelines had been prescribed out-of-hours, when the prescription was not in use.

Nine prescriptions were for upper respiratory tract infections which are usually viral and antibiotics have not been shown to improve outcomes.¹ This suggests that antibiotics are possibly being overused for this indication.

In conclusion, AED prescribers should be made aware of the Trust prescribing guidance for antimicrobials and use of the pre-printed AED prescription should be encouraged out-of-hours as a prescribing tool to encourage the prudent prescribing of antibiotics.

To establish whether paediatric PN regimens were correctly documented in medical notes, prescribed on electronic drug chart, endorsed on insert for notes (a written confirmation of the bag's constituents) and administered as per electronic prescription.

1. 100% of PN regimens (amount to be administered and number of hours of infusion) are documented daily in the patient's notes, as discussed at ward round.

2. 100% of PN regimens are clinically appropriate for the patient each day.

3. 100% of electronic PN prescriptions have the correct date, infusion volume, infusion rate and number of hours of infusion.

4. 100% of PN insert for notes are endorsed with amount to be administered, number of hours of infusion and signed by prescriber.

5. 100% of infusion pumps are set to run at the correct rate as per electronic prescription.

Data was collected prospectively for 5 weeks. All paediatric in-patients on PN were included. On weekdays, patient medical notes were checked for documentation of regimens. Each weekday morning, PN infusion pump rates were checked. Each weekday afternoon, electronic prescriptions were screened, prior to administration. PN for the weekend was prescribed and screened in advance on Friday. PN insert for notes were checked for endorsement and prescriber's signature.

There were 10 patients in total, with 3–7 paediatric in-patients on PN at any one time. There were 159 electronic prescriptions and 154 inserts for notes. Patient medical notes were checked for documentation 125 times. Infusion pumps were checked 108 times. All prescribed PN regimens were clinically appropriate for the patients each day (standard 2). All infusion pumps were set to run at the correct rate by nursing staff (standard 5). PN regimens were fully documented in patient notes only 42% (53/125) of the time (standard 1). Only 68% (105/154) of insert for notes were endorsed and signed by the prescribing doctor (standard 4). 18% (29/159) of electronic prescriptions were prescribed incorrectly (standard 3). 28 incorrect prescriptions were picked up by the pharmacist and amended prior to administration.

The audit demonstrated that documentation of PN regimens in medical notes and endorsement of PN insert for notes by prescribers was poor and needs to be improved. There were 29 electronic prescribing errors, of which 97% (28/29) were corrected by the pharmacist prior to administration. This audit highlighted that formal training for doctors new to electronic PN prescribing is required. A re-audit could be carried out after implementation of this. An electronic prescribing guideline is now available. The results have been presented at the paediatric clinical governance and gastroenterology educational meetings.

Patients who had been dispensed omeprazole 10 mg/5 ml from January to June 2012 were identified using the electronic pharmacy patient medical records system (Ascribe) and any magnesium levels available for these patients using the electronic paediatric laboratory medicine system (ICE). Data was also collected for the use, if any, of magnesium supplements in that time for these patients. A magnesium reference range of 0.6–1.0 mmol/l was used in this analysis. The data was analysed using Microsoft Excel 2007.

From the data analysed so far from a possible 234 patients, the average dose of omeprazole prescribed was 20 mg once a day. The average age of these patients was 12.75 years and 25% of these patients started on a different oral formulation before being transferred on to the 10 mg/5 ml suspension. 50% of patients did not have a magnesium level measured. Just over 17% had a low magnesium level (range=0.49–058 mmol/l) and none were on magnesium supplements. About 8% patients had high magnesium level and subsequently they were on a magnesium supplement in that 6 month period.

The MHRA report published in April 2012 highlights the need to assess for hypomagnesaemia in patients using a PPI especially following long term use. This study highlights that a trend in a paediatric population for hypomagnesaemia may also be seen but only 50% of patients assessed have had their magnesium levels measures which suggests that prescribers do not monitor magnesium levels for these patients.

Further study will be needed and the data should be presented to paediatric prescribers highlighting the extent of hypomagnesaemia in this group of patients. We should bear in mind the clinical risk that this may lead to such as other electrolyte imbalances² and Torsade de pointes² if not monitored.

To facilitate the prompt discharge of paediatric patients TTA pre-packs are dispensed by nurses from the wards for medicines prescribed on electronic TTAs. As paediatric dosing is complex and nurses do not have the same training as pharmacy staff to screen and dispense prescriptions, a validation programme was designed to train and accredit nursing staff. This consists of flow charts and monographs to screen, dispense and check prescribed medicines as well as recording patient details and the dispensed items. To restrict the scope of medicines supplied a limited list of TTA pre-packed medicines are stocked on wards. TTA pre-packs are chosen depending on the speciality of the ward and the focus is on high volume drugs.

The programme consists of two parts:

Three paediatric wards have now undertaken the training and use the validation programme with a further two wards half way through training. The short stay surgical and acute short stay medical unit ward finds the system very useful as it significantly reduces the waiting time for medicines prescribed to take home. There is increased confidence by nurses in dispensing these medicines as well as they have an accreditation system and drug monographs to use. The audit trail for any dispensed item is also available for analysing information.

The use of pre-packs has also reduced pharmacy workload by way of fewer bleeps for validation and volume of work going through dispensary for commonly prescribed drugs. This has freed up time for more complicated prescriptions and makes better use of specialist pharmacist time.

Implementation of this programme allows for the safe dispensing and checking of prescribed medicines on TTAs. This facilitates prompt discharges of patients thus reducing bed occupancy.

Over a 4 week period (January to February 2012) caregivers of children aged 6 months to 8 years attending the daycase surgery ward of a UK children's hospital were approached to participate in this study. Those who agreed to participate were randomised to be interviewed about paracetamol or ibuprofen by tossing a coin. They were provided with the appropriate GSL pack of analgesic suspension, asked 14 questions and then requested to demonstrate the dose of suspension they would measure for their child. Recommendations based on the findings were then shared with nursing staff who routinely provide GSL packs to caregivers following day-case surgery.

110 caregivers were approached to participate in the study. 73 agreed and were randomised to be interviewed about paracetamol (41) or ibuprofen (32). One caregiver randomised to answer questions about ibuprofen was excluded due to a contraindication to the use of ibuprofen in their child.

Eleven (15.1%) caregivers were unable to correctly identify the appropriate dose of paracetamol or ibuprofen for their child and 12 (16.4%) suggested an incorrect interval between doses. Once the appropriate dose was established, 67 (91.8%) were able to accurately measure the correct amount using the medicine spoon provided with the pack.

Caregivers were asked when they would give the next dose if their child received a dose at 9:00 h. 12 (16.4%) were not able to identify the right time with answers ranging between 2–8 h following the initial dose.

When caregivers were asked about what action they would take if their child experienced pain 2 h after giving a dose of analgesic, 10 (13.7%) stated they would give another dose immediately, 35 (47.9%) said they would wait for 4 h and 28 (38.4%) stated they would give an alternative analgesic.

This study has shown that although the majority of caregivers understand the dosing instructions included in GSL packs of Paracetamol and Ibuprofen suspension, at least 1 in 8 caregivers are not able to interpret the information provided in order to use these products optimally for their children. This study did not evaluate whether patient information for different brands of analgesics was easier to use but the need for understandable information about simple analgesics is vitally important to ensure these drugs are used safely and effectively in children.

To measure the concentration of sodium and potassium in ward prepared infusions and compare with the prescription.

Neonatal pharmacists across 12 units were asked to send used bags of glucose and electrolyte solution to Wessex Laboratories. Details of the infusion were sent to the investigator. The laboratory measured the concentration of electrolytes in each bag using atomic absorption spectrophotometry (Perkin-Elmer AA400). The results from the analysis were then compared with the expected value according to the prescription.

A total of 45 tests were carried out from 27 bags from 7 centres, 27 (60%) sodium and 18 (40%) potassium. The mean variation between ordered and measured electrolyte was +2.4% (95% CI –2.8 to +7.6%). The measured concentration was within the acceptable limits of 90–110% in 38 (84%) tests. Deviation outside these limits were seen in 7 (16%) tests (four sodium and three potassium). These tests were all taken from solutions in burettes rather than bags.

We found that 16% (7) of the tests deviated by more than 10% either above or below the prescribed concentration. To the authors knowledge this is the first study of the variability in concentration of this type of infusion although other studies have shown variable results.^2–4 Where tests were outside the limits no harm resulted from these discrepancies the use of the burette system is under review.

Pharmacists should be aware that errors can occur in the preparation of these infusions and to take this into account when assessing the patient.

Consideration should be given to the development of stock bags in a similar way to parenteral nutrition.

Consideration should be given to simplify both the prescribing and preparation process with the use of proformas.

Further work to test more samples and other drugs is planned.

A prospective cohort study in children aged 0–18 years, admitted to the medical ward, paediatric intensive care unit (PICU), and neonatal intensive care unit during a three-month period at a paediatric hospital in the UK. Patients' charts, medical records and laboratory data were reviewed daily to identify DRPs; their preventability and severity were assessed. Logistic regression was used to analyse the potential risk factors associated with DRP incidence.

373 children (median age 1.4 years, Interquartile range 3 months–7 years, 59.5% male) were included. 147 patients suffered from 220 DRPs and the overall DRP incidence was 39.4% (95% CI 34.4 to 44.6). Incidence was highest in PICU 60.0 (95% CI 45.2 to 73.6). Dosing problems were the most frequently reported DRPs (n=76, 34.5%). 67.7% of DRP (n=149) cases were preventable; 77.7% (n=171) of DRPs were assessed as minor; 22.3% (n=49) as moderate. Morphine and salbutamol were most frequently involved in DRPs (7.7% n=17/220, 6.4% n=14/220, respectively). Number of prescriptions (≥5) and presence of disease of respiratory system were strong predictors for DRPs occurrence in children (OR 2.3, 95% CI 1.4 to 3.6; OR 2.3, 95% CI 1.1 to 5.0, respectively; p<0.05).

DRPs were common in the hospitalised children in this study; the most frequent were dosing problems; the majority of them were preventable. Polypharmacy and presence of respiratory system diseases were strong predictors of DRPs. The high percentage of preventable DRPs emphasises the importance of providing more training to healthcare professionals in the prescribing and use of medicines in children to minimise the risk of DRPs.

To identify the type of discrepancies between hospital discharge prescription and the patient's medicines after their first GP prescription.

Over a 3 month period (March–June 2012) across two London NHS hospital sites, parents of children on long term medications aged 18 years and under, were approached and consented prior to discharge from the ward. The patients were followed up 21 days after discharge by telephone call or home visit depending on their preference. The parent was asked if they had contacted their GP for further medications during the follow up, and if not the follow up was rescheduled. The parents were interviewed to find out if there were any discrepancies that occurred post discharge by comparing the patient's hospital discharge letter and medication at follow up. All this information was captured on a data collection form.

Eighty-eight patients were consented and 60 patients (68%; 60/88) were followed up by telephone call 21 days post discharge. A total of 317 medications were ordered at discharge among the 60 patients. Of the 60 that were followed up, nine were lost to follow up, one died post discharge, one was excluded from the study, and 11 had not contacted the GP and were to be followed up at a later date. Of the 38 patients who were followed up, 254 medications were ordered. Of the 38 patients there were 12 (32%) patients who had discrepancies that occurred between the discharge letter and GP, 19 (50%) had no issues, and seven (18%) mentioned issues to do with post discharge that were not discrepancies. Of the 12 patients who had at least one medication discrepancy (total 34 medications, range 1–7 discrepancies per patient), six patients had GP discrepancies, four had discrepancies resulting from a hospital outpatient appointment, one related to the discharge letter order and one was a complex discrepancy. An example: a patient was discharged on amiodarone liquid 16.5 mg daily as opposed to 65 mg daily of amiodarone from the GP. Upon interview the parent used volume units to communicate dose as opposed to the actual dose itself and the strengths of liquid had changed.

The preliminary results from the study have shown that discrepancies due to several causes occur when paediatric patients leave hospital.

A prospective study of general surgery procedures was undertaken over an 8-week period. Patient's case notes, operative sheets and drug charts were reviewed and data collected on whether antibiotics were prescribed, choice of antibiotic, dose, duration, and switch to oral therapy. Data was analysed and tabulated in Microsoft Excel.

59 patients were included in the audit. In 24 cases, the patient did not receive prophylaxis. 11 of these cases (46%) should have received prophylaxis according to the Trust's guideline.

Fourty-two (49%) of the prescribed doses of antibiotics were not in accordance with doses recommended in the BNFc or the Trust care pathways, and the majority of these doses were lower doses than recommended.

For those patients prescribed antibiotics, duration was documented in 13(62%) case notes and on 5(24%) drug charts. In 8(38%) cases the prescribed duration was in accordance with the Trust's guideline.

None of the 10 cases that lasted >3 h received a second dose of antibiotic during surgery.

There was one case with a documented meticillin-resistant staphylococcus aureus (MRSA) positive status that did not have cefuroxime changed to teicoplanin and gentamicin as per the Trust guideline.

Overall adherence with all parts of the Trust guideline was 31%.

This audit showed that overall adherence with the Trust guideline was low. Problems highlighted were:

We aimed to improve nutrient delivery to preterm infants on the Neonatal Intensive Care Unit by the provision of an improved, all inclusive standardised PN supply from ready made bags and lipid syringes. In addition, we aimed to reduce the need for bespoke PN bags made in pharmacy in line with the local manufacturing unit capacity plan.

Existing ready made PN bags were compared with recommendations from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition, and felt to be inadequate. New, more concentrated formulations were proposed and checked to allow a minimum stability of 28 days. Three bags were re-formulated, a ‘preterm’ bag (sodium free, 28 day stability), a ‘preterm plus sodium’ bag and a ‘term’ bag (both 3 months stability).The new formulations were agreed with the neonatal clinical and nutrition teams.

Data on daily nutrient delivery during the first 2 weeks of life were collected prospectively following the introduction of the improved solutions, from 1 August to 31 December 2011 (Period 2). This was compared with data from a retrospective cohort of preterm infants born during 2009 (Period 1).

64 infants born during Period 1 (mean gestational age and weight at birth 28.6 weeks and 1.07 kg respectively) were compared with 36 born during Period 2 (mean gestational age and weight at birth 29.2 weeks and 1.03 kg respectively). Median values for nutrient intake were calculated, and the two periods compared using the Mann-Whitney U test.

During the first week of life, energy delivery improved from 63.6 to 70.0 kcal/kg/day, protein delivery from 1.8 to 2.0 g/kg/day, carbohydrate delivery from 10.2 to 11.5 g/kg/day, fat delivery from 1.3 to 1.6/kg/day, vitaminCQ1: Please check the text 'fat delivery from 1.3 to 1.6/kg/day'. A delivery from 218.3 to 330.0 IU/kg/day, vitamin D delivery from 35.3 to 54.7 IU/kg/day and vitamin E delivery from 0.7 to 1.1 IU/kg/day (p<0.01 for all except carbohydrate).

In the second week of life, energy delivery improved from 113.8 to 121.4 kcal/kg/day and protein delivery from 2.7 to 3.1 g/kg/day (p<0.01 for both). Delivery of carbohydrate, fat and vitamins A, D and E did not change significantly.

Reformulating ready made PN solutions significantly increased macro- and micronutrient delivery during the first week of life, and protein delivery during week two. Providing optimal nutrition to preterm infants is complicated by their need for other infusions, such as inotropes, reducing the volume available for PN. Concentrated formulae allow more nutrition to be delivered, more closely mimicking placental nutrient delivery. Providing an appropriately formulated complete standardised PN solution with appropriate levels of electrolytes can improve the nutritional intake of preterm infants.

A qualitative methodology was used; semi-structured interviews were conducted with parents regarding their child's oral chemotherapy. A diverse sample of parents was purposively chosen to encompass children at different stages of treatment and with different diagnoses. Interviews were audio-recorded and transcribed alongside field notes made by the interviewer. Data were analysed using thematic analysis.

Thirteen parents (12 mothers; one father) were interviewed. Two overarching themes were identified; the need for information and the parental struggle. Parents were found to have a wide variety of information needs ranging from treatment related information to information on drug-food/drug-drug interactions. Despite differences in the type of medicines related information parents required, all parents expressed the need for reassurance on aspects of their child's treatment. Most of the parents preferred to receive verbal and written information on the oral chemotherapy, with two parents suggesting the internet as an additional source of information.

Although all parents indicated they were satisfied with the information provided to them by the healthcare team, a number of unmet needs were identified. These included how to safely handle the oral chemotherapy and basic details about the drug, what it is and how it works. Parents encountered many difficulties at home such as dealing with the side effects of treatment and administering the medicines whilst trying to maintain normality for the family. Even though the majority of parents felt overloaded with information and struggled with the quantity of information provided, parents often sought further information from additional sources (eg, internet) for reassurance.

Information needs varied between parents but also at different stages of the disease pathway. Although the need for treatment related information was expressed by parents, the need for practical information, support and reassurance in connection with their coping strategies was fundamental to managing their child's cancer day to day. As a result of this study, the wording on the oral chemotherapy patient information leaflets has been changed to reflect issues highlighted. A medicines administration chart template and a bullet pointed do's and don'ts list regarding the oral chemotherapy are currently in development; these aim to further support parents in managing the oral chemotherapy at home.

Identify experiences of pharmacists implementing ePrescribing for paediatric units in NHS hospitals.

Compare and contrast with expectations of pharmacists, highlighting similarities in actual and perceived barriers.

Recommend evidence-based ways of addressing ePrescribing implementation, with specific reference to paediatrics.

Semi-structured, standardised telephone interviews were conducted with 13 pharmacists across GB with responsibilities for implementing ePrescribing; five were ‘post implementation’, others were about to be, or were involved in a local implementation project (8). The interviews explored themes of roles, expectations, barriers, resources and support. Analysis was conducted using a thematic matrix approach² and development of a coding frame. An external analyst reviewed the coding for credibility.

Pharmacists involved in an ePrescribing projects described significant impacts on their role and resources in meeting challenges with functionality to manage paediatric requirements in systems designed for adults.

Respondents ‘post implementation’ suggested early identification of an experienced ‘risk aware’ pharmacist; realistic strategies should be developed to address safety in paediatric dosing by separating paediatric prescribing guidance and dose rounding.

Respondents suggested that paediatric formularies and order sets need identifying: some had included all medicines but complex systems may lead to selection errors; others had simplified and only included the most common drugs used in paediatrics. Many had implemented systems without specific paediatric functions for example, dose checking and recommended simple prescribing screens with minimal options.

The ‘Early planners’ had a definite focus on system technicalities and had high expectations for the system. In contrast, experienced respondents had a greater relative focus on engagement and vision and found implementation of ePrescribing in paediatrics has similarities with adult areas. They reported training as a significant planning and resource issue.

Our results suggest that early engagement with others who had experience of systems is clearly important. Networking and sharing of best practice seems to be a concern for the respondents interviewed.

Lessons can be learnt from those who have implemented ePrescribing. National recommendations suggest that paediatric ePrescribing system implementation should be a later project for Trusts; however, those who have implemented these systems or are in the process of doing so, advise that paediatrics should be prioritised from the start of the process.

Pharmacists involved in implementation need support, and desire networking via existing groups such as Neonatal and Paediatric Pharmacists Group (NPPG) or Royal Pharmaceutical Society (RPS). Managers should be aware of resources for clinical support for paediatric ePrescribing. Issues of engagement, strategy, vision, teamwork and training need to be identified earlier in project designs.

To quantify the clinical significance of medication reconciliation in children on admission to hospital, to examine the availability and accuracy of different sources of pre-admission medication information and to investigate whether a successful strategy for medication reconciliation could be expanded to provide benefit for the Irish paediatric population.

A prospective observational study included paediatric inpatients admitted to pre-selected general medical wards between April and July 2011. Five different information sources were examined: healthcare record (HCR), patients' own drugs (PODs), the parents, drug kardex, community pharmacy (CP). A pre-admission medication list was subsequently compiled and discrepancies extracted and analysed. The clinical significance of these discrepancies was determined by an expert multidisciplinary panel using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification of medication discrepancies.

Forty patients were recruited to this study from pre-selected general medical wards over an 18 week period. Fifteen patients (37.5%) had at least one undocumented discrepancy on their drug kardex. Those patients on greater than four medicines and antiepileptic drug use were associated with a greater proportion of errors. Parents were the best source of medication history information (82.5%) followed by the drug kardex (65%), the CP (45%), the HCR (30%) and the patient's own drugs (20%) respectively.

The introduction of medication reconciliation in children on admission to hospital has the potential to reduce discomfort and clinical deterioration by reducing unintended medication discrepancies. Patients in Ireland should be encouraged to bring their medicines into hospital with them to facilitate the medication reconciliation. Multiple sources should be consulted when obtaining medication histories.

This was a nested case-control study within a 12 month prospective cohort study of paediatric inpatients. Cases were children who had experienced at least one probable or definite ADR during their admission, controls were children who had not experienced any probable or definite ADRs during their admission. An OLUL category was assigned to each medicine administered by comparison of its use with the terms of its marketing authorisation found in the SmPC¹ using a system based on the categories proposed by Turner et al. ² The OR of OLUL medicines being implicated in a probable or definite ADR was calculated. A multivariate Cox proportional hazards regression model was fit to the data to assess the influence that off label and unlicensed medicine use had on the hazard of an ADR occurring.

Of the 10 699 medicine courses administered to 1388 patients, 10 145 could be categorised. 68.8% were approved, 23.7% were off-label and 7.5% were unlicensed. 6.2% of all approved medicine courses were implicated in at least one ADR compared with 12.4% of off-label medicine courses and 14.9% of unlicensed medicine courses. The OR of an OLUL medicine being implicated in an ADR when compared with an approved medicine course was 2.3 (95% CI 2.0 to 2.6). Medicines licensed in children but given to a child below the minimum age or weight had the greatest risk of being implicated in an ADR when compared to approved medicines (OR 3·5, 95% CI 2.8 to 4.4). Fentanyl via any route excluding epidural had the greatest proportion of courses implicated (49.3%) and 98.6% of courses were off-label. Epidural fentanyl had 43.4% of courses implicated, 100% of courses were unlicensed. Multivariate analysis showed that age on admission and receipt of a general anaesthetic each had a significant effect on ADR risk. Each additional OLUL medicine given per day significantly increased the risk of an ADR (HR 1.267 95% CI 1.201 to 1.336 p<0.001). Similarly, each unit increase in the number of approved medicines in a single day also significantly increased the hazard of an ADR (HR 1.217 95% CI 1.171 to 1.263 p<0.001).

The increase in ADR risk associated with OLUL prescribing must be considered in the context of the types of medicine implicated, the frequency of their use, the frequency with which they are implicated in ADRs and the frequency with which they are categorised as off-label or unlicensed. Some of the most commonly implicated medicines in this study are frequently OLUL (eg, fentanyl). Both the number of approved AND the number of OLUL medicines administered significantly increase the hazard of an ADR.

A survey was circulated to NPPG members working in NICU to determine what prescribing was being undertaken, medicines being prescribed, benefits of, and barriers to, pharmacist prescribing

45 responses were received. Just under half (47%) were prescribers, with 40% being independent prescribers. Of those not currently an NMP only 27% had no plans to undertake the course.

Most prescribers were prescribing in NICU or Special Care Baby Unit (SCBU) (70%), with some also in out-patients. 19% of those qualified were not prescribing.

The main medicines being prescribed were Parenteral Nutrition (PN) (75%), supplements (75%), antibiotics (62%), caffeine (50%) and discharge prescriptions (50%). Two pharmacists had taken advantage of the change in legislation and were prescribing controlled drugs. Only one pharmacist was prescribing clinical trial medicines.

Improvement in safety was seen as a benefit of pharmacist prescribing, with potential reduction in communication errors (with the pharmacist making a change in medication or dosage, rather than asking a doctor to do it) and the ability to make timely correction of wrong prescriptions.

Pharmacist knowledge of PN and pharmacokinetics were seen to be better utilised with the person advising now also taking the prescribing responsibility.

The changes in medical training, with shorter rotas and more emphasis on diagnosis and procedures were seen as an area where NMP was a benefit to the team as a whole. It was also felt that being a prescriber helped the pharmacist to integrate more into the multidisciplinary team.

Many areas reported no barriers, with support from consultants and nursing staff. Lack of funding and time to undertake the course were seen as barriers, plus the potential need for a second pharmacist to clinically check what a pharmacist has prescribed. There was a desire for peer support and training to be available to potential prescribers

Pharmacist prescribing is not universal in NICUs, but has made significant inroads in this area. The most common areas of prescribing are those that have been identified as most suitable for pharmacist skills at previous NPPG conferences but there is scope to expand practice with experience.

Consideration should be given to setting up a peer support network for those contemplating undertaking prescribing in NICU.

Age-adapted questionnaires used in this piloting phase had previously been developed and pretested with the aid of children and young people, in line with the principles of patient and public involvement in research proton pump inhibitor. Specific versions were developed for children aged 6–9 years and 10 years and over. Following ethical approvals, data collection took place across three London hospitals, and community settings including pharmacies and schools. Participants in the study were thus diverse with regards to exposure and experience of medicines use. Following administration of questionnaires, item-validation involved showing participants various sizes of tablets and capsules, to determine whether this altered their accepted choices captured in the survey. Where appropriate, the attributes of any current medications and practices administering these were also recorded. Researchers also had the opportunity to obtain qualitative feedback.

To date, over 200 children and 150 parents/carers have been surveyed, with data collection ongoing. Preliminary analysis of results shows a strong preference for chewable forms over orodispersibles or multiparticulates/'sprinkles' by children across all age groups. In terms of dosage form attributes, taste and size were ranked most important, while more aesthetic properties such as colour were ranked least. There was a stronger preference for white medicines among respondents taking tablets almost every day, as opposed to those who had taken them rarely. Manipulation of dosage forms was evident, with around one-fifth of participants who had taken tablets 2 weeks prior having crushed or split them. Almost 80% of young people aged 12 years and over found 10 mm or larger tablets acceptable, in concordance with recent draft guidance from the European Medicines Agency stipulating acceptable sizes in relation to age.¹

This study supports the importance of eliciting children's unique perspectives relative to medicines use and acceptability. It also highlights that children and their parents/carers often manipulate dosage forms to aid administration; the frequency and clinical significance of these should be further evaluated. The questionnaires appear fit for purpose in relation to the capabilities of respondents, and show promise for the next stage of larger-scale data collection.

To evaluate how closely double checking policies are followed by nurses in paediatric areas. Also, to identify the types, frequency and rates of medication administration errors that occurred despite double checking.

This was a prospective observational study of paediatric nurses during double checking of medication administration in four wards in a 78 bed children's teaching hospital from April to July 2012. The observer followed the nurses during scheduled drug rounds (during week days and weekends) in each ward to observe and evaluate their adherence to the double checking procedure during the medication administration process. All data collected was anonymous and was recorded on a data collection form which was designed specifically for this study. Drugs were classified according to the BNF-C. The project was classed as service evaluation by the National Research Ethics Service and Trust clinical governance procedures were followed.

During a period of 11 weeks, 2000 drug dose administration events were observed in 876 paediatric patients. Oral drugs (84.7%) were administered and observed more frequently than other dosage forms. Non-opioid analgesic drugs were the most frequent group of medications administered (36%), followed by non-steroidal anti-inflammatory drugs (25%) and antibacterial drugs (24%). There was great variation between paediatric nurses in adherence to double checking steps during the medication administration process. Drug dose calculation was only double checked independently in 591 (29.5%) drug dose events, saline flush syringes were labelled and double checked in only 203 (67.2%) of 302 intravenous drugs. Intravenous bolus administration at the correct rate was double checked in only 213 (70.5%) of 302 intravenous drugs. Drug administration by two nurses at the bedside was observed in 1667 (83%) drug dose administrations. 128 medication administration errors were observed, an error rate of 6.4%. In addition, in 64 cases drugs were left for parents to administer without nurse's observation. Wrong administration technique errors (40%) was the most common type detected (eg, amoxicillin administered within 3 min instead of 5 min as prescribed) followed by incorrect preparation errors (35%) (eg, saline flush syringes prepared without label), and wrong time of administration errors (25%) (eg, ceftriaxone IV 2 h late).

There was a variation between paediatric nurses adherence to double checking steps during medication administration. Independent double checks were not apparent for all steps in practice. The majority of medication administration errors observed failed to be prevented by the double checking process.

Stage 1: Pre-piloted, structured, direct observation of dispensary clinical pharmacists resolving clinical concerns on hospital prescriptions, prior to dispensing, over an 11 day period (25 h observation). Setting was a single UK paediatric hospital providing both secondary and tertiary care that at the time of the study did not use FIRSTLight. Data set included: drug, route, dose, patient details, pharmacist, resources consulted, time taken, and if the query was resolved. Stage 2: Retrospective use of the decision support tool FIRSTLight to identify if relevant information was available from this source, and time taken to obtain.

Fifty-one clinical queries were observed during the study period that required reference to (drug) information sources for resolution. These were managed by eight different pharmacists and involved 41 different drugs (chemical entities). Seven different information sources were consulted a total of 61 times. Most frequently used resource was BNFc (n=34, 56%). FIRSTLight was shown retrospectively to provide the relevant information required to resolve the query on 33 occasions (65%). In comparison the BNFc was able to provide the required information alone on 27 (44%) of occasions. Time taken to resolve the queries, excluding those with delays (n=4) without using FIRSTLight ranged from 16 s to 18 min 53 s (mean 4 min 21 s). Time taken to identify relevant information using FIRSTLight ranged from 20 s to 5 min 21 s (mean 2 min 43 s). Overall FIRSTLight was both quicker and provided the necessary information on 19 occasions (37%).

FIRSTLight may be a useful resource to provide clinical information to pharmacists when clinically checking paediatric prescriptions in a hospital dispensary. Further work will be required to determine the most time effective pathway for obtaining or confirming necessary clinical information in this setting. FIRSTLight may also be considered by community pharmacists who are known to have difficulties managing hospital prescriptions.¹

To describe the process of building an electronic drug file for a paediatric intensive care unit (PICU).

(1) Commencement: Initial work consisted of setting out certain standards, such as acceptable abbreviations, units of measure and reference sources. As the unit caters for a wide range of patients from premature neonates to teenagers, it was a risk to use one upper dose limit for each drug. Patient categories were created, consisting of (a) premature (b) neonate (c) 1 month to 1 year (d) over 1 year up to 40 kg (e) over 40 kg. For each of these patient categories, a minimum and maximum body weight was assigned which would be used to calculate dose limits. (2) Configuration: Four limits for each drug dose were inputted: minimum, low normal, high normal and maximum. It was decided that all minima would be zero and low normal would reflect the lower end of the normal dose range (hence, dose reduction for renal impairment would be highlighted as abnormal). Drug configuration and corrections were done by one PICU pharmacist, who logged the reference for any unusual decisions. Each draft was checked by a second PICU pharmacist. A selected list of drugs and their various assigned limits was reviewed by a consultant intensivist. An ‘Issues Log’ was maintained for liaison with the vendor where issues were logged as they arose and their progress to resolution noted. (3) Testing: Teams of testers drawn from consultants and senior nursing staff volunteered for testing. They were assigned specific drugs and formulations to test, which they did by prescribing each drug for each patient category. A form was used to log details of the drug tested and any difficulties that arose. Progress of the testing phase was logged on a spreadsheet. (4) Miscellaneous: 556 drug formulations were configured, consisting of 3756 limits in total. Aciclovir alone has 180 limits because of the complexity of dosing for different age groups and indications, as well as different formulations (injection, cream, etc). (5) Time Frame: Work on this project took two pharmacists 9 months to complete, working 3–7 h/day. Testing was conducted over a 14 week period.

A formal structured approach is key when undertaking a large complex project. Tools, such as issues and progress logs are important to track the multitude of questions that arise. Close working relationships with all stakeholders need to be maintained throughout the process.

In times of reduced financial and human resources, sharing of information is critical to reducing waste. This roadmap will help other institutions undertaking a similar project.

To compile a drug library of standard concentration drugs administered via continuous infusion in PICU. To assign each drug soft and hard upper dose limits, as well as loading or bolus doses as appropriate. To measure the impact of its introduction though comparison of medication incident data and staff feedback survey.

Review medication safety reports for 2 month period, profiling errors associated with continuous infusions in PICU.

All stakeholders were identified and briefed on the project.

A PICU consultant and pharmacist devised a list of proposed standard concentrations. This took into account clinical factors—rule of six concentrations, dose ranges for different indications, loading and bolus doses, dosing in theatre and most importantly, soft and hard dosing limits. Drug-related factors were also considered—minimum and maximum concentrations, limitations for administration via peripheral line. For each weight band, a standard and fluid-restricted concentration was provided. It was realised that this technology could also improve safety around IV potassium chloride and IV paracetamol.

The proposed standard concentrations were circulated for feedback to all stakeholders.

Sample patient profiles were used to compare total daily volumes infused using ‘rule of six’ versus standard concentration infusion.

Once agreed, the logistics around roll out were discussed, agreed and communicated to all stakeholders (PICU, theatres, cardiac wards.).

Post implementation, a repeat review of medication safety reports was conducted. A survey of users was conducted to assess satisfaction and ongoing issues.

The change to standard concentration infusions with smart pump technology was successfully introduced. The drug library included 42 drugs. While one single concentration for each drug was the ideal, this was not achievable due to the diverse profile of patient sizes in the unit. We report on the comparison of infusion-related medication safety reports pre and post implementation as well as user feedback. We also report on some of the resistors to change and challenges encountered along the way.

A switch to standard concentration infusions is achievable with smart pump technology. Single concentrations were not achievable for most drugs. Retrospective review may facilitate a reduction in choices of concentration currently available. This technology should also be considered as an aid in making IV paracetamol and potassium administration safer.

A prospective, observational audit of interventions made to medications on PICU. The population audited were all paediatric patients admitted or present on PICU and prescribed any medication from 02 April 2012 to 04 May 2012.

During the audit 82 medication interventions were recorded, of these 54.9% were made by pharmacists and 28% by nurses. Of the 82 interventions that were audited, 71 were deemed to be appropriate and 10 were deemed to be inappropriate; the appropriateness of 1 of the interventions was undetermined.

The majority of interventions were made between the hours of 9:00 h–17:00 h on weekdays, during this period pharmacists made 68.3% of interventions and fewer inappropriate interventions were made. The majority of inappropriate interventions were made during the night, with the most common inappropriate intervention deemed to be changing of dose timings.

The most common medications with interventions were antibacterials and antivirals, with the most common intervention being stopping medications.

Medication interventions occur frequently within the PICU setting and are initiated by all members of staff. However not all of these interventions are appropriate for patients. Of the 82 interventions made 86.6% were deemed to be appropriate. Of those deemed to be inappropriate, the reasoning behind them has yet to be analysed.

Defining appropriateness is a qualitative exercise and further work must be undertaken to assess the perception of appropriate and inappropriate interventions. It is proposed that a 2-round Delphi method is used to test the appropriateness of the questioned interventions. This should help define what is an inappropriate intervention and allow for recommendations to be made to prevent these from occurring.

A qualitative investigation of 30 parents/carers of in-patients was undertaken during January and February 2012. Face-to-face interviews were conducted using a semi-structured questionnaire on the ward with telephone follow-up after discharge. The questions were based upon recommendations of the ASAT. The themes included in the questionnaire were knowledge that an antibiotic had been prescribed, indication for use, duration of therapy, knowledge of adverse effects, where to seek advice and whether any information provided met parent/carer expectations. Participant responses were transcribed verbatim and analysed using content analysis.

Thirty patients consented for a ward based interview with twenty (66.7%) consenting to telephone follow-up.

Twenty-five (83.3%) parents/carers had been advised that their child had been prescribed an antibiotic as an in-patient. Six (24%) of these had been informed about the adverse effects associated with treatment.

During the discharge process 19/20 (95%) parents/carers were informed that their child had been prescribed an antibiotic. Five (25%) had been informed about adverse effects. Eighteen parents/carers (90%) were advised of the course length. Eleven (55%) patients were informed where to seek further advice on their antimicrobial therapy.

Parents/carers suggested a number of areas where they required further information. These included the rationale for antibiotic therapy (n=1), changes made to therapy during treatment (n=1), the long term safety of therapy (n=1), the risk of tolerance/reduced effectiveness (n=2) and assurances of eradication of infection/risk of recurrence (n=5). One parent suggested that a patient information leaflet be provided whilst an in-patient.

This study demonstrates that a national antimicrobial stewardship quality indicator may be used to assess the provision of information to parents/carers in the paediatric setting. Further work is needed to improve the provision of information on adverse effects and where advice may be sought should these occur following discharge from hospital.

Parents/carers required more information about treatment decisions, expressed concerns about the safety of therapy and required assurances of treatment success. Addressing these concerns would further reinforce the importance of prudent antibiotic use among parents/carers and patients.

Patient/carer expectations may differ depending on the reason for admission and social/educational background. These were not formally evaluated in this study.

The results of this study will inform the development of interventions to improve information provision both at ward level and discharge. The use of written information to supplement verbal counselling is currently being considered.

A data collection form was used to prospectively obtain data over 2 weeks. Each form was second checked by a specialist pharmacist to ensure robust results.

140 prescriptions were received and 197 medications prescribed. 26/140 prescriptions were not timed stamped.

These results highlight that the use of pre-packs and FP10HNC prescriptions is not being optimised which may affect patient experience. The limitations of this audit are that not all prescriptions were timed in and out and that 1 week of the audit coincided with school holidays. The recommendations are:

A data collection form was designed and used to collect information from every cycle of prescribed chemotherapy (excluding UKALL03 maintenance prescriptions) over a 5 week period. Information was collected on clinical and non-clinical interventions, type/grade of prescriber, cycle of chemotherapy prescribed and whether or not the cycle was electronically prescribed or completed by hand. Each clinical intervention was graded in terms of severity by the checking pharmacist against set criteria. The grading allocated was checked by another independent pharmacist.

36 cycles of chemotherapy were prescribed and checked over the 5 week period by nine different prescribers. Most cycles were prescribed by consultants. 40 pharmacist interventions were made during the period with a mean intervention rate of 1.1 interventions per cycle of chemotherapy prescribed. The majority of clinical interventions (41%) were graded as minor, 33% as significant, 22% causing no harm, 6% as potentially serious and none as potentially lethal. The most common interventions were related to fluid volumes and supportive therapy. A total of eight non-clinical interventions were made with the most common being prescribers failing to identify that patients were part of a clinical trial. This was closely followed by not providing the required documentation such as oral chemotherapy records. The results also showed that transplant chemotherapy required the most pharmacist interventions. Fifteen of the cycles were prescribed using the electronic prescribing system (Chemocare). There were clear differences between the error rates when comparing electronically prescribed and hand written cycles of chemotherapy.

This audit clearly shows the importance of the role of the clinical pharmacist in paediatric chemotherapy. The majority of clinical interventions made were scored as minor with only 6% being scored as potentially serious. The most common clinical interventions relate to supportive therapy and incorrect fluid volumes. Electronic prescribing appears to be having a positive outcome in terms of clinical interventions but having the reverse effect on non-clinical interventions supporting a theory that electronic systems may encourage an absent minded approach to prescribing.

0% of prescriptions contain a prescribing/transcribing error

Data was collected prospectively by ward pharmacists over 2 weeks, on six paediatric wards and one neonatal ward. The prescribing errors were recorded using a validated list of paediatric prescribing error scenarios.¹ Data were collated and analysed using Microsoft Excel. The clinical significance of reported errors was evaluated by members of the multidisciplinary team using a validated visual analogue scale of (0–10) where 0 represents an error with no potential effect and 10 an error that would result in patient death.²

1411 new prescriptions were written and 500 transcribed. The audit did not meet its standard. 125 prescribing errors were identified, including 30 transcription errors. The prescribing error rate was 6.5% (125/1911). The overall prescribing error rate excluding transcription errors was 6.7% (95/1411).

The error rates were compared between specialities. Paediatric neurology reported the highest error rate (14.3%), High rates were observed in critical care areas, high dependency (13.6%) and intensive care (10.5%).

Medicines prescribed intravenously accounted for 39% of prescribing errors whilst 31% were in medicines prescribed via the oral route. Errors related to incorrect dosing accounted for 45% of those reported. The greatest number of errors were reported in children <4 years (45%). Drugs most commonly associated with prescribing errors were (n=125): paracetamol (14.4%); gentamicin (6.8%); morphine (6.8%) and tacrolimus (5.1%).

0 errors were reported on the ‘Datix’ system.

The clinical significance was evaluated for 109 reported errors. 4.5% were found to have a mean clinical significance rating of >6/10, 59% had a mean rating of >3 and ≤6/10 and 33% had a mean rating of ≥0 and ≤3/10.

The reported error rates represent a 2.4% increase from the 2011 audit but is significantly lower than rates reported in the literature.^{3 4} The results obtained will be utilised to target drugs and specialities associated with the highest error rates and the most clinically significant errors. Further work is indicated to improve error reporting on ‘Datix’.

Standards were developed and agreed with the paediatric A&E consultant. The records of all patients ≤16 year whom presented to A&E with a diagnosis of ‘UTI’ or ‘query UTI’ during a 6-month period were obtained via the hospital's A&E admissions database. Data was collected retrospectively. Patients were excluded from the audit if they did not meet the inclusion criteria of the guidelines.^1–3

Adherence to Audit Standards.

Overall the standards were well adhered to, more so in the diagnostic process than with treatment.

Variance in clinical judgement and practice plays a large role in the diagnosis of childhood UTIs and as such, may account for non-adherence to guidelines when requesting tests.

Adherence to treatment guidelines is poor according to these results. It was not possible to ascertain reasons for deviation from protocol from the records. Clinical judgement over oral versus IV treatment may depend on other factors not measured by this audit. Adherence to antibiotic guidelines in this audit was extremely poor, highlighting the need for education and signposting in this area.

The UTI pro-forma in A&E is not routinely used. If this was re-launched it would aid practitioners in signposting the appropriate tests, and should refer to the Trust antibiotic guidelines.

A random sample of 30 pharmacist interventions made on a neurosurgical ward were tabulated and sent to a multidisciplinary panel for review and grading using the National Reporting and Learning System risk scoring, one being negligible harm and five being catastrophic.¹ Each intervention was subjected to the Medication Error Reporting and Prevention Index for categorising actual medication errors.² The panel consisted of a consultant neurosurgeon, neurosurgical registrar, specialist nurse, senior pharmacist and junior pharmacist. Data included demographic and clinical details of the patient and the intervention made by the ward pharmacist. Each individual was asked to score each of the 30 interventions in terms of potential harm had the pharmacist not intervened.

The mode for this data set was 2, the median was 3 and the range was 4. The neurosurgical registrar rated the interventions with the highest average intervention score of 2.1. The neurosurgical consultant and the junior pharmacist both had an average intervention score of 2.06. The specialist nurse and the senior pharmacist had the lowest average score for the interventions which were 1.93 and 1.8 respectively. 21 of the 30 interventions were made prior to the administration of the prescribed medication. An example of a high scoring intervention is the failure to prescribe buccal midazolam for a child who suffers with seizures, severe enough to warrant a stay in our paediatric intensive care unit.

The basic grade pharmacist and the neurosurgical consultant were the only two who categorised any of the interventions as catastrophic. The specialist nurse categorised four of the interventions at a category of moderate to catastrophic, whereas the senior pharmacist categorised three within this category.

Nine (30%) of the interventions made involved the use of antibiotics. 33% of these interventions related to antibiotic drug omissions and 33% related to under dosing the patient with antibiotics. These under doses reported were due to the Trust switching from the use of cefuroxime to cefotaxime (in the neurosurgical ward) as a first line antibiotic which was being used at a dose of 30 mg/kg instead of the standard 50 mg/kg.

The results show that professionals with similar experiences score interventions similarly such as the specialist nurse and senior pharmacist (both sit on the Trust Medicines Safety Committee) or the neurosurgical registrar and consultant. Future study will include a larger cohort from the medical, pharmacy and nursing team.

This project was conducted as a prospective observational study whereby PICU patients receiving intravenous infusions were selected randomly over 6 months. Records were made of infusions being administered and detailed the following:

Name of the continuous drug infusions

Prescribed drug concentrations

Diluent

Name of non-continuous intravenous drugs

Combination of drugs administered through the same lumen of a central or peripheral line.

Trissel¹ was used to search for evidence of compatibility for the Y-sited infusion combinations. The PICU pharmacist reviewed the data with a view to identifying combinations considered safe practice due to clinical experience.

40 patients were reviewed with 47 drug combinations identified. Trissel¹ identified that all drug combinations were compatible where data was available; however it only provided data for 33 out of the 47 combinations. 12 out of the 47 identified combinations consisted of drug mixtures containing more than two drug solutions for which Trissel does not provide compatibility data. All combinations were considered safe by the PICU pharmacist.

Many intravenous drugs are being administered on the PICU in combination via a Y-site for which there is very limited scientific data to support their compatibility. Their use is considered safe due to clinical experience of use without adverse effect. Future work should involve research into physical and chemical compatibility for commonly prescribed Y-sited combinations to ensure safe practice.

This small pilot study aimed to examiine the intake of a sample of PICU patients, highlight common medicines used on PICU containing alcohol, provide alternatives where possible and where alternatives are not possible, provide the prescriber with a list of the higher alcohol containing medicines.

A retrospective medication chart review was undertaken as a two point snap shot. Data collected included age, weight, medications prescribed and the formulations used at time of the study. The patients' sedation score was recorded.

The electronic medicine compendium (EMC) was consulted for any ethanol content for the commercially available products. The manufacturer was contacted for ethanol content of all ‘specials’ and any commercial products found to contain ethanol from the EMC. The PICU patient's daily intake of ethanol was calculated. The calculation was converted to an adult equivalent alcohol unit intake and although this method of conversion is crude and does not take physiological differences of adult and children into account, it was done in order to provide the clinician with commonly used terminology in deciding the risk to the patient.

Twenty-eight patients were prescribed a range of 69 different medications. Of the 69 medicines, 12 products were found to contain ethanol. Patient ages ranged from a 26 week premature infant to 15 years old, weights ranges from 0.7 kg to 45 kg. Only 2 out of the 28 patients did not receive ethanol containing medications, and most patients were prescribed at least two medicines containing ethanol. Daily ethanol intake uncorrected for weight ranged from 0.006 ml to 2.18 ml (median 0.26 ml). Converting this to adult units per week, alcohol intake ranged from 0.07 to 15.2 units (median 1.4 units). The two patients receiving above 15 units/week adult equivalent were prescribed an oral morphine weaning regimen, therefore the high alcohol exposure was short term. The most common drugs prescribed containing alcohol were found to be nystatin, ranitidine, furosemide and morphine. No commercially available alcohol-free oral liquid preparations were found for ranitidine, furosemide or morphine at the time of the study.

Correlation of the sedation score against ethanol intake was difficult to analyse as most patients were actively sedated.

Polypharmacy in PICU patients increases the exposure to alcohol. Some commercially available medicines provide excessive ethanol intake, providing the clinician with ethical, potentially economical dilemmas of prescribing an unlicensed medicine to minimise ethanol exposure. Further research is required to evaluate the scope of the problem, effects of exposure and provision of alcohol free formulations.

The guidelines were informed by a number of work streams, undertaken under the umbrella of the MODRIC (Manipulating Drugs in Children) project. The evidence from a systematic review of the literature, an observational study of manipulations in clinical practice and a national survey of the experience of paediatric nurses in manipulating medicines, was reviewed and supplemented with the expertise of a guideline development group to develop an acceptable guideline.

This guideline describes situations where medicines should not be manipulated and has recommendations on avoiding manipulation (such as by procuring the appropriate dosage forms or using dose rounding where appropriate). Where a manipulation is considered necessary, recommendations have been developed for different dosage forms. In addition recommendations to the regulator, to industry and to inform further research have been included.

The use of this guideline will raise awareness about drug manipulation in paediatric and neonatal care settings and offer guidance for undertaking manipulations if they cannot be avoided. It is intended that the guideline will be used to inform hospital Medicines Management Policy on manipulation of medicines.

Community pharmacists based in the north west of England attending a clinically focussed learning event ‘Children and their Medicines’ were asked to complete a two-question survey designed to uncover the processes by which this educational intervention enhances community pharmacists' practice. The survey collected qualitative data (free text responses) related to how participants intended to put their learning into practice and reflections on perceived benefits of the learning for practice. Responses were initially coded into broad themes and subsequently organised into categories using content analysis. Data categories were then used to construct a database in SPSS (Statistical Package for the Social Sciences) to allow for the conversion of the qualitative data into quantitative data for further analyses.

Data were collected at six learning events; with 115/137 (83.9%) participants completing the survey. Of the 180 responses related to putting learning into practice, highest frequencies were recorded for responses coded under categories ‘communicating effectively with children and their parents/carers’ (35.7%) and ‘monitoring drug therapy through a medicines use review’ (28.9%). Many responses were also coded as ‘medicines-related issues necessary for the delivery of safe, effective patient-centred care’ such as using unlicensed medicines, dosing, formulation and how to obtain/supply specials. Of the 263 responses related to benefits for practice, most examples related to improved safety and quality (42.5%), as a result of increased awareness of dosing and formulations issues when dispensing medicines for children; improvements in medicines management (adherence) amongst children were also frequently mentioned (22.1%).

Supporting community pharmacists to play an important role in the safe and effective care of children and management of their medicines, community pharmacists attending a learning event reported complex outcomes likely to enhance their practice. The extent to which these outcomes are transferred to practice will be determined in a subsequent study.

The Trust's paediatric first line anti infective guideline¹ was used to audit performance against. Data were prospectively collected by a pharmacist working in conjunction with two doctors during a two week period Monday to Friday. New patients who had been admitted and initiated on empirical antibiotics were identified for inclusion. The intention was to include at least 50 patients in the audit. The data were collected from all paediatric wards excluding bone marrow transplant using a data collection tool. There were three standards that the data were audited against.

Standard 1: 90% of antibiotic prescriptions should adhere to the paediatric antibiotic guidelines for empirical treatment.

Standard 2: 90% of prescriptions should have an indication written on the drug chart or in the medical notes.

Standard 3: 90% of prescriptions should have a stop or review date written on the drug chart.

A target of 90% was chosen as this is the Trust's quality account target.

Data were collected for 62 patients, 12 were excluded from analysis because they were on antibiotics which were not in the guideline, were based on previous microbiology cultures, or were on prophylactic antibiotics which were outside of the scope of the guideline. For the 50 included patients the following results were obtained:

Standard 1: 36 (72%) of 50 prescription charts audited adhered to the paediatric antibiotic guidelines for empirical treatment.

Standard 2: 8 (16%) of 50 prescriptions audited had an indication written on the drug chart and 47 (94%) had an indication written in the medical notes.

Standard 3: 7 (14%) of 50 prescriptions audited had a stop or review date written on the drug chart.

The results have highlighted that there is non-compliance with the standards set. There was 72% compliance with the paediatric antibiotic guideline. Some treatment may have been clinically appropriate however this may not have been documented in the notes. There are some indications that are not included in the guideline that could be such as abdominal trauma, quinsy, cellulitis and open fracture. There is no guideline in place for prophylactic antibiotic treatment such as surgical prophylaxis. The need for this was identified.

The failure of documentation of an indication plus stop/review date on the drug chart suggests a need for education of doctors. This is something that could be incorporated during their induction. There is a proposal to redesign the current drug chart for a paediatric specific chart which includes a section for documentation of an indication and proposed duration of anti infectives; this may help to achieve compliance with this audit standard.

All patients admitted to three medical wards between 5 January 2012 to 19 January 2012 and whose drug chart and notes were available were included in the audit. A pilot was conducted between 5 January 2012 to 6 January 2012. Data were collected after the pharmacist had visited the ward. For each patient, the relevant pages of the drug chart and medical notes were photocopied for quality assurance which was carried out with the project supervisor.

44 patients were included in the audit and 70% (n=31) had a drug history taken on admission (either in A&E or on the ward) 97% (n=30) were completed within 6 h 64% (n=28) had MR performed by a pharmacist 100% (n=28) were completed within 72 h of admission.

Nine patients had no past medical history thus not requiring pharmacist MR, three patients may have required a repeat MR and four did require a repeat MR.

11% (n=5) had no MR documented by any healthcare professional.

25% (n=7) patients had an intentional or unintentional discrepancy between pre- and post-admission medication.

Ten discrepancies were identified with four intentional changes and six were unintentional which were rectified on discussion between the doctor and ward pharmacist.

Baseline data has been obtained regarding medicines reconciliation in paediatrics. The results have highlighted that doctors are not always documenting MR and pharmacists are not carrying out repeat MR in patients who require one, for example, those with a past medical history, however all discrepancies identified are clarified and when necessary are rectified.

To provide a brief overview of the disease, molybdenum cofactor deficiency (MOCD) and its prognosis.

To share the experiences and challenges in the sourcing, storage, manipulation, supply and administration of the novel product cPMP.

MOCD is an inherited metabolic disease in which the molybdenum dependant enzymes (sulfite oxidase, xanthine oxidase and aldehyde dehydrogenase) are unable to perform their normal metabolic processes. There are four separate subtypes but all are characterised by progressive neurological damage associated with sulfite accumulation.¹ There is significant morbidity and death usually occurs in early life.

MOCD Type A is characterised by a disorder early in the production of molybdenum cofactor.

Until recently there has been no treatment for MOCD Type A, however in 2009 Veldman et al² reported on the successful intravenous treatment with an E coli derived pre-cursor of molybdenum co-factor calledcPMP.

In December 2009 a male child was born to consanguineous parents with a family history of MOCD. Diagnosis was made and following ethical and financial approval treatment was started on day 4 of life. In April 2010 a second child was born to a separate family with no history of the disease. Diagnosis was made and following ethical and financial approval treatment was started on day 1 of life.

The nature of the product and the necessity for lifelong daily injections has led to challenges in the provision of this treatment for these two children.

These challenges include: Ethical approval for treatment; financial approval for treatment; importation; storage requirements at –80°C; preparation of an acceptable product for hospital and home use; dealing with variable concentrations; planning for home use (including storage and administration).

Both children remain on treatment and have passed their second birthdays. Both children have had admissions for line associated infections but are generally well.

The older child is developing with near normal milestones being met, whilst the younger child has significant neurological impairment.

Until recently the provision of care to children with MOCD has largely been palliative. The experience in these two children suggest that the longer term treatment of the disease is possible and that near normal development can be possible in a disease that was previously fatal.

The ongoing use of cPMP in these patients presents some challenges in supply of a product appropriate for use.

Data was collected retrospectively (over last 12 months) from all patients who had received prasugrel as part of their anti-platelet therapy whilst on a VAD. Data was collated from drug charts filed in patient notes for dosing information and the electronic pathology system for thromboelastography (TEG) results.

In total, two patients were identified as having received prasugrel as part of their anti-platelet therapy whilst on a VAD. Our VAD anticoagulation protocol states a loading dose of 1 mg/kg (no maximum) followed by 0.1 mg/kg (max 5 mg) maintenance, adjusted to achieve TEG ADP inhibition of >70%.¹

The mean age was 11 months (range 5–18 months) and mean weight 8.5 kgs (range 6–11 kgs). Both patients were female. Mean duration of treatment was 57 days (range 24–90 days). The mean loading dose was 1.04 mg/kg (0.91–1.17 mg/kg) and the mean maintenance dose was 0.30 mg/kg (0.21–0.49 mg/kg). The mean ADP inhibition was 64.0% (range 59.4–68.7%).

Additionally, in these two patients the mean dose of clopidogrel used prior to initiating prasugrel was 0.8 mg/kg (range 0.64–0.96 mg/kg). The previous mean ADP inhibition achieved on clopidogrel was 48.6% (range 40.8–56.5%). The average duration of treatment was 22 days (range 20–24 days).

The mean time taken to achieve an ADP inhibition of >70% was 10 days (range 4–16 days) and 15.5 days (range 13–18 days) for prasugrel and clopidogrel respectively.

The response seen in our patients to prasugrel is similar to studies conducted in adults where prasugrel achieves a greater ADP inhibition than clopidogrel.² Additionally the time take to achieve effective ADP inhibition was faster. One of the possible causes of this is likely to be due to the different expression of metabolising enzymes in individual patients as both drugs are metabolised in vivo to form their active substrates.³

As prasugrel gives more effective ADP inhibition than clopidogrel, the risk of bleeding events will also be higher. This has been observed in adult clinical trials.² The intra- and inter-patient variation in TEG response observed supports routine monitoring using TEG analysis to guide dosing and manage side effects such as bleeding.

Effective anticoagulation is imperative to prevent complications on VAD including cerebrovascular accidents that occur in about 30% of patients.⁴ The management of these patients highlights the importance of prescribers to have access to high quality medicines information to guide dosing, avoid interactions and ensure therapy is optimised.

To determine the accuracy of prescribing and whether a supply has been appropriately made for all unscreened TTOs.

All TTOs are prescribed using E-docs, an electronic TTO system. All TTOs in June 2011 which were unscreened and contained medication were collected. The accuracy of these TTOs was cross checked with the patient notes, checks were made on the weight, allergy status and the patient's medication history. The nurses discharge section on PAU admission forms were also checked to confirm what the patient received. A prescribing error was defined as any unintended discrepancy between the intended prescription and the actual TTO. A supply error was defined as the patient not receiving the drug or being sent home with a drug inappropriately dispensed.

A total of 105 patients, (aged: 7 days–17 years), were discharged with medication without pharmacist involvement, 68, (65%), of these were out of hours. 43 TTOs, (41%), contained a total of 49 errors, a break-down of the error type revealed: duration 44.9%; supply 20.4%; frequency 14.3%; dose 12.3%; formulation 6.1% and strength 2%. Nineteen, (38.7%), of these errors were made in pharmacy hours and 55% of the total errors were made by SHOs which correlated to the proportion of TTOs that they wrote.

43 (41%) TTOs that were unscreened by a pharmacist left the hospital containing errors. 38.7% of these errors may have been avoided if the pharmacist had been contacted to provide a clinical screen. 26.5% of errors were due to no duration being indicated on the TTO at all, this was as a result of the ‘From Ward’ option being selected which then deletes the automatic prompt for a duration. 42% of TTOs that did not contain errors had the ‘From Ward’ option selected which meant the prescriber had to remember to put the duration in the management plan.

PAU is a very busy environment with many distractions, the implementation of protected time when writing TTOs may see the error rate decrease. The introduction of ‘order sentences’ may prevent some drugs from being prescribed at the wrong time of day or with the wrong frequency.

Feedback will be given to prescribers and training provided if prescribers feel that this may reduce the number of errors. Further research will be done into the prescribing abilities of new doctors and their understanding of the E-docs system.

Nurses will be reminded of the procedures regarding supplying medication out of hours and given examples of what is and is not appropriate practice.

Parameters investigated included pH (citrate buffer at 3.5 and 5.5), drug concentration (0.75 mg/ml and 3.0 mg/ml), addition/absence of chelating agent (EDTA) and addition/absence of nitrogen purge (N2 Purge), yielding a total of 16 runs (24 design); the apparent first order rate constant (k1) was used as the response factor. Samples were stored under accelerated conditions (50°C) over 14 days and analysed using reversed phase High Performance Liquid Chromatography (HPLC).

Statistical analysis indicated that the main factors of pH, captopril concentration, chelating agent and N2 Purge all significantly influenced the oxidative degradation of captopril to some extent. The two –way interactions, pHxEDTA, pHxcaptopril concentration, EDTAxcaptopril concentration and N2 Purgexcaptopril were found to be significant. The only 3-way interaction found to be significant was pHxEDTAxcaptopril concentration. Surprisingly, the presence of EDTA was found to degrade captopril at both low and high pH. It is postulated that the addition of EDTA may sequester metal ions which otherwise could have a stabilising effect via a citrate-captopril-metal ion complex.³ The optimised formulation, with lowest degradation, was one which required a low pH (3.5), no EDTA, no N2 Purge and a high concentration of captopril (3.0 mg/ml), and yielded 95% accelerated stability at 50°C for 14 days.

When developing paediatric formulations one of the many important considerations is to minimise the use of excipients. The fact that EDTA may not be required is an important finding since EDTA is potentially nephrotoxic in chronic conditions.⁴ Only by using factorial design can such latent complex interactions be identified.

Two focus groups held (17 participants) onsite with NMPs from a variety of specialties with a range of prescribing experience. Participants followed a pre-set focus group guide with occasional direction from the facilitator. Text was transcribed and coded using NVivo software (V.9).

The reference source most frequently referred to was the BNFc. NMPs also refer to colleagues, local guidelines and clinic letters regularly. Most difficulties with prescribing refer to a lack of access to information about previous prescriptions and notes being unavailable. Participants agreed that ePrescribing should provide dosing support through calculations based on patient weight/BSA/age. Guidance on monitoring and access to historic prescriptions were also desirable. Alerts (eg, regarding allergies, monitoring or interactions) should require some form of acknowledgement, but participants expressed some concern about alert fatigue occurring. Concerns about ePrescribing implementation mainly referred to IT related problems due to the difficulties being experienced with the current systems. Further issues were raised about the availability of computers if all prescribing was electronic. Security of passwords and being able to trace editing of your prescribing also caused reservations. After IT related issues, the next most frequent concern was having a suitable lead in time to ensure all staff were comfortable with using the new system. Participants could describe many perceived benefits of a move to a successful ePrescribing system. Benefits stated include: always being able to access patient's medication history (n=5); better audit trail of prescriptions (eg, changes could be tracked) (n=5); easier monitoring of medicines and administration of medicines (n=5); guidance on dosing available and individualised to your patient (n=4); reduced waiting times for discharge medication (n=3); access to a local formulary that lists available unlicensed products (n=2).;less transcription errors (n=1); reduced delays in administration of medicines as charts would not be held in pharmacy (n=1) and no lost prescriptions (n=1).

NMPs currently use a wide range of resources to support their prescribing decisions. There are some difficulties accessing paediatric information for certain specialties (eg, palliative care and renal) and patients' prescribing histories. NMPs can see a range of benefits to moving to electronic prescribing, but there is a lack of optimism about its potential success due to the current technical difficulties experienced in the Trust's IT systems.

GMA, a method developed in astrophysics,¹ is a framework for structuring and investigating complex relationships contained in a multi-dimensional problem field.² A morphological field was developed by modelling the problem space of the paediatric drug development field by a subject-matter specialist team. The problem space is a set of critical parameters (aka factors or dimensions) where each parameter consists of possible states/values as identified by the working group. The workshop team comprised of an industrial pharmacist, a paediatric pharmacist, a Qualified Person and technical scientist from an international contract manufacturing organisation. The solution space was synthesised by excluding logically impossible and empirically improbable pair-wise combinations of parameter values achieved by a process known as the Cross-Consistency Assessment (CCA).³

The morphological field analysis isolated a 7-dimensional field with 55 values, giving a total set of 560 000 possible configurations for the five age groups as defined by the European Medicines Agency. A configuration is a point in a high-dimensional space that can be represented as a line cutting each parameter at the appropriate value.

Dimensions included age of the paediatric patient, dosage form type, problematic excipients, drug characteristics, delivery constraints, types of hurdles (eg, clinical, manufacturing) and the regulatory strategy (using the Ansoff typology). Facilitation of this vast problem space by the CCA process dramatically reduced the viable configurations to 57 457, a reduction close to 90%—reduction greater than 99% is not uncommon in such exercises. Deeper analysis revealed that only 78 schemes (ie, configurations) were available for the pre-term age group and 760 for the new born category (0–27 days).

As many of the values involved are not meaningfully quantifiable, containing strong social, regulatory and clinical concerns, GMA facilitated (i) a collective judgmental process to be placed on a grounded methodological basis, and (ii) a process of constructive dialogue amongst the diverse participants to develop shared concepts, terminology and ownership of the problem formulation.

Transdisciplinary approaches, such as GMA, allow a holistic picture of a fragmented and complex landscape to be developed by the relevant stakeholders. This not only gives decision support under genuine uncertainty but allows incorporation of emerging data derived from pure and applied (translational) research in early paediatric drug development programmes.

The details of all patients on the Neonatal Unit prescribed PN over an 11 month period from 1 August 2011 to 30 June 2012 was analysed retrospectively. Data was collated from the pharmacy technical services unit PN orders and patient's medical records to assess why patients were not prescribed stock PN. This was defined as either: changing from stock to compounded PN or that stock PN was unsuitable from the outset.

Over the 11 month period, 191 patients received PN resulting in 3047 PN days. The course length varied from 1 to 79 days, with a mean of 16 days.

45.5% of patients required PN for greater than 14 days, and 14.1% for greater than 28 days.

52.4% of the patients initiated on PN were prescribed stock PN for the whole of their treatment course, which accounted for 1579 PN days: 47.6% of patients required compounded PN at some point during their stay, equating to a total of 1468 compounded PN days.

The main reason (19.8%) for changing from stock to compounded PN was to reduce the glucose concentration due to hyperglycaemia. Other reasons included concentrating the PN either due to: illness or other infusion volumes (18.7%) or during the transition to enteral feeds (13.2%). 11% and 15.4% of patients needed an increase in the amount of sodium and potassium respectively.

The final 14% were documented as needing an increase in fluid volume, acetate, glucose, calcium, phosphate or a decrease in potassium. 7.7% of reasons were not documented.

Sick newborn infants admitted to the neonatal unit may not be able to obtain adequate nutrition for growth and development via the enteral route, therefore PN is required until enteral feeding is established.

The primary aim of this audit was to evaluate whether the new ‘stock’ PN recipes met the metabolic requirements of the majority of our Neonatal Unit population, in the hope of reducing the amount of compounded PN required. From this data, it can be concluded that for over half the patients, stock PN met these requirements. There were numerous reasons for compounded PN demonstrating that a change in recipe would not negate the need for compounded PN.

Stock PN enables and encourages nutrition to be initiated soon after birth and has been shown to meet the requirements of the majority of patients.

A new, taste-masked, coated-granule formulation (Luc 01) has been developed and the taste characteristics, dissolution and bioequivalence, including taste, safety and tolerability, of this form were compared to the available, licensed granule product.

The in vitro taste profile of NaPB indicated a highly stimulant molecule. Luc 01 released NaPB only after a lag-time of ~10 s followed by a very slow release during several minutes compared with complete, immediate release of NaPB from licensed granules. Pharmacokinetic evaluation demonstrated bioequivalence of a 5 g dose of both products in 13 healthy volunteers. No statistical difference was observed for maximal plasma concentration or area under the plasma concentration-time. Luc 01 was significantly more acceptable, less bitter and less salty (p<0.01).

In vitro and in vivo taste profiles indicate that Luc 01 can be swallowed before stimulation of taste receptors by NaPB and is bioequivalent to the licensed product. The availability of Luc 01 should improve compliance/efficacy of NaPB treatment and alleviate the burden of administration particularly in children.

Retrospective audit in a Paediatric Intensive Care Unit (PICU) comparing 2010–2011 and 2011–2012 examining usage, expenditure (expressed as a gross figure, and cost per unit of therapy) and population serum electrolytes using archived Biochemistry data.

Serum electrolytes showed no significant change between the two periods:

Sodium: 141 mmol/l (2010–2011; range 95–187, median 140) to 143 mmol/l (2011–2012; range 126–190, median 141)

Potassium: 3.99 mmol/l (2010–11; range 1.9–9.2, median 3.9) to 3.81 mmol/l (2011–2012; range 1.9–9.0, median 3.7)

Chloride: 106 mmol/l (2010–11; range 70–142, median 105) to 106 mmol/l (2010–11; range 68–141, median 105)

Between both periods there was a 35% increase in fluid consumption (2522 units in FY11/12; 1860 units in FY10/11) but average cost per unit fell by 57% (£1.83/unit in FY11/12; £4.18/unit in FY10/11)

Hypotonic fluid usage and isotonic-hyperchloraemic fluid use was reduced by 50%.

There were no reported cases of iatrogenic hyponatraemia in the period after introduction of the new balanced fluid. However there were three admissions to PICU from paediatric wards where fluid-associated hyponatraemia were considered significant contributing factors.

Plasmalyte148–5% Glucose as the standard maintenance fluid for PICU is safe and effective; it has facilitated a reduction in the use of hypotonic fluids meeting Trust obligations under NPSA Safety Alert 22. There have been no documented cases of iatrogenic hyponatraemia in PICU since the adoption of this solution. There has been no change in electrolyte balance in the PICU patient population with the use of the balanced solution.

Using a licensed balanced solution has reduced overall expenditure on maintenance fluids in PICU by 40% representing a saving in 1 year of £3200. We advocate the use of this balanced solution for all children in acute hospitals requiring intravenous fluids.

All children with TB infection (defined as TST ≥10 mm and/or positive IGRA) presenting to The Royal Children's Hospital Melbourne during a 54-month period were included. All CXRs were reviewed by a senior radiologist blinded to the clinical details. The medical records of those with radiological abnormalities suggestive of TB were examined to identify those who were asymptomatic when the CXR was done. Demographical data were also collected.

CXRs were available for 268 of 330 TB-infected children, of whom 60 had CXR findings suggestive of TB. Of the 57 for whom clinical details were available, 26 were asymptomatic. Of these asymptomatic children with radiological abnormalities suggestive of TB, 6 had CXR findings suggestive of active TB, 14 had CXR findings suggestive of prior TB and 6 had isolated non-calcified hilar lymphadenopathy. The six with findings suggestive of active TB represented 2.6% (95% CI 0.9 to 5.5%) of asymptomatic TST/IGRA-positive children with evaluable CXRs. One child with isolated hilar lymphadenopathy had microbiologically-confirmed TB.

In contrast to the results from studies in adults, a CXR identified a small but noteworthy number of children with findings suggestive of pulmonary TB in the absence of clinical symptoms.

We aimed to determine whether the frequency of diagnosis, the age at presentation and the clinical presentation of CD have changed between 2005 and 2011 compared with previously published data from 1983 to 2004. We reviewed all patients with CD presenting to the South Wales’ Regional Centre between 2005 and 2011 and compared the age and documented mode of presentation with previous data from the same area.

163 cases of CD were diagnosed between 2005 and 2011 (23 cases/year) with the median age at diagnosis increasing to 14 years (range 0.8–16 years) compared with 50 cases (8/year) between 1999 and 2004 (median age at diagnosis 8 years), 25 cases (2.5/year) between 1990 and 1998 and 11 cases (1.5/year) between 1983 and 1989. 41% presented with specific gastro-intestinal symptoms, 23% with non-gastro-intestinal features and 36% were asymptomatic and diagnosed after serological screening of high-risk groups. Compared with the most recent previous study from the same population, the percentage of patients presenting with gastro-intestinal symptoms remain similar (42% vs 41%) but patients diagnosed after targeted screening had increased from 26% to 36%.

The frequency of diagnosis of CD in this defined population has continued to rise, with an increase in the median age at diagnosis, and over 50% of patients exhibited few or no symptoms.

Using a prospective population-based study, we identified infants with any possible adverse reaction to cow's milk (n=381) from a cohort of 13 019 infants followed from birth. They had a detailed history taken, skin prick tests and an oral food challenge when indicated. Infants with symptoms for which the causative relationship to cow's milk protein was excluded were compared with infants with IgE-mediated CMA and with a control group, and followed for 2–5 years.

Overall, 243 infants (1.87%) with mislabelled CMA were identified. Compared with 66 infants with IgE-mediated CMA, those with mislabelled CMA presented earlier and with symptoms usually involving a single organ system. Doctor-diagnosed atopic dermatitis (AD) was associated with mislabelled CMA (p<0.001), manifested primarily as skin rashes, compared with control infants. Higher maternal and paternal education were also associated with mislabelled CMA (p=0.007 and p=0.035, respectively) and manifested primarily as non-specific symptoms.

Mislabelled CMA typically presents within the first 3 months of life involving a single organ. Infant AD and higher parental academic education are associated with mislabelled reactions. Better parental and physician awareness of the importance of objectively diagnosing milk allergy is required to avoid mislabelling of infants as being allergic to cow's milk and to prevent potential nutritional deficiencies.

A 2 h training course on ‘Best practice guidelines for informing families of their child's disability’ was designed based on the findings of a nationally representative study of parents and professionals. The classroom-based course comprised a presentation of the research and recommendations of the best practice guidelines; a DVD film of parent stories and professional advice; group discussion; and a half-hour input from a parent of two children with disabilities. An anonymous, pretraining and post-training questionnaire was administered to measure knowledge and confidence levels, using scales adapted from a study by Ferguson et al (2006).

235 participants, including medical students, nursing students, and junior hospital doctors (JHDs).

Knowledge of best practice and confidence in communicating diagnosis of disability.

Significant improvements in knowledge (time 1 mean (M)=14.31, SD=2.961; time 2 M=18.17, SD=3.068) and confidence (time 1 M=20.87, SD=5.333; time 2 M=12.43, SD=3.803) following training were found. In addition, a significant interaction between time and cohort (medical students, nurses and JHDs) was found for knowledge. Further examination suggested medical students’ knowledge was developing to the extent that post-training, their scores were higher than nurses, but not significantly different to JHDs.

The increase in reported levels of knowledge and confidence following training in best practice for informing families of their child's disability indicates the potential for providing communication skills training in this area.

A population-level case series was carried out by reviewing mortality records. Sociodemographic characteristics, diagnosis and referral to paediatric palliative care (PPC) were analysed for association with location of death.

New Zealand

Children and young people aged 28 days–18 years who died from a life-limiting illness between 2006 and 2009 inclusive.

Location of death—home, hospital, other.

Of 494 deaths, 53.6% (256/494) died in hospital and 41.9% (203/494) died at home. Asian (OR=2.66, 95% CI 1.17 to 6.04) and Pacific children (OR=2.22, 95% CI 1.15 to 4.29) had an increased risk of death in hospital compared with European children, while children with cancer (adjusted OR=0.48, 95% CI 0.3 to 0.75) and children referred to the PPC service (adjusted OR=0.60, 95% CI 0.38 to 0.96) had a decreased risk. Population-attributable risk for referral to the PPC service was 28.2% (95% CI 11.25 to 47.75).

Most children in New Zealand with a life-limiting illness die in hospital with a significant influence resulting from ethnic background, diagnosis and referral to the PPC service. These findings have implications for resourcing PPC services and end-of-life care.

Cross-sectional survey data using the Hospital Anxiety and Depression Scale (HADS) collected at assessment.

Specialist paediatric CFS/ME service in the South West.

Children aged 12–18 years with CFS/ME.

Depression was defined as scoring >9 on the HADS depression scale.

542 subjects had complete data for the HADS and 29% (156/542) (95% CI 25% to 33%) had depression. In a univariable analysis, female sex, poorer school attendance, and higher levels of fatigue, disability, pain, and anxiety were associated with higher odds of depression. Age of child and duration of illness were not associated with depression. In a multivariable analysis, the factors most strongly associated with depression were disability, with higher scores on the physical function subscale of the 36 item Short Form (SF-36).

Depression is commonly comorbid with CFS/ME, much more common than in the general population, and is associated with markers of disease severity. It is important to screen for, identify and treat depression in this population.

Serological survey.

Five UK sites (Berkshire East, Birmingham, Buckinghamshire, Milton Keynes and Oxfordshire).

Children from 3 years 4 months to 10 years of age (mean age 6.2 years), vaccinated against HBV from birth following perinatal exposure.

A single booster dose of the paediatric formulation of a recombinant HBV vaccine.

Titres of antibody against hepatitis B Surface Antigen (anti-HBs) measured immediately before and 21–35 days after the HBV vaccine booster.

Prebooster anti-HBs titres were >10 mIU/ml in 84.6% of children (n=26; 95% CI 65.1 to 95.6%). All children (n=25, 95% CI 86.3 to 100%) had titres >100 mIU/ml after the booster.

This study of antibody persistence among UK children born to hepatitis B infected women, immunised with a 3-dose infant schedule with a toddler booster suggests sustained immunity through early childhood. These data should prompt further studies to address the need for a preschool booster.

Eudract Number 2008-004785-98.

Cross-sectional questionnaire survey conducted at home visits in nine regions in seven European countries. Participants were 13 to 17-year-olds (n=667) drawn from population CP registers in eight regions and from multiple sources in one region. 429 could self-report; parent-reports were obtained for 657. Data were collected on: severity, frequency, site and circumstances of pain in previous week; severity of pain associated with therapy in previous year.

The estimated population prevalence of any pain in previous week was 74% (95% CI 69% to 79%) for self-reported pain and 77% (95% CI 73% to 81%) for parent-reported pain. 40% experienced leg pains, 34% reported headaches and 45% of those who received physiotherapy experienced pain during therapy. Girls reported more pain than boys (OR=2.1, 95% CI 1.5 to 3.0) and young people reported more pain if they had emotional difficulties (comparing highest and lowest quartiles: OR=3.1, 95% CI 1.7 to 5.6). Parents reported more pain in children with emotional difficulties (OR=4.2, 95% CI 2.7 to 6.6), or with more impaired walking ability.

Pain in young people with CP is highly prevalent. Because pain causes immediate distress and is associated with lower subjective well-being and reduced participation, clinicians should routinely assess pain. Clinical interventions to reduce pain should be implemented and evaluated. The efficacy of medical and therapeutic interventions causing pain should be re-examined to establish if their benefit justifies the pain and fear of pain that accompany them.

The paper by Zhao et al1 represents a logical investigation into the issues surrounding vancomycin dosage in neonates. Recent work has shown large variability in practice across units in dose, frequency...]]> 2013-05-09T02:05:40-07:00 info:doi/10.1136/archdischild-2012-303414 hwp:master-id:archdischild;archdischild-2012-303414 BMJ Publishing Group Ltd 2013-06-01 Drug therapy 98 6 447 448 http://adc.bmj.com/cgi/content/short/98/6/448?rss=1

Children with severe acute malnutrition may be infected and the routine addition of antibiotics to nutritional treatment has been recommended although there have been no clinical trials and there is observational evidence that giving antibiotics may be unnecessary or even harmful. Now, a trial in rural Malawi (Indi Trehan and colleagues, New England Journal of Medicine 2013;368:425–35) has shown antibiotics are beneficial.

At 18 rural feeding clinics a total of 2767 children aged 6–59 months with uncomplicated severe acute malnutrition were randomised to three groups: amoxicillin suspension 80–90 mg per kg daily in two divided doses, cefdinir suspension 14 mg per kg in two divided doses, or placebo twice daily. All children received ready-to-use therapeutic food and were treated as outpatients. Recovery (no oedema and weight for height z score –2 or higher) occurred in 88.7% (amoxicillin), 90.9% (cefdinir), and 85.1% (placebo). The risk of treatment failure with placebo...]]> 2013-05-09T02:05:40-07:00 info:doi/10.1136/archdischild-2013-304020 hwp:master-id:archdischild;archdischild-2013-304020 BMJ Publishing Group Ltd 2013-06-01 Miscellanea 98 6 448 448 http://adc.bmj.com/cgi/content/short/98/6/449?rss=1 Objective

Because pharmacokinetic data are limited, continuous infusions of vancomycin in neonates are administered using different dosing regimens. The aim of this work was to evaluate the results of vancomycin therapeutic drug monitoring (TDM) under three different dosing regimens and to optimise vancomycin therapy.

Vancomycin TDM concentrations were noted and compared prospectively in three hospitals. Population pharmacokinetic analysis was performed to optimise dosing using NONMEM software. Patient-tailored optimised dosing regimens were evaluated in a prospective study.

Two hundred and seven serum vancomycin concentrations from 116 neonates were analysed. Only 48 neonates (41%) had serum vancomycin concentrations within the therapeutic range of 15–25 mg/l using a current dosing regimen. Concentrations ranged from 5.1 to 61.5 mg/l. Loading doses were required to decrease the risk of sub-therapeutic levels during early treatment. An optimised dosing regimen, taking into account birth weight, current weight, postnatal age and serum creatinine, was developed based on a one-compartment pharmacokinetic model. A prospective validation study in 58 neonates demonstrated a higher percentage of neonates (70.7%, n=41) reaching the therapeutic range and early dosage adaptation (6–12 h post-dose) using an optimised dosing regimen.

A patient-tailored optimised dosing regimen should be used routinely to individualise vancomycin continuous infusion therapy in neonates.

A literature search was conducted to identify key material published in English in relation to the dosages of medicines used for specific IEM. Textbooks, peer reviewed articles, papers and other journal items were identified. The PubMed and Embase databases were searched for material published since 1947 and 1974, respectively. The medications found and their respective dosages were graded according to their level of evidence, using the grading system of the Oxford Centre for Evidence-Based Medicine.

83 medicines used in various IEM were identified. The dosages of 17 medications (21%) had grade 1 level of evidence, 61 (74%) had grade 4, two medications were in level 2 and 3 respectively, and three had grade 5.

To the best of our knowledge, this is the first review to address this matter and the authors hope that it will serve as a quickly accessible reference for medications used in this important clinical field.

In a child with LTBI [patient], what is the best treatment regimen [intervention] taking into account four criteria: treatment compliance, drug adverse effects, treatment efficacy and cost [outcomes]?

Medline and EMBASE were searched using the Ovid interface (1974 to current date) in December 2012. The following keywords were used: (latent tuberculosis/[drug therapy, therapy]) OR (latent AND *tuberculosis/[diet therapy, drug therapy, surgery, therapy]). Limit set: English-language. Studies of LTBI treatment that included children aged less than 15 years were...]]> 2013-05-09T02:05:40-07:00 info:doi/10.1136/archdischild-2013-303876 hwp:master-id:archdischild;archdischild-2013-303876 BMJ Publishing Group Ltd 2013-06-01 Archimedes 98 6 468 474 http://adc.bmj.com/cgi/content/short/98/6/468-a?rss=1

Getting it straight from the start

For  more than a decade Archimedes has presented clinical queries and appraised the evidence that emerges, leading on to a clinical conclusion to the dilemma. What is strikingly common is that many questions can start in a muddle, and a failure to get an ‘evidence-based answer’ might actually be a failure to ask an accurate question.

In a recent trans-disciplinary teaching session, one anaesthetist summarised the formulation of evidence-based medicine (EBM) questions as ‘Does drug A compared to drug B make outcome X happen more or less in patient group Z?’—a brilliant anagram of the ‘PICO’ formula into Intervention, Comparator, Outcome, Patients. Now if your question doesn't fit, or can be fudged to fit, this, then you need to unpack it.

Is it a diagnostic test? Try ‘Does super-TB-detector kit compared with Proper Microbiological Stuff indicate the presence of Mycobacterium tuberculosis...]]> 2013-05-09T02:05:40-07:00 info:doi/10.1136/archdischild-2013-304148 hwp:master-id:archdischild;archdischild-2013-304148 BMJ Publishing Group Ltd 2013-06-01 Archimedes 98 6 468 468 http://adc.bmj.com/cgi/content/short/98/6/474?rss=1 Scenario

A 6-week-old boy with projectile non-bilious vomiting is diagnosed with infantile hypertrophic pyloric stenosis (IHPS). His parents are advised that surgical pyloromyotomy is the gold standard treatment for their son's condition, yet they are not keen for him to have an operation and a general anaesthetic. When looking for alternatives, you come across medical therapy of IHPS with atropine. You wonder if this treatment really works?

In a 3-week-old infant with hypertrophic pyloric stenosis [patient], does therapy with atropine [intervention] achieve sufficient resolution of the condition so as to avoid the need for surgical pyloromyotomy [outcome]?